Health

Summary

Mr C had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were busy, they asked another consultant to carry out the tests. Both consultants thought that the other would be responsible for Mr C's ongoing care, so neither of them wrote a discharge letter. While Mr C attended a follow up appointment at the second consultant's clinic, he saw another doctor who referred him back to the first consultant, instead of to the multi-disciplinary team (MDT), which is what should have happened. The first consultant did not see the referral.

Mr C and his GP both tried to contact the first consultant to find out what was happening, but it is not clear whether Mr C's phone messages were passed on and his GP's letter was not seen by the first consultant. Eventually, about six months after the scan, Mr C's GP spoke with the first consultant, who then referred Mr C to the MDT for consideration and Mr C was offered palliative radiotherapy. Mr C was told that his cancer was terminal, and he was concerned that the delay may have affected this outcome. He complained to the board about this.

In response to Mr C's complaint, the board accepted that there was an unreasonable delay and a failure to communicate with Mr C about his treatment. They apologised for this and said that they had taken action to prevent this happening again. The board had put in place a new protocol for passing care between two consultants, and a message book to ensure phone messages are recorded and signed off by consultants. The board said that the delay would not have affected the outcome in Mr C's case, although they acknowledged that palliative radiotherapy should have been offered sooner. Mr C remained unhappy and brought his complaints to us.

We took independent advice from a thoracic surgeon (a surgeon who deals with treatment of conditions of the organs inside the chest). We found that the delay in arranging treatment for the mass on Mr C's lung was unreasonable. We upheld this complaint, however we noted that, although Mr C's cancer grew during this time, the delay would not have affected his outcome, as surgery or radical radiotherapy would not have been available even if he had been considered immediately. As the board had already put in place measures to avoid this happening again in the future, we did not make any further recommendations in this regard.

Mr C also complained that the hospital failed to communicate reasonably with him about the arrangements for his treatment. We found that there were failings in communication, including a failure by the first consultant to pick up on two important letters. We upheld this aspect of Mr C's complaint. We noted that the board had already taken some steps to avoid similar failings occuring in the future, however we made a further recommendation regarding mail processes.

Recommendations

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

• Consultants should have robust mail processes in place to ensure that important letters are not missed or overlooked.

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 care and treatment her husband (Mr A) received at Forth Valley Royal Hospital. Mr A was admitted to hospital after sustaining a fracture to his thigh bone. An operation was carried out to insert a pin into the thigh bone to secure the fracture. During the operation, the wrong size of screw was used to fix the pin to the bone. Medical staff discussed this situation with Mr A following the operation, and it was agreed that a further operation would be carried out to replace the screws with those of a correct size. This operation was completed successfully and, after a period of recovery, Mr A was discharged home. Mr A was then re-admitted to hospital after he became unwell. The board carried out blood tests which showed signs of infection, yet it was not clear where the source of the infection was. Mr A's condition deteriorated and he died from a bowel condition related to the infection.

Mrs C complained that the wrong screw was used in the first operation and she felt that the second operation had caused the infection that led to Mr C's death. The board apologised to Mrs C about the use of the wrong screw and informed us that this issue had been discussed at a number of clinical meetings in order to prevent the issue from happening again.

We took independent advice from a consultant orthopaedic and trauma surgeon. They considered that the care and treatment provided to Mr A was reasonable, with the exception of the use of the incorrect screws. The adviser said that, in their opinion, the infection related to Mr A's re-admission was not linked to the orthopaedic treatment he received. Although we were unable to conclude that the orthopaedic treatment received led to Mr A's death, we upheld this complaint and asked that the board send us evidence of the steps they said they had already taken to prevent this from happening again.

Summary

Mrs C complained about the care and treatment her husband (Mr A) received during an admission to St Andrew's Community Hospital for a period of rehabilitation. She complained that Mr A's suspected urinary tract infection and delirium were not treated appropriately and with sufficient urgency, thus prolonging his admission unnecessarily. She also raised concerns that he was inappropriately sedated over the weekend prior to discharge.

