Health

Summary

Mr C complained about the actions of the prison health care service. Following a medication spot check, Mr C was found to be short of antidepressant tablets, and as a result his medications were stopped with immediate effect. Mr C explained that his medication count was short as his medication safe was broken into recently and everything was taken. In response to his complaint, the board explained they would not reinstate Mr C's medication. They also stated they had made enquiries with the Scottish Prison Service (SPS) and were informed that Mr C had not reported his safe being broken into.

Mr C complained to us about his medication being stopped and about the enquiries the board made into whether or not he had reported his safe being broken into.

In respect of the complaint about Mr C's medication being stopped, we took independent advice from an GP adviser. We noted that, ideally, a GP would not withdraw anti-depressant medication suddenly. However, we found that this may not be the case if there is poor compliance with the requirements of the medication. We also highlighted guidance about prescribing medication in a prison setting and noted that Mr C had signed a medical agreement treatment form that acknowledged his medication may be stopped if not appropriately managed. After reviewing Mr C's medical records, we noted that an early entry had suggested potential drug misuse. Based on the review of the information available, we concluded that healthcare staff's decision to stop Mr C's medication was appropriate and their actions reasonable. Therefore, we did not uphold this complaint.

In respect of the second complaint, the board acknowledged that they had not appropriately described their enquiries in their responses to Mr C. The board had spoken with SPS staff and stated that SPS had confirmed Mr C had not reported his safe being broken into. However, Mr C had, in fact, reported his safe as being broken into to SPS staff. The board accepted this error had caused Mr C further concern and apologised for this. We considered this likely to be a case of miscommunication rather than any attempt by the board or SPS staff to mislead. However, although we considered the enquiries made by the board to be in good faith, we concluded that they could have been clearer and taken into account the content of Mr C's complaint more closely. Furthermore, the outcome of the enquiries could have been relayed to Mr C more accurately. On this basis, we 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 make reasonable enquiries to the SPS about what happened to his medication and whether his safe had been broken into. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

Ms C complained about the care and treatment her late child (Child A) received from the board before their death. Child A had been diagnosed with a rare disorder that affected their development. Child A had a CT scan (a scan which creates detailed images of the inside of the body) of their brain, which identified cerebellar tonsillar descent (the lower part of the brain pushes down into the spinal canal). Ms C found out about this after Child A died. She said that Child A's behaviour had changed around that time, and she complained that the board had failed to tell her about this.

We took independent advice from a consultant neuroradiologist (a specialist who uses scans to diagnose and characterise abnormalities of the central and peripheral nervous system, spine, and head and neck). We found that it had been unreasonable not to discuss the findings and the clinical implications with Ms C and, therefore, upheld this aspect of the complaint.

Ms C also complained that the board had failed to provide reasonable care and treatment to Child A in relation to this. We found that it had been unreasonable not to carry out further investigations, and specifically an MRI scan, to evaluate this. We upheld this aspect of the complaint. However, the evidence suggests that it would not have been possible to prevent Child A's death at that time.

Finally, Ms C complained that the board delayed in responding to her complaint. The board had acknowledged that there were delays in responding to Ms C's complaint and that she was not kept updated on the delays. We also upheld this aspect of the complaint, although we noted that the board had apologised to Ms C for this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to discuss the findings and implications of the CT scan and for failing to carry out further investigations to evaluate Child A's condition. 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 of this nature, the imaging findings should be shared with patients and their carers.
• Radiology staff reporting head CT scans should be aware of the clinical implications of cerebellar tonsillar descent (congenital or acquired) and appropriate imaging confirmation and evaluation should be undertaken where clinically relevant.

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.

Amendment

When originally published (18/9/2019), this summary included the line: "However, the evidence suggests that it would not have been possible to prevent Child A's death."

For clarification, this has since been changed to: "However, the evidence suggests that it would not have been possible to prevent Child A's death at that time."  We apologise for any confusion caused.

