Summary
Ms C complained about the care and treatment she received when she presented to the Neurology Department (the Department) at Aberdeen Royal Infirmary following a referral from an out-of-hours GP. Two days following her first presentation to the Department, Ms C was diagnosed with cauda equina syndrome (a rare and serious neurological condition that affects the bundle of nerves (cauda equina) at the base of the spine). Ms C raised concern that there had been a delay in carrying out an MRI scan and, following this, performing surgery for her condition. Ms C felt that if her condition had been diagnosed and treated sooner, her chance of making a more complete recovery would have increased.
We took independent advice from a consultant neurosurgeon, which we accepted.
We found that there was an unreasonable delay in providing Ms C with appropriate treatment. We noted that, under the clinical guidance in place at the time, the Board should have carried out an emergency MRI scan and then performed emergency surgery during Ms C's first admission. We considered that it was unreasonable that Ms C did not receive an MRI scan and surgery until she returned to the Department two days later. We concluded that, if the surgery had been carried out when it should have been, then it is more likely that Ms C would have maintained better urological and sexual function. However, we were unable to say that Ms C would have recovered to normal function. We also found failings with the documentation of the assessments carried out in the Department during both admissions and we were unable to conclude that the assessments were reasonable.
Ms C was also dissatisfied with the Board's response to her complaint. We found that the Board's response had referred to a timescale for providing surgery that was not relevant in this case. We considered that the Board should have considered their response more carefully and referred to relevant guidelines. We considered that the Board failed to establish all of the facts relevant to the points Ms C raised. We concluded that the Board's response to Ms C's complaint was unreasonable.
We upheld Ms C's two complaints and made a number of recommendations to address the issues identified. The Board have accepted these recommendations and we will follow-up on these recommendations. The Board are asked to inform us of the steps that have been taken to implement these recommendations by the dates specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm the recommendations have been implemented.
Redress and Recommendations
The Ombudsman's recommendations are set out below:
What we are asking the Board to do for Ms C:
|
Complaint number |
What we found |
What the organisation should do |
Evidence SPSO needs to check that this has happened and the deadline |
|---|---|---|---|
|
(a) and (b) |
There was an unreasonable delay in performing an MRI scan and carrying out surgical treatment on Ms C There was a failure to adequately document Ms C's medical assessments on 14 and 16 June 2017 The Board's response to Ms C's complaint failed to establish all of the facts relevant to the points Ms C raised and was unreasonable |
Apologise to Ms C for the unreasonable delay in providing her with treatment and the impact this has had upon her, the failure to adequately document medical assessments and for failing to respond to her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance |
A copy or record of the apology By: 20 June 2018 |
We are asking the Board to improve the way they do things:
|
Complaint number |
What we found |
What should change |
Evidence SPSO needs to check that this has happened and deadline |
|---|---|---|---|
|
(a) |
There was an unreasonable delay in performing an MRI scan and carrying out surgical treatment on Ms C |
Neurology, Neurosurgery, Neuroradiology staff should be aware of current pathways and guidelines for the management of patients with cauda equina syndrome Patients with suspected cauda equina syndrome should receive an emergency MRI scan |
Evidence that the cauda equina pathway and guidance in place has been shared with staff who assess and investigate emergency neurosurgery admissions Evidence that the Board, when assessing the proposal to increase access to weekend MRI scanning, have taken into account the recognised standards in place for access to emergency MRI. The Board should provide me with reasons for their decision to take action (or not do so) in relation to this matter By: 15 August 2018 |
|
(a) |
There was no documentation of the neurological assessments carried out on 14 and 16 January 2017, nor the discussion between the Registrar and the Neurosurgeon |
Assessments of patients, referral conversations and conclusions should be fully documented in their medical records |
Evidence that SPSO's findings on this complaint have been fed back in a supportive manner to the staff involved in Ms C's care and that they have reflected on the Adviser's comments. (For instance, a copy of a meeting note or summary of a discussion) By: 20 June 2018 |
|
(b) |
The Board failed to establish all of the facts relevant to the points Ms C raised and it was not apparent that relevant standards and guidance were considered | In line with the NHS Scotland Complaints Handling Procedure, complaints investigation should establish all the facts relevant to the points made in the complaint and give the person making the complaint a full, objective and proportionate response that represents the Board's final position |
Evidence that SPSO's findings on this complaint have been fed back in a supportive manner to the staff involved in investigating and handling Ms C's complaint. (For instance, a copy of a meeting note or summary of a discussion) By: 20 June 2018 |
Feedback
Response to SPSO investigation
The Board should ensure that all relevant evidence is provided to my office when this is first requested. In this case, the Board's failure to do this contributed to delays in the investigation.
Points to note on best practice
In view of the record-keeping and complaints handling issues identified, the Board should consider sharing this report more widely with staff in other services to highlight the importance of these matters.