Health

Following publication on 24 March 2021, this complaint was subject to a review.  The overall outcome of the complaint remained unchanged however, amendments were made to both the summary and recommendations.  The summary as originally published can be found at the bottom of the page. 02/03/2022

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C’s lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C’s lung lesion was unstructured. We were advised that a CT PET scan was not carried out in a timely manner; there was no referral to a lung multi-disciplinary team (MDT) when scans subsequently showed an increase in lesions; and there was a delay in referring to oncology for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C’s prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C’s associated distress. We accepted the advice and upheld this complaint. Whilst not raised in the complaint, the adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a ‘near miss’.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and carry out a CT PET scan in a timely manner; the delay in referring to oncology; and the failure to check for the tattoo marker during surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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.

Original summary published on 24/03/2021

Summary

C complained about the care and treatment they received from Inverclyde Royal Hospital. C underwent colorectal surgery during which it was identified that they had rectal cancer which had spread into the vascular system. Prior to the surgery, a lesion on C's lung was noted but was not thought to be typical of cancer and a plan was made to keep it under review. C raised a number of concerns regarding the reasonableness of the management plan for their cancer and delays to their treatment. They considered that treatment decisions were made without their involvement and they were given misleading information about their treatment options.

We took advice from a general and colorectal surgeon who noted that the monitoring of C's lung lesion was unstructured. A respiratory physician's recommendation was not followed up and C was not referred to a lung multidisciplinary team (MDT) when scans showed that the lung lesions had increased in size and number. The adviser also identified a delay in referring C to an oncologist for discussion of treatment options. As such, C was not provided with a clear picture of their condition and management plan, and treatment was not instigated as soon as it might have been. While it was accepted that treatment options were limited and earlier treatment may not have altered C's prognosis, earlier discussion with oncology could have cleared up some of the uncertainty and alleviated C's associated distress. We upheld this complaint. The adviser also observed a failure during the colorectal surgery to check for a tattoo marker that had previously been placed to mark the tumour. While this did not result in a failure to fully remove the tumour, the adviser described it as a 'near miss'.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C's next-of-kin for the lack of clarity in follow-up monitoring; the failure to refer C to the lung MDT and follow up the respiratory physician's recommendation; the delay in referring to oncology; and the failure to check for the tattoo marker during surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should review and identify why the respiratory physician's recommendation was not followed up.
• The board should tell the Ombudsman what their process is for reporting and reviewing 'near miss' events, and why there was an apparent failure to identify this one.
• The colorectal MDT should reflect on C's care and treatment and review its processes for referrals to oncology or other MDTs, to ensure appropriate input is received and acted upon.
• The colorectal MDT should review its processes in respect of ensuring there is a clear pathway for monitoring specific issues separate to standard post-surgical follow-up.
• The colorectal team should discuss the failure to check for the tattoo marker during surgery, and how a similar future error can be avoided.

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

C complained that the board's treatment of their breast cancer was unreasonable. Following a routine breast screening, C was diagnosed with breast cancer. They underwent surgery and were told that the tumour was successfully removed and no further surgery would be required.

C was referred to the oncologist (a doctor who specialises in the diagnosis and treatment of cancer) for ongoing treatments including chemotherapy. Before commencing the treatments, it was identified that the initial surgery had not cleared the cancer. Further surgery was organised but that procedure was not successful. Chemotherapy could not be delayed further so C had to undergo a mastectomy (an operation to remove a breast).

Through its own investigation, the board acknowledged that there had been a failure to review the correct and relevant postoperative pathology information from C's surgery. Appropriate action was taken by the board as soon as the error was identified. We took independent advice from a consultant breast surgeon who agreed that overall the failing in C's case was very significant but that it did not result in significant harm as it was discovered and appropriate steps were taken to rectify it before any further treatments were commenced. We upheld this aspect of C's complaint but did not make any recommendations.

C also complained that the board failed to respond appropriately to their complaint. We found that the board took C's complaint seriously, they acknowledged that an error occurred and they committed to reviewing the process to ensure that the same kind of error would not happen again. The board also gave an appropriate apology. Therefore, we did not uphold this aspect of C's complaint.

Summary

C was taken into Queen Elizabeth University Hospital for a kidney removal after the discovery of a cancerous cyst. A few days after the operation they were detained under the Mental Health Act and transferred to Stobhill Hospital. C believed they were not physically fit for discharge at that stage, and that there was insufficient evidence of risk to justify detaining them. In addition, they considered that their medication was mishandled throughout their time in both hospitals and that staff failed to treat them with respect and dignity. C is also blind and felt that the board had failed to reasonably take account of this in the way they interacted with and cared for them.