Summary

Ms C complained about the care provided to her by the Scottish Ambulance Service (SAS) when she experienced an episode of cellulitis (a potentially serious skin infection). She said that SAS failed to identify that she was suffering from sepsis (a serious complication of infection) and take the appropriate action.

We took independent advice from an adviser who is experienced in pre-hospital, emergency and unscheduled care. We found that the care and treatment provided by SAS to Ms C was reasonable and in line with relevant guidance. We did not uphold Ms C's complaint.

However, during our investigation we identified that SAS had failed to respond to Ms C's complaint within the appropriate timescales and had not kept her updated on the delay. We therefore made a recommendation under section 16G of the SPSO Act 2002, which requires the Ombudsman to monitor and promote best practice in relation to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that her complaint was responded to outwith 20 working days and she was not provided with an explanation for the delay or a revised timetable for sending the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaints should be responded to within 20 working days, and if the investigation will take longer, SAS should discuss this with the complainant and agree revised time limits.

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 on behalf of her late husband (Mr A) that the Royal Infirmary of Edinburgh Hospital failed to call Mr A to a follow-up review appointment with the cardiology department.

Mr A had been diagnosed with heart disease. He attended an out-patient appointment and saw a consultant cardiologist. During that appointment, it was agreed that Mr A should be reviewed two years from then. Some years later, Mr A collapsed. An ambulance took Mr A to hospital, but he died on arrival. On becoming aware that Mr A had not attended his follow-up appointment with cardiology, Mrs C wrote to the board to ask why he had not been called back to the follow-up appointment as agreed. The board said that Mr A had been asked to make a follow-up appointment but nothing was noted in the system, and they were unable to explain this conclusively. Mrs C complained about the board's failure to call Mr A in for his review appointment. She said that the appointment system seemed flawed and there needed to be a backup system in place so no one else missed an important appointment.

We found that at the time when Mr A was advised to make a review appointment, all patients were advised during their consultation if and when a follow-up appointment was required. The patient would be asked to book an appointment accordingly at the reception desk. Once the appointment was booked, a letter was sent out confirming the date and time of the appointment. No further letters or reminders were sent. It was the patient's responsibility to remember to attend the appointment.

The board told us that having reflected on Mr A's case, they acknowledged that there were failings in the appointment process. They told us that going forward, when staff typed the clinic outcome letter, they would now check that any requested follow-up appointments had been made. If an appointment had not been made, staff would contact the out-patient department requesting that the appointment be made and confirmation sent to the patient.

We took independent advice from a consultant cardiologist. We found that the appointment process described by the board was not common practice and it was susceptible to problems. We found that the boards process placed undue responsibility on the patient.

We considered that the appointment process was open to weaknesses and because of that, the board had been unable to say whether Mr C's review appointment was in fact scheduled. We noted that the most common appointment process would be for each patient to be given a routing card at the end of their consultation which they would return to the clinic reception desk; this would be a record of the discussion held with the patient and the next steps agreed. Even though the board's proposed change would be an improvement to the current process, it did not go far enough as it relied only on verbal communication between clinical staff, the patient and staff at the reception desk. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to arrange an appropriate review appointment for Mr A. 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 board should reflect on these findings, particularly the view of the adviser and the feedback provided by Mrs C, and consider what further improvements can be made to the appointment process.

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 that she and her family were unreasonably removed from the practice list of patients. Mrs C said that she had no trust in the service provided by the practice and that she had never received explanations about what diagnoses had been reached about her numerous medical conditions.

We took independent advice from a GP. We found that prior to removing Mrs C and her family from the patient list, the practice had repeatedly made an offer of a meeting with Mrs C to discuss her concerns. When Mrs C failed to accept the offers, the practice viewed the doctor/patient relationship had irretrievably broken down and that it was in Mrs C's best interests to register with another medical practice. The hope was that she could build up a good doctor/patient relationship with her new practice. We did not uphold the complaint.

