Health

Summary

C complained that surgery performed to remove material from their leg was not carried out to a reasonable standard. C broke their leg and underwent an operation to insert pins, plates, and a device known as a ‘TightRope’ (a device where string is passed through a channel in the bone and secured with ‘buttons’ at each side) to stabilise their leg. C developed an infection in their leg and subsequently underwent a further procedure to remove the ‘TightRope’. The procedure was not successful, some material was retained in C’s leg and the infection persisted. C then underwent further procedures to have the material removed completely, however, the infection proved to be too advanced and C had a below knee amputation. C complained that the board did not appropriately remove the ‘TightRope’ material during the initial procedure when they should have done.

The board said that although there was an intention to remove all of the ‘TightRope’, the material is not always visible. Cutting through the ‘TightRope’ in order to pull it through, staff expected all of the material to come out. Staff assumed that they had removed all of the suture, however, some of the material had stayed behind. The only way to have fully confirmed this would have been to make a larger hole through the bone, which could have allowed further spread of the infection.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the surgeon who carried out the initial procedure to remove the ‘TightRope’ should have been familiar with the device, including the volume of material, and should therefore have been able to assess whether removal was complete. The surgeon should have curetted (cleaned/scraped) the channel in the bone to ensure that all material was removed. We noted that an experienced surgeon would likely have undertaken a more complete removal of the material and suggested that the board could consider reviewing their arrangements for supervision of surgeons who are not experienced in a specific procedure. We considered that the initial surgery performed to remove the ‘TightRope’ material was not carried out to a reasonable standard. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out the procedure to an acceptable standard resulting in some material being retained in the TightRope channel and for the impact this had on C. 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:

• Operations should be carried out to a high standard.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Complaints Handling Procedure. Particular notice should be given to the responsibility to ensure that staff learn from complaints, especially when mistakes have been identified. Good practice should be followed when compiling the complaint response.

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

C complained that their cancer diagnosis was unreasonably delayed. They had previously suffered from cancer which had been successfully treated. C believed there was an inappropriate focus on the wrong part of their throat as a consequence, and that this combined with inadequate review of the CT imaging of their oesophagus had resulted in a delayed diagnosis, much more significant surgery and had allowed the cancer to spread to other parts of their body. C believed the extent of the cancer when diagnosed, meant it must have been visible earlier in the diagnostic process.

We took advice from a consultant ear, nose and throat surgeon. We found that C was correctly examined and there was no evidence of failings in their care. It was not possible to determine whether earlier diagnosis would have resulted in a different outcome for C. We did not uphold the complaint.

Summary

C complained on behalf of a family member (A) who was diagnosed with breast cancer and died less than two years later. C complained that during a consultation the consultant oncologist (specialist in the treatment of cancer) treating A had given the impression that despite having a condition that was treatable but not curable, A was likely to live for many more years. C noted that they had been present when this had been explained, and that it was evident that A had made important life decisions based on what C considered, in light of subsequent events, to be have been highly misleading communication. C also noted a lack of documentation relating to the initial consultation.

In response, the board stated that the oncologist treating A was clear that it had been explained that they had metastatic, stage four cancer. The consultant was also certain that they had not stated that the treatment would definitely work in an on-going sense and life-expectancy would be unchanged. The board apologised if this has been the impression formed by A.

We took independent advice from an oncologist. We found that the board’s position that it was not the oncologist’s custom to discuss life expectancy at the first meeting in order not to overwhelm a patient, and that such predictions can be very difficult to make was reasonable. Additionally, we noted that a letter had been sent to A’s GP following the initial consultation. We found it was not unreasonable for a letter to be in lieu of additional notes in a paperless system, and that it is not a requirement for a copy to also be sent to the patient. We also noted that this was one of a number of records and communications with A’s GP that were somewhat generic in nature, noting that while a further letter referenced discussions of palliative options, which implied a discussion about the seriousness of A’s condition, this letter could have been more specific in relation to what exactly was discussed.

Overall, we found that while communication and documentation could have been better and more detailed, it was reasonable. For this reason, we did not uphold C’s complaint. However, we did provide feedback for the board outlining the adviser’s criticisms of the documentation in relation to communication.

Summary

C complained about arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

Recommendations

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

• That the board review their policies and practice regarding inter-hospital transfers, specifically around documentation accompanying patients and verbal ward-to-ward handovers and that the board feedback the findings of this investigation to the medical team involved with C to highlight the poor communication with C and their family whilst they were in hospital.

