Health

Summary

C complained about the board's communications with them regarding the treatment of their children. C’s children have a congenital condition which requires steroid replacement treatment and regular monitoring. C was dissatisfied with the treatment provided by the board and initiated the process to have the children transferred to another provider for treatment. The board gave inconsistent messages about the referral process and C was left unclear about the steps being taken to transfer the children’s treatment. Some months elapsed during which the children did not receive treatment.

During our investigation, we found that the board’s position regarding the referral had been inconsistent and confusing. Had they been clearer with C about the referral process, C's children could have accessed treatment much sooner. Given their need for regular monitoring, this was a significant failing. We found that the board’s communication had been unreasonable and, therefore, upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in communication, with a recognition of the impact this had on their family.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Staff should communicate clearly about who is responsible for doing what in this type of situation. In particular they must ensure the relevant information is clearly conveyed to the patient.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C was diagnosed with a meningioma (a tumour that forms on membranes that cover the brain and spinal cord just inside the skull), which required surgical removal. C complained about the failure of the practice to appropriately assess their symptoms in the years preceding diagnosis. C said their records showed that they presented at the practice with red flag symptoms on a number of occasions dating back years. C also said that the practice failed to make appropriate referrals for investigation.

We took independent advice from a GP. We considered that C had been assessed appropriately by the practice. We found that C’s care was reasonable and in line with General Medical Council Good Medical Practice. We did not consider that there had been any missed opportunities to refer to secondary care in respect of C’s meningioma, taking into account their presenting symptoms. We did not uphold either aspect of C's complaints.

Summary

C complained on behalf of their client (B) in relation to the care and treatment provided to B’s spouse (A) whilst A was a patient within the board. A had a complex medical history and was referred to Queen Elizabeth University Hospital, receiving care and treatment over two days. B’s specific concerns related to a procedure A underwent on the second day. On that day, CT scan findings showed the presence of a large liver abscess which was possibly the result of a perforated gallbladder. Treatment options were reviewed and the best option was considered to be draining the abscess percutaneously (by accessing the abscess through the skin rather than operating and opening the abdomen). A passed away that day.

C told us that B believed that the procedure was not the best clinical option for A and that A would not have died had the procedure not been undertaken. B felt that A’s judgement was impaired because of medication which they had been prescribed, and as such was not competent at the time of making the decision to have the procedure, so could not agree to it.

We took independent advice from a surgical adviser. We found that the care A received during their admission was reasonable and followed accepted management pathways. We noted that the board assessed and provided the best clinical option of treatment. We found no evidence to suggest that A was impaired by the medication prescribed to them and as such was competent to consent to the procedure. We did not uphold C's complaint.

Summary

C complained on behalf of their child (A), who was admitted to the Royal Hospital for Children with multiple bruises. Medical staff initiated child protection procedures to investigate if A's bruising had been caused by physical abuse. C raised various concerns about A's care and treatment. In particular, that the decision to initiate child protections was disproportionate; that unnecessary and distressing medical investigations were carried out on A; and there was a lack of communication with C.

We took independent advice from a consultant paediatrician. We found that it was reasonable child protection procedures were initiated and that no unnecessary medical investigations were carried out. However, we found that there was a failure to communicate clearly with C about what was happening at the outset so we upheld their complaint.

C also raised concerns about how the child protection process was concluded. We found that there was an unreasonable delay in the board concluding their part of the child protection process. We also found that the outcome should have been recorded in A's medical records. We upheld their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in the communication with them and in relation to how the child protection process was concluded. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• As it could be relevant to future care and treatment, A's medical record should contain information about the final outcome of the child protection process.

