Health

Summary

Mr C complained about the care and treatment he received during two admissions at Royal Infirmary of Edinburgh. During our consideration of Mr C's complaint, we received independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and a registered nurse.

During Mr C's first admission, he was diagnosed with appendicitis and received surgery to remove his appendix. Mr C was unhappy that his appendix was not fully removed during the procedure. We found that the initial assessment and treatment were appropriate and timely. We noted that whilst part of Mr C's appendix was not removed, this was a rare but recognised complication of the surgery. We did not conclude that there was an unreasonable failing by staff that resulted in this complication. We were also satisfied that Mr C's discharge from the ward was reasonable. We did not uphold this complaint.

During Mr C's second admission, he was diagnosed with stump appendicitis (recurrent inflammation of the residual appendix after the appendix has been only partially removed during surgery). Further surgery was performed to remove the residual appendix tissue. Following the procedure, Mr C's recovery was complicated by infection. We found that the second procedure had been carried out to a very high standard. We considered that the post-operative care was reasonable and we noted that there were appropriate arrangements made for wound care in the community following Mr C's discharge. We did not uphold this complaint.

Summary

Mr C complained on behalf of his wife (Mrs A) about the care and treatment she received at Western General Hospital. Mrs A was admitted to the surgical assessment unit in the evening with a serious bowel condition. She experienced severe pain in the overnight period whilst she waited to receive surgery. The following morning surgery was successfully performed. Mrs A remained critically unwell for a number of weeks following the procedure.

In response to Mr C's complaint, the board acknowledged that better care could have been provided overnight and the operation should have been performed sooner. Mr C remained concerned about what happened and brought his complaint to us.

We took independent advice from a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques) and a registered nurse. We identified a number of issues with the care and treatment provided to Mrs A in the overnight period. In particular, we found that the CT scan performed was not reported accurately as it failed to mention the radiological evidence of mesenteric ischemia (a serious condition involving sudden interruption of the blood supply to a segment of the small intestine). We also found that the medical review and nursing monitoring in the period under consideration were unreasonable, and we noted issues with record-keeping.

We also found that nursing and medical staff had failed to escalate matters to senior medical staff when this would have been appropriate. Finally, and in line with the board's findings, we found that there was an unreasonable delay in transferring Mrs A to theatre for emergency surgery. We considered that earlier surgery would not have impacted on the extent of surgery required, but might have mitigated the severity of Mrs A's critical illness. We upheld Mr C's complaint and made a number of recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A and her family for the failings in CT reporting; failings in medical review; failings in nursing record-keeping; and failure to escalate the deterioration. 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:

• CT imaging should be accurately reported. Arrangements for supervision of on-call radiology registrars should conform to Royal College of Radiologists guidelines. The service should be satisfied that they have minimised the contribution of any systems deficiencies to radiological error.
• Nursing records should be maintained in line with the standards required by the Nursing and Midwifery Council Code.
• Nursing staff should have appropriate expertise and confidence in identifying deteriorating patients and escalating concerns to medical staff.
• Surgical staff should be alert to a patient's clinical condition and respond promptly to contact from medical colleagues.
• Where there is a risk that patient safety may be compromised, prompt action should be taken to escalate the matter to appropriate senior staff.
• The board should have an appropriate pathway in place for emergency laparotomy care.

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 advice and support worker, complained on behalf of her client (Mr A) regarding the decision by a psychiatrist to change Mr A's antidepressant medication. Mr A felt that the change in medication had resulted in him suffering agitation and insomnia and that he had to approach his GP to have the dosage of medication altered.

We took independent medical advice from a psychiatric consultant. We found that it was reasonable from a clinical perspective for the psychiatrist to change the medication. If a patient remains on a particular medication for a prolonged period this can lead to a lack of symptomatic relief. It is accepted practice to gradually reduce the dosage of the previous medication while at the same time gradually increase the dosage of the new medication in an effort to prevent withdrawal symptoms. We did not uphold the complaint.

