Mr C complained about the follow-up care and treatment Greater Glasgow and Clyde NHS Board (the Board) provided to Mr A after he suffered a subarachnoid haemorrhage (a type of stroke caused by bleeding on the surface of the brain) which occurred when an aneurysm (a bulge in a blood vessel in the brain) ruptured.
Mr A underwent an endovascular coiling procedure (a procedure to block blood flow into an aneurysm) at Queen Elizabeth University Hospital (the Hospital) in August 2016. During his admission, he developed a perforated bowel and had colostomy surgery (a surgical procedure to divert one end of the colon (part of the bowel) through an opening in the tummy. The opening is called a stoma). He was discharged the following month.
In February 2017, Mr A attended the Hospital for a follow-up Magnetic Resonance (MR) angiogram scan (a test that provides images of the blood vessels). This showed a recurrence of the aneurysm. A further examination in the form of a Digital Subtraction Angiogram (a procedure which provides an image of blood vessels) was recommended, which was requested in July 2017.
In September 2017, the Digital Subtraction Angiogram was carried out and Mr A’s case was discussed at the neurovascular Multi-Disciplinary Team (MDT) meeting. The meeting proposed that Mr A have further endovascular treatment.
In November 2017, Mr A attended an out-patient appointment with a consultant neuroradiologist (a radiologist who specializes in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system) where it was recommended that the reversal of the colostomy be undertaken prior to the endovascular treatment. The colostomy reversal was to be carried out at Mr A’s local hospital, which is the responsibility of a different health board.
The Board wrote to the consultant general surgeon at Mr A's local hospital in December 2017 advising that it was considered it would be better to perform the colostomy reversal before the endovascular treatment. However, Mr A died the same month having suffered a further brain aneurysm.
Mr C complained that there were unreasonable delays, poor decision-making and poor communication by the Board, which he considered resulted in Mr A’s death. In making the complaint, Mr C was representing his family (including Mrs B, Mr A’s sister).
We took independent advice from a consultant neurosurgeon (a surgeon who specialised in surgery on the nervous system, especially the brain and spinal cord).
We found that when Mr A suffered a subarachnoid haemorrhage in August 2016, the care and treatment he received during his admission to the Hospital was timely and expedient and his overall management was reasonable.
A significant recurrence of the aneurysm was identified following the MR angiogram scan in February 2017 and a follow-up Digital Subtraction Angiogram was recommended. Despite this, no action appeared to have been taken for five months, until requested in July 2017. There was then a further two month delay until the Digital Subtraction Angiogram was carried out in September 2017. By this time the aneurysm had grown in size. We found that these delays were significant and unreasonable.
We also found that there was a lack of communication with Mr A subsequent to the identification of the presence of the recurrence of the aneurysm and the need for prompt further management to make him aware of this. However, communication subsequent to the Digital Subtraction Angiogram in September 2017 appeared overall to have been reasonable although the Board acknowledged that communication in relation to a letter which Mr A received about the colostomy reversal could have been better.
Mr A did not have a consultant review for a further two months until November 2017. We found that there were then further unreasonable and significant delays and poor communication in following up the need for the colostomy reversal prior to treating the aneurysm. This was further exacerbated by the fact that the general surgical team were in a different hospital. Relying solely on written communication between clinicians about this was inappropriate and insufficient in this case, which was urgent.
Whilst it is not possible to say whether earlier treatment would have led to a different outcome for Mr A and there was risks attached to surgery, we found that treating Mr A at the earliest opportunity would have minimised this possibility.
Mr C also complained about the Board’s handling of their complaint, which was made to the Board by Mrs B.
We noted that the Board held a Morbidity and Mortality meeting in February 2018 to review Mr A’s case which was attended by a number of consultants including Mr A’s doctors. This outlined a number of contributory factors leading to Mr A’s poor outcome, the reasons why, and the action to be initiated to help mitigate future occurrence and as future learning points.
However, despite this, at no point during the Board’s correspondence with Mrs B or our office was any reference made to the Morbidity and Mortality meeting and its findings. While the Board acknowledged that there had been process failures in their second response to Mrs B, more could have and should have been done to identify and act transparently on the failings the Morbidity and Mortality meeting identified. It was not clear from the Board’s responses to Mrs B and to our office whether all of the actions identified had been completed.
Our investigation identified significant failings and, accordingly, we upheld both of Mr C’s complaints.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Mr C and his family:
| Complaint number |
What we found
|
What the organisation should do
|
What we need to see
|
| (a) and (b) |
The Board failed to provide Mr A with a reasonable standard of care and treatment
There was failings in communication with Mr A after he suffered a recurrence of a brain aneurysm
There was failings in communication between staff involved in Mr A’s care and treatment
There were failings in the Board’s handling of the complaint
|
Apologise to Mr C, Mrs B and Mr A’s
family for:
- the failings in care and treatment and communication identified in the report; and
- the failings in complaint handling.
The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
|
A copy or record of the apology
By: 18 December 2020
|
We are asking the Board to improve the way they do things:
| Complaint number |
What we found
|
Outcome needed
|
What we need to see
|
| (a) |
There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm
There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm
There was unreasonable failings in communication between staff involved in Mr A’s care and treatment
|
There should be in place a streamlined and efficient system for highlighting reports of an aneurysm and acting upon its findings
Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis
Communication between staff should be appropriate and timely especially where a patient has had a serious diagnosis and requires treatment
|
Evidence that the Board have reflected on the failings identified in Mr A’s case and reviewed their processes and guidance for highlighting reports of an aneurysm
Details of the review and any changes, including how any changes will be shared with relevant staff, to be provided to this office
Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning, including reference to what that learning is (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions)
By: 18 February 2020
|
Evidence of action already taken
The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened:
| Complaint number |
What we found
|
Outcome needed
|
What we need to see
|
| (a) |
There were unreasonable delays in Mr A’s care and treatment after he suffered a recurrence of a brain aneurysm
There was unreasonable failings in communication with Mr A after he suffered a recurrence of a brain aneurysm
There was unreasonable failings in communication between staff involved in Mr A’s care and treatment
|
The Board convened a Morbidity and Mortality Meeting in February 2018 in which they recommended action points
Action included:
- a more robust system for MDT referral;
- improved team working and communication between the neurosurgery and neuroradiology departments;
- better safety netting to ensure that a patient diagnosed with a recurrent aneurysm is tracked for urgent review;
- at least one vascular neurosurgeon is present at a Morbidity and Mortality meeting; and
- standard operating procedure for Digital Subtraction Angiogram views for coil embolisation
|
Confirmation of the action the Board say they have taken (evidence of guidelines circulated and training sessions attended, such as emails; memos minutes)
By: 18 February 2020
|