Health

Summary

Mr C made a number of complaints to us about care and treatment he had received after he attended the Royal Alexandra Hospital with back pain. He was subsequently diagnosed with metastatic prostate cancer. He was transferred to the Beatson West of Scotland Cancer Centre and was given radiotherapy (a treatment using high-energy radiation). Mr C considered that the primary treatment at that time should have been surgical.

We took independent advice on the complaints from an emergency medicine consultant, an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system), a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) and a neurosurgery consultant (a specialist in the diagnosis and treatment of disorders of the nervous system, especially the brain and spinal cord).

Firstly, Mr C complained that there was a delay in carrying out an MRI scan. We found that he should have had an MRI scan within 24 hours, but there was a delay in carrying this out. We upheld this complaint.

Mr C also complained that when he attended A&E at the Royal Alexandra Hospital, he was inappropriately referred to the orthopaedics team. We found that it had been reasonable to refer him to the orthopaedics team and we did not uphold this complaint.

Mr C complained that there had been a failure to communicate effectively and to discuss the result of the MRI scan with the neurosurgery team. We did not find any failings in relation to this and we did not uphold the complaint.

Mr C complained that he was unreasonably given radiotherapy without consent being obtained for this appropriately. We found that it had been appropriate to give him radiotherapy at that time, given his deteriorating neurological symptom. We did not find any failings in relation to this matter and we did not uphold the complaint.

Mr C also complained that staff failed to communicate reasonably with him. We found that staff had not met his needs in relation to communication and upheld this complaint. However, we noted that the board had acknowledged and apologised for this failing.

Mr C complained that medical staff failed to adequately communicate to nursing staff that he should have been given Clexane (medication that helps to reduce the risk of blood clots) before an operation. We found that it was unreasonable that medical staff failed to communicate this adequately and upheld this complaint. The board said that they had already taken action in relation this complaint and we asked them for evidence of this.

Finally, Mr C complained that there was an unreasonable delay in deciding that surgery should be carried out after the MRI scan was reviewed by a spinal surgeon. We found that the timescale was reasonable and did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in carrying out an MRI 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:

• The board should consider developing a standardised pathway for the management of Malignant Spinal Cord compression based on NICE Guidance and including access to urgent MRI scans within 24 hours. This should also take bank holidays into account.

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, who has diabetes, damaged their foot. C was diagnosed with a broken 4th metatarsal (one of the long bones in the foot). A scan was taken and C was seen at a fracture clinic. C was unhappy with the assessment and the lack of further scans at the fracture clinic appointment.

We took independent advice from an orthopaedic surgeon (a medical expert who treats patients with problems in their muscles, bones, joints and other related structures). We found that, due to C's diabetes, C had a high risk of developing a delayed or non-union of the fracture and that this was not recognised by the doctor. Scans should have been taken at the clinic appointment to monitor healing and C was unreasonably discharged before the fracture was healed. Therefore, we upheld this aspect of the complaint.

C also complained about the management of their diabetes while they were awaiting surgery on their foot. We took independent advice from a nurse. We found that the management of C's diabetes was reasonable. C had a libre device which monitored their blood sugar levels. While the documentation of the management of C's diabetes should have been clearer, it was reasonable for C to continue to monitor their blood sugar levels on the ward and report the results to staff. We did not uphold this aspect of C's complaint.

Lastly, C complained that there was an unreasonable delay in their surgery being carried out. We found that the initial surgery was delayed due to equipment being unavailable. The surgery was a planned procedure and therefore the equipment should have been ordered prior to the day of surgery. When C's surgery was rescheduled, C was unreasonably placed on the trauma list when they should have been placed on the urgent planned list, where there would have been less likelihood C's surgery would be cancelled. 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 as identified in the appointment and for the delay in carrying out surgery. 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:

• Diabetic fracture healing should be appropriately assessed.
• Ordering/procurement systems are in place to ensure necessary equipment is available in advance of operations.
• Surgery should be scheduled on the appropriate list.

