Health

Summary

C complained about the consent process and the standard of surgery for a procedure they had received from the board. C was listed for a surgical procedure with the aim of removing a stoma (an opening in the abdomen formed during a colostomy procedure) and a para-stomal hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards). The surgeon was unable to safely perform the procedure as planned and the decision was made to create a new stoma site. C experienced complications with the wound following surgery and was unhappy with the outcome.

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C should have been informed about the risk that it might not be possible to complete the intended procedure successfully and the implications of this. In the absence of evidence that C was informed of this, we concluded that the board had failed to obtain appropriate consent for the procedure, in line with recognised guidance. We upheld this aspect of C's complaint.

In relation to the surgical procedure, we found that this was performed to a reasonable standard and the decisions made by the surgeon during the operation were reasonable. Given the findings, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the risks for the surgical procedure were not fully outlined as part of the consent process. 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:

• A patient's medical history should be considered to anticipate difficulties in a procedure and the likely scenarios that could emerge. Patients should receive information about the risks in a way they can understand (including side effects; complications; or failure of an intervention to achieve the desired aim), taking into account the information they want or need to know. This should be fully documented.

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 about matters relating to their previous GP practice. C had been removed from the practice list as in the practice's view there had been a complete breakdown in the doctor/patient relationship due to the way C was using a prescribed antibiotic medication. The practice wrote to C to inform them of their decision.

C had concerns about the practice's decision to remove them from the list. We found that the practice had failed to provide C with a warning before removing them from the practice list. Therefore, we upheld this aspect of the complaint.

C was also unhappy with the factual accuracy of a letter sent by the practice regarding the removal decision. We did not find that the practice's letter contained inaccuracies and we were unable to conclude that it was unreasonable. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to issue a warning before removing C from their practice list. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reconsider any application to register received from C.

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

• A breakdown in a doctor/patient relationship should be managed in line with General Medical Council guidance and the relevant legislation.

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 practice failed to provide them with effective treatment for a skin complaint and that they waited an unreasonable length of time before they saw a doctor.

We took independent advice from a nurse adviser and a GP adviser. C had first attended two nurse consultations, a week apart, as they had developed an itchy rash on their back. We noted that the initial working diagnoses (insect bites/fungal infection) and the care and treatment provided at this point was reasonable. Ten days after C's first consultation, they contacted the practice again. As the triage telephone call mentioned 'shingles' as another possible diagnosis, a referral to see a GP should have been made at this time. However, C was given an appointment with an advanced nurse practitioner. Although C was being treated with an allergy tablet, there was no documented working diagnosis of what was causing the itch. We found that the management of C at this time was not reasonable.

C contacted the practice again the following day and requested to be seen by a GP. This was the fourth time C had contact with the practice in eleven days since the onset of the rash, which was getting worse and becoming painful. Although the advanced paramedic practitioner who saw C on this occasion sought advice of a GP regarding treatment, we considered that it was unreasonable that C was not referred to be seen by a GP at this time.

C made a further request for a GP appointment two weeks later and again was given an appointment with an advanced paramedic practitioner. We found that this was unreasonable given that this was C's second request for a GP appointment, they had seen nurse and paramedic practitioners four times over a period of several weeks and had attended the out-of-hours service, during which time their rash was getting worse/not responding to prescribed treatment and was painful.

Due to their ongoing symptoms, C attended again at the out-of-hours service when they were prescribed an oral steroid and advised to contact their GP to expedite a dermatology (diseases of the skin, hair and nails) appointment as soon as possible. At this time, C had still not seen a GP in the practice and we considered this to be unreasonable. When C eventually saw a GP, an urgent referral to dermatology was made. The care and treatment provided by the GP at this time was reasonable.

Taking into account all of the evidence and the advice we received, we found that the practice failed to provide C with reasonable care and treatment. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to have an appropriate management plan in place and for failing to refer C to be seen by a GP earlier. 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:

• Where a patient presents on several occasions with an acute condition that is not responding to treatment, an appropriate management plan should be in place. Where a patient has seen advanced practitioners on two occasions and requires to be seen a third time with the same acute condition, consideration should be given to having a GP review the patient.