We took independent advice from a nephrologist (a doctor who specialises in kidney care and treating diseases of the kidney), a psychiatrist and a nurse. We found that C's care and treatment was generally reasonable, with the exception of the handover between the two hospitals, which was insufficient and led to problems with the dosage of C's medication. On this basis, we upheld C's complaint that the board failed to provide reasonable clinical treatment, but did not uphold their other complaints.

Recommendations

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

• Reasonable handover notes should be provided when patients are transferred between hospitals, to ensure continuity of care.

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

C attended their GP with shoulder pain and was referred to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) who, during the initial consultation, reviewed x-rays and ultrasound imaging and concluded no broken bones were shown. A was diagnosed with muscle patterning (when the pattern of muscle contractions is altered) and referred to the physiotherapy department for treatment.

C had a number of follow-up appointments and was discharged around four months later as it was considered that there was no further treatments they could be offered to alleviate the symptoms. C was then referred to the neurology department (the branch of medicine concerned with the diagnosis and treatment of disorders of the nervous system). Around the same time, after seeing a private doctor, C had an MRI scan and the results showed that C had broken ribs. C considered that medical professionals focused on their disability and other medical conditions, unreasonably delayed in diagnosing the broken bones and that it was only because they instructed a private consultant, that the injuries were diagnosed.

We took independent advice from an appropriately qualified medical professional. We found that the board performed appropriate investigations following C's referral by their GP. There was an appropriate multidisciplinary approach following the initial consultation involving physiotherapy, rheumatology (the branch of medicine that deals with rheumatism, arthritis, and other disorders of the joints, muscles, and ligaments), orthopaedics and neurology. The fractures identified occurred after the initial consultation and investigations carried out following the GPs referral. We considered that there was no unreasonable delay in diagnosing C's broken bones and therefore we did not uphold the complaint.

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C underwent splenic artery embolization (a procedure that involves inserting a fine tube into the blood vessel that supplies blood to the spleen and deploying a device to treat an aneurysm). A complication occurred and following the procedure it was identified that a fine piece of filament was retained in Ms C's leg. A further procedure was performed the following day and the filament was removed. Ms C experienced significant discomfort during and after the procedure. Ms C remained dissatisfied following receipt of the board's response to her complaint and brought her complaint to us.

We received independent advice from a radiology adviser (a specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the first procedure was not performed reasonably as there was a failure to identify the retained filament before the procedure ended. We found that the second procedure was performed reasonably and we considered that the board had taken reasonable action to learn from the complication that occurred. Finally, we considered that the consent process was inadequate as it was not clear that Ms C was informed about the possibility of pain as a result of the procedure. We upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in care and treatment identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be informed about discomfort and common relatively minor side effects following a procedure as well as more serious complications using simple terms.

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 care and treatment that his late mother (Mrs A) received at Glasgow Royal Infirmary. Mrs A had vascular dementia (a common type of dementia caused by reduced blood flow to the brain, which can cause problems with mental abilities and the physical activities of daily life). Mrs A was admitted to hospital with a fractured collarbone, following a fall at home. During her hospital admission, Mrs A had difficulties swallowing and eating. Her condition worsened and she was diagnosed with aspiration pneumonia (an infection caused by food, saliva or stomach acid being inhaled into the lungs). After Mrs A was discharged home, she was readmitted to the hospital around a week later. Her condition failed to improve and she died in hospital.

Mr C complained that the board had failed to provide Mrs A with reasonable medical care and treatment. In particular, Mr C felt that Mrs A's swallowing difficulties were wrongly attributed to her having advanced dementia. Mr C felt that Mrs A was not given appropriate treatment for her pneumonia because of this. We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that it was reasonable that Mrs A's swallowing difficulties were attributed to her having advanced dementia. We also found that overall, Mrs A's pneumonia was treated appropriately; and there was no evidence that it was left untreated because of her having advanced dementia. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide Mrs A with reasonable nursing care; in particular, that she was not given appropriate nutritional care in light of her difficulties swallowing and eating. We took independent advice from a nurse. We found that the nursing staff took reasonable action to try to address Mrs A's nutritional needs. However, we found that on one occasion, Mrs A was given the wrong meal for her diet. We also found that when Mrs A's condition worsened during her first admission, nursing staff failed to escalate this to medical staff. These failings had been identified and acknowledged by the board.

In light of these failings, we upheld this aspect of Mr C's complaint.

Recommendations

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

• Patients on a restricted diet should receive the appropriate meal.

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

C complained on behalf of A who has a terminal cancer diagnosis. A was diagnosed with a metastatic carcinoma (a cancer that grows at sites distant from the primary site of origin) of possible colorectal (colon) or ovarian origin and progress lung nodules. C complained that A was misdiagnosed multiple times and given the wrong treatment.

