Health

Summary

Mr C complained that there was a delay in a scan taken of his chest area being formally reported at the Glasgow Royal Infirmary. Mr C had lung cancer and was undergoing treatment for this. At an appointment with a cancer specialist he reported symptoms of breathlessness and the specialist referred him for a scan and to a respiratory consultant. Mr C underwent the scan the same day as his respiratory appointment, at which point there was no formal report of his scan. The formal report was produced ten days later, and it was discovered that Mr C had a pulmonary embolism (blockage of a blood vessel in the lung). He was therefore immediately admitted to hospital for treatment. Mr C complained that the scan should have been checked and reported on the same day as it was taken, in order to ensure there were no significant problems.

We took independent advice from a consultant radiologist. We found that there are no specific standards for reporting scans and that there was not an unreasonable delay in Mr C's scan being reported. We also found that the area of pulmonary embolism shown on the scan was relatively small and would not have been recognised by a non-radiologist. We found it reasonable that the scan was not reviewed by a radiologist on the day it was taken and that the board had reasonable protocols in place to ensure significant pathology was related to clinicians in a timely manner. We did not uphold Mr C's complaint.

Summary

Mrs C complained that the board had failed to provide her with reasonable treatment at the Ear, Nose and Throat (ENT) service at Inverclyde Royal Hospital in relation to her balance problems. Mrs C considered that the problem was being caused by fluid in the tubes in her ears. She was referred to a number of clinicians in the ENT service, but they were unable to establish what was causing her balance problems.

We took independent advice from an ENT consultant. We found that staff in the ENT service had carried extensive tests and there was no evidence that Mrs C's balance problems were being caused by fluid in the tubes in her ears. Mrs C felt that some tests had not been carried out because of her age and because of cutbacks. We found that there was no evidence of this and we found that the investigations carried out by the board into the problem had been reasonable and appropriate. In addition, there had not been any unreasonable delays in carrying out the tests. In view of all of this, we did not uphold Mrs C's complaint.

Summary

Ms C attended the plastic surgery clinic at Glasgow Royal Infirmary, after being referred by her GP because of concerns about changes to her breast implants and a discharge from her nipple. Ms C said that she had many symptoms and, after doing her own research, concluded that these were the consequence of problems with her breast implants. However, she complained that the consultant she saw failed to listen to her, and as a result, misdiagnosed her and referred her to a psychiatrist. Ms C said that she felt that she had no alternative but to pay to have her breast implants removed privately. She complained to the board who took the view that she had been treated reasonably, holistically and in accordance with usual practice. Ms C remained unhappy and brought her complaint to us.

We took independent advice from a consultant plastic surgeon. We found that the consultant at the clinic had spent a considerable time discussing Ms C's symptoms with her and examined her appropriately. However, as Ms C had expressed thoughts about self-harm, the consultant was duty bound to recommend and arrange for psychological assessment. They did not refuse to remove her implants but wanted to ensure that any treatable conditions or symptoms she was experiencing could be dealt with appropriately. The adviser confirmed that Ms C had been treated in accordance with current practice. For these reasons, we did not uphold Ms C's complaint.

Summary

Mrs C complained about the care and treatment provided to her late relative (Miss A). Miss A attended the GP practice with an abdominal swelling and was urgently referred to the gynaecology department at a hospital. Surgery was subsequently carried out to remove an ovarian cyst. Over the course of the following year, Miss A attended the practice on several occasions with various symptoms and ultimately attended the emergency department at a hospital. After various attendances at hospital, tests identified that Miss A had advanced cancer and she died within a few weeks. Mrs C believed that tests could have been carried out sooner if the practice had not ignored a family history of bowel cancer.

We took independent advice from GP adviser. We found that, prior to final visits to the practice, Miss A had not presented with symptoms that required urgent investigation or referral to a colorectal specialist (a doctor specialising in the colon and the rectum), in accordance with the relevant guidelines. We considered that there was no indication for genetic screening. We also found that it was reasonable of the practice to accept hospital staff's advice that the ovarian cyst that had been removed was non-cancerous and did not require follow-up. In light of these findings, we did not uphold Mrs C's complaint.

Summary

Mrs C complained about the care and treatment provided to her late relative (Miss A). Miss A attended her GP practice with an abdominal swelling, which led to an urgent referral to the gynaecology service at Glasgow Royal Infirmary. Tests showed that Miss A had an ovarian cyst and arrangements were made for her to have it surgically removed. She was then discharged from the gynaecology service. Over the course of the following year Miss A attended her GP with various symptoms and ultimately attended the emergency department at Glasgow Royal Infirmary. After several attendances at hospital, tests identified that she had advanced cancer. Miss A was then transferred to the Beatson West of Scotland Cancer Centre for treatment and she died a short time later.

