Health

Summary

Mrs C, an advice worker, complained on behalf of her client (Ms A) about the treatment which Ms A received following admission to Aberdeen Royal Infirmary with symptoms of right upper quadrant pain and inflammation. Investigations led to a diagnosis of chronic cholecystitis (inflamed gallbladder). Treatment options were considered and it was decided to insert a drain, rather than perform surgery at that time, with a referral to a hepatobiliary surgeon (surgeon specialising in the treatment of the liver, bile duct and pancreas) for ongoing treatment. Ms A was discharged home but was readmitted to hospital as an emergency due to further right upper quadrant pain and required surgery. By the time of readmission, Ms A had not received any correspondence from the surgeon. Ms A said that surgery should have been performed during the initial admission and that the delay in treatment caused her additional health problems.

We took independent advice from a consultant in general surgery. We found that Ms A had multiple medical problems and that upon admission to attempt keyhole surgery would be impossible and open surgery would be challenging. It was appropriate to discharge Ms A with a drain in situation for follow-up by specialists at a later date. Although there were gaps in communication with Ms A, this did not impact on her clinical treatment. We did not uphold the complaint.

Summary

C was referred to the board's plastic surgery department with a suspected sebaceous cyst (a common non-cancerous cyst of the skin) as a routine referral. It was found that C had a squamous cell carcinoma (a type of skin cancer). After diagnosis of the cancer C subsequently underwent treatment to remove it. After surgery the board's district and community nurses managed C's wound in the community. C complained about the treatment provided by the board and subsequent wound care.

We took independent advice from a consultant plastic surgeon. We found that the board's investigation, diagnosis and treatment of C was reasonable and met the waiting times specified by the Scottish Government in 'Better Cancer Care, An Action Plan'. While there had been some communication failings, the treatment provided was reasonable. We did not uphold this aspect of C's complaint.

We took independent advice from a nurse regarding C's wound care. We found that the wound care provided by the board was unreasonable. It was not evidenced that C's wound had been seen and assessed by an appropriate clinician before agreeing how the wound would be cared for. The board accepted there was a lack of documentation relating to C's wound care. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable wound care to them. 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:

• Wounds should be assessed by an appropriate clinician before determining the best course of treatment.

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

Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery for patients entered onto the list in the previous year. She decided that she could not wait for the surgery and had it privately.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that there had been a delay in arranging the surgery and we upheld the complaint. However, we also considered that the action the board were taking to reduce waiting times was reasonable. This included addressing their referral pathways and seeking to increase their consultant capacity. In addition, the board had apologised to Ms C that they had failed to meet the treatment time guarantee. When the board had received contact from Ms C's GP about the delay, they had acted on this quickly and a plan for escalation was commenced. We did not, therefore, recommend that Ms C was reimbursed for the costs of the operation, as we were unable to conclude that Ms C had no option but to arrange treatment privately. We did not make any recommendations to the board in relation to Ms C's complaint.

Summary

C complained about the care provided by the board during their admission to Woodend Hospital. C said that the board unreasonably administered an overdose of an opioid drug. We took independent advice from an appropriately qualified adviser. We found that the board failed to follow local protocol and unreasonably administered an opioid drug to C. We upheld this part of C's complaint.

C also complained that the board failed to reasonably monitor them after they underwent an operation. C was being monitored using National Early Warning Score (NEWS). NEWS is a guide used by medical services to quickly determine the degree of illness of a patient. We found that when C triggered a NEWS score of one, they should have been observed every four hours, however C was next observed 11 hours later. This was unreasonable and we upheld this part of C's complaint.

C complained that their spouse (B) was unreasonably communicated with after their condition deteriorated. We found that while it was identified in the morning of that day that B should have been contacted, B was not made aware of C's condition until they entered the ward almost eight hours later. This was unreasonable and we upheld this part of C's complaint.

The board said that they had already taken action in response to these failings. We asked them to provide evidence of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for failing to communicate with them in a timely manner.
• Apologise to C for the failings as identified by the board and from our investigation. The apologies should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 their partner (A) was prematurely discharged from the Golden Jubilee National Hospital following cardiac surgery. The surgery was successfully performed with no reported complications. A was discharged home from hospital as staff deemed they were clinically fit for discharge. C was concerned that A had been discharged as they had severely swollen feet. A's health deteriorated, and days after discharge an ambulance was called as A had severe shortness of breath and a high temperature. A was then admitted to another hospital where they were an in-patient for several weeks.

We took independent advice from a cardiology consultant (doctor who deals with diseases and abnormalities of the heart). We found that insufficient action was taken to establish the extent of A's heart failure and possible wound infection prior to their discharge from the Golden Jubilee National Hospital, which amounted to a failing in the standard of care and treatment required. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failure to ensure their symptoms of severe fluid retention and possible infection were resolving prior to discharge from hospital. 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 ensure that, where a patient shows symptoms of severe fluid retention and possible infection, appropriate clinical investigations take place to ensure that the symptoms are resolving prior to hospital discharge.

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 on behalf of her husband (Mr A) about the treatment he received when he attended A&E of Forth Valley Royal Hospital due to experiencing pain that had started in his neck and had travelled to his hands. In particular, Mrs C was concerned that there was a delay in diagnosing Mr A with sepsis (blood infection).

