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Health

  • Case ref:
    201808400
  • Date:
    March 2020
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Ms C complained to us about the care and treatment she received at University Hospital Ayr. Ms C underwent total hip replacement surgery (a surgical procedure where a damaged hip joint is replaced with an artificial one) on both hips. Ms C raised concerns that the risks of each surgery were not communicated appropriately to her; there were failings in carrying them out, which caused her to experience pain and mobility issues; and her post-surgical care was unreasonable.

We took independent advice from a medical adviser who is a consultant orthopaedic and trauma surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). For both surgeries, we found no evidence of failings in carrying them out. We found that Ms C experienced recognised complications of total hip replacement surgery. We also found that Ms C's post-surgical care was reasonable. However, we found that there was no evidence Ms C was appropriately informed of the risks involved in each surgery during the consent process. Therefore, we upheld Ms C's complaints.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Ms C for the failings identified in the surgical consent process for both hip surgeries. 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:

  • The consent process should follow national guidelines. Consent should be taken, where possible, prior to the day of surgery. As part of the consent process, there should be a clear discussion of the risks and benefits (of having the surgery and not having the surgery) and of any alternative treatment options; and those discussions should be clearly documented

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.

Related reading

  • Case ref:
    201805705
  • Date:
    March 2020
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the aftercare and treatment provided to him following his knee surgery. Mr C underwent a full knee replacement and following the surgery he experienced difficulty with bending and positioning his knee, as well as extreme pain. Despite completing physiotherapy, hydrotherapy and intense exercises, the problem did not resolve.

The board acknowledged a rare complication had occurred following Mr C's surgery, however, they consider that there was no undue delay in addressing the stiffness in Mr C's knee and that it was dealt with in a reasonable timescale.

We took independent advice from a consultant orthopaedic surgeon (a medical expert who treats patients with problems in their muscles, bones, joints and other related structures). We found that the aftercare was provided promptly and that there was no unreasonable delay. The board were not provided the opportunity to carry out further investigations or treatment as Mr C chose to seek private treatment. The board acted reasonably by offering a second opinion, however the offer was declined. We did not uphold the complaint.

Related reading

  • Case ref:
    201803462
  • Date:
    March 2020
  • Body:
    A Dentist in the Ayrshire and Arran NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about a dentist's failed attempts to restore his broken tooth with a white composite filling. The filling fell out a week later and was replaced but unfortunately it failed again and fell out two days later. The option of fitting a crown was discussed but Mr C did not consider that he should have to contribute to the cost of this. He subsequently changed dentist and requested that the cost of subsequent treatment under the new dentist was reimbursed. We took independent advice from a dentist. We found that the treatment provided in attempting to restore Mr C's broken tooth was reasonable and in line with standard clinical practice. The dentist had no obligation to contribute to the cost of any treatment Mr C received from his new dentist. Therefore, we did not uphold the complaint.

Mr C also complained about concurrent root canal treatment he was undergoing on a different tooth. This was carried out over several visits and, at the second visit, the dentist temporarily restored the tooth and booked Mr C a further appointment. However, Mr C reported that the tooth broke around four hours later when he was eating soft food. We found that the treatment provided was reasonable and in line with normal clinical practice. There was no evidence to support Mr C's concerns that failings in his treatment contributed to the tooth breaking a few hours later, and did not consider that the quality of this treatment should be associated with the subsequent extraction of the tooth by the new dentist. We did not uphold the complaint.

Related reading

  • Case ref:
    201803008
  • Date:
    March 2020
  • Body:
    Ayrshire and Arran NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment he received from Ayr Hospital in relation to surgery he underwent for penile deviation (curvature of the penis). Mr C was dissatisfied with aspects of the medical and nursing care. Following surgery, he developed a haematoma and infection. In addition, the end result of the surgery was unsatisfactory for him.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs) and a registered nurse.

We found no evidence that the surgery was of an unreasonable standard. However, we found that informed consent for the surgery undertaken was not properly obtained from Mr C, in line with the General Medical Council's (GMC) guidance on consent. We considered that the medical care Mr C received was unreasonable and upheld this aspect of his complaint.

