Health

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Beatson West of Scotland Cancer Centre for metastatic breast cancer. Ms C raised concerns that there were delays between scans and treatment for Mrs A, and in particular that there was a lack of urgency when Mrs A's kidneys were failing.

We took independent advice from an oncology consultant (a specialist in the study and treatment of tumours). We found that whilst overall the scans and treatment for Mrs A's cancer were reasonable, when Mrs A's worsening kidney function was noted in a scan there was a delay in referring her to urology (the  branch of medicine and physiology concerned with the function and disorders of the urinary system). The referral was then lost which the board acknowledged and apologised for. However, they did not explain what action they had taken to prevent this reoccurring in the future, therefore, we made a recommendation on this matter. We also found that when a scan showed that there was disease progression, this should have been escalated to Mrs A's consultant in a more timely manner to allow a discussion regarding stopping Mrs  A's treatment to happen more quickly. We considered the care and treatment provided to Mrs A was unreasonable and upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the delay in referring Mrs A to urology and that the results of the scan which showed disease progression were not escalated to the consultant more promptly. 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:

• There should be a policy for escalating significant findings of investigations, in particular scans, to the relevant team or on call team in order to ensure that any required actions regarding these findings are not delayed until a patient attends clinic.
• There should be a system in place to ensure that referrals to urology are acknowledged and acted upon to prevent the situation of a referral letter going missing or not being acted upon.
• Patients with disease progression should have their results escalated to the consultant caring for them as quickly as possible to enable any discussion regarding stopping of treatment and switching to best supportive care to take place as soon as possible.

Summary

Mr C complained about the medical treatment which his late friend (Mr A) received when a request was made for the out-of-hours (OOH) service GP to call at the house and assess Mr A. Mr C said that the OOH GP examined Mr A and decided that he should be admitted to hospital. However, they did not request an immediate ambulance and ordered another ambulance to arrive within a two hour timeframe. Mr C complained that the OOH service failed to appropriately assess Mr A and failed to call for an immediate ambulance.

We took independent medical advice from a GP. We found that the OOH GP had carried out a thorough assessment based on Mr A's medical history and his presenting symptoms. It was reasonable for them to arrive at a working diagnosis that Mr A had an infection and that he required a hospital admission. However, there was no evidence of sepsis and we found that it was appropriate to order an ambulance to arrive within a two hour timeframe as Mr A did not meet the criteria for a 999 ambulance. We did not uphold Mr C's complaints.

Summary

Mr C complained about the clinical treatment he received at Inverclyde Royal Hospital. Specifically, that the treatment that he had to remove debris from his ear (known as microsuction) caused him to develop tinnitus (a ringing or buzzing noise in the ears) and that he should have had a hearing test before the treatment. Mr C also complained that questions which he raised at a follow-up clinic appointment were not fully responded to.

In response to the complaint, the board did not identify any failings in treatment or the communication that took place with Mr C about the questions he had raised at a follow-up appointment. The board also said that tinnitus is not a recognised complication of microsuction.

We took independent advice from a consultant ear, nose and throat surgeon. We found that the treatment Mr C received was of a reasonable standard and in accordance with ear care guidance issued by Health Improvement Scotland. In addition, we found that there was no requirement in terms of consent guidance issued by the General Medical Council to warn patients of the risk of tinnitus, as it is a less serious side effect that does not occur frequently with this type of procedure. We did not uphold this aspect of the complaint. However, we considered that tinnitus is a recognised risk of any noise or mechanical trauma to the ear and provided feedback to the board that they may wish to consider displaying a notice or providing a leaflet for patients in this respect.

Mr C should have received responses to the questions he had raised at his follow- up appointment. Therefore, we upheld this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not responding fully to the points he raised. 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:

• Full responses should be provided to patients regarding their care and treatment, either in writing or verbally, with documentation to demonstrate what was discussed.

Summary

Mr C complained about the dental treatment he received over a number of years from a number of dentists. Mr C had recently moved to a new dental practice, where the dentist discovered that he had a blood clot in his lower jaw which had been present for some time and caused the bone to degrade. Mr C felt that the previous dentists should have discovered this at an earlier stage.

We took independent advice from a dentist. We found that there was no evidence that Mr C had reported any problems with his lower jaw, or that the lower teeth were unstable. We found that Mr C had had reasonable assessments in view of his reported symptoms over a number of consultations. We did not uphold the complaint.