Mr A had been examined and then discharged to the care of his GP on the same day. We found that there was no evidence that Mr A had sepsis at that time. A diagnosis of sepsis requires a source of infection and evidence of abnormal physiology; however, the urinalysis showed no signs of infection. Therefore, there was no failure to identify sepsis at this stage. The following morning Mr A was taken by ambulance to hospital and was admitted again. Mr A was diagnosed with a urinary tract infection and then developed sepsis. While we did not consider there to be a failure to diagnose sepsis, Mr A is a diabetic and we found that there was a failure to carry out a bedside blood glucose finger prick test during his first attendence at hospital given glucose was found in Mr A's urine following the urinalysis. On this basis, we considered that the board failed to provide Mr A with reasonable care and treatment. Therefore, we upheld this complaint.

Mrs C also complained about the response she received to her complaint regarding the content of the discharge letter to Mr A. The response to the complaint correctly stated what was in A&E notes (the GP was to consider referring Mr A to neurology (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system)), but the discharge letter to Mr A's GP did not mention this. We upheld the complaint on the basis that the discharge letter should have contained this information and the complaint response should have identified this discrepancy. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for (a) an unreasonable failure to carry out a bedside finger prick blood glucose test; (b) an unreasonable failure to include within the discharge letter to Mr A's GP information about a possible GP referral to neurology; and (c) a failure to ensure the response to the complaint correctly reflected what was in the discharge letter to the GP regarding a neurology referral. 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:

• To ensure clinical staff are aware of the circumstances in which a bedside fingerprick blood glucose test should be carried out.
• To ensure clinical staff include relevant information in discharge correspondence to GPs.

In relation to complaints handling, we recommended:

• To ensure the facts of an investigation are correctly reported to a complainant.

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

Mr C complained on behalf of his daughter (Ms A). Ms A was suspected to have gallstones (small stones that form in the gallbladder) and was referred for laparoscopic (keyhole) surgery. During the surgery Ms A's gallbladder could not be located and following further investigations, it was confirmed that Ms A had gallbladder agenesis (absent from birth). Mr C complained that Ms A's surgery could have been avoided had further investigations been performed when it was observed during the ultrasound that the gallbladder could not be definitively seen. Mr C also complained about the board's handling of his complaint. The board said that they considered the appropriate investigations were carried out and that further scans prior to surgery were not clinically indicated.

We took independent advice from a consultant surgeon. We found that the conclusion of Ms A's scan, which stated it was “suggestive of a contracted bladder” was reasonable on the basis that gallbladder agenesis is sufficiently rare. Further scans were not warranted in this case as Ms A did not meet the criteria. We also concluded that, while the board's final response to the complaint was somewhat delayed, the delay was reasonable in the circumstances. We did not uphold Mr C's complaints.

Summary

Mrs C complained about the care and treatment provided to her late sister (Miss A). Miss A attended the practice and was prescribed medication for suspected vertigo (a sensation of whirling and loss of balance). The following day she collapsed at home and was admitted to hospital. It was found that she had hypercalcaemia (excessive calcium levels), acute pancreatitis (inflammation of the pancreas) and severe dehydration. Miss A's condition continued to deteriorate and she died. Mrs C raised concerns about the level of medication Miss A was prescribed and queried whether they played a role in her death. Mrs C complained that the practice failed to monitor Miss A's medication regime appropriately, to ensure that she received appropriate follow-up for specialist care and that they failed to carry out an appropriate assessment of her condition the day before she collapsed.

We took independent advice from a GP. We found that the practice correctly followed the prescribing instruction received by Miss A's specialist and that the list of medications prescribed were reasonable given her symptoms. We concluded it was not the practice's responsibility to chase up the hospital with regards to follow-up appointments. We also found that an appropriate and thorough examination was carried out and there was no evidence to suggest that Miss A was suffering from pancreatitis the day before she collapsed. We did not uphold Mrs C's complaints.

Summary

Miss C complained about the antenatal (before a baby's birth) care and treatment she received when she attended Forth Valley Royal Hospital where her child was stillborn at full term.

Miss C raised concerns that, despite attending triage on a number of occasions, in relation to concerns about her blood pressure and possible pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine), she was not adequately supported. Miss C said that she felt that her concerns were not taken seriously, that she received poor continuity of care and that these failings meant that there were missed opportunities to save her baby.

The board said that Miss C was provided with reasonable care and treatment. The board found that staff provided appropriate care and treatment and there was nothing that could have been done to prevent the stillbirth of Miss C's baby. The board also requested an external review to be carried out in relation to Miss C's care.

We took independent advice from two advisers – a midwife and an obstetrician (a doctor who specialises in pregnancy and childbirth).

We found that the midwifery care and treatment given to Miss C was appropriate and in line with relevant guidance. We also found that the obstetric care and treatment given to Miss C was reasonable and in accordance with national guidelines. We found no evidence of missed opportunities which could have affected the outcome in this case and concluded that Miss C's antenatal care was of a high standard. As such, we did not uphold this complaint.

Summary

C attended the practice a number of times over several years with recurring urinary tract infections (UTIs). C said that in that period, the practice had failed to undertake a test for a prostate specific antigen (PSA test) despite C's repeated requests. When the practice did agree to undertake a PSA test the result for this was high and caused the practice to urgently refer C to the local NHS board's urology department for further investigation. Subsequently, C was informed that they had prostate cancer. C complained that the treatment provided by the practice was unreasonable.

We took independent advice from a GP. We found that the practice provided reasonable treatment to C. We considered that C's condition of recurrent UTIs had been identified by the practice, who appropriately noted that this should be managed by the urology department. The referral to this department was in line with General Medical Council's Good Medical Practice as the ongoing symptom management of the patient lay outwith the practice's professional expertise. We concluded that the care provided by the practice was reasonable. We did not uphold this complaint.