Not upheld, no recommendations

Summary

C is a kidney transplant patient who was suffering from COVID-19 when they were admitted to hospital. C’s COVID-19 worsened and C developed blood clots in their lungs. C was treated with anti-coagulant medication. However, over time C developed a haematoma (a collection of blood) in their right arm and a large haematoma which caused permanent damage to nerves in C’s left thigh. C complained that staff had not been proactive enough in monitoring the effects of the anti-coagulant medication or in managing the blood clots and haematomas. C also complained that a referral to a neurologist should have taken place at the time and would have improved their long term prognosis.

The board explained that the effect of the anti-coagulant was not usually measured, but could be useful in patients with kidney disease. They had therefore monitored as required. Medication was changed due to concerns that the blood clots were getting worse and then stopped in light of the bleed into C’s thigh. A neurology referral was not made, as following discussion with surgical and radiological experts it was determined that supportive therapy was the most suitable management strategy for C’s case.

We took advice from a consultant haematologist and consultant neurologist. We found that C had both blood clots and significant bleeding. Both can be life-threatening, and treating one may make the other worse. We found that the monitoring and management of the anti-coagulant medication and the management of the haematomas and blood clots was reasonable and that it was reasonable not to refer to neurology and not to have considered femoral neuropathy. Therefore, we did not uphold the complaint.

Summary

C complained that the advice and treatment provided by the board following their positive COVID-19 test was unreasonable. C was a kidney transplant patient who tested positive for COVID-19 in early 2022. C said that they had contacted the renal unit who referred them on to the Covid Pathway (a central unit offering treatment advice and antiviral medication for high-risk patients). C received antiviral medication from a Covid Pathway nurse but was not referred to a renal clinician or advised to stop the immunosuppressant medication they were taking.

C later contacted the renal unit with concerns about diarrhoea. C was advised to stop the immunosuppressant over the weekend and was given advice on what to do if their condition worsened. C felt that they were given wrong advice about their medication and that their disease progression was more severe because of this.

The board advised that they had no record of C’s contact with the renal unit about COVID-19. Their first record was 11 days later, when they spoke to a renal nurse with concerns about diarrhoea.

We took independent advice from a pharmacist and a consultant nephrologist (specialist in the diagnosis, treatment, and management of kidney conditions). We found that if C had indeed phoned the renal unit initially, C should have been escalated to a clinician for medication advice. We were also critical that the nurse at the Covid Pathway had not sought advice from or referred C to the renal unit.

However, we noted that the immunosuppression medication was new and the situation was fluid at the time. We noted that improvements were made within two weeks, during which, guidance was published to ensure robust advice and treatment for COVID-19 positive, immunosuppressed patients and contact details for specialist clinical units were provided to the Covid Pathway. We also considered that the COVID-19 pandemic had since largely subsided.

We considered that the advice and treatment that C received was reasonable as we could not definitively say that C had initially contacted the renal unit, the situation was new and fluid, and improvements to the process had been appropriately and quickly made. Therefore, we did not uphold C's complaint.

Summary

C complained that the board failed to provide them with reasonable care and treatment in relation to their breast cancer care. C raised concerns that that the board failed to carry out necessary scans and failed to offer neoadjuvant chemotherapy (treatment given before the primary course of treatment to reduce the size of the tumour). C also complained about the waiting times in relation to surgeries and the mastectomy report; and that the board failed to adhere to the relevant local and national guidelines.

We took independent advice from a consultant breast surgeon. We found that the care and treatment provided to C was reasonable. In particular, we found that C did not meet the requirements to receive neoadjuvant chemotherapy prior to surgery and, accordingly, it was not unreasonable that the board did not perform further scans. We found that the waiting times were reasonable. We also found that the board’s medical team had followed relevant local and national guidelines and C had been provided with reasonable care and treatment based on the information available to the clinicians at the time. Therefore, we did not uphold C’s complaint.

In relation to complaint handling, we found that C was provided with updates on the progress of their investigation and the reason for the delay. However, C was not given a revised timescale for completion so we provided feedback to the board on this point.

Summary

C had a number of concerns about their child (A)’s behaviour, development, and educational attainment. A was referred to Child and Adolescent Mental Health Services (CAMHS) in the board. An assessment was carried out, the result of which was that A was not diagnosed with a neurodevelopmental condition.

C complained that the board had unreasonably discharged A from the CAMHS service after having determined that they did not have attention deficit hyperactivity disorder (ADHD), without sufficient consideration being given to other potential diagnoses, and that the board failed to provide reasonable support following the lack of a diagnosis.

We took independent advice from a psychologist specialising in CAMHS. We found that the while the board had ruled out ADHD, their assessment had also considered other neurodevelopmental conditions such as autism spectrum disorder (ASD) and intellectual disability (ID), as well as a broader consideration of A’s circumstances and early life experiences. It was evident that A did not meet the criteria for ongoing treatment via CAMHS and that that the board had carried out a sufficiently thorough and comprehensive assessment prior to discharging A. We also found that appropriate thought and consideration had been given to ensuring that A and C were engaged with the relevant agencies with respect to ongoing support being available, in particular through A’s schooling.

For these reasons, we found that the care and treatment provided to C and A had been reasonable and we did not uphold C’s complaints.

Summary

C complained about the care and treatment provided to their friend (A) when they were admitted to hospital. A was in hospital for around three and a half months after being admitted with weakness and reduced mobility, with a short history of dysuria (pain or discomfort when urinating) and urinary urgency. A died during their stay in hospital.