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

Following lower back surgery, Mr C complained about pain in his mid-back which had not been there before. Further reviews of Mr C's symptoms were carried out by the orthopaedic (conditions involving the musculoskeletal system) department and the pain clinic but the cause of his pain, and the pain itself, was not resolved. Mr C considers that his original surgery was not carried out properly and that something went wrong to cause his pain.

The board confirmed that Mr C's original surgery was carried out to alleviate leg pain. They said guidelines stated that surgeons should not operate for back pain alone and confirmed that further surgery in Mr C's case was unlikely to help. The board explained that Mr C had been reviewed by a different orthopaedic consultant, and a second opinion had been sought from a consultant in another board area, both of whom agreed that further surgery would not help the symptoms of pain in Mr C's back.

We took independent advice from an orthopaedic consultant. We found reasonable history and examinations of Mr C were carried out and that appropriate scans and referrals were made. We concluded that the board provided appropriate treatment in view of Mr C's presenting symptoms. We did not uphold Mr C's complaint.

Summary

Ms C, an advocacy worker, complained on behalf of her client (Ms A) about the care and treatment provided to Ms A's late mother (Mrs B) by the practice following a home visit by a doctor from the out-of-hours (OOH) service. Mrs B was later admitted to hospital where she died.

We took independent advice from a GP. We found that there was no indication, based on the report from the OOH doctor, for the practice to arrange an emergency home visit to Mrs B or that the OOH doctor had requested the practice carry out a home visit. There was also no evidence to suggest that Mrs B was deteriorating in the days following the visit of the OOH doctor.

We found that the subsequent sudden deterioration in Mrs B's condition could not have been foreseen and the care provided by the practice following the visit from the OOH doctor, and the plan to visit Mrs B as a routine house visit, was reasonable and consistent with good medical practice.

Therefore, we did not uphold the complaint.

Summary

Ms C complained about both the health visitor and hospital care provided to her child (Child A) in the context of child protection safeguarding. Ms C felt that there had been a lack of action taken by the health visitor when she reported Child A had ongoing diarrhoea and had a hard and bloated stomach. Ms C was also concerned that child protection procedures should not have been instigated and that the process was not properly communicated to her or reasonably followed in terms of the alleged facial markings on Child A.

In responding to the complaint, the board considered that the actions and care provided by staff were appropriate in terms of Ms C's complaints.

We took independent advice from a registered health visitor and from a consultant paediatrician.

In terms of the care provided by the health visitor, we considered that the care provided to Child A was appropriate and that it was correct to instigate child protection proceedings. However, we upheld this complaint on the basis that there was a failure to either reasonably communicate the decision about instigating child protection proceedings to Ms C or to record the decision not to communicate this to her.

We found that the care provided by the hospital was reasonable, therefore, we did not uphold this complaint on the basis that child protection procedures were appropriately followed.

However, we were critical of the board's original complaint response to Ms C as it provided limited detail of their complaints investigation in relation to the actions of the health visitor.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for not following the National Guidance for Child Protection in Scotland. 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 document that they have either communicated the decision to instigate child protection procedures to the family or to record the decision not to do so, in line with the National Guidance for Child Protection in Scotland.

In relation to complaints handling, we recommended:

• Complaint responses should address the issues raised, in line with the Model Complaints Handling 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

Miss C complained about the care and treatment provided to her child (Child A) by the board. Child A was born by caesarean section. When Child A was older, they experienced a seizure and a scan showed right-sided ventricular enlargement (when the muscle on the right side of the heart becomes thickened and enlarged) and associated white matter loss, indicating brain damage or brain injury.

Miss C had concerns about how the brain damage occurred, when it occurred, and the delay in identifying this. She said that her view was that the board had caused the brain injury when Child A was born. She also complained that Child A had not received a brain scan earlier despite developmental difficulties.

We took independent advice from a paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there was no indication in the medical records of any events which were likely to have caused brain injury in Child A during birth or during the neonatal period. We also found that Child A's early developmental course did not suggest the need for a scan and there did not appear to have been any delay in diagnosing the brain injury. We did not uphold Miss C's complaint.