What we said should change to put things right in future:

• Families should be given prompt and clear information about the child protection process. It should then be documented in sufficient detail.
• When child protection concerns have been raised, medical reports should be provided within a reasonable timeframe, taking into account relevant clinical guidance.
• When child protection concerns have been raised, the child's x-rays should be reported in a timely manner, taking into account relevant clinical guidance.
• When child protection procedures are initiated in hospital, the child's medical record should contain information about the final outcome so it is available to hospital based medical staff if the child is readmitted.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed properly to investigate the causes of their neck and shoulder pain. As a result, they said that they experienced up to 20 migraines a month and spent a large part of time in bed. C said that they regularly asked for an x-ray but were told that it would not be appropriate and were prescribed a number of medications and botox, none of which had effect. Because they were struggling with their quality of life, C attended a private chiropractor (a person who treats diseases by pressing a person's joints, especially those in the back) who took x-rays which revealed that the vertebrae at the top of their spine were out of alignment. The chiropractor then carried out a procedure to address this, as a consequence of which, C said, their migraines largely disappeared.

C believed that the board ignored their concerns about neck and shoulder pain and said that had they been addressed when requested, they would have had a better quality of life.

The board’s view was that, throughout, C had been treated appropriately and in line with clinical guidance; x-rays were not normally recommended in migraine diagnosis and management and were not standard practice. They also said that clinicians were not trained in alternative procedures and were unable to recommend them.

We took independent clinical advice. We found that x-rays were not part of the normal practice in the diagnosis and management of migraine and that neck and shoulder pain can occur in 90% of patients with migraine. We also found that the alternative procedure given to C was not an approach offered by the NHS and that C had been treated in line with clinical best practice. We did not uphold the complaint.

Summary

C, an advocacy worker, complained to us on behalf of their client (A) about the care and treatment they received at Aberdeen Royal Infirmary. A had an autologous fascia sling procedure (where a strip of tissue from the abdomen is used to create a sling under the urethra) to treat stress urinary incontinence (where urine leaks out of the bladder when it is under pressure). A suffered two complications from the surgery; including a bladder injury and overactive bladder (needing to get to the toilet in a hurry or leaking urine before reaching the toilet). C complained that A was not properly informed about the risks during the consent process.

We took independent gynaecology (specialists in the female reproductive system) advice. We found that at A's clinic appointments, they were given appropriate information about the risks involved in the surgical options available. However, a significant period of time passed until A had the surgery. Moreover, surgery had not been A's first choice of treatment, and there was a change to the planned procedure. In the circumstances, we found that it was particularly important to have reiterated all the significant risks of surgery when A signed the consent form. However, we found no evidence that A was advised about the risk of overactive bladder, even though it is a common complication. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to appropriately inform them of the risk of overactive bladder. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The consent process should follow national guidelines. As part of the consent process, information about the common and serious complications of surgery should be reiterated to the patient as close as possible to their surgery; and that information should then be clearly documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr A). Mr A was admitted to hospital after he attended A&E complaining of abdominal pain with a background of hiatus hernia (where part of the stomach pushes up into the lower chest). Mr A had a nasogastric tube (where a tube is placed through the nose into the stomach) inserted to decompress the hiatus hernia, however on one occasion it fell out and a number attempts had to be made before it was reinserted. During this procedure, Mr A suffered a cardiac arrest and died.

Mrs C complained that the board inappropriately handled the insertion of his nasogastric tube and raised concerns that it may have caused Mr A's cardiac arrest. Mrs C also complained that insufficient attempts were made to resuscitate Mr A when he suffered cardiac arrest.

The board explained that nursing staff escalated the procedure for passing the nasogastric tube appropriately and that Mr A arrested before any further escalation could happen. The board also explained that Mr A’s cardiac rhythm was asystole (unshockable) therefore attempts to prolong resuscitation would be ineffective.

We took independent advice from a consultant general surgeon and from a consultant in acute medicine. We found that reasonable action was taken by the nursing staff in escalating the reinsertion of the nasogastric tube and there was no evidence that the procedure was inappropriately handled. We also found that the decision to stop resuscitation was made in consultation with the clinical staff present and the decision was reasonable in light of his additional conditions and the fact that his heart rhythm was asystole. Therefore, we did not uphold Mrs C's complaints.

