Health

Summary

Mrs C complained on behalf of her son (Mr A) about the care and treatment provided to him by the board in relation to his Crohn's disease (a chronic inflammatory disease of the intestines). Mrs C had a number of concerns, including that one of the medications he was prescribed resulted in him developing steroid-induced diabetes and that this had not been monitored appropriately. She was also concerned that Mr A was not appropriately prepared prior to surgery to remove the colon. Mrs C felt that Mr A should have been offered support and counselling on the seriousness and potential consequences of the surgery.

We took independent advice from a gastroenterologist, a GP, and a colorectal surgeon. We found that there were aspects of Mr A's care that were reasonable, including the care provided to him prior to his surgery. However, we found that there was a failing of a consultant to clearly delegate the monitoring of Mr A's blood sugar levels to his GP. We also found that the board had not followed the UK Inflammatory Bowel Disease standards when managing Mr A's care in that they did not discuss him at a multi-disciplinary meeting. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to provide reasonable clinical treatment. 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:

• Any instructions from a consultant to a GP should be communicated to the GP in a clear manner.
• The board should consider adopting the UK Inflammatory Bowel Disease standards in the management of similar 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

Mr C complained about the care and treatment he received from the board in relation to a urodynamics assessment (a test which uses pressure readings to assess the function of the bladder) carried out at the Queen Elizabeth University Hospital. Although Mr C returned home on the day of the assessment, he later became unwell and was admitted to the hospital for over two weeks. Mr C considered that the urodynamics assessment had not been carried out appropriately and he complained that this resulted in his subsequent symptoms, including haematuria (blood in the urine) and urine retention (the inability to completely empty the bladder). Mr C also complained that, after he had received treatment as an in-patient, his discharge was unreasonably delayed.

After taking independent advice on this case from a consultant urologist, we upheld Mr C's complaint about the urodynamics assessment as we found that there were technical problems with the way that the assessment was carried out. We did not, however, find that these failings had resulted in Mr C's later symptoms. We found that verbal consent had been obtained from Mr C before the procedure, and we made a recommendation to the board that they consider obtaining consent in writing in the future. We made a number of further recommendations on the basis of our findings, including that the board review their patient information leaflet for urodynamics procedures.

Regarding Mr C's discharge, the advice we received was that there had been no unreasonable delay in discharging Mr C from hospital and we did not uphold this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mr C with an apology for the failure to carry out the urodynamics assessment in line with relevant guidance and advise him if any re-assessment is necessary. 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 the guidance on good urodynamics practice.
• Consideration should be given to introducing a documented informed consent process for urodynamics assessments.
• The patient information sheets should be reviewed and consideration should be given to including reference to urinary retention and haematuria, plus advice on what to do if these symptoms are experienced.

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

Ms C had a vaginal hysterectomy (a surgical procedure to remove the uterus through the vagina) at the Royal Alexandra Hospital. Two weeks after the surgery, Ms C started to experience sharp pains in her vulva (the skin surrounding the entrance to the vagina). She attended the gynaecology clinic at Inverclyde Royal Hospital on three occasions over the following months for treatment and was seen by a consultant and an associate specialist. Ms C's pain persisted and by the following year was intolerable. Ms C continued to try to obtain treatment for her pain and, nearly three years after her hysterectomy, was diagnosed with vulvodynia (persistent unexplained pain in the vulva). She then started treatment for this condition.

Ms C complained that the board unreasonably failed to make her aware, prior to her surgery, that vulvodynia was a possible complication of the hysterectomy surgery. She also raised concerns that the consultant and the specialist at Inverclyde Royal Hospital failed to provide her with adequate care and treatment in the three months following her surgery. She also complained that in their response to her complaint, the board failed to adequately acknowledge that the pain she experienced, and continued to experience, was directly linked to the hysterectomy surgery.

We took independent advice from a consultant gynaecologist. The adviser said that vulvodynia following vaginal hysterectomy is rare, but that there is no data to quantify how rare it is. They said that the average surgeon might never encounter it and that they would therefore not have expected Ms C to have been made aware during the consent process that vulvodynia could be a possible complication of her surgery. We did not uphold this part of Ms C's complaint.

The adviser said that Ms C should not have been discharged from care after each of her appointments with the gynaecological team at Inverclyde Royal Hospital, as her core problem was still unresolved. We upheld this aspect of Ms C's complaint.

In relation to complaints handling, the adviser explained that although Ms C's pain being directly liked to her vaginal hysterectomy was a rare risk, the timing of her symptoms in relation to the surgery was undeniable. The adviser said that at least a strong association should have been acknowledged by the board. On balance, we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for discharging her from care after each of her appointments at Inverclyde Royal Hospital, as her core problem was unresolved. Also apologise for failing to acknowledge the strong association between the surgery and the pain Ms C experienced.

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 standard of pressure area care which his mother (Mrs A) received while she was a patient in Woodend Hospital. Mrs A was in hospital for a number of months and, due to her reduced mobility, developed a grade two pressure ulcer which progressed to a grade four pressure ulcer. A grade four pressure ulcer is the most severe kind, and people with grade four pressure ulcers have a high risk of developing life-threatening infections.

