Health

Summary

Mr C complained that the board delayed in providing him with surgery for his feet and knees, and that they unreasonably failed to explain the reasons for the delays.

We took independent advice from an orthopaedic surgeon (a surgon who specialises in the musculoskeletal system). We found that the Treatment Time Guarantee places a legal requirement on health boards so that, once planned treatment has been agreed with the patient, the patient must receive that treatment within 12 weeks. We found that Mr C waited around six months for the surgery on his first foot, and then ten months before being seen by a knee surgeon. We found that, whilst medically Mr C came to no harm as a result of the delays, he clearly suffered pain and functional restriction for longer than was reasonable. We upheld this aspect of the complaint.

Regarding communication, we noted that Mr C had received a letter confirming a guarantee of treatment within 12 weeks for his first surgery. The next documented communication was several months later, and was only sent in response to contact from Mr C. We considered that there should have been further communication from the board, apologising for the delay and setting out the steps being taken to minimise this. We found that Mr C had been left for many months without knowng when he might receive surgery. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delays in his orthopaedic treatment.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to explain the reasons for delays in treatment, and for failing to keep Mr C updated with regard to when he could expect to have his surgery.

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

• In the event that the Treatment Time Guarantee is not going to be met, letters to patients should make this clear, in accordance with the Patient Rights (Scotland) Act 2011.
• Be clearer with patients about any delays, the reasons for the delay and the steps being taken to improve matters.

Summary

Ms C began to experience stiffness and pain, to the extent that she was struggling with everyday tasks. Her GP prescribed her steroids (a type of anti-inflammatory medicine), which improved her symptoms. Her GP then referred her to rheumatology (the branch of medicine concerned with immune-mediated disorders of the musculoskeletal system) at Royal Alexandria Hospital. Ms C complained that, when she attended her rheumatology appointment, her condition was not appropriately assessed. Ms C said she was told to stop taking steroids but when she did this, her symptoms returned. Ms C raised concerns that she was not given any follow-up appointment to check on her condition. She also complained that, when her GP raised concerns about her worsening symptoms with rheumatology, no action was taken.

We took independent advice from a consultant rheumatologist. We found that there was a lack of useful clinical information in the clinic note and GP letter relating to Ms C's initial rheumatology appointment. As a result, the adviser was unable to confirm if her assessment was reasonable or not. We found that consideration should have been given to reducing Ms C's steroid dose gradually before it was stopped. We found that Ms C should have been given a follow-up appointment or the means to contact rheumatology directly for advice if her symptoms returned. We also found that when her GP contacted rheumatology with concerns, Ms C should have been offered a prompt review. In addition, we found that phone conversations, in which advice was given to Ms C's GP, were not recorded in her medical records.

We found that due to these failings, there was an unreasonable delay in diagnosing Ms C's underlying condition of inflammatory arthritis (an autoimmune condition that causes joint pain and swelling). We upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately document and update both Ms C and her GP on her rheumatology appointment; not giving Ms C a follow-up appointment or the means to contact rheumatology directly for advice; and the delay in offering Ms C a rheumatology review when her symptoms returned and worsened. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Appropriate clinical information should be documented in clinic notes, given to GPs and copied to the patient, with enough detail to understand how a clinical decision or diagnosis has been reached.
• Patients should receive appropriate follow-up care and a prompt rheumatology review if required.
• Clinical advice, which is given to GPs, should be recorded appropriately.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Queen Elizabeth University Hospital. During a surgical procedure Ms A was diagnosed with endometriosis (a condition where the lining of the womb grows outside the womb) and she was given treatment to alleviate her symptoms. Afterwards, Ms A was discharged back to the care of her GP and her symptoms returned a few months later. Mr C considered that Ms A should have received a standard follow-up gynaecology (the branch of medicine which specialises in the female reproductive system) appointment, instead of being discharged back to her GP's care.

During our investigation we took independent advice from a consultant gynaecologist. We found that there was no clinical guidance that Ms A should have received a standard follow-up gynaecology appointment after her diagnosis. We considered that it was reasonable that the board expected that Ms A's treatment would improve her symptoms. We further considered that, even if the board suspected her symptoms might return, it is possible for endometriosis to be managed by a GP, with advice from gynaecology if required. Therefore, we considered it was reasonable that Ms A was discharged back to the care of her GP. We did not uphold the complaint.

However, the adviser noted that the post-surgical verbal advice given to Ms A was not documented. Also, Ms A did not appear to receive any written advice as back up, even though she was still recovering from the anaesthetic when the verbal advice was given. We made some recommendations regarding this.

Recommendations

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

• There should be a clear record of the verbal advice given to patients after surgery.
• In similar circumstances, consideration should be given to patients receiving written post-surgical advice to back up any verbal advice given to them.