Summary

Mr C complained about the care and treatment provided to his partner (Miss A) at Aberdeen Maternity Hospital. Mr C said that when Miss A attended a pre-caesarean section assessment, the doctor failed to identify that she was in the early stages of labour. Mr C also complained that the board failed to explain why their baby required antibiotics and a breathing tube after they were born, and that the board's handling of his complaint was unreasonable.

The board acknowledged that the doctor assessing Miss A had failed to carry out a full assessment. The board noted that the reasons why their baby required antibiotics and a breathing tube had been explained to Mr C by hospital staff and later in email correspondence. The board also carried out a comprehensive review of their handling of the complaint and identified areas for learning and improvement.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We accepted the board's view that the doctor failed to carry out a full of assessment of Miss A's condition when she attended for the pre-caesarean section appointment and that their handling of the complaint was unreasonable. We upheld these complaints on that basis and made further recommendations for learning and improvement. We concluded that there was reasonable evidence it had been explained to Mr C why his baby required antibiotics and a breathing tube at the time of the event and later in email correspondence. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we said should change to put things right in future:

• The board should have a guideline in place for the management of patients attending the pre-caesarean section clinic. This should include standard questions to ask all patients such as about presence of vaginal bleeding, fetal movements, as well as contractions and leaking fluid vaginally.
• The board should have guidelines in place about the turnover time for issuing letters following debrief meetings.
• The board should have in place template letters which can be used when inviting patients for debrief meetings that make the purpose of the meeting explicit.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment which they received at the Golden Jubilee National Hospital. C had undergone a total right hip joint replacement but post operatively reported problems with right foot drop and loss of sensation in the right foot and leg. C was put on medication and referred to physiotherapy but still remained in pain with loss of sensation. C felt that something must have gone wrong during the surgery.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that there was no indication from the clinical records that complications had been encountered during C’s surgery in that the surgery was completed within normal timescales and that blood loss was within expected levels. It was possible that the sciatic nerve (nerve in the lower back area) could have been inadvertently damaged during the surgical procedure but there was no documentation to support such a view.

While we did not uphold the complaint, we noted concerns about the standard of the record-keeping regarding the brevity of the actual operation notes and whether sufficient discussions about C’s high body mass index (BMI, a measure for estimating human body fat) level, which would increase risks of any surgery, were discussed with them prior to surgery. The concerns were highlighted as feedback to the hospital who have already amended their procedures in an effort to improve learning.

Summary

C complained about the care and treatment they received regarding a fractured collarbone. C was scheduled to have surgery but on the day of the surgery a decision was made to cancel on the basis that C’s collarbone had healed. C complained about the decision to cancel the surgery and that a decision was not made to proceed with surgery at an earlier date.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that it was reasonable for the board to allow for six months of conservative (non-operative) management and to cancel the surgery following an x-ray which showed the fracture had joined together.

However, we found that it was unreasonable not to mention or discuss operative intervention and its associated risks at earlier clinic appointments. This is because patients should be informed of all treatment options including that of no treatment in accordance with the General Medical Council’s guidance on consent. We also found that it was unreasonable for one of the clinic letters to state that the x-rays showed hypertrophic (healing tissue has formed but the bone fractures have not joined) non-union. We noted that the x-rays actually showed a delayed union (when a fracture takes longer than usual to heal) because approximately four months had passed since C’s injury at that point. We also found that the decision to proceed with surgical intervention was unreasonable given that the x-rays showed delayed union, rather than hypertrophic non-union and there was no evidence that the clinician had discussed C’s case with the consultant. In light of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing operative intervention and its associated risks at their clinic appointments, and that the decision to proceed with surgical intervention was made when the x-rays showed delayed union rather than hypertrophic non-union, and while the clinician had not discussed C’s case with the consultant. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Decisions to proceed with surgery for clavicle fractures should be based on an accurate assessment of the patient including any available radiograph. Changes in a patient’s management plan from a consultant’s decision should be discussed with the consultant and documented.
• Patients should be informed of all treatment options, including that of no treatment and these discussions should be documented.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.