Health

Summary

C complained that the care and treatment they received at Borders General Hospital was unreasonable, including that they should not have been admitted; that they were not advised of the side effects of their medication; and that staff did not adequately explain what the medication was to treat.

We took independent advice from an adviser qualified in psychiatry. We found that it was appropriate for C to be admitted to hospital for assessment and treatment. While we found that there was no evidence of a specific discussion with C regarding the potential side-effects of their medication, we considered that the board's acknowledgement and apology for this in their letter to C to be a reasonable response. We found that, overall, there was good evidence of engagement and dialogue with C regarding their treatment plan and medication, and that the board's prescribing and administering of medication was reasonable. As a result, we did not uphold the complaint.

Summary

Mrs C was listed for a procedure to decompress a nerve in her foot. This procedure was agreed by a consultant but they resigned so Mrs C was transferred to another consultant (consultant 2) whose preferred treatment was non-surgical. Mrs C expressed concern at the treatment proposed for her so she met with a third consultant (consultant 3). It was agreed that she would be listed for surgery. Mrs C understood the procedure would involve removal of a bone spur (bony lumps that grow on the bones of the spine or around the joints) along with decompression of the deep peroneal nerve (a nerve that runs from the leg to the top of the foot). After surgery, Mrs C became aware that the procedure carried out by consultant 3 involved only the removal of the bone spur. Mrs C complained that the board unreasonably changed the original treatment plan agreed for her and that they inappropriately failed to carry out the procedure she consented to. She also complained that the board unreasonably failed to arrange a follow-up appointment with a different consultant.

We took advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that consultant 2's preferred treatment was reasonable although we did note that pre-operative investigation was limited with no apparent x-rays being arranged until Mrs C was seen by consultant 3. We found that consultants can have differing opinions in relation to proposed treatment and therefore, it was reasonable to change the original treatment plan for Mrs C given her care was transferred between different consultants. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to consent for the surgery, we found that the consent form signed by Mrs C and the letter issued by consultant 3 confirming the proposed surgery did not match the surgery she received. It may have been the case that removing the bone spur released pressure on the nerve anyway but this should have been explained clearly to Mrs C. We found that whilst the procedure may have been clinically appropriate, the communication surrounding the procedure was unclear and inconsistent so we upheld this aspect of the complaint.

In relation to arranging a follow-up appointment for Mrs C with a different consultant, we saw evidence that Mrs C had clearly communicated that she was unhappy with the response provided to her complaint and she asked that her follow-up appointments be with someone else other than consultant 3. We saw evidence that consultant 3 wrote to Mrs C offering to facilitate her receiving an opinion from someone else. Mrs C said she did not receive that letter. The board told Mrs C that because she did not have an open referral, she should return to her GP to discuss further treatment options.

We found that it would have been reasonable for the board, as part of its handling of Mrs C's complaint, to offer her the opportunity to meet with a different consultant. Doing so would have demonstrated a willingness to try to better understand and resolve Mrs C's ongoing concerns about her surgery. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to clearly and consistently communicate with her in relation to her surgery and for not offering her the opportunity to meet with a different orthopaedic consultant as part of their final complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Clearly communicate to Mrs C details of the surgery including the procedure consented to and the procedure actually carried out detailing whether that involved decompression of the deep peroneal nerve.
• Consider offering Mrs C the opportunity to meet with an orthopaedic consultant to discuss her concerns about the surgery.

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, an advocacy worker, complained on behalf of her client (Mr A) about the treatment he received following a cataract operation (a surgical procedure to replace the eye lens with an artificial one). During the surgery a complication occurred whereby the lens unfolded in an unusual fashion. Mr A underwent a number of other procedures and is concerned that these may have been unnecessary had his concerns about his eyes been listened to. The board accepted that a complication occurred during the cataract surgery, however, they consider it was managed appropriately. The board consider Mr A was kept informed of his clinical condition as it evolved.

We took independent advice from a consultant ophthalmologist (a clinician who treats disorders and diseases of the eye). We found that Mr A suffered a recognised complication during the cataract surgery and there is no evidence to suggest that his post-operative symptoms were not managed appropriately. However, we did consider that there was an unreasonable delay in performing the second surgery to repair the complication. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the unreasonable delay in dealing with the complication that occurred, which caused Mr A unnecessary and prolonged pain and discomfort. 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:

• All surgeons who perform cataract surgery for the board should know how to deal effectively with the complications of posterior capsular rupture during cataract surgery efficiently and promptly.

