Health

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.

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.