Mrs C also complained that it was unreasonable to have her family removed from the patient list as well. Guidance suggests that members of a patient's family should not be removed automatically from the practice list where there is a breakdown in the doctor/patient relationship. However, in instances where children and/or carers are involved, it is appropriate to remove the whole family, as this will allow better communication and the sharing of information where all family members are registered with the same practice. Therefore, we did not uphold this complaint.

Summary

Mr C complained that that board failed to provide his late wife (Mrs A) with reasonable care and treatment at Western General Hospital and that they did not respond reasonably to his complaint.

We took independent advice from a consultant radiologist (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a consultant surgeon and a consultant oncologist (cancer specialist).

In relation to a CT scan, we found that a lymph node which was partially visible at the bottom of the CT scan, despite being enlarged and abnormal looking, was not noted by the reporting radiologist at the time. The failure to identify the abnormal lymph node was an unreasonable error. We also noted that the review of the CT scan showed concerning nodes with an increase in size in comparison with a CT scan of Mrs A's chest carried out previously. Given this and Mrs A's clinical history, this should have been noted in the scan report. We considered that, had these nodes been noted on the CT scan report, it was likely further investigation would have occurred as a result. We acknowledged that the board had accepted there was a missed potential to make a detailed diagnosis of Mrs A's condition and said they have taken action to learn from this. We asked the board to provide us with evidence of this.

We also found that a haematology consultant (a specialist in blood and bone marrow) appropriately referred Mrs A to the surgical department for an excision biopsy of the lymph node. However, due to poor communication between the haematologist and the surgeon about the exact anatomical position of the lymph node, the wrong lymph node was removed for biopsy and the diseased lymph node was left in Mrs A's groin. As a result, the pathology report of the biopsy was falsely reassuring.

We also considered that the errors identified in Mrs A's care and treatment led to a delay in the diagnosis that she had terminal metastatic lung cancer. However, it was most likely that when Mrs A first presented with the swelling in her groin, this was evidence of metastatic cancer and she was already in an incurable state. Although earlier diagnosis of the cancer could have been made, it would have made no difference to Mrs A's outcome.

We found that the palliative treatment Mrs A received was reasonable and appropriate and was consistent with national clinical guidelines. However, the delay in diagnosis of the cancer would have caused Mrs A intrusive and distressing symptoms that could have been mitigated had the excision biopsy been correctly undertaken or palliative treatment instigated at an earlier time.

We also found failings in communication concerning how the news that Mrs A had cancer had been conveyed to her. Apart from the delay in diagnosing Mrs A's cancer, there was also an unreasonable delay in informing her that she had metastatic terminal cancer. We considered that the board failed to provide Mrs A with reasonable care and treatment and upheld this aspect of Mr C's complaint.

In relation to complaint handling, we considered that the board's letter to Mr C about his complaint contained medical jargon which could have been better explained. We also considered that Mr C was not provided with all the relevant information. Given that there were a number of medical specialities involved, we considered it would have been helpful if the board's offer of a meeting to Mr C to discuss his complaint had not been restricted to the radiology service. We also noted that the board's complaint response contained factual errors in relation to dates. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the care and treatment that Mrs A received from the radiology, haematology and surgical departments in relation to the diagnosis of her cancer; for the unreasonable delay in the diagnosis; for the unreasonable delay in informing Mrs A about her diagnosis; for the poor communication with Mrs A and Mr C about her diagnosis. 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:

• Patients should have all relevant areas of their scan reviewed and reported. When referring a patient for surgical excision biopsy, communication between the referring clinician and the operating surgeon about the exact anatomical position of target lymph nodes should be clear. Communicating significant news, especially bad news, to a patient and/or their family should be carried out in a clear and sensitive manner and without any unreasonable delay.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate, user friendly and easily understood by the complainant and include details of action taken to address failings identified.

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 complained about the treatment which he received from the practice. He reported stomach and bowel problems to a number of GPs. They treated him for irritable bowel syndrome but they failed to diagnose that he had a bowel obstruction and that resulted in him having to have a colostomy (an operation to divert part of the bowel through an opening in the tummy) and undergo chemotherapy.