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, an advocate, made a complaint on behalf of her client (Ms B). Mrs C complained about the care and treatment provided to Ms B's late partner (Mr A). Mr A had attended Ayr University Hospital after rupturing his patella tendon. He underwent surgical repair of his ruptured patella tendon and was discharged home the following day. Over the next few weeks, there was delay and a lack of clarity over how Mr A was to access follow-up care and treatment. His GP informed him that they had not received a copy of the discharge letter in the post and Mr A did not know who was to arrange a follow-up appointment at his local orthopaedic (specialism in the treatment of disease and injury of the musculoskeletal system) department, which was located in a different NHS Board area from the hospital where he received surgery.

These matters were resolved after discussion with the orthopaedic consultant who treated Mr A. However, Mr A suddenly became very unwell some days after his surgery and died following a cardiac arrest. The cause of Mr A's death was later recorded as a pulmonary embolism (a condition when a blood clot breaks off and ends up blocking a blood vessel in a person's lungs), resulting from deep vein thrombosis (a condition that happens when a blood clot forms in a deep vein, usually in the leg) in his calf.

Mrs C complained that Mr A had not been prescribed with chemical thromboprophylaxis (drugs to prevent thrombosis) on discharge and that his discharge was not handled reasonably or appropriately. In particular, she complained that he was discharged without an appropriate post-operative medical review, and that there was a delay in the hospital issuing the discharge letter and arranging an appointment with Mr A's local orthopaedic department.

The board acknowledged that there was a failure to follow the instructions of the orthopaedic consultant who had operated on Mr A and outlined what steps they intended to take to prevent this happening again. However, they concluded that the choice to discharge Mr A without recommending or prescribing chemical thromboprophylaxis was acceptable.

We took independent advice from an orthopaedic consultant. We found that, given Mr A's individual circumstances, the relevant guidance supported chemical thromboprophylaxis being prescribed to him on discharge. Therefore, we upheld this aspect of the complaint. However, we agreed with the board's position that there was no strong evidence to suggest chemical thromboprophylaxis would have prevented Mr A's pulmonary embolism.

In respect of Mr A's discharge from hospital, we found that patients who live outwith the board area should be given two copies of their immediate discharge letter, one for their own records and one to pass onto their GP. The board were unable to say whether this happened in this case. We concluded that it was likely that the board's policy on providing immediate discharge letters to people who live outwith the area was not followed on this occasion.

The board were also unable to confirm whether Mr A was provided with instructions about how to arrange a follow-up appointment with his local orthopaedic department or whether this was to be arranged by the orthopaedic department. We noted that, once the orthopaedic consultant who carried out the surgery became aware of this uncertainty, they appear to have acted promptly to resolve this. However, we considered that the lack of clarity prior to this to be a failing on the part of the board.

We considered whether it was appropriate for Mr A to be discharged without a review by the orthopaedic consultant. We confirmed that it is normal practice for a patient to be reviewed by a health care professional prior to discharge, and that a nurse-led discharge is commonplace in Scotland. Therefore, we considered it reasonable for Mr A to be discharged without being reviewed by a consultant.

Overall, we concluded that Mr A's discharge from hospital was not carried out in a reasonable and appropriate manner. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to provide Mr A with chemical thromboprophylaxis and discharge him reasonably and appropriately. 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 from outwith the health board area should be discharged in line with the existing policy and provided with two copies of their discharge letter. Patients should be made aware whether on-going appointments are to be arranged by the discharging department or by the patient and their GP.
• Staff should be aware of when it is appropriate to utilise chemical thromboprophylaxis after surgery of this type.

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 attended hospital for a coronary angiogram (a test to find out if a person has any problems with the blood vessels that supply the heart muscle with oxygen and how well the pumping chambers and valves in the heart are working).

Following the procedure, Mrs C was left feeling pain in her right leg and described her right foot as feeling frozen. A procedure was carried out to try and alleviate Mrs C's symptoms but she felt no improvement. Mrs C complained that the angiogram was not carried out to an appropriate standard. In responding to Mrs C's complaint, the board apologised but explained that she appeared to have suffered known complications of the procedure.

We took independent advice from a consultant cardiologist (a specialist that deals with diseases and abnormalities of the heart). We found that Mrs C's procedure was carried out to an appropriate standard. Therefore, we did not uphold the complaint.

Summary

Mr C complained that his pain medication had been stopped and said that he suffered significant pain as a result.