Summary

Ms C complained on behalf of her mother (Mrs A). Mrs A was discharged from Gartnavel Hospital and then re-admitted two days later with a urinary tract infection and fluid on her lungs. Ms C complained that the board failed to discharge Mrs A in a reasonable way.

We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that, medically, it had not been unreasonable to have Mrs A discharged. While she may have had both a urinary tract infection and fluid on her lungs at the point of discharge, these were not doing her harm at that point. However, we found that Mrs A's risk of falls had not been adequately assessed prior to her discharge, and that this risk had also not been adequately communicated to Ms C. We noted that more should have been done to assess and reduce Mrs A's risk of falling before she was discharged, and that it was unreasonable to have discharged her due to her mobility issues. We, therefore, upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Mrs A for failing to assess Mrs A's falls risk prior to her discharge, and for failing to communicate this risk to Ms C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients at high risk of falls should be adequately assessed prior to discharge. Plans should be put in place to manage a patient at high risk of falls prior to their discharge.

Summary

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review.

We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint.

However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to keep her under review pending the outcome of further out-patient cardiology investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for the failure to recognise that she had been discharged from hospital while on two types of calcium channel blocking medication. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware to keep patients under review pending the outcome of further out-patient cardiology investigations.
• Pharmacy and ward staff should be aware that when patients are discharged from hospital that their medication is appropriate.

Summary

Mr C's child (Child A) was born with several rare conditions that threaten life, affect physical and mental development and require extensive clinical and day- to-day management. Mr C complained that the board unreasonably failed to identify any indication of developmental conditions from scans of Child A during his partner's pregnancy. The board said that Child A's conditions were not identified earlier because they were either not detectable by ultrasound at any stage of pregnancy, were not part of the routine checks undertaken or appeared to be within normal limits for the relevant stage of pregnancy. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from an obstetric and sonography adviser (a specialist in the use of ultrasound in pregnancy). We found that Child A's kidneys did not appear normal in the 20 week scan and that immediate referral to a specialist would have been reasonable practice in those circumstances. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Acknowledge that they unreasonably considered Child A's kidneys appeared normal on the 20 week scan, and apologise to Mr C for this. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• A risk management multidisciplinary review should be undertaken about the board having missed the abnormality in Child A's kidneys.

Summary

Mrs C, an advocacy and support worker, complained on behalf of her client Mrs A about the care and treatment Mrs A received at Dr Gray's Hospital. Mrs A suffered a miscarriage and attended hospital for an assisted delivery. She signed a consent form for the treatment and indicated that she wanted to take her baby home with her following the procedure. Mrs A believed she had passed her baby's foetus on the first day she was in hospital but was assured that this was not the case by her midwife. When Mrs A was to be discharged, the hospital were unable to locate the tub used for storage of what Mrs A believed to be the remains of her baby.

We took independent advice from a midwife. We found that the midwifes failed to follow the correct procedures in relation to the storage and disposal of pregnancy loss products. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the board failed to take adequate steps to address the acknowledged failings in Mrs A's care. Mrs A contacted the hospital following her discharge to discuss her treatment and the location of the tub. After discovering it had been incorrectly disposed of, Mrs A asked for an explanation from the board. Mrs A was told that actions had been taken to prevent a reoccurrence. Mrs A contacted the board's complaint department some weeks later and was told that the incident had not been reported formally or logged as a complaint.

We found that there was no evidence of any actions taken by the board to learn from the incident. We also found that the board had told Mrs A, in their first response to her, that action had been taken and the incident formally logged, which was incorrect. The board then failed to identify this inaccuracy in their second response to Mrs A. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the board failed to handle Mrs A's complaint reasonably. We found that the board's handling of the complaint failed to meet the standards expected of them by their complaints handling procedure. We considered that the board did not show an appropriate level of empathy or compassion for Mrs A in their response to the incident and failed to record or respond to the complaint properly. Therefore, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to provide an appropriate level of care for her, and for failing to handle her complaint appropriately. The apology should meet the standards setout in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff are aware of and are implementing the appropriate guidelines in relation to caring for women suffering from a miscarriage.
• Staff are aware of what constitutes a significant incident and how this should be reported and recorded.

In relation to complaints handling, we recommended:

• Staff have the knowledge and skills to identify and register complaints in line with the board's complaint handling procedure.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and that action has been taken to ensure there is learning from complaints to inform service development and improvement.
• The board should use clear and accessible language, sensitive to the patient in cases of miscarriage.

Summary

Mr C complained on behalf of his late grandmother (Mrs A) about the care and treatment she received at Aberdeen Royal Infirmary (ARI) and Kincardine Community Hospital (KCH).

Mrs A suffered from severe pain in her back and a suspected chest infection. She was referred by her GP to ARI, discharged on day five and then re-admitted to KCH ten days later. Mrs A was transferred back to ARI over a month later, and then back to KCH, where she later died.

