Health

Summary

C complained about the care and treatment they received from the board. C’s local NHS board referred them to a consultant bariatric (branch of medicine that deals with the causes, prevention, and treatment of obesity) surgeon at Tayside NHS Board. C complained that, although they had made lifestyle and health changes as requested by the multidisciplinary specialist weight management team, they were not put forward for surgery on a number of occasions. C complained that a consultant bariatric surgeon acted inappropriately during consultations with them and that information C provided upon request was ignored when considering their suitability for surgery. C considered the delays to their surgery to have been unreasonable and raised further complaints about the board’s handling of their concerns.

We found that the consultant bariatric surgeon inappropriately required C to bring their test results to a consultation and inappropriately referred to them having made a complaint during a consultation. We found that the decision to postpone the surgery until such time as C’s diabetes was being better managed was reasonable. However, in relation to the decision to postpone surgery, we found that the board’s poor administration of C’s case and poor communication with them led to C not being suitable for surgery. We found, therefore, that this had led to C’s request for later surgery being denied and that the board had contributed to this situation. We found that the board had taken reasonable action in response to C’s complaint but that they had unreasonably failed to advise C of the outcome of a multidisciplinary team meeting. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the consultant inappropriately raised their formal complaint about them during a consultation. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• That the board invite C to an multidisciplinary team review of their case with a view to forming a clear plan for them with specific targets and timescales for progression to surgery should that remain the best option for them.

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

• That the board take steps to ensure specialist weight management team's from other health boards receive clear communication as to what criteria each patient needs to meet to progress to surgery.
• The board’s procedures should ensure bariatric patients are given a clear plan with scheduled review points as to their progression through Tiers 3 and 4, and onto surgery, and the criteria they must meet.
• All board staff should be aware of the importance of allowing the complaints procedure to operate independently of clinical discussions. Patients must be able to raise concerns about services or individuals without fear of confrontation or of their criticisms affecting decisions regarding their ongoing 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 about the care and treatment her late mother (Mrs A) received at Gilbert Bain Hospital. Mrs A had widespread bladder cancer and she was admitted to the hospital because she was experiencing pain and discomfort. Medical staff decided it would be appropriate to try to insert a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). Ms C raised concerns that the decision to try to insert a urinary catheter was unreasonable; and that medical staff should have stopped the attempts sooner, as Mrs A was in pain and shouting for them to stop.

We took independent advice from a general surgeon. We found it was reasonable that medical staff tried to insert a urinary catheter. However, we found that the repeated and distressing attempts to do so were unreasonable. We considered that the first attempt to insert a urinary catheter should have been carried out by a more senior member of medical staff. We considered that Mrs A should have been given better pain relief/sedation before any further attempts were made. We also considered that medical staff had failed to recognise Mrs A's distress and to respond to her clear withdrawal of consent. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified. 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:

• Patients, at the end of their life, should only undergo invasive procedures and interventions if they will ease their distress or pain. When such procedures are carried out, it should be by medical staff with an appropriate level of expertise; with appropriate consent from the patient; and only after adequate pain relief has been administered.

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 care and treatment they received from A&E of St John's Hospital. C has a history of painful skin conditions requiring hospitalisation. C presented at A&E and was triaged by a nurse. The nurse carried out an assessment of C’s condition and discussed it with the a doctor. C was referred to the out-of-hours GP service. C said that they should have been examined by a doctor in light of their symptoms and previous history.

We took independent advice from a senior emergency nurse practitioner. We found that C’s medical history was considered and observations of their temperature, heart rate and blood oxygen were recorded. The notes did not contain details of the physical examination nor the discussion with the doctor. The out-of-hours GP that C was referred to did not refer them back to the doctor, as they could have done, if they thought the referral was not appropriate. We concluded that C had received a reasonable standard of care and treatment and did not uphold the complaint.