We took independent advice from a GP adviser who considered that Mr A received appropriate treatment for his infection symptoms and delirium. They noted in particular that his blood results were negative for infection when Mrs C first requested more aggressive antibiotic treatment. The adviser also considered it clinically reasonable to prescribe a sleeping tablet as a trial to treat restlessness at night, although they said that it would have been good practice for staff to have discussed this with Mrs C in advance. The board had already acknowledged that it would have been helpful for this to have been discussed with Mrs C. We accepted the advice received and concluded that the medical care provided to Mr A was reasonable. We did not uphold the complaint.

Summary

After the birth of her child at Borders General Hospital, Mrs C made a number of complaints about the procedures involved. She said that there was a failure to obtain properly informed consent for intimate examinations and that the board provided incorrect information about who had acted as a chaperone. She also complained that the board did not ensure that she was anaesthetised by an anaesthetist of sufficient seniority given that she had scoliosis (a musculoskeletal disorder in which there is a sideways curvature of the spine). Mrs C also complained that she and her new born baby were not given reasonable nursing care when she was in hospital.

The board said that they had followed their usual practice of obtaining implied consent to treatment set against a background of the clinical care they had already given. They also said that they had provided the correct name of the chaperone as requested and that Mrs C's spinal injection had been performed by both a consultant and a senior trainee. They were also of the view that Mrs C's nursing care had been reasonable.

We took independent advice from a consultant in obstetrics and gynaecology and a consultant in obstetrics and general anaesthesia. We also took independent nursing advice. We found that implied consent was insufficient for intimate examinations and that consent must be recorded in patients' notes. It was not recorded in Mrs C's notes and, therefore, we upheld this complaint.

Regarding Mrs C's other complaints, we found evidence in the notes to confirm who had acted as chaperone and we found that Mrs C had been given her anaesthetic reasonably by clinicians of appropriate seniority and expertise. We found no evidence of unreasonable nursing care. As such, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to seek formal consent for intimate examinations.

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

• The board should develop a guideline on consent for intimate examinations and the use of chaperones, with reference to national guidance, including documentation.

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 that staff at the dental practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to the dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a second dentist who also said that he was not to worry and that the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital, where the bleeding eventually stopped and he was sent home.

We took independent advice from an adviser in general dentistry and concluded that the second dentist was aware that Mr C was on warfarin medication and that they had repeated the advice given earlier by the first dentist about what Mr C should do in the event of bleeding from his gums. We considered this to be reasonable and we did not uphold the complaint.

Summary

Mr C complained that dental staff at the practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to a dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a different dentist, who also said that he was not to worry and the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital where the bleeding eventually stopped and he was sent home.

We took independent advice from an adviser in general dentistry and concluded that the first dentist was aware that Mr C was on warfarin medication, that they had checked his clotting status prior to the extractions and that they had stitched and packed the tooth sockets following the extractions. The first dentist had also provided Mr C with a detailed post-operative instruction sheet, which provided advice on action which should be taken regarding any bleeding. We did not uphold the complaint.

Summary

Ms C complained about a number of consultations, for different medical complaints, that she had at her GP practice. Ms C also complained that she had been unreasonably removed from the practice list, and she complained about how the practice had responded to her complaint.

We took independent advice from a GP adviser. We found that Ms C had received a reasonable standard of care and treatment, and so we did not uphold this aspect of the complaint. However, we did find a consultation which had happened had not been noted in the clinical records. We made a recommendation to address this.

We found that the practice had followed the correct procedure when removing Ms C from their patient list and that they had responded thoroughly to her complaint. We did not uphold these complaints.

Recommendations

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

• All interactions with patients should be documented, adhering to the standard of record-keeping set out in the General Medical Council's Good Medical Practice 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

Mr C complained about the care provided to his wife (Mrs A) during out-patient appointments at the cardiology department at Ninewells Hospital. Mrs A was referred to the cardiology department by her GP because of drop attacks (sudden episodes of collapse). Over the following 18 months, Mrs A attended consultations in the department and a number of investigations into her symptoms were carried out. During the period that Mrs A was waiting to be fitted with a cardiac event monitor device (a device to measure the heart's activity), she sustained a stroke and was admitted to hospital for treatment. Tests carried out during this admission indicated that Mrs A was in atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). Mr C complained that the board had failed to provide Mrs A with a appropriate treatment in view of her presenting symptoms and medical history.

