Health

Summary

C was admitted to University Hospital Monklands with abdominal pain, vomiting and an inability to pass urine. C was diagnosed with possible appendicitis (inflammation of the appendix) and was operated on the next day. C was discharged after surgery but was later readmitted and underwent further surgery. C complained they should have had their first operation sooner, given the pain they were in.

We took independent advice from a consultant in general and colorectal surgery (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C's first operation was carried out within an acceptable timeframe. We did not uphold this aspect of the complaint.

C complained their first operation was not carried out in a reasonable manner, as they experienced problems afterwards. C had suffered a recognised complication of the operation and we did not find failings in how C's first operation was carried out. We did not uphold this aspect of the complaint.

C also complained that they should not have been discharged home after their first operation, as they were still unwell. We found it was unreasonable that C was discharged home, as they had a raised temperature and inflammatory marker. We upheld this aspect of the complaint.

When C was readmitted to hospital for a further operation, C said that there was an unreasonable delay in carrying it out. We found there was an unreasonable delay giving C a scan, which caused a delay in carrying out their second operation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable discharge and the delay in carrying out the CT scan. 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:

• A CT scan should be carried out to aid diagnosis in patients with similar symptoms.
• Continuing post-operative symptoms of infection should be investigated before discharge in patients at higher risk of infective complications.

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 time taken by the practice to refer them to the breast clinic. C initially attended at the practice with pain in their breast, which was diagnosed as musculoskeletal pain. C later returned to the practice with ongoing pain and a new lump in their breast. The practice referred them urgently to the breast clinic and a scan found a large breast cancer.

We took independent advice from a GP and from a breast surgeon. We found that the treatment provided at the initial appointment was, for the most part, reasonable, and we did not find sufficient evidence to conclude that the practice missed the breast cancer in that appointment. However, we considered that the practice should have advised C, at their initial appointment, to return within three months (in keeping with guidelines). Ideally, the practice should also have sent the referral to the breast clinic as 'urgent – suspected cancer' rather than simply 'urgent', although we accepted that, on balance, this was not unreasonable. Based on the failings identified, we upheld C's complaint. We noted that the practice accepted both these points and considered the action taken was appropriate for reflection and learning .

Under section 16G of the SPSO Act, SPSO has a responsibility to monitor and promote good practice in complaint handling by organisations under our jurisdiction. We found that the practice failed to fully reflect on and learn from C's complaint until prompted by this office. We therefore made recommendations to address the failings we identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not advising them to return within three months, and for failing to fully reflect on their complaint until prompted by our investigation. 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 practice should be willing to reflect on and learn from complaints (without being prompted by an investigation from this office).

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 medical and nursing care and treatment given to their late parent (A) during their admission to Wishaw General Hospital. They also complained about the way staff behaved and communicated with the family and the way the board responded to their complaints. A was admitted to hospital suffering from breathing difficulties, after a chest infection. A was registered blind and had poor hearing and limited mobility. C was concerned about A's level of confusion, as well as a lack of personal care from nursing staff. Although C had power of attorney for A and had provided this to the board, they were not informed for a number of days that staff considered A lacked the mental capacity to make decisions about their treatment. C said that on one occasion they had overheard staff making derogatory remarks about C and A. Although C had felt that A was improving during their last visit, A was found dead early the following morning.

C complained to the board about A's care and treatment and met with medical and complaints staff twice. C was unhappy with the board's records of these meetings, as they had taken their own notes and they felt there were significant and substantial differences between the two. C felt that the board's complaint response was inaccurate and the findings inadequate. C told us they felt they had let A down and it was clear from C's submissions that the experience had been distressing for them.

We took independent advice from a consultant geriatrician and a nurse. In relation to A's medical care and treatment, we found that treatment of A's infection and the management of A's medication was appropriate. There was, however, a failure to monitor or assess A's delirium appropriately, and for this reason we found the medical care and treatment they had received fell below a reasonable standard. We upheld this aspect of C's complaint.

In relation to nursing care, we found that aspects of A's care had fallen below a reasonable standard, particularly the assessment of A's mobility and communication needs, and the response to A's repeated falls. We upheld this aspect of C's complaint. We noted that the board had already accepted there had been serious failings in nursing care and had taken steps to address these with individual staff, as well as an organisation.

Without independent witnesses, it is not possible for this office to determine what happened in relation to the alleged remarks made by staff. However, we considered that C's complaint in relation to this point was escalated and investigated appropriately. We did not uphold this aspect of C's complaint.