The board said that A underwent a number of investigations in order to identify the source of the primary cancer. They explained that surgery was not a viable treatment option.

We took independent advice from a consultant clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer).

We found that the investigations carried out were appropriate and the length of time taken reflected the challenges faced in trying to identify the source of the primary cancer. There was no evidence to suggest that A was misdiagnosed or given the wrong treatment. We identified that there was a delay in completing the colorectal investigations however, on balance, we did not consider that this delay was significant as it did not have a detrimental impact on A's prognosis. As such, we concluded that the care and treatment was reasonable and we did not uphold the complaint.

Summary

C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the brain. B experienced a neurological deficit following the procedure and the surgeons identified that the burr hole (a small hole drilled into the skull) was not placed at the intended site. Over the following months, the neurological deficit improved but B continued to experience severe headaches following the procedure. Follow-up care was provided by paediatric oncology (specialists in treating children with cancer) and paediatric neurology (specialists in treating children with disorders of the nervous system) as well as other specialties over the following years.

We took independent advice from a consultant paediatric neurosurgeon and a consultant paediatric neurologist.

Firstly, C raised concern that the board did not obtain informed consent for the surgery and that the surgery was not performed to a reasonable standard. We found that there was limited reference to complications within the consent form and the written notes, whilst a number of known serious complications were not included in the consent form. We also found that the incorrect placement of the burr hole was unreasonable and that this likely caused the neurological deficit that B experienced. We upheld these aspects of C's complaint.

C also complained that the board did not manage B's pain reasonably following the surgery. We found that this aspect of B's care had been reasonable, with close involvement from both a consultant paediatric oncologist and a consultant paediatric neurologist over a number of years. We did not uphold this aspect of C's complaint.

Finally, C raised concern about the communication between the board and the family about B's care. We found that the documentation of discussion with B's parents about the surgical complication was poor. We found that the communication in relation to B's headaches was, on balance, reasonable. However, we noted that there should have been better communication from the paediatric oncology team. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B and B's parents for the failings identified in the consent process, in the surgical procedure and in communication with the family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Adequate systems should be in place to ensure that technical errors are minimised.
• In accordance with the professional duty of candour, health professionals must tell the patient (or, where appropriate, the patient's advocate, carer or family) when something has gone wrong and apologise for what happened. This should be clearly documented.
• Informed consent should be obtained in accordance with the General Medical Council's guidance on this matter.

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

C's adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought that it appeared different to A's previous episodes and called the GP who visited A at home.

The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where A was quickly assessed and taken to the Intensive Care Unit. A died later that day.

C complained that the GP had not properly assessed A, they had not taken blood pressure readings or their temperature. C said that the GP assessed A through the prism of mental health and had not properly considered whether there could be another cause to their presentation, which was different from previous ones.

We took independent advice from a GP. We found that it was appropriate for the GP to consider A's prior medical history when assessing their condition. We found that the GP correctly identified that assessment at hospital was needed, recognising the seriousness of A's condition.

On the basis of information available to the GP at the time, their assessment and conclusions were reasonable. Therefore, we did not uphold the complaint.

Summary

C complained about a psychiatric consultation at Falkirk Community Hospital. They complained that they did not receive adequate support from the psychiatrist and that the psychiatrist made inappropriate comments regarding the impact of suicide on others and the best way to complete suicide. We took independent advice from a consultant psychiatrist. It was not possible to confirm from the notes the way the psychiatrist communicated with C or exactly what was discussed surrounding suicide. The board explained that it was the psychiatrist's normal practice to discuss the impact of suicide on others but refuted that C was advised of the best way to take their own life. We considered that the psychiatrist carried out a reasonable assessment and proposed an appropriate management plan. We did not uphold this complaint.

C also complained that a board run GP practice refused to continue their prescription for gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) until C had been seen by the psychiatrist. This medication had been prescribed overseas and C noted that it was for restless leg syndrome (RLS) and not a psychological condition. The board explained that gabapentin is a controlled drug in the UK which can only be prescribed in specific circumstances and with specialist input. They noted it is unlicensed for RLS. We took independent advice from a GP, who noted that gabapentin can be prescribed 'off-label' to treat RLS and they saw no reason for changing this if C had been taking it with good effect and was established on a reasonable dose. However, if the practice had concerns and wished to change this, it should have been gradually reduced and not stopped suddenly. We concluded that it was unreasonable to have refused to prescribe C gabapentin pending a psychiatric review. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the stoppage of their gabapentin without a reduction regime. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should ensure the practice GPs familiarise themselves with gabapentin reduction regimes and the indications for the same.

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.