Summary

Mrs C, an advocate, complained on behalf of her client (Ms A) about the care and treatment they received from the board. Ms A was seen by an ophthalmologist (a specialist in medical and surgical eye problems) and complained that they did not carry out an appropriate assessment and did not record their observation that the discs at the back of her eyes were enlarged. Ms A also complained that her discharge was inappropriately handled and that a mix up regarding her blood test results caused a delay to her discharge.

The board advised that it was determined by the ophthalmologist that no further follow-up was required. The board acknowledged that there was confusion about how long Ms A had to wait following a procedure before she could be discharged and that her blood test results had been misread.

We took independent advice from a consultant ophthalmologist and from a consultant physician. We found that the ophthalmologist's assessment was reasonable and that the swelling identified at the back of Ms A's eyes did not require to be acted upon. We did not uphold this aspect of the complaint. With regards to Ms A's discharge, while we noted that there was a mix up regarding Ms A's blood test results, we considered that the board acted in the best interest of the patient, in light of the information available to them at the time, and it was therefore appropriate to require Ms A to remain in hospital for one further night for observation. Therefore, we did not uphold this aspect of the complaint.

Summary

Ms C complained on behalf of her in-law (Mr B) about the care and treatment provided to his wife (Mrs A). Mrs A was diagnosed with breast cancer and a full computerised tomography (CT) scan was carried out. The CT scan of Mrs A's chest, abdomen and pelvis showed liver and bony metastases (the development of secondary malignant growths) at a distance from a primary site of cancer. The head scan showed a 6mm lesion of uncertain significance on the left frontal lobe of Mrs A's brain. The consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer) involved in Mrs A's care advised her of the liver and bony metastases. However, they did not share the results of the head scan. Following this, the board's records indicate that the results of this scan were not shared with Mrs A by the consultant oncologist, the clinical nurse specialist (CNS) involved in her care, or any other member of staff.

Ms C complained that the board had unreasonably failed to disclose information about the lesion on Mrs A's brain. We took independent advice from an oncology adviser. We found that it was unreasonable for the board not to disclose this information to Mrs A. The board had advised that the medical professionals involved did not disclose this information to avoid causing further anxiety or upset to Mrs A. Even if the board had good intentions, we considered the evidence to strongly indicate that this was not a reasonable course of action to take and, under the circumstances, was not a medical professional's choice to make. This evidence included the General Medical Council's (GMC) guidance Good Medical Practice and Consent: Patients and Doctors Making Decisions Together. We concluded that it was not reasonable for information about the head scan not to be shared with Mrs A. Therefore, we upheld this aspect of the complaint.

Ms C also complained that, following the head scan, the board unreasonably failed to provide appropriate treatment to Mrs A or manage her condition appropriately. We found that, overall, Mrs A received a good quality of care and treatment. However, we noted that it would have been reasonable for a Magnetic Resonance Imaging (MRI) scan to be carried out, in line with the recommendations of the consultant radiologist (a specialist in the analysis of images of the body). This would have resulted in clearer information about the lesion on Mrs A's brain and identify whether there were other smaller lesions. Further MRI or CT scanning would also have helped identify whether brain radiotherapy would have been an appropriate or effective form of treatment.

We found that the evidence suggested that further scanning would not have extended Mrs A's life but may have made some difference to her treatment. We concluded that, by not carrying out further MRI or CT scans, the board failed to provide appropriate treatment to Mrs A or manage her condition appropriately. Therefore, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to both Ms C and Mr B for the failings my investigation identified. 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 be aware of the circumstances in which it is acceptable to withhold information from a patient.
• The board should reflect on their position on disclosing information to patients, as detailed in their response to my enquiries.

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 reported experiencing unpleasant side effects when taking methadone (a drug used medically as a heroin substitute) and felt the prison health centre unreasonably dismissed his symptoms. Mr C also complained that the board would not ask for a second opinion from someone outwith the health centre.

The board explained that clinical and nursing staff felt the symptoms reported by Mr C were likely caused by opiates, rather than methadone. It was noted that Mr C did not accept that position, but the board explained medications were prescribed based on evidence that indicated their effectiveness whilst remaining mindful of guidelines in place. The board told Mr C that methadone was considered the best option available for those with opiate misuse.