Summary

Following open surgery, Miss C’s abdomen was closed. Miss C was unhappy with the stitching of her abdomen as it had a ‘dog eared’ appearance at one end. Miss C considered that the stitching was inadequate and she should have been given corrective surgery. As the board did not consider that this was necessary at the time, Miss C proceeded to have private surgery to change the appearance of the scar.

We took independent advice form a plastic surgeon. We found that the closure of the surgical wound was achieved by an acceptable technique using appropriate materials. We found the stitching was of a reasonable standard. After several months, there was a small ‘dog ear’ at the end of the scar. We found that the scar was immature at this stage and that it was reasonable to state that it should be allowed to heal, rather than performing corrective surgery at that time. We did not uphold the complaint.

Summary

Mrs C, who has power of attorney for her mother (Mrs A) complained about the treatment provided to Mrs A at the eye clinic at Wishaw General Hospital. Mrs C had been referred from her optician with symptoms of distortion in her right eye which had been present for two months. An Optical Coherence Tomography diagnostic test (a non-invasive imaging test which uses light waves to take pictures of the retina) was performed and the result was subsequently reviewed by a consultant ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). The consultant reviewed the test results and phoned Mrs A to advise her that she had Age Related Macular Degeneration (ARMD, eye disease which can lead to severe loss of vision) and that due to previous scarring, injections would not improve the vision in her right eye. Mrs A’s obtained a second opinion privately. The private opinion was that Mrs A required an injection which would stabilise her condition. Mrs C complained that the consultant relayed the results of the diagnostic test over the phone to Mrs A without seeing her and that as a result she had to obtain a private opinion.

We took independent advice from an ophthalmologist. We found that it was reasonable that the consultant had diagnosed that Mrs A had advanced ARMD which was unlikely to improve with injections and that it was appropriate for the consultant to have called Mrs A with the result and to arrange a follow-up at the clinic. We did not uphold the complaint.

Summary

C complained about the care and treatment provided to them by the board when they presented with a suspected ectopic pregnancy (a pregnancy in which the fetus develops outside the uterus, typically in a fallopian tube). C’s main concern was that they were not scanned on arrival at the hospital as it was outwith scanning hours. C ultimately had surgery to remove the ectopic pregnancy and a fallopian (tubes along which eggs travel from the ovaries to the uterus). C was concerned that had a scan occurred at an earlier point, it may have resulted in a better outcome.

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 C was triaged and transferred within a reasonable timescale on arrival to the hospital and that their management was appropriate in the context of being seen outwith the working hours of the early pregnancy assessment scanning service. We did not uphold C’s complaint.

Summary

Mrs C, an advice and support worker, complained to the board on behalf of her client (Mr A) about treatment which Mr A received at Raigmore Hospital. Mr A was diagnosed with bowel cancer following a positive bowel screen and endoscopy. Mr A underwent surgery to remove the tumour. Initially, keyhole surgery was planned but during the procedure the surgeon was unable to locate the tumour and the operation was changed to full surgery. Mr A developed an infection in his abdomen following the surgery and had to be taken back to theatre. Mr A remained in hospital for a number of weeks and was subsequently discharged home with a stoma and wound bag. Mr A wished to know what went wrong with his care and treatment.

We took independent advice from a consultant surgeon. We found that there were no concerns about the standard of treatment which Mr A received. Initially, it was appropriate to consider keyhole surgery based on the scan results but when the surgery commenced it was noticed that the tumour was in a different position. It was then appropriate to proceed to open surgery, which was completed appropriately with no issues. However, Mr A subsequently developed an infection, which is recognised complication of surgery rather than an indication that the surgery was not performed appropriately. We did not uphold the complaint.

Summary

After injuring her finger, Mrs C was referred to the orthopaedic department. Her injury was reviewed on a number of occasions before being diagnosed as dislocated. A procedure was carried out to put the joint back into place. The pain in Mrs C’s finger did not improve, despite cast treatment and physiotherapy, so she was referred back to the orthopaedic department. After a further review, it became apparent that Mrs C had developed a complex regional pain syndrome (CRPS) in her right hand.