We took independent advice from a nursing adviser who noted that appropriate risk assessments were not carried out and incorrect equipment had been used in an effort to prevent the development of and healing of pressure ulcers. While the staff had taken action to change Mrs A's position in bed and when she was sitting in a chair, these were not changed frequently enough. There was also a delay by the staff in referring Mrs A for an assessment by the tissue viability service. We upheld the complaint.

However, we did note that the board have since carried out an investigation and audit which identified learning opportunities for staff in regards to knowledge and awareness of pressure area care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings in pressure area care. The apology should meet the standards set out in the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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 on behalf of her brother (Mr A) about the care and treatment provided to him across numerous admissions to Aberdeen Royal Infirmary. Mr A underwent various surgeries to treat spinal cord compression and a spinal abscess. After surgery to drain the spinal abscess, Mr A was left paralysed from his waist down and was left with only partial movement in his upper body.

Miss C complained to the board as she felt that Mr A had not been properly cared for and treated. She believed that opportunities were lost to treat him sooner, and that his outcome may have been different if these opportunities had been taken. The board responded, however Miss C remained unhappy and brought her complaints to us.

Miss C complained that the board did not provide reasonable treatment to Mr A across his numerous admissions to the hospital. We took independent advice from consultants in radiology and neurosurgery, and from a nurse. We found that there was an opportunity missed to drain the spinal abscess. Had the abscess been drained at that time we considered that Mr A's outcome may have been different. We found that a scan that was carried out by an outsourced company out-of-hours did not meet a satisfactory standard, however this was not identified as having impacted Mr A's outcome. We also found that Mr A's case could have been considered in a more holistic way. We upheld this aspect of Miss C's complaint.

In relation to Mr A's discharge home from hospital, Miss C complained that he was unreasonably discharged on one occasion, and that the board unreasonably failed to ensure that there was a suitable home care package in place for him following that discharge. We found no evidence to suggest that Mr A was discharged unreasonably. We found that the relevant paperwork had been completed, and that Mr A had capacity and was in agreement with the decision to discharge him at that time. We also found that there was no evidence of a need for Mr A to have a home care package in place on his discharge home. We therefore did not uphold these aspects of Miss C's complaint.

Miss C also complained that the board did not respond reasonably to her complaints. We found that the board delayed in providing a response to Miss C's complaints and that she was not kept updated. We upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for not draining his abscess at an earlier time and for the lack of a holistic approach to his care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise to Miss C for the failure to provide a timely response to her complaint and for failing to reasonably update her. 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:

• In circumstances similar to those of Mr A, consideration should be given to draining any abscess. The decision should be fully documented and care should be considered holistically.
• All outsourced advice on scans should reach the same standards as those provided in-house.

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 length of time it had taken the board to provide him with treatment for varicose veins. Mr C was referred to vascular surgery at Victoria Hospital by his GP. Around four months later he saw a vascular consultant who said that he needed a special scan before treatment could be decided. He was told that there was a long waiting time for scans and that it was likely he would be seen approximately five months later, which Mr C said was contrary to relevant waiting times standards for treatment (18 weeks from initial referral to start of treatment). Ultimately Mr C received treatment seven months after his appointment with the vascular consultant, and 11 months after his initial referral. Mr C told us that the long delay had caused him considerable stress and that he was in pain on a daily basis. He also said that the board failed to deal with his complaint in a reasonable way.

We took independent advice from a nursing adviser with experience in surgical nursing care. We found that, whilst varicose veins is not considered an urgent clinical need, the waiting time from referral to treatment in this case was excessive (11 months) and clearly breached the relevant standards. We upheld this part of Mr C's complaint. However, we found that the board had already apologised and had taken measures taken to address the long waiting times and so we did not make any recommendations.

In relation to Mr C's complaint about complaints handling, we were satisfied that the complaint was dealt with in a reasonable time and that the response clearly reflected the position in relation to waiting times and reasons for the delays. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained about the care that his late wife (Mrs A) received from the board's out-of-hours GP service and the care she received from Victoria Hospital after she was admitted with symptoms of ongoing diarrhoea. Mr C was concerned that Mrs A's bowel cancer, which was at an advanced stage, would have been identified sooner had a CT scan been carried out sooner. He also raised concerns that there was a delay in pain relief medication being provided and that the board's response to his complaint was poor.

We took independent advice from a general practitioner and from a consultant in acute medicine. We found that the care provided by the out-of-hours GP service was of a reasonable standard because Mrs A's symptoms, and their duration, were in keeping with a working diagnosis of infective diarrhoea. We found that there was no evidence of an abdominal mass and that her vital observations (pulse rate, blood pressure and oxygen saturates) were stable with no indication of an acute emergency. We also considered that there were appropriate reasons for not carrying out the CT scan earlier. These reasons included the initial working diagnosis of infection, Mrs A's fluctuating kidney function, her warfarin (blood thinning) levels and Mrs A's preference to avoid further investigations. We did not uphold these aspects of Mr C's complaint.