We took advice from an independent clinical adviser. We found that the board had appropriately considered Mr C's concerns about the side effects of methadone. We considered that the board had explained their position reasonably to Mr C and their actions were in line with good practice guidance. We also found that the steps taken by the board in having another doctor from the health centre review the matter was in line with good medical practice.

We concluded that the board responded reasonably to Mr C's reports of unpleasant side effects from methadone and dealt with Mr C's request for a second opinion reasonably. Therefore, we did not uphold the complaints.

Summary

Mrs C complained on behalf of Mr B about the care and treatment provided to Mr B's late wife (Mrs A). Mrs A had an underlying heart condition and her medication had to be carefully balanced to avoid kidney damage. Mrs A saw her GP about problems with bowel function and her deteriorating general condition. The GP referred her to the colorectal (relating to or affecting the colon and rectum) clinic. Blood tests taken around the same time showed her kidneys were deteriorating and she was referred for an urgent renal (relating to the kidneys) appointment.

During her colorectal consultation, Mrs A was offered various investigations but a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) and colonoscopy (examination of the bowel with a camera on a flexible tube) both involved some kidney risk, so she wished to wait for her renal appointment before making a decision. She received a renal appointment four months after her GP appointment and was admitted the following day for further tests including a CT scan performed without contrast (contract material is a dye used to help highlight areas of the body being examined) as this was safer for her kidneys. Around a month after admission for tests, stage 4 cancer was found in bowel, stomach and lungs, which Mrs A was advised had been present for months. A decision had been taken to downgrade Mrs A's renal referral without seeing her, and without informing her GP. Mrs C complained that this decision was unreasonable.

The board confirmed that Mrs A's urgent renal referral was downgraded without her being seen, based on the likelihood that her renal dysfunction was a composite of her heart disease and medication. As her blood test results were relatively stable the board had considered there was no need for an urgent referral. The board apologised that the GP had not been informed. We took independent advice from a nephrology (the branch of medicine that deals with the physiology and diseased of the kidney) adviser. We found the downgrading of the referral to be reasonable under the circumstances. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board unreasonably failed to offer Mrs A a CT scan without contrast at an earlier stage. We took independent advice from a colorectal adviser. We found that although this could have been offered, the consultant responsible reasonably balanced consideration of establishing a diagnosis and of investigating only should her symptoms recur, given the severity of her underlying disease. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained that the communication between specialisms involved in Mrs A's care and treatment was unreasonable. We found that the decision to downgrade the renal referral was not conveyed to Mrs A's GP or her cardiac consultant and that Mrs A's cardiac consultant had delayed in informing her about the availability of the advanced heart failure specialist nurse. We also found that communication between medical staff had not been copied to the Mrs A, noting that if this had done, the perceived lack of communication could have been avoided. Overall, we found that the board's systems were reasonable, in that all Mrs A's records were available to those involved in her care. However, we upheld this aspect of Mrs C's complaint on the basis that the board had accepted errors and delays.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B for the failings in communication, with a recognition of the cumulative impact of these failings on Mrs A's treatment experience. The apology should acknowledge the impact of these failings on Mrs A and her family. The apology should meet the standards set out in the SPSO guidelines on apology 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

Miss C complained about the care and treatment provided to her late mother (Mrs A) prior to her death. Mrs A was admitted to Hairmyres Hospital after having a fall and developing chest pain. Miss C had a power of attorney (POA, a legal document appointing someone to act or make decisions for another person) in respect of her mother.

Miss C complained that the POA was not appropriately taken into account; communication in relation to Mrs A's deterioration was unreasonable; and the nursing care and treatment provided to Mrs A was unreasonable.

The board in response to the complaint carried out a local review of Mrs A's care and also held a debrief action plan meeting, following the local review.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that the POA was respected and there was no indication it was disregarded.

In relation to communication concerning Mrs A's deterioration, the clinical records showed that medical staff engaged with Miss C frequently to discuss Mrs A's condition, symptoms and how these were being managed. There was also evidence of frequent and detailed discussions between Miss C and clinical staff at the point at which Mrs A's condition began to deteriorate. We, therefore, found that communication was of a reasonable standard.