In relation to communication, we found that although some aspects of medical staff's communication with C was reasonable, overall there had been a failure to communicate with them about decisions relating to A's lack of capacity. Nursing staff's communication with C had also fallen below a reasonable standard. We upheld this aspect of C's complaint. However, appropriate action had been taken by the board to address those failings.

Finally, we found that the handling of C's complaint to the board had also fallen below a reasonable standard. We found that the board had not explained their approach clearly to C and although it was not unreasonable to attempt to resolve C's concerns by meeting with them, the board should have been clear with C what the process would be and they should also have provided C with a clear indication of the conclusions of those meetings, as well as when the complaints process was at an end. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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 should be assessed using current delirium screening tools.

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 was referred for orthotics and fitted with insoles. He attended a follow-up appointment with a private consultant as his symptoms were not improving and was diagnosed with anterior impingement syndrome (compression of the bone or soft tissue). After the consultation Mr C decided surgery was his preferred option. Mr C's GP subsequently referred him to the orthopaedics department (specialists in the treatment of diseases and injuries of the musculoskeletal system) at Hairmyres Hospital. His referral was refused as consultants considered that he was receiving appropriate first line care already. Mr C was unhappy with his treatment and told us that, had consultants acted on the report of the private consultant, he would have had surgery much earlier and his pain and suffering would not have gone on for so long.

We took independent medical advice from a clinical adviser who is experienced in orthopaedics. We found that Mr C was treated in accordance with guidelines and that conservative treatment was the appropriate response. It is not uncommon for medical professionals to have different views on treatment, but that the board's treatment following the GP's referral was appropriate. We did not uphold the complaint.

Summary

C, an advice and support worker, complained on behalf of their client (A) who had concerns about the treatment which A had received at Raigmore Hospital. A had a kidney stone and was operated on, which resulted in a ureteric stent (a thin tube structure allowing urine to drain into the bladder) being inserted. The stone remained in place and Levofloxacin (an antibiotic) was prescribed and A was discharged from hospital. A then began to suffer from leg pains, attended their GP and was readmitted to hospital after a few days with tendon issues. The stent and the kidney stones were removed and the antibiotic was stopped. A felt that the kidney stone should have been removed at the initial surgery and that Levofloxacin should not have been prescribed as this would have prevented their tendon issues which were as a result of a reaction to the Levofloxacin.

We took independent advice from a consultant urologist (a doctor specialising in the diagnoses and treatment of disorders of the kidneys, ureters, bladder, prostate and male reproductive organs). We found that A received an appropriate standard of care and treatment, but suffered a rare but recognised complication of antibiotic medication. We did not uphold the complaint although we highlighted as feedback that the board may wish to review their antimicrobial guidelines.

Summary

C was referred to the ear, nose and throat (ENT) service by their GP practice because they had been suffering from worsening headaches, balance problems and nausea. C was reviewed several times by the ENT service.

C later returned to the practice because their symptoms were not improving. A referral was made to a private healthcare provider for C to see a neurologist. An MRI scan was arranged and following that, C was diagnosed with a brain tumour.

C complained to the board. They felt that the ENT service had failed to adequately investigate their symptoms and, because of that, they failed to diagnose C's brain tumour. In response, the board confirmed it was felt that C was experiencing vestibular migraine (a nervous system problem that causes repeated dizziness), based on the symptoms. It was noted that a neurological examination was not performed at the initial examination, but was carried out at a subsequent review. The board accepted it would have been preferable to perform the neurological examination at the initial appointment, although in C's case it was unlikely to have led to an earlier diagnosis.

We took independent advice from a clinical adviser who is an ENT consultant. We found that the tumour was a rare find in what was a common presentation of vertigo and headaches. It was difficult to know whether or not there would have been any earlier cues to instigate the MRI scan. We noted information from C's first encounter with the ENT service was limited but, overall, the evidence available suggested that the initial diagnosis and treatment were reasonable.

We did not uphold the complaint.