We took independent medical advice from a GP. We found that the GPs who treated Mr C carried out appropriate investigations in view of the stomach and bowel symptoms which he presented with. When Mr C reported passing blood the GPs made a referral for a colonoscopy (examination of the bowel with a camera on a flexible tube). However, before the colonoscopy could take place, Mr C was admitted to hospital as an emergency and was diagnosed with a bowel obstruction. We did not uphold the complaint.

Summary

Ms C complained about the actions of staff at the GP practice when she had a seizure in the reception area. Ms C has a medical condition in which she experiences seizures. During seizures she is unable to move or speak, however, is aware of what is happening and can feel pain. Ms C complained that when she had a seizure at the GP practice, her dignity and privacy was not maintained.

We took independent advice from a GP. We found that Ms C was not given appropriate privacy when she had the seizure, and this was unreasonable. We also found that Ms C's son was called to take her home in a wheelchair, before she had recovered from the seizure. Staff at the practice should have waited until Ms C had recovered in order to assess her clinically when she was fully conscious and allow her to coordinate her own transfer home as appropriate. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to act reasonably to ensure her privacy, and regarding the arrangements for her to return home. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.
• Review Ms C's care plan in light of the findings of this investigation, and discuss with her whether further details should be added in order to prevent similar failings recurring.

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

• The practice should ensure that patient dignity and privacy is maintained in similar situations where a patient has a medical event such as a seizure or collapse at the practice.

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 care and treatment provided to her late daughter (Ms A). Ms A had a history of breast cancer and she had been complaining of severe leg pain. She attended A&E to request an emergency MRI scan, however, she was advised by hospital staff that she did not meet the criteria for an emergency scan. An out-patient referral was made instead. Ms A was later diagnosed with cancer and underwent surgery to repair a cancer related fracture of her hip. Following the surgery, it was identified that Ms A had a neck fracture.

Mrs C complained that the hospital staff unreasonably refused to perform the MRI scan when Ms A attended A&E and that the board failed to provide a reasonable explanation for the cause of Ms A's neck fractures.

We took independent medical advice from an orthopaedic (conditions involving the musculoskeletal system) surgeon. We found that an emergency MRI scan can only be performed if the patient is suffering from a neurological deficit, therefore it was correct that Ms A was advised she did not meet the criteria. We also found that there was no evidence to suggest that Ms A's neck fracture occurred during surgery, and it was reasonable to conclude that the fracture developed due to the progression of the cancer into her bones. We did not uphold the complaints.

Summary

Mrs C complained about the treatment which her son (Mr A) received at Hairmyres Hospital. Mr A was admitted with severe stomach pains, vomiting of blood and blood in his stools. The diagnosis was a bleed within his intestinal tract. Initially the plans were that an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside) would be carried out while Mr A was a patient. Mr A was then discharged home after a few days and arrangements were made for him have an endoscopy as an out-patient within four to six weeks. A letter was issued to Mr A asking him to make contact for a date for the endoscopy, but he did not respond. He was then admitted to another hospital as an emergency where he underwent surgery for a perforated gastric ulcer (condition in which an untreated ulcer can burn through the wall of the stomach or other areas of the gastrointestinal tract). Mrs C felt that had Mr A received the endoscopy while an in-patient, it may have prevented the ulcer perforation.

We took independent advice from a surgeon. We found that while Mr A was in hospital the staff carried out appropriate investigations in order to arrive at a diagnosis. There is guidance that Mr A should have received an endoscopy while an in-patient. However, this would have been for the purposes of establishing whether Mr A was continuing to lose blood; but as Mr A showed signs of improvement, this was not the case. It was appropriate to discharge Mr A from hospital as he appeared to be stable, and the revised plan for an out-patient endoscopy was then reasonable in the circumstances. We did not uphold the complaint.

Although we did not uphold the complaint we highlighted issues of concern regarding record-keeping, risk assessment and communication with primary care as feedback to the board in an effort to improve learning.