Decision Report 201607409

Summary

Miss C complained on behalf of her brother (Mr A) about the care and treatment provided to him across numerous admissions to Aberdeen Royal Infirmary. Mr A underwent various surgeries to treat spinal cord compression and a spinal abscess. After surgery to drain the spinal abscess, Mr A was left paralysed from his waist down and was left with only partial movement in his upper body.

Miss C complained to the board as she felt that Mr A had not been properly cared for and treated. She believed that opportunities were lost to treat him sooner, and that his outcome may have been different if these opportunities had been taken. The board responded, however Miss C remained unhappy and brought her complaints to us.

Miss C complained that the board did not provide reasonable treatment to Mr A across his numerous admissions to the hospital. We took independent advice from consultants in radiology and neurosurgery, and from a nurse. We found that there was an opportunity missed to drain the spinal abscess. Had the abscess been drained at that time we considered that Mr A's outcome may have been different. We found that a scan that was carried out by an outsourced company out-of-hours did not meet a satisfactory standard, however this was not identified as having impacted Mr A's outcome. We also found that Mr A's case could have been considered in a more holistic way. We upheld this aspect of Miss C's complaint.

In relation to Mr A's discharge home from hospital, Miss C complained that he was unreasonably discharged on one occasion, and that the board unreasonably failed to ensure that there was a suitable home care package in place for him following that discharge. We found no evidence to suggest that Mr A was discharged unreasonably. We found that the relevant paperwork had been completed, and that Mr A had capacity and was in agreement with the decision to discharge him at that time. We also found that there was no evidence of a need for Mr A to have a home care package in place on his discharge home. We therefore did not uphold these aspects of Miss C's complaint.

Miss C also complained that the board did not respond reasonably to her complaints. We found that the board delayed in providing a response to Miss C's complaints and that she was not kept updated. We upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not draining his abscess at an earlier time and for the lack of a holistic approach to his care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Miss C for the failure to provide a timely response to her complaint and for failing to reasonably update her. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• In circumstances similar to those of Mr A, consideration should be given to draining any abscess. The decision should be fully documented and care should be considered holistically.
• All outsourced advice on scans should reach the same standards as those provided in-house.

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.