Health

Summary

Ms C underwent gallbladder removal surgery at University Hospital Monklands. She became unstable in recovery and needed to return to theatre for open surgery to repair tears in her bowel and an artery. She required a large blood transfusion.

Ms C complained that the procedure was described to her as a simple keyhole operation, and she did not recall being told of any potential risks as serious as her bowel or anterior aortic wall being damaged. We took independent medical advice from a general and colorectal (bowel) surgeon. It was noted that steps were taken to obtain Ms C's consent the day before her surgery, and many of the risks were explained to her. However, she received no explanation of the small risk of major vascular (circulatory system) injury, or what actions may be necessary in the event of a serious complication. We, therefore, upheld this complaint.

Ms C also complained that a mistake had been made during her surgery. We considered that the major vascular injury could have been avoided if the operating surgeon had exercised reasonable skill and care. In technical delivery, decision-making and note-keeping, the surgical care provided during the operation fell seriously below the standard we would expect of a reasonably competent consultant general surgeon. Additionally, in their failure to undertake a formal investigation into the incident, the board's response also fell seriously below the standard we would expect. We upheld this complaint.

Finally, Ms C complained to us about the board's response to her complaint. She was concerned that the board had failed to provide her with a copy of any internal investigation report, and also that they had not spoken to the operating surgeon as they were on a period of extended leave and subsequently did not return to their post. In the surgeon's absence, the board received comments from another surgeon but these were submitted late, after the board had issued their complaint response. The board acknowledged that they should have sent these comments to Ms C. It was also unclear from the response whether the complaint had been upheld. We considered that the board failed to address Ms C's desired outcome. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately inform her of all the risks and the likelihood of those risks prior to gallbladder removal surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets. The apology currently offered by the board in their response to SPSO enquiries does not meet these standards.
• Apologise to Ms C for failing to properly investigate what happened during her operation. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/information-leaflets.
• Apologise to Ms C for failing to provide a full response to her complaint. 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 ensure that all surgical departments are reminded of the requirement to obtain informed consent, with discussion of all material risks, to the current Royal College of Surgeons standard.
• The board should develop a standardised consent process for patients undergoing gallbladder removal and ensure staff are fully trained in it. This should include an operation-specific patient information leaflet that outlines all material risks of the gallbladder removal procedure.
• The board should initiate a root cause analysis and disseminate any learning from it to all surgeons undertaking gallbladder removal surgery. That analysis should include the decision-making and subsequent responses to the event.
• The board should contact the General Medical Council to make them aware of concerns about the main operating surgeon in this case. If the surgeon is practising in a country outside the UK, if known, the board should contact the relevant healthcare regulator in that country and advise them about the concerns raised.
• The board should remind surgical staff that operation notes should be as accurate and complete as possible.
• The board should remind clinical staff of the need to respond to requests for information relating to a complaint within the appropriate timescale.

In relation to complaints handling, we recommended:

• The board should ensure that their complaint responses: address complainants' desired outcomes, and make clear whether or not they have upheld a complaint and what action they will take as a result of it. This may involve a reminder to staff, further staff training, and/or a change to their template letter to ensure these issues are not omitted.

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 that the practice had over-prescribed Diazepam and Nitrazepam (both belonging to a class of sedative medication called benzodiazepines) for a period of ten years. He believed that this had caused long-term damage to his mental health including aggression and anger. He said that the practice had failed in their care by not managing a controlled withdrawal.

We took independent advice from a GP. We found that Diazepam was being prescribed along with antipsychotic medication, as instructed and monitored by psychiatry. We noted that the practice closely monitored Mr C, made efforts to refer him to addiction services for Diazepam detoxification and, when he defaulted from the services, they monitored and gradually reduced his Diazepam within the practice. We found that the practice's management of his prescription was reasonable, and we did not uphold this complaint.

Mr C also complained that the practice unreasonably removed him from their practice list. The practice said he had been removed from their list due to aggressive behaviour, and that this was not the first instance of such. Mr C felt that this was unreasonable as he considered he had been displaying the symptoms of over-prescription of Diazepam and Nitrazepam.

We noted that the records showed Mr C was 'repeatedly harassing the reception staff' and had received previous warnings for inappropriate and aggressive behaviour. We confirmed that benzodiazepines are noted to have a rare side effect of aggression, but having reviewed Mr C's records going back 16 years, we found that suggesting his medication was the cause of his aggression was the least likely explanation. We noted from the records that there had been an irrevocable breakdown in the relationship between Mr C and the practice and we considered it reasonable to remove him from the list. We did not uphold this complaint.