Summary

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of the surgery. Mr C complained that he had not been reasonably informed of all the recognised complications when consenting to his surgery. Mr C was also concerned that his surgery was not carried out properly, that he was discharged too soon from hospital after the inginual hernia repair, and that there was an unreasonable delay in receiving a review appointment following the operation to remove his testicle. The board apologised that they were unable to offer him a review appointment within the original planned timescale due to a high volume of patients and took action to address this problem. The board identified no other issues with Mr C's treatment. He was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant general surgeon. We considered that the board's handling of the consent process was below a reasonable standard. It was not clear to what extent the term testicular atrophy (shrinkage/wasting) was explained to Mr C at the time of his clinic appointment or whether he understood this, nor was any additional patient information on the procedure provided to Mr C for reflection at this time. In addition, the consent form Mr C signed was completed on the day of surgery instead of at the out- patient clinical consultation and it did not list the possible but rare risk of testicular complication. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the procedure, we considered that this was completed to a reasonable and appropriate standard. The adviser noted that the rare complication Mr C suffered was not a result of a failing in the surgery. However, we noted that the board incorrectly suggested in their response to Mr C's complaint that a consultant surgeon had performed the surgery when in fact they were supervising it to ensure the quality of the procedure. We did not uphold this aspect of Mr C's complaint but made a recommendation in light of this finding.

In relation to Mr C's discharge, we found no evidence to suggest that he was unreasonably discharged following the inguinal hernia repair. We did not uphold this aspect of Mr C's complaint.

Finally, we found that given the distressing complication Mr C experienced following his surgery, it was unreasonable for him to wait over 26 weeks to be reviewed following removal of his testicle rather than within the planned six to eight weeks. We upheld this aspect of Mr C's complaint but noted that the board had already taken action to address this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the consent process and the failure to provide accurate information in relation to who had performed the surgery. 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:

• Surgeons should complete the consent process in the pre-operative clinic; ensure the risks are clearly explained to the patient, checking that the patient understands the information and that this is documented; and ensure the patients take a copy of the consent form to enable reflection. Information for patients should be available concerning inguinal hernia repair in a separate booklet that details 'the risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications'.

In relation to complaints handling, we recommended:

• The board should ensure transparent and open communication with patients. In particular, the board should ensure that patients are informed about who undertook their surgery.

Summary

Mrs C complained that the board failed to ensure a reasonable standard of communication with herself and her late husband (Mr A). Mr A had been diagnosed with cancer, and Mrs C complained that the communication about his diagnosis, prognosis and treatment options was poor and that, as such, Mrs C and Mr A were unable to make an informed decision about the treatment options offered.

We took independent advice from an oncology (cancer) nurse and from an adviser who specialises in the care of the elderly. We found that board staff discussed treatment options and potential risks in a reasonable way, and that the records suggested that Mr A understood the nature of his condition and treatment options. We also found that staff followed the relevant General Medical Council Guidance in this respect, and that they acted reasonably in respecting Mr A's stated preferences for information and his decision-making ability. We did not uphold the complaint.

Summary

Mrs C complained on behalf of her father-in-law (Mr A) about the care and treatment he received from Victoria Hospital and Glenrothes Hospital over a six  month admission period. Mrs C's concerns related to surgical treatment, nursing care, physiotherapy, speech and language therapy (SALT) and medical care.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), two registered nurses and a consultant geriatrician (a doctor who specialises in medicine of the elderly). In relation to Mr A's surgical treatment, Mrs C felt that a perforated ulcer should have been identified at the time Mr A underwent an emergency operation. We found that it was reasonable that the perforated ulcer was not recognised at the time of the emergency surgery given a number of relevant factors. We did not uphold this aspect of Mrs C's complaint.

In relation to the nursing care, Mrs C was concerned that Mr A developed as significant pressure ulcer, monitoring of his fluid intake/output was poor and Parkinson's medication was not administered when it should have been. We found no evidence that administration of Mr A's Parkinson's medication was unreasonable. However, we found significant failings in relation to the prevention, monitoring and management of pressure ulcers and that fluid intake/output charts were not adequately completed. We upheld this aspect of Mrs C's complaint. However, we noted that the board had identified failings in regards to pressure ulcer damage and fluid monitoring and had taken steps to address these issues.

In relation to the physiotherapy treatment Mr A received, Mrs C was concerned that there was a lack of regular visits from the physiotherapist. We found that Mr  A received regular visits from physiotherapy staff and that their care was appropriate. We did not uphold this aspect of Mrs C's complaint.

Mrs C was also concerned that there was a lack of visits from SALT and a lack of effective communication with other staff regarding Mr A's altered diet. We found that review by SALT was sporadic and not carried out in a timely manner at either hospital. We considered that Mr A's risk of aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) would have been reduced had timely SALT review taken place. We upheld this aspect of Mrs C's complaint.