We took independent advice from a GP. We found that the decision to stop Mr C's pain medication was reasonable and he was reasonably followed up with, and offered appropriate alternatives, for his pain. Therefore, we did not uphold Mr C's complaint.

Summary

Miss C was referred by her GP to a health board in Scotland for gender reassignment. However, although she was assessed as being eligible and referred to the board's gender identity clinic, she is still waiting for some treatment including surgery. Miss C said that the delay in treatment has had an adverse effect on her mental health, which has been exacerbated by the failure to keep her informed about the delays in a reasonable way.

We considered the relevant Scottish Government protocol, which requires health boards to ensure their gender reassignment service is provided in an effective way and within a reasonable time. We also considered the evidence from Miss C's clinical records about her contact with the clinic. We found that the board do not yet have a functioning gender reassignment pathway. We recognised the continuing difficulties the board experienced in providing some aspects of their gender reassignment service and noted the steps they had taken to re-establish this and address the remaining gaps identified. Even so, the board are still not in a position to provide a full gender reassignment service, which has a far-reaching impact on transgender patients.

In relation to communication, we found that the standard of communication between staff and Miss C and her family was unreasonable and noted it was likely the impact of delays on transgender patients would be compounded by any communication failings. In addition to staff failing to respond at all to communication, there was a failure to be open and transparent about the difficulties the board had in providing a gender reassignment service. We upheld the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in this investigation and acknowledge the impact that this has had on her. 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:

• Carry out an equality impact assessment when all the relevant services are established and provide a copy to this office.
• Finalise an action/improvement plan of the board's activities underway to establish a functioning gender reassignment pathway and provide a copy to this office.
• Review the current arrangements for communication and implement any changes identified to ensure the board meets the requirements of the protocol and the needs of transgender patients.
• Review the psychological support offered to patients accessing the board's gender reassignment service to ensure it is adequate in light of the potential impact delays and gaps in the service will have on patients.

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 about the way NHS 24 managed a number of phone calls which he made to them reporting that he felt that he had something stuck in his throat. Mr C said that NHS 24 staff had initially referred him to the out-of-hours service where he spoke to a GP and was given advice to drink fizzy drinks. Mr C then contacted NHS 24 again as the problem had not resolved and subsequently an ambulance was despatched to take him to hospital. Mr C felt that NHS 24 staff failed to take his concerns seriously.

We took independent professional advice from an experienced nurse. We found that NHS 24 staff had recorded Mr C's symptoms appropriately and that his breathing was not compromised and initially made a referral that Mr C should be assessed by an out-of-hours service GP. When Mr C made further contact as his condition had not resolved, he stated that he felt he was choking and therefore arrangements were made for an ambulance to attend. We found that it was appropriate for NHS 24 staff to have referred Mr C to the other organisations in view of his symptoms reported during the telephone calls. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided to him by the hospital when he had been admitted for a biopsy (a tissue sample taken for testing) and insertion of chest drain (a flexible plastic tube is inserted through the chest wall and into the affected area to drain it of fluid). He complained that pain relief had been inappropriate and caused urinary blockage; that there had been a failure to make a referral to his local hospital for urinary issues; and that his relatives had been informed there was a crash in his blood pressure, but that this was then denied.

We took independent advice from a surgeon. We found that the referral to Mr C's local urinary team was made appropriately and there was no evidence that Mr C had a blood pressure crash. However, we found that there were failures in Mr C's care and treatment in relation to the management of his pain; his pain was not assessed regularly and in line with the pain assessment chart, and the pain relief that was given was not adequate for Mr C's needs and was not in line with the British National Formulary on prescribing. We also found that management and monitoring of Mr C's urinary output and retention was unreasonable. We therefore upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failures in relation to the management of his pain, and management and monitoring of his urinary output and urinary retention. 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:

• Medication given for pain relief should be adequate for the patient's needs and in line with the British National Formulary on prescribing.
• Pain levels should be assessed in line with the general pain assessment chart.
• Urinary output should be monitored closely after surgery and staff should be alert to the possibility of urinary retention.

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's complained about the care and treatment provided by the board to her husband (Mr A) over several of years, in a number of respects. Mrs C said that this had an adverse effect on the care provided to Mr A and, as a result, his mental health had suffered.

We took independent advice from an adviser who specialises in psychiatry. We found that the standard of care and provision of treatment was reasonable in all respects and we did not uphold this aspect of the complaint.

Mrs C was also concerned about the way the board had handled her complaint. We found that the board's complaint response reflected the findings of their investigation and was reasonable. Therefore, we did not uphold this aspect of Mrs C's complaint.