C complained about several aspects of the nursing care provided to A. In addition to this, they complained about the physiotherapy input provided to A. Finally, C complained about what they considered to be insufficient detail in A’s death certificate.

In respect of the nursing care provided to A, the board acknowledged that there was learning or areas for improvement. We took independent nursing advice. We found that the board provided A with a reasonable standard of care. We recognised that there was learning to take from A’s experience, however, we did not consider that the care provided unreasonable. Therefore, we did not uphold this complaint.

In respect of the physiotherapy provided to A, we took independent physiotherapy advice. We found that the physiotherapy input provided to A was reasonable, given the circumstances at the time. Therefore, we did not uphold this complaint.

Summary

C complained that the board failed to provide them with appropriate orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) care and treatment following a fall. The board operated on C’s left wrist the day after the fall. Two days later, they performed revision surgery on C’s wrist and operated on their left elbow. C said that they had been advised by an orthopaedic surgeon at the board that their initial wrist surgery had not been done correctly. C said they had developed nerve compression pain issues and would require further surgery.

We took independent advice from an orthopaedic consultant. We found that C’s initial wrist surgery was reasonable. However, the tilt of the radius was slightly beyond the normal range, which carried a minor increased risk of longer term functional impairment in the wrist. We considered that, if C had not required additional surgery for the elbow, the initial wrist fixation might have been left unchanged, as any potential long-term dysfunction could still have been treated later if necessary. However, given that C was already scheduled for elbow surgery, the decision to proceed with revision surgery on the wrist was considered reasonable. We also noted that key indicators related to pain were appropriately assessed in C’s case, and there was no indication that the surgery had been performed in a manner likely to cause excessive pain. Therefore, we did not uphold C’s complaint.

Summary

C complained about communication from the council's social work department relating to C’s involvement in the Looked After Child (LAC) review process. C held parental rights and responsibilities for their child. C raised concerns about not being invited to attend a review meeting and not receiving a legible copy of a relevant report in advance of the meeting. In their response to the complaint, the council explained a watermark was incorrectly applied in the wrong font colour and apologised for this error.

We found that C was reasonably informed of the arrangements for the LAC review meeting and how they could contribute to it. In the month prior to the review meeting, the council’s Independent Reviewing Officer (IRO) contacted C. The role of an IRO is to work autonomously to manage and chair LAC reviews for children who are looked after and accommodated by the council. The IRO told C by email that there would be no option for C to attend the LAC review meeting, and C could submit their views via a proforma. C received a copy of the relevant report prior to the review meeting.

We found that the council had reasonably acknowledged, apologised for and rectified the error of the incorrectly applied watermark. Overall, we found that the provision of the relevant report, proforma that invited C’s views and email correspondence demonstrated that the council intentionally communicated with C in line with their responsibilities to seek the views of C as a person holding parental rights and responsibilities, in line with the relevant legislation and the council’s procedure. On this basis, we did not uphold this complaint.

Summary

C complained about the care and treatment provided to their spouse (A). A had been diagnosed with lung cancer and were due to start treatment. A had become unwell overnight and attended the A&E twice in 24 hours. At the first attendance A had been examined but sent home. A’s condition had worsened, and they had been taken back to the A&E by paramedics. A had been examined and then admitted to hospital but died shortly after.

C believed that A’s first assessment was inadequate, and that their concerns about pneumonia were dismissed unreasonably. They felt strongly that had A been given antibiotics and admitted, they might have had a better outcome. C believed that on A’s second attendance, A’s cancer specialists should have been contacted sooner.

We took independent advice from an emergency medicine adviser. We found that A’s assessments were reasonable and that it was unlikely that the outcome would have been different had A been prescribed antibiotics or admitted sooner. We did not uphold the complaint.

Summary

The complainant (C) had a right top hip replacement. Some years later, C began to experience back pain and left ankle pain for which they attended physiotherapists and podiatrists. C told us that two years after their hip replacement, a podiatrist identified that C had a leg length discrepancy. C complained that they now have a leg length discrepancy of approximately 17 mm which they considered to be unacceptable.

The board said that leg length discrepancy is a recognised risk following hip replacement surgery. This was confirmed on a form signed by C prior to the procedure.

We took independent advice from a consultant orthopaedic surgeon. We found that the risk of leg length discrepancy was reasonably discussed before the procedure and that the true discrepancy was 5mm which was reasonable. We noted that the operation was carried out to a reasonable standard.

As such, we found that the care and treatment provided by the board was reasonable and we did not uphold the complaint.

Summary

C complained on behalf of their spouse (A). A was taken into hospital with COVID-19 and low blood sugar and was discharged after two days. That night C was concerned that A’s condition had deteriorated. A was taken to ICU and died 4 days later. The cause of death was recorded as COVID-19, ketoacidosis (where a lack of insulin causes harmful substances called ketones to build up in the blood) and renal failure. C considered that A had been discharged inappropriately in the first instance.

The board explained that A was frail. They came into hospital with chest pains from COVID-19 and were checked for pulmonary embolism. A was discharged appropriately but unfortunately deteriorated rapidly at home. Every effort was made to treat A on readmission.

We took independent advice from a consultant physician, specialising in acute medicine. We found that A had a poor state of health prior to admission, that their discharge on the first occasion was reasonable and that there was no way the discharging team could have predicted A’s subsequent deterioration. Upon A’s second admission, medical teams and intensive care teams provided a reasonable standard of management and care. Overall, we considered that the care and treatment had been reasonable and that there was no requirement for a Severe Adverse Event Review or Duty of Candour to be initiated. Therefore, we did not uphold the complaints.