In terms of the nursing care, we identified failings in that there was a lack of record-keeping to show that Mr C's wound was regularly checked and assessed with the appropriate dressings applied. In addition, in terms of his discharge from hospital, there was no evidence to show that Mr C was given information about caring for his wound at home or that he was supplied with sufficient dressings. We considered that these aspects were unreasonable and upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for failing to obtain informed consent from him and for the nursing care failings in relation to wound care, record-keeping, and discharge information. 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:

  • The consent process should follow GMC guidelines.
  • Patients should be provided with appropriate information as part of discharge planning and document that this should be documented.
  • Patients should receive appropriate wound dressings in line with the wound dressing formulary.
  • Post-operative patients should have their wound checked and this should be recorded on each occasion.

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.

Related reading

  • Report no:
    201805020
  • Date:
    February 2020
  • Body:
    Tayside NHS Board
  • Sector:
    Health

Summary

Mrs C complained to me about the care and treatment that her mother (Mrs A) received from Tayside NHS Board (the Board). In May 2017, Mrs A was diagnosed with renal cell carcinoma (a type of kidney cancer) and she was referred for kidney surgery to treat it. Following her kidney surgery in August 2017, Mrs A developed excess fluid around her lungs and an infection; and her condition continued to worsen. In late September 2017, Mrs A was discharged home for end of life care and she died the next day. 

Mrs C complained that the Board failed to provide Mrs A with reasonable clinical care and treatment in relation to her kidney surgery. We took independent advice from a consultant urologist (a clinician who treats disorders of the urinary system). We found that the decision to refer Mrs A for kidney surgery was unreasonable. We found there was a low risk the renal cell carcinoma would harm Mrs A; and she was at exceptionally high-risk from kidney surgery.

Mrs C also complained that the Board failed to give Mrs A reasonable care and treatment in response to her worsening condition after her kidney surgery. We found there was an unreasonable delay in recognising Mrs A had a haemothorax (a collection of blood in the lung cavity) but it was then treated appropriately.

Mrs C raised concerns that the Board failed to provide Mrs A with reasonable nursing care. We took independent nursing advice. We found a number of failings in Mrs A's nursing care in relation to the prevention of pressure ulcers (an injury to the skin and underlying tissue, usually caused by prolonged pressure), diabetes management and nutritional care.

Mrs C complained about Mrs A being discharged home for end of life care without appropriate pain relief. We found Mrs A was not prescribed enough hours of pain relief medication; and she should have been given a syringe driver (a machine that delivers continuous pain relief medication), as otherwise a carer would have had to give her hourly injections. 

Mrs C raised concerns about the Board's communication with Mrs A and her family about her condition and treatment. The Board acknowledged inadequacies in their communication; and we found that their communication was unreasonable overall. We found that the Board had appropriately apologised to Mrs C for this and we asked them to provide us with evidence of the action they had taken to address this.

We upheld all aspects of Mrs C's complaint. We made a number of recommendations to address the issues identified. The Board have accepted the recommendations and will act on them accordingly. 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 date specified. We will expect evidence (including supporting documentation) that appropriate action has been taken before we can confirm that 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 Mrs C:

Complaint number

What we found

What the organisation should do

What we need to see
(a) (b) (c) and (d) 
  • The decision to refer Mrs A for kidney surgery was unreasonable and there was a failure to evidence a robust multi-disciplinary team meeting (MDT) outcome and consent process; 
  • There was an unreasonable delay in diagnosing and treating Mrs A's haemothorax; 
  • There were failings in Mrs A's nursing care; and 
  • Mrs A was discharged home without appropriate pain relief 

Apologise to Mrs A's family for the failings in her medical and nursing care.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance 

A copy or record of the apology.

By:  19 March 2020

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The decision to refer Mrs A for kidney surgery was unreasonable

 In similar circumstances, full consideration should be given to non-surgical treatment options for patients with renal cell carcinoma, in accordance with the relevant guidance

Evidence that these findings have been fed back to the relevant staff and managers in a supportive manner that encourages learning (e.g. a record of a meeting with staff; or feedback given at one-to-one sessions).

By: 20 April 2020
(a) The urology MDT outcome; and the discussion and/or record-keeping was inadequate
  • All potential treatment options should be discussed by urology MDTs and then clearly recorded to facilitate proper engagement with the patient.
  • Urology MDTs should provide and record an expert opinion on patient management and treatment

Evidence that the Board's urology MDT approach ensures MDT meetings are appropriately recorded and an expert opinion on management and treatment is given.