Summary

C complained on behalf of their parent (A) about the care and treatment A received at Raigmore Hospital. C was concerned that A was told by the hospital, following a CT scan, that they had a brain tumour (and likely metastases due to their lung cancer) when it later became apparent after an MRI scan that A had a stroke rather than a brain tumour.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant in acute medicine. We found many aspects of A's care and treatment to be reasonable. However, the CT scan report stated there was uncertainty over a diagnosis of metastases and that an MRI scan should be carried out. Over a 24-hour period, a diagnostic momentum increased. This meant whilst there was uncertainty around this diagnosis it was not picked up by successive clinicians and the working diagnosis became more certain despite a confirmatory MRI having yet to be carried out. A and their family were led to believe by successive clinicians over a 7-day period that A had a brain tumour when this was not certain. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure of successive clinicians to pick up on the fact the CT brain scan was uncertain around the diagnosis of a metastasis which led them to convey to A and their relatives that it was definitive. 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 board should ensure CT scans commenting on diagnostic uncertainty should not be taken as definitive in their diagnostic conclusion.

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 board failed to follow relevant procedures for moving his mother-in-law (Mrs A) from a hospital in Scotland to a residential care home in England. We took independent advice from a social worker. We found that there are three contractual routes available and that the board entered into a Route 2 contract without giving Mr C a choice about the contractual route he wished to take. This was contrary to the guidance that was in place at the time of events and we upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to communicate reasonably with him about the process of moving Mrs A to a residential care home in England. We found that there was no clear communication with Mr C about the process for a cross-border placement, the contractual requirements, or transport arrangements. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to clearly communicate the process for a cross border placement, the contractual requirements, and transport arrangements and for entering into a Route 2 contract without giving him a choice about the contractual route he wished to take. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Consider whether it would be possible to offer Mr C other contractual options, including the Route 3 option.

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

• Individuals should be given relevant information about the different contractual arrangements, which they can fully understand and then act upon in accordance with the Guidance on Charging for Residential Accommodation (CCD2/2019).
• There should be clear communication with family members at the earliest opportunity about the process for a cross-border placement, the contractual requirements, and transport arrangements.

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 she received during childbirth from the board. Mrs C's baby was born by low cavity forceps delivery which required her to have her legs in supports. She found the process painful and traumatic and complained that staff failed to explore or act upon her pain. She also said that the orthopaedic (specialists in the musculoskeletal system) care she received after the birth was unreasonable and that she was not satisfied with the way the board investigated her complaint. The board said that as a result of her complaint they had learned not to make assumptions when a woman was very vocal during labour but that she had had anaesthetic to deal with pain. They also apologised for the lack of support she had received and for poor communication.

We took independent advice from a midwife and consultants in orthopaedics, and obstetrics (the medical specialism for pregnancy and childbirth) and gynaecology (medicine of the female genital tract and its disorders). We found that it had been reasonable to undertake a forceps delivery as Mrs C had been pushing for an hour without her baby being delivered. To assist this, Mrs C's legs had been placed in lithotomy (leg restraints). This was associated with symphysis pubic diastasis (the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture) in up to 25% of cases and Mrs C suffered this. While Mrs C said that she was crying out in pain as a consequence, the clinical records did not support this, therefore, we could not conclude that she was ignored. However, we noted that there was no mention of a pudendal block (local anaesthesia commonly used to relieve pain during the delivery of a baby by forceps) in Mrs C's records. On this basis, we considered that the board failed to explore or act upon the causes of Mrs C's pain and upheld this aspect of her complaint.

We found that Mrs C's orthopaedic care and management after the birth had been reasonable and did not uphold this aspect of her complaint. However, the board did not investigate Mrs C's complaint well and she experienced several months delay before receiving the boards response. This was too long and, accordingly, we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in responding to her complaint and for the lack of detail in her clinical records, in particular that there was no mention of a pudendal block. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All relevant documentation should be completed appropriately and as required. In line with Nursing and Midwifery Council/General Medical Council guidelines.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the board's formal complaints procedure.

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 they received at the Queen Elizabeth University Hospital. They were treated for sigmoid diverticulitis (colon disease) and were prescribed antibiotics and discharged home. C continued to suffer from abdominal pains and saw their GP, who referred them back to the hospital. C then underwent surgery to resolve their symptoms.

C felt that the surgery should have been performed on the initial admittance and that it was unreasonable to discharge them home on antibiotics.

We took independent advice from an appropriately qualified adviser. We found that in the initial admission it was appropriate to treat C with antibiotics rather than proceed to surgery, which could have left C with a permanent stoma (large intestine diverted through opening on abdomen to collect waste in bag or pouch). Additionally, when C was readmitted, it was also appropriate to administer antibiotics in the first instance and it was only when C's condition deteriorated that it was appropriate to proceed to surgery. We did not uphold the complaint.