In relation to Mr A's medical care, Mrs C was concerned that communication about placing a do not attempt cardio-pulmonary resuscitation (DNACPR) mandate in place was inappropriate, Mr A's usual Parkinson's medication was not prescribed causing problems with his movement and interaction, and transfer arrangements were unreasonable. We found that the conversation which took place about DNACPR were appropriate and that the changes made to Mr A's Parkinsons medication was reasonable. We also found overall that the transfer arrangements were reasonable, however, we were critical that there was no evidence to show that a formal record of discharge was documented to support a thorough hand-over. We did not uphold Mrs C's complaint but made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in SALT review and follow-up. 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:

• Staff should carry out pressure ulcer prevention and management in accordance with national guidance.
• SALT should ensure patients with complex needs are seen within agreed timescales.
• Complex patients should have a careful and thorough hand-over documented.

Summary

Mrs C complained to us that the practice had failed to provide appropriate care and treatment to her late daughter (Miss A). Miss A had attended the practice with her partner and had reported symptoms of severe headaches, tiredness and constantly dropping items from her left hand. The GP took Miss A's blood pressure and gave her a vitamin injection. Miss A died at home the following day.

We took independent advice from a GP adviser. We found that the doctor should have arranged further investigations of Miss A's weakness and dropping items with her left hand as this was a new symptom. The doctor should have arranged for an urgent review by a stroke specialist to establish if there were signs of a Transient Ischaemic Attack (a mini stroke) which was a risk factor for subsequent stroke or myocardial infarction (heart attack). However, we found that the doctor had carried out a reasonable assessment and examination which was in line with national guidance. There was no indication at that time that Miss A required an urgent hospital admission. Miss A had a complex medical history and her symptoms of high blood pressure, headache and tiredness were longstanding.

On balance, we took the view that the doctor provided reasonable treatment and we did not uphold the complaint. Whilst we did not uphold the complaint we provided feedback to the doctor that they should review the standard of their record-keeping and refresh their knowledge about the presenting symptoms of a Transient Ischaemic Attack.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at University Hospital Crosshouse. In particular, Mr C complained that Mrs A's medication had been changed and that she had not been provided with a reasonable standard of clinical care and treatment during two admissions to the hospital.

We took advice from a consultant hepatologist and gastroenterologist (a  specialist in the diagnosis and treatment of disorders of the digestive tract and liver). We found that it had been reasonable to have treated Mrs A with strong immunosuppressants (a drug that can suppress or prevent the immune response) and that the change in her medication was reasonable. We did not uphold this aspect of Mr C's complaint.

In relation to both of Mrs A's hospital admissions, we found that the management of her care and treatment had been reasonable. We also noted that, during her first admission, Mrs A was booked in for an ultrasound scan as an out-patient, with an ear, nose and throat review afterwards. We considered that this action was reasonable and in line with national guidelines. We did not uphold Mr C's complaints.

Summary

Mr C complained about his care and treatment when he attended Crosshouse Hospital after experiencing stroke-like symptoms. Mr C was taken to the emergency department (ED) and was told he would be admitted to a ward but he was discharged a few hours later. Mr C suffered a seizure later that day and was returned to hospital by ambulance. He was admitted to the high dependency unit and kept in for two days for investigations. Mr C complained that it was not reasonable for staff to discharge him when he first attended. He was concerned he was not monitored frequently and that staff did not give him a clear explanation or diagnosis.

The board acknowledged that nurses should have recorded more frequent ward rounds and apologised for this. However, they explained that Mr C was also kept under observation via electronic monitors. The board considered that the medical care and treatment was reasonable. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant in emergency medicine, a consultant in general medicine and a nurse. We found that Mr C was given prompt treatment for tonsillitis (inflammation of the tonsils) and suspected meningitis (infection of the coverings of the brain). We noted that this was investigated further but it was found that he did not have meningitis. Mr C was followed up by the neurology department (branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) after his discharge and was diagnosed with hemiplegic migraine (a rare and serious type of migraine that has symptoms similar to those of a stroke). We considered that Mr C's medical care and the decision to discharge him was reasonable. We did not uphold these aspects of Mr C's complaint.

In relation to the nursing care Mr C received, we found that nurses had not clearly recorded what action was taken when he had a high National Early Warning Score (NEWS, an indicator of a patient's overall health) or why the plan had changed from admitting him to discharging him from the ED. 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 not repeating his observations before discharge and for the gaps in record-keeping. 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:

• Nurses should record what action is taken in response to an elevated NEWS and repeat the NEWS check before discharging the patient.
• Where a plan of care changes, the nursing records should show the reasoning behind this.