 

By: 20 April 2020
(a) The consent process for Mrs A's kidney surgery was unreasonable. There was a failure to discuss and record the risks of Mrs A not having kidney surgery, as well as the non-surgical treatment options

Patients should be fully advised of:

  • the risks relating to both having and not having surgery, and
  • any non-surgical treatment options.

Those discussions should then be
clearly recorded as part of the
consent process

Evidence that this has been fed back to relevant medical staff in a supportive manner that encourages learning.

The SPSO thematic report on informed consent may assist in encouraging learning for staff in this area: http://www.valuingcomplaints.
org.uk/spso-thematic-reports

By: 20 April 2020
(b) There were unreasonable failings in diagnosing and treating Mrs A's haemothorax Patients should be given timely comprehensive assessments and an appropriate diagnosis

Evidence that this case has been used as a learning tool for relevant medical staff, in a supportive way that encourages learning, to help ensure that an appropriate and timely diagnosis is reached in cases such as this

By: 19 May 2020
(c) There were a number of failings in the nursing care provided to Mrs A in relation to pressure ulcer prevention Patients should receive nursing care to prevent and manage pressure ulcers in line with relevant standards and the Board's own guidance

Evidence that the Board have reviewed the training needs
of nursing staff in relation to the diagnosis, grading, prevention and management of pressure ulcers.

By: 19 May 2020
(c) There were a number of failings in the nursing care provided to Mrs A in relation to managing her diabetes Patients should receive nursing care in relation to managing their diabetes in line with relevant standards and the Board's own guidance

A copy of an improvement plan to address the issues
identified, which details any training, practice development or other intervention planned.

By: 19 May 2020
(c) There were a number of failings in the nursing care provided to Mrs A in relation to nutritional care Patients should receive adequate nutritional assessment and care planning in accordance with relevant standards

A copy of an improvement plan to address the issues identified, which details any training, practice development or other intervention planned.

 

By: 19 May 2020
(d) Mrs A was discharged home for end of life care with insufficient pain relief medication Patients discharged home for end of life care should be given sufficient and appropriate pain relief medication with clear instructions on how it is to be administered and by whom
  • Evidence that appropriate guidance/protocols are in place for palliative pain relief; and
  • Evidence that the findings on this complaint have been fed back to relevant medical staff in a supportive manner that encourages learning.

 

By: 20 April 2020

We are asking the Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(a) (b) (c) and (d)

The Board's own complaints investigation did not identify or address all of the failings in Mrs A's medical and nursing care

The Board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified; and that learning from complaints is used to drive service development and improvement

Evidence that the Board have reviewed why its own investigation into the complaint did not identify or acknowledge all the failings highlighted here and what learning they identified and what changes (if any) they will make.

By: 19 May 2020

The Board told us they had already taken action to fix the problem. We will ask them for evidence that this has happened.

Complaint number What we found Outcome needed What we need to see
(c)

The Board acknowledged there were times when Mrs A's bed table was left out of reach

The Board said they had discussed the need to ensure that bed tables are left within easy reach of patients with relevant nursing staff

Evidence that this was discussed with relevant nursing staff and whether any changes will be made as a result.

By: 20 April 2020
(e) The Board acknowledged their communication with Mrs A's family about her condition and treatment was unreasonable The Board confirmed that they had shared learning with relevant staff

Evidence that the learning was shared with relevant staff.

By: 20 April 2020

Related reading

  • Report no:
    201803897
  • Date:
    January 2020
  • Body:
    Fife NHS Board
  • Sector:
    Health

Summary

Mrs C complained about the care and treatment her mother (Mrs A) received at Victoria Hospital.  Mrs A was admitted to hospital with a suspected infection in her leg, but died shortly afterwards.  Mrs C said that the Board gave contradictory and incomplete replies to her questions about Mrs A's treatment.  In particular, Mrs C believed that Mrs A's existing longstanding health condition, medications and associated immunosuppression had not been properly taken into account during her treatment.  Mrs C was also concerned that medical staff did not communicate reasonably with the family during Mrs A's admission, which meant Mrs A's death had been unexpected and traumatic.  Mrs C noted that the Board had failed to respond comprehensively to the questions she had asked, despite multiple meetings with staff, and a protracted correspondence.  Finally, Mrs C said that Mrs A's death certificate contained errors, and that the Board had not made an adequate effort to correct these. 