Miss C raised a number of issues with regards to Mrs A's nursing care. Our investigation confirmed that the shortcomings identified within the local review would not have had an impact upon Mrs A's condition and subsequent deterioration. Whilst we recognised the board had apologised for a number of aspects of Mrs A's nursing care, overall, we considered that Mrs A received care of a reasonable standard. We considered that the local review and work carried out by the board was thorough and showed Miss C's complaint was taken seriously.

As a result, we did not uphold Miss C's complaints.

Summary

Mrs C complained about the care and treatment she received at University Hospital Monklands where she had surgery to remove her gallbladder. Mrs C said that she developed a number of unpleasant symptoms following the surgery and, despite seeking treatment for these from the board, including attendance at the hospital's emergency department, they remained unresolved.

We took independent medical advice on the complaint from a consultant general surgeon and a consultant in emergency medicine. In her complaint, Mrs C said that the consent process followed by the board did not include reasonable information about the consequences of gallbladder removal. We found that the symptoms Mrs C experienced were not recognised as complications directly related to her gallbladder surgery and were, therefore, not discussed with her prior to her surgery. We found that efforts were made to ensure that reasonable explanations were given to Mrs C on the risks and benefits of her surgery and her consent form listed the risks of the surgery. We did not uphold this aspect of the complaint.

Mrs C said that the care and treatment provided to her in the emergency department was unreasonable. We found that the treatment Mrs C received was reasonable and there was no reason to admit her to hospital at that time. While we note that the time that Mrs C waited to be seen was slightly outwith the triage timescales, we did not identify this as a failing or evidence of unreasonable care. Therefore, we did not uphold this aspect of the complaint.

Mrs C also complained that the follow-up surgical care and treatment was unreasonable. We found that once Mrs C made the board aware that she was experiencing significant symptoms following her surgery, and given her anxiety issues, they should have offered her an early out-patient appointment within a few weeks. It would also have been reasonable to have arranged to see her in clinic to discuss her endoscopy and biopsy results and options open to her at that time. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to offer her an early out-patient appointment after she reported she was experiencing significant symptoms following her surgery; and failing to arrange to see her in clinic to discuss her endoscopy and biopsy results and options open to her at that time. 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:

• In cases such as this, the board should arrange to see patients in clinic to discuss their test results.
• In cases such as this, the board should offer patients out-patient appointments within a reasonable time.

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 complained about the treatment her husband (Mr A) received during his admission to Wishaw General Hospital. Mr A was admitted with abdominal pain and a temperature and was discharged the same day with a principal diagnosis of gastritis (inflammation of the lining of the stomach). Mr A latter suffered a ruptured appendix and damaged bowel which required emergency surgery. Mrs C complained that if Mr A had received the correct diagnosis in his initial admission, with reasonable investigations carried out, the rupture could have been avoided.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that the treatment provided to Mr A was unreasonable. Insufficient notice was taken of Mr A's raised temperature, white cell count and CRP (inflammatory marker) as objective evidence together with lower abdominal pain. We considered that appendicitis should have been considered as a possible diagnosis. We also found that Mr A was discharged too early without a second examination and on discharge the wrong diagnosis was recorded and advice on what to do next was unclear. We upheld this aspect of Mrs C's complaint.

Mrs C also complained about the board's response to her complaint. Mrs C raised a number of questions about the treatment Mr A received. The board explained the actions taken and why they considered this was reasonable.

We sought advice about the accuracy of the board's response in terms of Mr A's presentation and treatment. We found that the board failed to provide a reasonable response to Mrs C's complaint. While the board responded to the questions Mrs C raised, the medical records did not evidence the board's outline of the treatment provided, including that appendicitis was considered in Mr A's initial admission and the advice provided when discharging Mr A. We also 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 provide a reasonable complaint response.
• Apologise to Mr A for failing to provide reasonable treatment to him. The apologies should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets .

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

• Documentation, including discharge summaries, needs to be clear, including who saw, when and what.
• Formal discharge summaries should be completed in a timely manner.
• Learning should be taken from the complaint and reflected upon in a morbidity review to highlight the importance of high index of suspicion of appendicitis in young adults with abnormal tests and atypical history.
• Relevant staff should be reminded of the importance of difficult cases being re-assessed by more senior clinicians.

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.