Mrs C complained to the board that there was an unreasonable delay in identifying that her finger was dislocated. She considered that the procedure to correct the dislocation should have happened sooner and, if it had, she would not have developed CRPS. She remained unhappy with the board’s response so brought her complaint to us.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there were a number of opportunities in Mrs C’s case for her dislocated finger to be identified earlier. We concluded that there was an unreasonable delay in reporting of the x-rays taken of her hand. We upheld Mrs C's complaint.

Recommendations

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

• The board should ensure timely reporting of images to avoid delays as identified in Mrs C’s case in future.

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 that the practice failed to provide his late wife (Mrs A) with reasonable care and treatment.

Mrs A had presented to the practice several times with severe back pain over a ten month period. Mrs A was told to self refer for physiotherapy. Mrs A subsequently went to A&E due to the pain she was suffering in her back. Mrs A was diagnosed with renal cancer which had spread to her spinal column and brain. Mrs A died from her illness.

We took independent advice from a GP and a nurse. We found that although the practice doctors had been involved in prescribing painkillers and muscle relaxants to Mrs A, her back pain management and treatment plan was effectively being managed by the physiotherapy service who are independent practitioners. It was reasonable for a GP to expect that if a physiotherapist was concerned about deteriorating or urgent clinical signs in a patient that they would arrange appropriate hospital assessment or a scan. Mrs A had at no stage when she saw the practice doctors presented with red flag signs (indicators that a more serious problem may be developing/underlying) to suggest cancer. As such, the care provided by the practice doctors was reasonable.

We found that with regard to Mrs A’s consultations with the advanced nurse practitioner, she had presented with potential red flag signs including unexplained weight loss. While Mrs A’s presenting symptoms were very atypical of renal cancer, it had not appeared that cancer had been considered given Mrs A had shown potential red flag symptoms and signs. We found that these red flag symptoms and signs had not been acted upon. Therefore, we upheld the complaint.

We acknowledged that the practice in their complaint response to Mrs A and to this office accepted there were failings by the practice. They said they had learnt from Mrs A's case and we acknowledged the action the practice had taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to identify that Mrs A had presented with red flag symptoms and signs for cancer at consultations with the Advanced Nurse Practitioner and to take appropriate action. 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:

• Relevant staff should be aware of the local and national guidelines on presentations with acute and chronic back pain and ensure they are up-to-date with current best local and national practice, including red flag presentations.

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 provided to their parent (A) while a patient at Glasgow Royal Infirmary. A was admitted with a large bowel obstruction. C complained about the delay in a stent procedure being carried out (a procedure where a small tube is inserted to keep a passageway open).

We took independent advice from a consultant colorectal (a surgeon who specialises in conditions in the colon, rectum or anus) and general surgeon. We found that there was an unreasonable delay in the stenting procedure being carried out and a combination of the delays and A’s deteriorating health, with rising C-reactive protein (CRP - an inflammatory marker) and National Early Warning Scores (NEWS a system that records key observations about the health of a patient with the higher the score the greater the clinical risk), was not reasonably responded to. When the stent procedure was delayed there was a lack of alertness to A’s deterioration and the management plan was not reviewed. We found that the board could have been better in assessing A’s fluid balance, noting their continued deterioration over a several day period, and attention to the worsening CRP. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their sibling for failing to provide reasonable treatment to A during their admission and for the inaccuracies in the complaint response. 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:

• Fluid balance recording and management in critically ill patients should be reasonably managed.
• The board staff should actively review trends in NEWS scores in critically ill patients.
• When management plans are in place and patients are awaiting treatment, there needs to be ongoing review of the management plan.
• Treatment for bowel obstruction should be appropriately prioritised in the board's hospital.
• Stenting in bowel obstructions should be appropriately prioritised, based on the clinical picture and have a limit of no longer than 48 hours from admission, when there is evidence of obstruction in an emergency setting.

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.