We took independent medical advice from a consultant in acute medicine.  We found that there were significant failings on the part of the Board.  The advice noted that there was no record that the most significant drugs Mrs A was receiving were identified by medical staff or taken into account in her treatment.  In addition, although Mrs A had received initial treatment with antibiotics, this had been stopped and there was no detail or reasoning for this recorded in Mrs A's medical records.  Following Mrs A death, the Board did not appear to have properly followed its own procedures for reviewing incidents where a patient had come to harm.  We considered that Mrs A did not receive a reasonable standard of care and treatment and upheld this aspect of Mrs C's complaint. 

We also found that the Board had failed to take reasonable steps to ensure Mrs A's death certificate was accurate.  This included a failure to attempt to correct the death certificate.  We upheld this aspect of Mrs C's complaint. 

In relation to communication with the family, we did not uphold this aspect of Mrs C's complaint.  Although we recognised that the family had found Mrs A's deterioration distressing, the standard of communication between medical staff and the family was reasonable.

Finally, we found that the Board failed to handle Mrs C's complaint reasonably and upheld this aspect of her complaint.

 

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mrs C:

Complaint number

What we found

What the organisation should do

What we need to see
(a), (b) and (d)

The Board failed to provide reasonable care and treatment to Mrs A, the Board failed to provide an accurate death certificate for Mrs A and the Board failed to handle Mrs C's complaint reasonably

Apologise to Mrs C for the failures identified in the report.

 

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

A copy of the apology.

 

By:  19 February 2020
(b)

The Board failed to issue an accurate death certificate for Mrs A

Issue an accurate Form 11 (new medical certificate of death), so that the family can provide this to the Vital Events Team at the National Records of Scotland

A copy of the Form 11, with evidence it has been provided to the family

 

By: 5 February 2020

We are asking the Board to improve the way they do things:

Complaint number

What we found

Outcome needed

What we need to see
(a)

The Board appeared to have failed to follow their own guidance on reporting on adverse incidents and holding SAERs

Review this case in light of the relevant guidance on SAERs, to determine why this was not followed

 

A copy of the review

 

By: 19 February 2020
(a) The Board had failed to resolve the questions over staff access to medical records and the decision to stop antibiotic therapy for Mrs A

Staff should have access to medical records and other patient information to ensure that treatment takes account of appropriate information at the appropriate time.

Decisions about care and treatment should be clearly and accurately documented

Evidence of a SAER into Mrs A's care and treatment.  This should include whether Mrs A's rheumatology records were accessed by medical staff and investigate whether staff were able to access rheumatology records.  It should also review the decision to stop Mrs A's antibiotics, to establish why this decision was taken.

A copy of the review report should be provided, including any action plans put in place as a result of it

 

By:  22 April 2020
(b) The Board failed to issue an accurate death certificate for Mrs A The Board should have adequate systems in place to ensure that death certificates are accurate when issued 

The Board should demonstrate they have reflected on the mistakes made in Mrs A's case and report any resulting changes to processes for completing and issuing death certificates

 

By: 4 March 2020

We are asking the Board to improve their complaints handling:

Complaint number What we found Outcome needed What we need to see
(d)

We found the Board's complaint investigation had not answered all the questions raised by Mrs C and had failed to identify and address significant failings on the part of the Board

The Board should ensure complaint investigations conform to the NHS model complaints handling procedures, particularly in relation to time scales.  It should ensure that all the issues raised by complainants are addressed, or explain clearly why it is not appropriate to do so

Evidence that the Board have reviewed the complaint investigation and established why it failed to respond to all the questions raised, or identify significant failures on the part of the Board.  This should include the actions the Board intends to take to improve its complaint handling

 

By:  4 March 2020

Related reading

  • Case ref:
    201804687
  • Date:
    November 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained about the care and treatment the board provided to his late wife (Mrs A). In particular, he was concerned that there had been a delay in diagnosing an occurrence of cancer. In response to Mr C's complaint, the board did not identify any delay in the diagnosis.