Summary

Mrs C, an advice worker, complained on behalf of her client (Mrs A) who had concerns about the treatment which she received from a consultant rheumatologist (specialism of the medical treatment of the musculoskeletal and its disorders) at Raigmore Hospital. Mrs A had a leg ulcer and was being considered for treatment for her arthritis (a disease causing painful inflammation and stiffness of the joints). She requested that the board provide her with a certain medication that she had identified when researching the internet. However, the board refused as the requested medication could not be used as first line treatment until alternative medication had been considered in the first instance.

We took independent advice from a consultant rheumatologist. We found that the decision not to provide the requested medication until alternative first line medication had been attempted was reasonable and in line with accepted medical practice. We did not uphold the complaint.

Summary

Mr and Mrs C complained about the care and treatment their child (Child A) had received in Raigmore Hospital. Child A had asthma and was referred to the hospital by their GP because of breathing problems. They were admitted to the children's ward and was discharged on the following day. They were readmitted three days later and were then discharged later that day. Child A was readmitted again on the same day after a rapid deterioration in their symptoms. Their condition continued to deteriorate and the emergency team in the hospital took them to theatre. They were then transferred to the intensive therapy unit before being transferred back to the children's ward three days later.

Mr and Mrs C complained that staff had unreasonably considered that Child A had anxiety. We acknowledged that it can be difficult on occasions for both clinicians and patients to distinguish feelings of breathlessness due to asthma from those due to anxiety or a combination of both. We found that much of the care and treatment provided to Child A had been reasonable. It was reasonable to carry out spot-checks of their oxygen saturations, and their medication was also in keeping with standard asthma guidelines. However, on balance, the delay by medical staff in responding when nursing staff continued to raise concerns about Child A's condition had been unreasonable. The discharge letter was also inadequate, as it did not describe the clinical course accurately and did not give GPs and those subsequently involved in Child A's care a full picture of the issues. We upheld this complaint.

However, we did not make any recommendations, as the board had already apologised to Mr and Mrs C. They had also stressed to staff the importance of listening to patients and the importance of appropriate assessment of any child with breathing difficulties. The board also told us that in future, discharge letters would be verified by a consultant.

Summary

Mr C complained about the treatment he received at Queen Elizabeth University Hospital when he attended for a kidney biopsy. Mr C said that the doctor performing the procedure was unsuccessful in obtaining the tissue sample and that a consultant had to complete the procedure. Mr C subsequently went on to suffer a bleed from the site of the biopsy and required a blood transfusion. Mr C felt that the procedure may have been carried out incorrectly.

We took independent advice from a consultant nephrologist (doctor specialising in medical treatment of the kidneys). We found that Mr C had suffered from a recognised complication of the kidney biopsy procedure. Initially the procedure was carried out by a trainee under consultant supervision but when difficulties were encountered, it was appropriate for the consultant to complete the procedure which was successful. While minor bleeding can occur at the site of the biopsy needle, on occasions more significant bleeding can happen. This was the case with Mr C, and it was not an indication that the procedure had been carried out incorrectly. We also found that the risks of the procedure were explained to Mr C and appropriate consent was obtained. We did not uphold the complaint.

Summary

Mrs C complained about the care and treatment provided to her late daughter (Ms A) by the practice. Ms A attended the practice complaining of severe leg pain and was diagnosed some time later with cancer. Mrs C complained that the practice failed to carry out the appropriate investigations in response to Ms A's symptoms and previous history of breast cancer.

We took independent advice from a GP. We found that Ms A's symptoms, which she discussed with the GP on the first two appointments, were not indicative that cancer was a likely diagnosis and the appropriate treatment was provided.

When Ms A began to complain of back pain, and it was noted that she had weight loss, we found that the practice acted appropriately by making an urgent referral for imaging and arranging for blood tests to be carried out. We concluded that the treatment provided was in line with national guidelines and we did not uphold the complaint.

Summary

Ms C complained about the care and treatment provided to her late father (Mr A) at the Royal Alexandra Hospital. Mr A had dementia and was admitted with drowsiness, fever, confusion, and crackles in the lung. Ms C felt that there was not sufficient screening for sepsis when Mr A was admitted, that he was not given appropriate pain relief, and that discharge was unreasonable. Ms C also raised concerns about the nursing care provided to Mr A.

We took independent advice from a consultant in acute and general medicine, and from a nurse. We found that Mr A was appropriately assessed when he was admitted to hospital, that his pain was managed appropriately, and that his discharge was reasonable. We did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst there were some areas of nursing care which were reasonable, there were a number of failings. Namely, we found that there was limited evidence of care planning being carried out appropriately, there was no 'Getting to Know Me' document completed (this document should be completed for all patients with dementia). We also considered that a non-verbal pain assessment tool should have been used, but noted that the board had acknowledged this. We upheld this aspect of Ms C's complaint.