Mrs C complained that there was an initial failure to diagnosis that Miss A had cancer when she was referred to gynaecology and the ovarian cyst was removed. Mrs C also complained that there was a delay in diagnosing Miss A with cancer after she attended the emergency department the following year, and that appropriate treatment had not been given to Miss A.

We took independent advice from consultants in pathology, gynaecology and surgery. We found that appropriate tests and investigations were initially carried out when Miss A attended the gynaecology service. However, we found that there should have been a record to show that family history of ovarian or breast cancer had been enquired into, in line with relevant guidance. In addition, we found that there was evidence to indicate that the ovarian cyst had burst during surgery, but that the records did not contain clear information about this having occurred. We also found that there was a failure to accurately report the pathology specimens after the cyst was removed. We considered that, had these been reported in a timely manner, this would have altered Miss A's clinical management and she would not have been discharged from the gynaecology service with no follow-up. We upheld Mrs C's complaint about an initial failure to diagnose Miss A.

Regarding the delay in diagnosing Miss A the following year, we found that biopsies taken at the time of a sigmoidoscopy (a procedure to visualise the rectum and lower colon) showed evidence of cancer, but that there was a two week delay in this being recognised by the clinical team and Miss A being informed of the results. We upheld this aspect of Mrs C's complaint.

We found that the appropriate option of palliative chemotherapy was decided upon and that reasonable surgical care had been provided to Miss A. However, we concluded that there may have been a lost opportunity to halt the progression of the cancer because of the time taken to communicate the findings of the sigmoidoscopy and also because of a delay in arranging treatment for blocked kidneys which Miss A had also developed. On balance, we concluded that Miss A had not been provided with appropriate treatment, and we upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and the family for the inaccurate reporting of the pathology specimens, the delays in communicating the cancer diagnosis and a delay in treating blocked kidneys. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• Staff should follow the guidance about enquiring into family history of ovarian or breast cancer, as recommended in the Royal College of Obstetricians and Gynaecologists' Green-top guideline No.62.
• Consideration should be given to amending the proforma to include a subheading for family history.
• Staff should record whether a cyst has been removed intact or has burst during surgery.
• Staff should ensure that pathology specimens are sampled and correlated in accordance with the Royal College of Pathologists' guidelines on ovarian tumours.
• Staff should ensure they are aware of the Royal College of Pathologists' guidelines on the examination of ovarian tumours.
• Pathology staff should ensure that new cancer diagnoses are communicated promptly to the clinical team.
• Staff should ensure in similar cases that appropriate treatment for blocked kidneys is commenced in a timely manner. An appropriate care pathway should be in place.

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 to us about the fact that his medical practice had not carried out a home visit. He had phoned twice on the same day with severe back pain. The duty GP made a diagnosis over the phone and recommended a course of action, but did not arrange a home visit. The next day, Mr C's back pain persisted and he experienced numbness after suffering a fall. The GP on duty that day arranged for a home visit to be carried out and Mr C was transferred to hospital and subsequently diagnosed with cauda equina syndrome (a disorder that affects the nerves). This required surgery which has left him with ongoing difficulties. Mr C feels that the consequences may not have been as severe had the original GP arranged for a home visit to be carried out. In addition to this, Mr C complained about some aspects of the practice's complaints handling.

We considered the information provided by Mr C and the information provided by the practice. We also took independent advice from a GP adviser. We found that the original duty GP's actions were appropriate on the basis of Mr C's presenting symptoms. When further symptoms developed, it was appropriate to arrange a home visit but it was reasonable not to on the basis of the original phone calls. We concluded that the original duty GP's actions were in line with the relevant guidance and regulations. We did not uphold this aspect of Mr C's complaint.

In respect of the practice's complaints handling, we agreed that there were some measures they could put in place to improve the customer experience. However, we considered their handling and response to Mr C's complaint to be reasonable on the whole. Although we did not uphold Mr C's complaint about this, we did offer some feedback to the board about how they can improve their complaints handling.

Summary

Mrs C complained on behalf of her husband (Mr A) who was treated for cancer at Aberdeen Royal Infirmary. Mrs C complained that there was a lack of communication about Mr A's care between the staff and his family and between the staff themselves. Mrs C also complained that Mr A was over-sedated which was causing periods of delirium and that his feeding and nutritional needs were not met.

We took independent advice from a nursing adviser and a consultant physician. We found that communication between hospital staff and Mr A's family and between hospital staff themselves was reasonable. However, Mrs C had raised concerns about Mr A having delirium and this was not appropriately acted upon in line with the Health Improvement Scotland (HIS) programme on identifying delirium in patients. On balance, we upheld this part of Mrs C's complaint.