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 spouse (A) received care and treatment from the board for a recurrence of bowel cancer. C complained that the communication and actions by the board in relation to that were unreasonable.

C complained that the board failed to provide reasonable treatment to A. We took independent advice from a senior clinical oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that the treatment offered to A was reasonable and in line with guidance. We did not uphold the complaint.

C complained that the board failed to provide reasonable care to A. We found that the board had acknowledged there were some failings relating to staff responding to care requests and there were challenges when a procedure was undertaken. Overall we found that while there were failings in specific instances, the care provided over the entire period was reasonable. On balance, we did not uphold the complaint.

C complained that the board failed to reasonably communicate with A and C in relation to A's diagnosis and the potential risks of treatment. We found, based on the written records available, that the communication was reasonable, noting that the written records could not illustrate the level of empathy exhibited by clinicians. The written records did demonstrate that the risks relating to treatment were discussed. We did not uphold the complaint.

Summary

C complained about their urology care (the branch of medicine and physiology concerned with the function and disorders of the urinary system) and treatment at Borders General Hospital. C has a complex past urological and surgical history including a total cystectomy (bladder removal), and was referred to urology with ongoing pain and discomfort around their stoma region (an opening in the abdomen formed during a colostomy procedure). C complained that the urologist did not see them and that they were instead seen by a general surgical registrar who failed to identify symptoms of a kidney stone. C subsequently became very unwell and was admitted to hospital with an obstructed infected kidney.

In their response to C's complaint, the board confirmed that the urologist felt it best for C to be seen by the consultant general surgeon who had carried out their most recent hernia (a weakness in the abdominal wall beside a stoma which allows the bowel to protrude outwards) repair surgery. They noted that, when C was then assessed by the surgical registrar, they did not have any specific symptoms which would have indicated the presence of a kidney stone.

We took independent medical advice from a consultant urological surgeon. We found that it was reasonable for C's clinical assessment to have taken place with either the surgical or urological consultant team. We, therefore, did not uphold C's complaint about a lack of urological review. We considered that C was appropriately assessed by the surgical registrar, and there was no clinical evidence at that time to indicate the presence of a kidney stone. We did not uphold C's complaint about a failure to diagnose their kidney stone. We noted, however, that C should have been seen by the consultant general surgeon, rather than a surgical trainee, in light of their complex history. We fed this back to the board.

Summary

C complained on behalf of their parent (A) about the care and treatment they received during an admission to Ninewells Hospital. A was given a working diagnosis of a urinary tract infection (UTI) with delirium but was later diagnosed with encephalitis (inflammation of the brain). C said that because A regularly suffered UTIs, assumptions were made that A was experiencing the same again. C said that, as a result, appropriate investigations were not carried out and there was an unreasonable delay in diagnosis which affected A's outcome.

The board said that a UTI had been given as a reasonable working diagnosis and that blood and urine tests confirmed this. They considered that A had been treated reasonably in the circumstances.

We took independent medical advice. We found that at the time of their admission, A had non-specific symptoms which were reasonable to diagnose as a UTI. When A deteriorated and their symptoms changed, A was cared for reasonably with an appropriate degree of urgency, and a prompt diagnosis of encephalitis was made. While A suffered a poor outcome, we could not conclude that this was as a result of an unreasonable delay in diagnosis. We did not uphold C's complaint.

Summary

C suffered from a gastrointestinal (stomach) disorder and was receiving treatment from the board. C complained that the treatment in response to their condition was unreasonable.

We took independent advice from a consultant hepatologist and gastroenterologist (specialist in disorders of the gastrointestinal tract, liver, pancreas and gall bladder). We found the clinicians involved in C’s care considered both the physical and psychological elements relating to C’s condition, undertook reasonable investigations into their condition and provided reasonable treatment in terms of C’s symptoms. We noted that it was reasonable in conditions such as C's, where there was no cure, to focus on the management and improvement of symptoms and prevent harm. As such, we did not uphold this complaint.