Ms C further complained about communication and complaints handling. We found that there was a failure to appropriately communicate with Ms C when her father was in hospital, particularly as she was his power of attorney and next of kin, and we upheld this aspect of her complaint. We also found that in relation to complaint handling, there was confusion regarding whether Ms C's complaint was in fact feedback, and this resulted in a delay in acknowledging the complaint. We also found that the response was delayed and the reasons for this were not clear. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable nursing care and treatment; failing to communicate reasonably; and failing to handle Ms C's complaint reasonably. 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:

• Appropriate care planning should be carried out and should take into account the specific needs of patients with dementia.
• A 'Getting to Know Me' document should be completed on admission for all patients with dementia.
• Communication with relatives should be proactive, well documented, and should appropriately involve the input of power of attorneys and next of kin.

In relation to complaints handling, we recommended:

• Prompt action should be taken to determine whether someone is making a formal complaint.
• Complaint acknowledgement letters should be sent out as per the complaints handling procedure.
• Responses should be sent where possible within 20 days and without undue delay in line with the board's complaint handling procedure.

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 that the care and treatment provided to her late mother (Mrs A) was inadequate. Mrs A died following a short admission to hospital, following emergency surgery. Ms C was specifically concerned that Mrs A had been diagnosed correctly early in her admission to hospital, but that this had not been properly acted upon. Ms C also suggested that surgery should have been performed earlier and that this had contributed to Mrs A's death. Ms C said that the subsequent morbidity and mortality meetings investigating Mrs A's death had not been appropriately carried out, as they had not identified the reason for her admission correctly.

We took independent medical advice from a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). We found that Mrs A had been suffering from a condition which was difficult to diagnose and which shared symptoms with a number of conditions. Mrs A had been given a differential diagnosis, and although this included the condition she was suffering from, it was not accurate to say that she had been conclusively diagnosed early in her admission. We concluded that the process of diagnosis had followed the correct procedures, and that the test result which could most reliably diagnose her condition was inconclusive. Mrs A had undergone surgery within a reasonable timeframe. The morbidity and mortality meetings had reflected on the condition Mrs A had been suffering from, rather the reason her GP had referred her to hospital. We concluded that Mrs A's care and treatment had been reasonable and, therefore, did not uphold the complaint.

Summary

Ms C was suffering from, amongst other symptoms, back pain and was referred to a physiotherapist. Shortly after, a magnetic resonance imaging (MRI) scan of her back was taken. Months later Ms C was referred to a gynaecologist (medical specialism of the female genital tract and its disorders) who ordered a further MRI scan as her symptoms continued. When the radiologist reviewed this request, Ms C's previous MRI scan was also reviewed. This second review noted the abnormalities in Ms C's pelvis and documentation was added to their records at that point. A subsequent CT scan confirmed that Ms C had ovarian cancer, and she had an operation to remove two large tumours. However, it was only during an appointment with her consultant oncologist (cancer specialist) a year later that she learned that these tumours had been detected in the MRI scan taken years earlier.

We took independent advice from a medical adviser who specialises in radiology (the analysis of images of the body). We found that the report of the first MRI was unreasonable, because it failed to mention abnormalities in the pelvis and advise further investigations. This meant that there was, at the least, a missed opportunity to diagnose Ms C with ovarian cancer earlier. We also found that it would have been reasonable for the gynaecologist to have informed Ms C earlier about what happened. Instead, Ms C only found out after asking specifically how long the tumours had been present. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in the initial review of the scan and communication identified in this investigation. 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:

• Review what happened in light of the medical adviser's comments and address any systemic or training issues.
• Share the results of this investigation with the radiologist.
• Discuss the imaging at a learning discrepancy meeting.
• Share the results of this investigation with all relevant clinicians including the gynaecologist.

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 was diagnosed with prostate cancer and he understood from his surgeon that for the best outcome, he should travel to Germany for a specific procedure (nerve sparing radical prostatectomy - a surgical procedure that removes the prostate gland and pelvic lymph nodes while attempting to save the nerves that help cause penile erections). He subsequently travelled to Germany and underwent the mentioned procedure privately. He complained that the failure by the board to offer him the operation was unreasonable and he incurred significant financial cost as a result.

We took independent advice from a medical adviser. We found that Mr C had been advised by the surgeon that he would be a suitable candidate for the aforementioned procedure, but only if a specific type of biopsy procedure was available, which was not reasonable, and that the procedure was not available by the board, which is incorrect. We found no evidence that the three options that were available to Mr C on the NHS were explored with him by clinicians in a reasonable way. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.
• Reimburse Mr C for the direct costs of the operation he underwent privately on receipt of evidence of the costs. The payment should be made by the date indicated: if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from that date to the date of payment.

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

• Ensure all suitable patients are offered nerve-sparing surgery and that they are fully informed about all options, including the possibility for surgery with intra-operative frozen section within the UK.
• Ensure that the multidisciplinary team process is clear and well documented and that changes in staging are explained.

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.