However, we noted during our investigation that there were failings in the board's handling of Miss C's complaint in relation to updating Miss C, not responding to her questions, failing to refer to SPSO, and failing to acknowledge correspondence in a timely manner. Therefore, we made a recommendation to the board in light of this under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

In relation to complaints handling, we recommended:

• Complaints should be handled in line with Model Complaint Handling Procedures.

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 underwent a polypectomy (a procedure used to remove polyps from the inside of the colon). C said that they informed staff prior to the procedure that they had a platelet disorder (platelets are the cells responsible for making blood clot. A platelet disorders mean that injured blood vessels bleed more than usual and heal more slowly), however, no precautions were taken prior to the polypectomy being carried out. C later experienced bleeding. C complained that the board unreasonably managed their care in relation to their history of a platelet disorder and failed to reasonably manage their care after they were admitted with bleeding.

We took independent medical advice. We found that clinicians undertook a pre-assessment with C. While C had a history of experiencing bleeding as a child, a more recent operation had not resulted in significant bleeding. We found that it was reasonable that no further tests were carried out prior to the procedure being undertaken, as there was full blood count and clotting information available to clinicians which would have highlighted any long standing problem with the number of platelets if there were any. We did not uphold this aspect of the complaint.

We found the board's management of C in the acute situation was adequate and carried out in a reasonable timescale. There was no indication a specific platelet or clotting factor transfusion was required. We did not uphold this aspect of C's complaint.

Summary

C complained that the board had unreasonably stopped their medication in prison. We took advice on the complaint from a medical adviser. The medication had been stopped after a check had been carried out and it had been found that some of C's medication was missing. We found that it had been reasonable to stop the medication and that the care provided to C had been reasonable. Medical staff had acknowledged C's mental health conditions and had directed them to engage with the mental health team. We did not uphold the complaint.

Summary

Ms C complained to us about the care and treatment provided to her father (Mr A) before his death from suicide. Mr A was admitted to Forth Valley Royal Hospital after expressing suicidal thoughts. He was discharged on the following day. Ms C complained that it was unreasonable to discharge Mr A at that time.

We took independent advice from a psychiatric adviser. We found that there was no evidence that Mr A had been adequately assessed and we upheld the complaint that he was discharged unreasonably.

Mr A returned to the hospital on the day he was discharged and asked to be readmitted. However, it was decided that he would not be readmitted. Ms C complained that this decision was unreasonable. We found that it was unreasonable that the nursing staff did not consult a doctor and carry out an assessment when Mr A returned to the hospital. We also upheld this complaint.

Ms C complained that Mr A's medical records were inadequate. We found that there were failings in relation to describing the assessment of risk, the clinical rationale for the management of Mr A, discharge planning, changes in his mental state and information available from his family. We upheld this complaint.

Finally, Ms C complained that the board had delayed in completing a significant adverse event review. The board had accepted that there were delays in this and had apologised for this. We upheld this complaint.

We were satisfied, however, that the board had taken reasonable and appropriate action to try to prevent all of these failings recurring. They had also apologised to the family for most of the failings, although we recommended that they issue a further apology for the delay in completing the significant adverse event review.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in completing asignificant adverse event review. The apology should meet the standards set out in the SPSO guidelines onapology 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 submitted a complaint on behalf of their child (A) about the treatment provided by the board in relation to A's eating disorder. C said that A had been diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID), however, in subsequent contact this term was not used by board staff.

We took independent advice from a consultant psychiatrist who had experience working with people with eating disorders. We found that the board had provided reasonable treatment to A. It was recognised that A would benefit from intensive input and the board offered an individualised approach to treatment. The board set out a clear rationale for the proposed treatment that was appropriate for A's identified needs. While there was inconsistency in using the term ARFID to describe A's diagnosis this did not impact on the treatment offered to A. Therefore, we did not uphold C's complaint.

While we did not uphold this complaint, we have made recommendations to the board for failing to explain the varying use of ARFID in the complaint response. We have made these recommendations under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable explanation regarding the varying use of the term ARFID when responding to their complaint. The apology should meet thestandards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• The board's complaints responses should provide reasonable explanations of the actions taken/terms used as necessary to respond to a complaint.

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.