We took independent advice from a consultant cardiologist. We found that the board managed Mrs A's condition appropriately, with the exception of the way they handled a referral from her GP approximately five months prior to the date of the stroke. We found that this referral described a change in Mrs A's symptoms and their pattern and the adviser said that the referral should have been considered more promptly and carefully by the cardiologist. The adviser said that further tests could have been considered and that, had these been carried out promptly, atrial fibrillation might have been diagnosed sooner. The adviser said that if atrial fibrillation was diagnosed, then medication would have been started and the likelihood of the subsequent stroke would have reduced. We were unable to conclude that better management would have changed the eventual outcome in this case. However, we upheld the complaint and made recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings to handle the GP referral five months before the stroke in an appropriate manner. 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 carefully assess whether a referral highlights a change in symptoms and their pattern, before promptly considering whether further investigations or actions are indicated.
• Waiting times for routine investigations, such as a patient being fitted with a cardiac event monitor device, should be minimised as far as possible.

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 care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints.

During the birth, Mrs C's baby became stuck after delivery of the head due to shoulder dystocia (where one of the shoulders becomes trapped behind the mother's pubic bone) and additional help had to be called to assist the midwife who was attending to her. The baby was delivered following this, but died a few days after the birth.

After Mrs C raised her complaints with the board, they carried out a local adverse event review and also had an external review conducted by a senior midwife from another NHS board area. These reviews identified some failings with regards to aspects of Mrs C's care. However, it was found that these failings did not affect the outcome, which was considered to be unavoidable.

After taking independent advice from a midwife, we upheld Mrs C's complaint about the induction of her labour. We found that there had been delays which affected her access to pain relief and that there had been poor communication. We did not make any recommendations relating to this as these failings had already been addressed by the board.

We also upheld Mrs C's complaint about her care during labour. We found that the board had already identified issues, including the way that examinations were carried out to monitor Mrs C's progress. The advice we received highlighted further concerns about monitoring of blood pressure and listening to and recording Mrs C's preferences during labour. We made recommendations to address these matters.

We did not uphold Mrs C's complaint about the care that was provided to her during the birth of her baby. The advice we received was that this care was timely and that the shoulder dystocia could not have been identified earlier or avoided.

We upheld Mrs C's complaint about the way her complaint was handled by the board. We found that the timescale for completing the investigation of her complaint had not been met and that Mrs C had not been kept updated during the process. We made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care during induction and labour, and for failing to handle her complaint reasonably. 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 should be listened to. Their preferences and concerns should be responded to. Clear and accurate records of this should be kept.
• Blood pressure should be recorded 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

Ms C complained to us that that a GP at the health centre had failed to provide her with appropriate treatment during a consultation. She had attended the GP and had reported that a couple of days earlier she had been woken with severe pain on her left side. She wondered whether she had ruptured an ovarian cyst which she was known to have. Ms C said that the GP did not examine her or take her temperature. Ms C said that five days later she began vomiting and was admitted to hospital, where it was found that she had ruptured her bowel.

We took independent advice from a GP adviser. We found that the GP had suspected that Ms C may have ruptured an ovarian cyst and that they did arrange for an appropriate blood test and an ultrasound to be carried out. However, the adviser also said that the GP should have examined Ms C's abdomen and checked a urine sample as she had reported abdominal pain. Although the adviser felt that the GP should have performed a clinical examination, the adviser thought it was unlikely that Ms C had ruptured her bowel at the time she saw the GP as this would normally involve the onset of acute sudden symptoms. Ms C had also reported that her symptoms were improving when she saw the GP. The GP had carried out a Significant Event Analysis and they had recognised that they should have examined Ms C's abdomen. The GP said that they would examine patients' abdomen in future. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide a written apology for failing to carry out an appropriate assessment. 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:

• The GP should ensure that full and appropriate assessments are carried out based on the patient's reported symptoms.

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.