Mr C complained that the board failed to provide a reasonable standard of medical care and treatment, failed to provide a reasonable standard of nursing care and failed to handle his complaint appropriately.

Regarding medical care, Mr C complained about Mrs A's pain management and a lack of communication around her treatment. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mrs A did not receive sufficient attention for her pain relief requirements. We found that this was an issue that could have been easily avoided, and one that caused Mrs A pain and the need for readmission. We also found that there was a lack of consideration for Mrs A's decision-making capacity regarding an operation that she underwent, and that there was a failure to discuss her care with Mr C and the family at this time. We upheld this aspect of the complaint.

With regards to nursing care, we took independent advice from a nursing adviser. We found that, while the communication did not meet Mr C's family's needs for specific periods of time, there was no evidence in the nursing records to indicate that the overall level of nursing care Mrs A received was unreasonable. We did not uphold this part of the complaint.

Lastly, regarding the board's handling of Mr C's complaint, we found that the board had apologised to Mr C for a delay in handling his complaint. However, we were concerned that, having given Mr C a revised timescale for providing a response, this was not then met and the board were not proactive about keeping him advised about the subsequent process of his complaint. We were also concerned that the complaint response appeared to be incomplete and did not address all of the questions Mr C raised. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failure to provide Mrs A with sufficient attention for her pain relief and for the failure to adequately communicate with Mr C and his family about Mrs A's pain and its management. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients' pain relief needs should be fully assessed at the time of discharge from hospital. The management of a patient's pain after discharge should be fully discussed with patients and their families.
• Where a patient lacks decision-making capacity, their mental health should be respected and their care discussed with their family.

In relation to complaints handling, we recommended:

• Communication about revised complaint response timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable. Responses to complaints should be accurate and address all the issues raised.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A) by the urology service (the service which deals with the male and female urinary-tract system and the male reproductive organs) at Victoria Hospital. Mr  A had a diagnosis of metastatic prostate cancer (prostate cancer that had spread to his bones) and had been reviewed roughly every three months by prostate cancer nurse specialists. Mr A received hormone therapy injections and his PSA (prostate specific antigen - a protein produced by normal cells in the prostate and also by prostate cancer cells) levels were measured to monitor his disease.

Over two years following his diagnosis, Mr A experienced back pain and he had a number of consultations with his GP. After Mr A's condition did not improve, the GP made a referral to the urology service to request urgent investigation. The urology service received the referral one day later and then made a referral to the radiology department to request a scan. A week passed following the initial GP referral, and by this time Mr A was struggling to move. Mr A was then admitted to hospital and a scan was performed. This indicated that he had a spinal fracture and cord compression from metastatic cancer. As a result of his condition, Mr A became paralysed below the waist.

Mrs C complained that the urology service did not carry out scans following Mr  A's diagnosis, even though it was known that the cancer had already spread to his bones. We took independent advice from a consultant 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) and a consultant oncologist (a doctor who specialises in cancer). We found that it was reasonable for the board to monitor Mr A's prostate cancer using PSA testing and not with routine scans. We did not uphold this complaint. However, we noted that the board had failed to respond to this part of Mrs C's complaint and had not handled a request for a meeting about this appropriately.

Mrs C also complained that there was an unreasonable delay in arranging a scan when Mr A's condition began to deteriorate. The board acknowledged that there were issues with how the urology service made the referral for a scan and also how it was handled by the radiology department. The board provided us with details of a process improvement that aimed to help avoid delays in future. However, we found that the referral from the urology service was made using the incorrect pathway. We concluded that the Malignant Spinal Cord Compression Pathway should have been used, which would have resulted in a scan within 24 hours of the referral. We concluded that if this had happened, Mr A would have had an improved chance of receiving treatment to maintain mobility. We informed the board of this finding and asked them to consider what action would effectively reduce the chance of the issue reoccurring. We upheld this complaint and made a recommendation. We also asked for evidence of the actions the board had already said they were taking or planned to take.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in arranging a scan when Mr A's condition deteriorated; not fully responding to all the points Mrs C raised in her complaint; and not responding to Mrs C's request for a meeting appropriately.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C complained on behalf of his wife (Mrs A) about a delay in carrying out a CT scan (a scan that creates detailed images of the inside of the body). Mrs A was taken to A&E at Dumfries and Galloway Royal Infirmary and following a CT scan, was diagnosed with having suffered a stroke. Mr C felt that the scan should have been carried out sooner.

We took independent advice from a medical adviser. We found that records of Mrs A's history and examination were inadequate. This meant that we were unable to conclude what Mrs A's condition was at the time of her assessment in A&E and, therefore, if the CT scan was completed within a reasonable time frame. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to document Mrs A's history and examination in line with the relevant guidance. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should be aware of relevant standards of documentation in terms of timed entries in clinical notes, documentation of relevant history and examination appropriate to the presenting complaint and documentation and timing of changes in clinical condition, clinical findings and action plan.