We were critical that there was a delay in providing Mrs A with pain relief and we upheld this aspect of Mr C's complaint. The board have acknowledged and apologised for this. Whilst the board have taken some action, which we have asked them to provide evidence of, we made a recommendation for them to address the lack of available anticipatory medications (medicines that might be required at any time of the day or night in end of life care).

With regards to complaints handling, we found that the board's letter of response lacked clarity and should have been more accurate. We also found that some of their comments in the response letter were unneccesary. The board accepted that some of the information contained within their letter was conveyed inadequately and have taken action to ensure learning from this case. We upheld this part of Mr C's complaint. We have asked the board to provide evidence of the action they have taken and to apologise to Mr C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the complaints handling failings. 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 ensure that appropriate anticipatory medications are prescribed and administered for relevant patients in line with NHS Scotland's palliative care guidelines.

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

Ms C was in the early stages of pregnancy when she had a miscarriage. Ms C complained about the care that she received when she contacted the board's early pregnancy service by phone and she was concerned that appropriate testing had not been carried out following the miscarriage. Ms C also complained about the way that staff had communicated both with her and between departments, as she had to explain to a member of staff carrying out a scan that the pregnancy had miscarried.

We took independent advice from a nursing adviser and from a midwifery adviser. We found that the clinical advice Ms C was given was reasonable and that the management of the miscarriage was in line with relevant guidance. We also found that some testing had been carried out following the miscarriage and that further investigations were not required in Ms C's circumstances. We did not uphold Ms C's complaint about the care provided to her by the early pregnancy service.

Regarding communication, we found that, on some occasions, it had been difficult for Ms C to reach someone at the early pregnancy service. We found that the board had identified a programme of enhanced communication training to be implemented as a result of Ms C's concerns. We also found that the board planned to change their process when referring women for scans so that more information was available to the scanning staff. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failing in communication between staff. 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:

• Patients should have a 24 hour contact phone number for the early pregnancy service, in line with national guidance.

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 support provided to her following the birth of her daughter at the Victoria Hospital. She raised concerns about both her hospital care and her care in the community following her discharge. In particular, she complained about a lack of breastfeeding support, which she considered contributed to her subsequent development of postnatal depression.

We took independent advice from a midwifery adviser, who reviewed the records and concluded that appropriate support was provided to Mrs C by both the hospital and community midwives, and by the breastfeeding support worker who visited her the day after discharge. It was noted that an apparent breakdown in communication within the breastfeeding support team meant that they did not follow up with Mrs C as planned. The board had already acknowledged this oversight and undertook to discuss how they can better document requests for follow-up. The adviser also observed that the community midwives documented Mrs C's tearfulness and low mood but that they did not pass this information on to the health visiting team, as they should have. It was noted that the board had asked the community midwives to carry out a piece of work in relation to women's emotional states. On balance, we did not uphold the complaint but we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the breastfeeding support team's failure to contact her to arrange a follow-up appointment; and for the community midwives' failure to pass on details of her low mood to the health visitor. 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:

• The breastfeeding support team should review their follow-up referral process and implement measures to ensure follow-up appointments are not missed in future.

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 medical treatment and nursing care that her late mother (Mrs A) received at Victoria Hospital. Mrs A had been diagnosed with advanced lung cancer and was admitted to hospital with symptoms of nausea and persistent vomiting. The issues Mrs C raised concern about related to a lack of blood testing to monitor Mrs A's kidney function as she had chronic kidney disease, that no intravenous (IV) fluids were given over two specific days and that fluids were not appropriately monitored, that there was a delay in a urinary catheter being inserted and that communication with the family was poor.

We took independent advice from a consultant in respiratory medicine and from a nurse. We found that there were a number of unreasonable delays in relation to Mrs A's medical care and treatment. We considered that if IV fluids had been administered in a timely manner, this may have delayed or prevented the development of an acute kidney injury (the inability to turn waste material into urine) and may have allowed Mrs A to spend more time with her family. We upheld Mrs C's complaint about medical care and treatment.

In terms of the nursing care, we found that there was a lack of comprehensive monitoring of Mrs A's fluid intake and urine output which the board's complaint investigation did not identify. We considered that such monitoring may have helped assist medical staff identify issues with urinary output sooner. We upheld Mrs C's complaint about nursing care.

We noted that the board had accepted that there were problems with the way in which staff had communicated with Mrs C and the family. Therefore, we have asked the board to provide evidence of the action that they said they would be taking to address this. However, we also recommended that the board take further action to address how they review the care and treatment of patients as their response to the complaint contained inaccurate information.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in Mrs A's medical and nursing care, and for the fact that the board's complaints investigation was not thorough enough.

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

• Review by a senior doctor for patients admitted as an emergency should be carried out in a timely manner.
• Difficulties with IV access should be escalated in an appropriate and timely manner.
• Fluid balance charts should be fully completed when indicated.
• Appropriate clinicians should be involved in the review of patient care to ensure that comprehensive responses to complaints are provided.

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.