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

C, an MSP, complained on behalf of their constituent (B) about the standard of care B’s late spouse (A) received from their GP practice. A attended an appointment with a GP and received antibiotics and steroids for a possible chest infection. A’s health deteriorated a short time later and they suffered a cardiac arrest at their home. B complained that the practice failed to recognise that A was suffering from a serious cardiac condition.

The practice said that a full examination and history had been taken from A. The GP concluded that the symptoms were from the chest wall rather than originating from the heart, with a suggestion of chest infection and narrowing of the airways. A received steroids and an antibiotic in treatment of a chest infection, and given advice on what to do if their condition worsened. On learning of A’s death, a Significant Event Analysis was carried out by the GP, which identified learning points in relation to arranging ECGs (a test that records the electrical activity of the heart, including the rate and rhythm), and strengthening the advice given to a patient about phoning again should their condition worsen.

We took independent advice from a GP. We found that it was reasonable for the GP to treat A on suspicion of a respiratory infection having taken a history and clinical examination. While A’s oxygen saturation levels were low, this can also be found in cases of acute or chronic lung disease, such as infection. A also displayed symptoms that were not typical of classic heart attack pain. We found that A’s blood pressure and heart rate were both normal which did not suggest a heart attack. We considered that the GP made a careful assessment and reached a reasonable working diagnosis at the time based on the information available and their clinical judgement. Therefore, we did not uphold C’s complaint.

Summary

C complained about the care and treatment they received from the board. C suffered a subarachnoid haemorrhage (a form of stroke caused by bleeding on the surface of the brain). Following a period of admission to different hospitals, C was discharged home. C complained that the board failed to communicate appropriately with them after their admission, that they were not fit for discharge and that inadequate rehabilitation plans were made in the community. C chose to stay at a relative’s property and was eventually admitted to a rehabilitation unit but believed this had affected their prognosis. C also complained that the board failed to respond reasonably to their concerns about the COVID-19 vaccine they had received.

We took independent advice from a consultant neurologist (specialist in the diagnosis and treatment of disorders of the nervous system) and an occupational therapist. We found that communication with C was unclear and confusing and did not always address the main points C was raising. Therefore, we upheld this part of C’s complaint.

In relation to C’s discharge, we noted that more consideration could have been given to supporting C prior to their discharge, given C’s concerns at the time. However, we found the decision making to be appropriate and did not uphold this part of C’s complaint.

In relation to plans for C’s rehabilitation, we found that the board made reasonable plans and attempted to commence the initial assessment that would have established what support C required. However, we found that there was a failure to provide C with written information about the plans for their rehabilitation. C was unable to retain this information when given verbally which meant they were unaware of the plan and could not access the support available to them when they were unable to return to their property as quickly as anticipated. Therefore, we upheld this part of C’s complaint.

We also found that the board failed to follow up on a commitment given to C to explore any potential link between the COVID-19 vaccine and C’s brain injury. They also failed to support C’s attempts to gather information to assess the risk of further vaccine doses. Therefore, we upheld this part of the complaint.

C also complained about the board’s handling of their complaint. We found that although there were some failings, in the circumstances the board were operating under at the time these were apologised for and reasonably addressed. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues identified in this decision. 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:

• That the board confirm what action they have taken to ensure patients with brain injuries are provided with discharge information in a format they can understand and refer back to after leaving hospital. The Board should share this decision with the clinical team involved in C’s care with a view to identifying points of learning.

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

C complained about arterial surgery. The board accepted that there were issues related to the surgery and communication with C before the procedure.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, overall, the clinical treatment provided to C was reasonable. We did not uphold the complaint.

Summary

C complained that the board failed to provide reasonable care and treatment to their late parent (A). A was admitted to hospital but was discharged later that month. Two days after discharge, A was readmitted and died a short time later.

We took independent advice from a consultant in geriatric and general medicine. We found that some aspects of A’s care were reasonable particularly in relation to COVID-19, A’s diabetes, and detailed assessments from physiotherapists and occupational therapists prior to discharge. However, we found that while A’s last blood tests were normal, A was then unwell for several days which could have developed into kidney impairment if levels of hydration in the body became low. A’s blood tests were not repeated prior to discharge. Had A received blood tests prior to discharge, taking into account A’s blood tests on readmission, it is likely that the test would have been abnormal which would have resulted in A remaining in hospital. We considered that the board failed to provide A with reasonable care and treatment. Therefore, we upheld this part of C’s complaint.