In relation to over-sedation, the adviser said that the medication Mr A received is often accompanied by side effects and that it could have been a contributing factor to him developing a period of delirium. However, these side effects were not sufficient to say that Mr A's care was unreasonable or that he was over-sedated. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, we found that Mr A was having difficulty eating and drinking and that this was due to damage to his mouth, a common consequence of the cancer treatment he was receiving. The adviser said that the hospital staff took reasonable steps to encourage and promote Mr A's nutritional care. There was evidence that Mr A had declined artificial feeding which would have improved his ability to eat. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not appropriately acting on her concerns raised about Mr A having delirium. 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:

• Ensure that staff are following the HIS programme by involving families or carers in identifying delirium in patients and in their use of assessment tools to identify delirium in patients.

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

Miss C's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable.

We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint.

We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in their complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should be confident about when consent is required before a complaint can be investigated. In this instance, matters could have been investigated without the need for Miss A's consent.

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

Miss C complained that her GP practice was not recognising her mental health problems and that they refused to carry out home visits. Miss C told us that she believes she has agoraphobia (a fear of entering open or crowded places, of leaving one's own home, or of being in places from which escape is difficult), although she has not been given a formal diagnosis.

Miss C wanted a diagnosis of agoraphobia and also had various concerns about her physical health. Given her condition, she wanted to be seen at home. In their response to our enquiry, the practice confirmed that Miss C had been referred to mental health services and that they had prescribed appropriate medication. They explained that they would always discourage home visits as they are not the correct setting for most medical problems. They said that in Miss C's case, they had concerns about visiting at home due to a mental health assessment which identified a concern that home visits could have a negative effect on Miss C's wellbeing.

We took independent advice from a GP adviser. We found that the treatment provided to Miss C was reasonable and the adviser had no concerns about the care provided by the practice. In relation to the home visit requests, the adviser noted that Miss C had not been diagnosed with an acute mental illness which would stop her from attending the surgery. They said that unless the patient is housebound, patients are best seen in a practice environment. We found that the practice had taken reasonable measures to support Miss C by offering quiet appointment times, phone consultations and offering home visits from a community psychiatric team. We noted that Miss C had declined to engage with services or treatment to help her, and considered that there was no further action the practice could reasonably take. Therefore, we did not uphold either of these complaints.

Summary

Mr C complained about a consultation he had at the fracture clinic at Perth Royal Infirmary and the following care and treatment he received. Mr C was referred to the clinic after he fell and injured his hip. Prior to attending the consultation, an x-ray of Mr C's hip had been arranged by his GP, whilst an MRI scan had been carried out privately. Mr C brought the written MRI report to the consultation, but did not bring the imaging CD. After examination, the surgeon decided that conservative treatment (medical treatment avoiding radical therapy or an operation) was appropriate and they arranged to review Mr C in three months' time. Mr C obtained a different opinion on the treatment of his injury from a surgeon at a different NHS board. Mr C then agreed to have surgery on his hip at this same NHS board and said that this improved his condition.

Mr C raised concern that the surgeon at Perth Royal Infirmary failed to carry out an appropriate assessment of his condition. Mr C felt that the surgeon should have reviewed the MRI images and spoken to the radiologist who carried out the MRI privately. We received independent advice from a consultant orthopaedic surgeon. They said that Mr C was responsible for providing the MRI images, if he wished for them to be considered. The adviser considered that the assessment carried out was reasonable, and we did not uphold the complaint.

Mr C also complained that the board had failed to provide him with the same care that he subsequently received from another health board. In response to our enquiries, the board said that, based on the information available to them, they could see no reason for surgery and were satisfied that conservative treatment was appropriate. The adviser was satisfied that the surgeon's diagnosis was reasonable and consistent with Mr C's symptoms and the radiological findings. The adviser said that it was appropriate for the surgeon to arrange to review Mr C again, but suggested that an earlier review might have been more reassuring for Mr C. The adviser did not consider the different treatment by another NHS board to reflect failure in care on the part of the board, and they were satisfied that the care and treatment provided by them was reasonable. We did not uphold this complaint.

Finally, Mr C raised concern about the quality of the board's complaint investigation. We found that the board's complaint response did provide an explanation about the surgeon's findings and a reason for the treatment they suggested. We noted that an independent clinician had reviewed the surgeon's findings and the medical records, which informed the board's response to the complaint. We were satisfied that the approach taken to investigating the complaint was reasonable, and we did not uphold this complaint.