Mrs A was initially diagnosed with bowel cancer. Surgery was performed to remove part of Mrs A's bowel, and she also received chemotherapy treatment. Mrs A received follow-up care from the colorectal (conditions of the colon, rectum and anus) and oncology (cancer) teams. In this period, she continued to experience abdominal symptoms. Following an annual surveillance scan, peritoneal cancer (a cancer that develops in a thin layer of tissue that lines the abdomen) was diagnosed. Mrs A received palliative treatment until she later died from her illness.

We received independent advice from a colorectal surgeon and a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the abdominal symptoms Mrs A experienced were associated with the treatment she received for bowel cancer. We also noted that development of primary peritoneal cancer was very rare. Therefore, we concluded that there was no failing by the board to have identified peritoneal cancer at an earlier stage. We did not uphold this complaint.

Related reading

  • Case ref:
    201804379
  • Date:
    November 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, no recommendations
  • Subject:
    appointments / admissions (delay / cancellation / waiting lists)

Summary

Ms C complained that Ninewells Hospital failed to provide her with reasonable care and treatment when she was admitted for investigations by the gastroenterology (branch of medicine which deals with disorders of the stomach and intestines) team.

We took independent advice from a consultant gastroenterologist. We found that the treatment Ms C received was reasonable and that it was appropriate for a senior gastroenterologist to review her situation before determining what other investigations should be carried out. We did not uphold this aspect of the complaint.

Ms C also complained about a failure to provide her with a reasonable response to her complaint and within a reasonable period of time. We found that communication with Ms C regarding a change to her care management plan was unreasonable; there was a failure to let her know what was happening as she received an appointment for a clinic review rather than a colonoscopy. This was a communication error in the internal referral process. Therefore, we upheld this aspect of the complaint. Wenoted that the board have already taken action to address this failing so madeno further recommendations.

Related reading

  • Case ref:
    201709322
  • Date:
    November 2019
  • Body:
    Tayside NHS Board
  • Sector:
    Health
  • Outcome:
    Upheld, recommendations
  • Subject:
    nurses / nursing care

Summary

Mr C complained about the clinical and nursing care and treatment provided to his late wife (Mrs A) during her admission to Ninewells Hospital. Mrs A was admitted with a history of leg swelling and a failing liver.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) and from a nurse. In relation to the clinical care and treatment given to Mrs A, we found that the majority of the clinical management of Mrs A had been reasonable. However, we found that Mrs A's infection could have been handled better and that antibiotic therapy should have been started earlier. Given the failings identified, we upheld this aspect of the complaint.

In relation to the nursing care and treatment given to Mrs A, we found that the care delivered, documented and communicated was lacking at times. Also the specialist knowledge of nurses managing a patient with decompensated liver disease was lacking and the interventions needed to ensure a clear treatment plan was in place. We upheld this aspect of Mr C's complaint. However, we noted that the board has accepted and apologised for the failings in communication.

Mr C also complained that the board had failed to record an incident on the ward, in a reasonable way. The board accepted that on this occasion the actions of the nursing team fell below the standard they aimed to provide and apologised to Mr C. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

  • Apologise to Mr C for the failings this investigation has 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 need to be aware of the policy around escalation of patients and the board needs an assurance mechanism in place to monitor if this is being followed.
  • All staff in the ward should have access to education specific to the speciality and patient condition - including care planning, nutrition and managing encephalopathy.
  • Gastroenterology staff should be aware of the indications of antibiotics in liver failure and the ‘liver bundle’ guidance in caring for patients with end stage liver disease.

Related reading

  • Case ref:
    201808122
  • Date:
    November 2019
  • Body:
    Lothian NHS Board - Acute Division
  • Sector:
    Health
  • Outcome:
    Upheld, no recommendations
  • Subject:
    clinical treatment / diagnosis

Summary

Mr C complained that St Johns Hospital did not provide reasonable treatment to his late father (Mr A) during his hospital admission. During admission Mr A received an incorrect dose of paracetamol which the hospital recognised and responded to. The board determined that the medication error was not a contributory factor to Mr A's death.

We took independent advice from a consultant geriatrician (a doctor who specialises inmedicine of the elderly). We found while the general treatment provided to Mr A was reasonable, a significant error occurred, leading to Mr A receiving an overdose of paracetamol. Therefore, we upheld the complaint. Wenoted that the board have already taken action to address this failing so madeno further recommendations.

Related reading

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