C also complained that the board unreasonably failed to consider their concerns in sufficient detail when responding to their complaint. We found that the board’s complaint response did not reasonably address C’s specific concern in relation to the comments of a nurse. We also found that when investigating the complaint there was a lack of attention given to the reasons for readmission and a lack of reflection by the medical team to ensure lessons were learned. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment to A and to appropriately consider and respond to C’s 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:

• Patients should be appropriately assessed prior to discharge and any tests required e.g. blood tests carried out in accordance with their symptoms.
• The board should ensure that their complaint investigations and responses appropriately consider and respond to the points raised by the complainant and that, where appropriate, there is reflection on the issues raised by the staff involved, for example discussion at a team meeting/huddle.

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

C complained about the care and treatment provided to their late spouse (A). A had a history of Parkinson’s Disease (a condition in which parts of the brain become progressively damaged over many years), dementia and cerebrovascular disease (a range of conditions that affect the flow of blood through the brain). A was admitted to hospital with a suspected urinary tract infection but their condition deteriorated and they died a few months later.

C complained that the board failed to provide A with appropriate nutrition and hydration in the first few weeks following admission, that staff had not treated A with dignity and ascribed A’s symptoms to their pre-existing conditions rather than treating individual needs. C also complained about the personal care provided to A, particularly with respect to management of their skin during admission.

The board considered that they provided A with reasonable care and treatment but acknowledged and apologised for a delay in inserting an nasogastric tube (NG tube, a tube that carries food and medicine to the stomach through the nose).

We took independent advice from a consultant geriatrician (specialists in care of the elderly) and a registered nurse with experience in tissue viability care.

We found that the management of A’s hydration was reasonable. However, there was a period of up to two weeks where A was Nil by Mouth without any other arrangements in place to ensure their nutritional needs were being met. We also found that staff were aware of A’s Parkinson’s Disease and it remained a priority during their admission. However, whilst specialist advice was sought, there was only limited input from relevant specialists and we found it unreasonable that there was not more direct involvement from relevant specialities. We also found that there was a failure to document the reasons for the provision of different medication and changes in delivery method. In relation to wound management, we considered that there were gaps between wound assessments and that the documentation was not completed appropriately, resulting in no structured or measurable approach to assessing A’s pressure sore. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision notice. 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:

• Decisions in relation to medication changes should be appropriately documented and, where appropriate, the risks and benefits of a particular medication regime and its delivery fully considered and documented.
• Patients at risk of or with existing pressure sore damage should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Patients that have complex care needs should receive appropriate input and care from all the relevant clinical specialities when requested.

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

C complained on behalf of their partner (A) that their initial CT scan was misread and their symptoms misdiagnosed as ischaemic colitis (injury to the colon as a result of reduced blood flow), leading to a delay in treatment and diagnosis of a bowel obstruction. C felt as A’s condition deteriorated, further investigation should have taken place to identify the cause of A’s symptoms.

The board maintained that there was no misdiagnosis as the first CT scan showed the appearance of ischaemic colitis, with no obstruction reported. A was treated appropriately with antibiotics and there was no evidence of deterioration during the period of observation. When A developed symptoms after the reintroduction of food, a second CT scan was ordered and the bowel obstruction identified. The board considered that A had an incomplete or evolving obstruction on admission, which was not picked up by the CT scan.

We took independent advice from an experienced general and colorectal surgeon. We found that while the reading of the scan was reasonable, the failure to consider clinical presentation alongside the scan was unreasonable. We found that this led to a focus on treating ischaemic colitis and no consideration was given to identifying the underlying cause. There was minimal investigation carried out to identify the cause and consideration should have been given to endoscopic investigation, a contrast enema, a colonoscopy and listening to bowel sounds. All would have identified a bowel obstruction, resulting in the correct diagnosis and earlier treatment for A. We also found that as the delay led to A’s deterioration and an increase in treatment, the incident met the Duty of Candour threshold, which the board failed to identify. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings 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:

• For the board to undertake the Duty of Candour Process. It is important to note that should C or A not wish to meet with the Board in person an alternative way of including them in the process should be explored.
• Staff to be reminded that NEWS and blood tests can appear normal in patients with a bowel obstruction and can deteriorate later.
• Staff to be reminded that scans should not be read in isolation and a patient’s clinical presentation must be considered along with the reason for requesting the scan.
• That staff recognise ischaemic colitis is the consequence of an underlying problem and investigations should continue until a cause is 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.