C complained that the board failed to reasonably respond to their complaint. We found that the board failed to reply to all the points raised by C. C raised a number of concerns regarding the treatment they had received. In response, the board advised that the review undertaken indicated that clinical management was appropriate; however, no details were provided to explain how they had reached that view. While we considered it was reasonable that the board focused on a way forward, to ensure appropriate treatment was carried out in the future and this was a resolution-based approach, this did not remove the requirement to respond to the points C had raised about previous treatment. There was also an unreasonable delay in responding to C’s complaint. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable response to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all of the points of complaint raised by a complainant and be issued in a reasonable timescale.

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 has felt that they have obsessive compulsive disorder (OCD) for some years. C has seen various clinicians at the board about this but does not feel that they received appropriate care or treatment. C complained to the board about their care and treatment over the previous years. C said that a psychologist did not provide reasonable care or treatment, that a community mental health nurse did not provide reasonable care and that a psychiatrist unreasonably diagnosed C with anxiety.

In their responses, the board told C that the psychologist had reviewed their care and treatment. The board outlined the care and treatment C had been offered and had taken up and concluded that C’s care and treatment had been handled reasonably. C was dissatisfied with the board’s response and raised their complaints with our office.

We found that the overall standard of treatment provided to C between the period in question by all of the board staff complained of was of reasonable quality and in line with relevant guidance. We did not uphold the complaints.

Summary

C complained on behalf of their partner (A) about surgery they had on their hip. A, who had previously had their hip replaced, was admitted to hospital with an infection which was found to have originated in their hip and required surgery (the first surgery). The following year, A developed pain in their hip again. Scans confirmed that this would again require surgery, which was carried out later that year (the second surgery). A was discharged shortly after, but required to be readmitted twice due to pain. On the second readmission a fracture was identified above their knee, requiring additional surgery. C complained about the first surgery, the second surgery, the aftercare A received and how the board responded to their complaint.

We took independent advice from a consultant orthopaedic surgeon (a surgeon who specialises in the musculoskeletal system). We found that the first surgery was carried out appropriately. C had been concerned that the surgeon had used an incorrectly sized piece of orthopaedic equipment (a stem), however, we noted that the surgeon either used an identical, or slightly smaller stem as they decided not to remove the original cement. We found that this was reasonable.

We found that the second surgery was also carried out appropriately. The surgeon cut a small ‘window’ in the bone to facilitate removal of the cement which was established practice. We considered that this was probably the source of the fracture which A was later found to have, however, there was no indication of a fracture at the time of the surgery.

We were satisfied that the care and treatment A received after their second surgery was reasonable.

As the evidence indicated that the clinical care provided was reasonable, we did not uphold these complaints.

In relation to complaint handling, we found that there was miscommunication regarding delays and a failure to clarify all the issues of complaint. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for miscommunication regarding delays and a failure to clarify the confusion surrounding point two in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• For the findings of this investigation to be shared with staff.

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

The complainants (B & C) raised concerns about the practice following the suicide of their child (A). A and B had attended the practice two weeks prior to A’s death and B & C told us that they held concerns regarding the manner of the GP they saw, which A and B had found to be dismissive and unsupportive. While they did not consider that the doctor could have predicted the extent of A’s distress, they considered that the doctor’s demeanour may have contributed towards A feeling unsupported.

B & C also held concerns regarding the way in which the practice had cared for them following A’s death, as they had concerns about a prescription for Diazepam (a drug which belongs to a group of medicines called benzodiazepines and usually used to treat anxiety) they both received, the lack of other support offered, and the way in which the practice carried out a Significant Adverse Event Review (SAER) into what had occurred.

On investigation, we found that the doctor in question had already accepted that their body language had been inappropriate and apologised for this, when responding to B & C’s original complaint. We took independent advice from a GP on the care and treatment offered and we considered that the support provided by the doctor at the appointment was otherwise reasonable. Therefore, we did not uphold that element of the complaint.

We considered that the handling of the prescription of Diazepam and the bereavement support otherwise offered to B & C had been inappropriate. We also found that the SAER had been unreasonably delayed. Therefore, we upheld these complaints.

Recommendations

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

• Patients should be appropriately consulted before being prescribed benzodiazepines; patients should not be prescribed benzodiazepines for longer than is appropriate; the practice should consider whether prescribing benzodiazepines is appropriate for grieving families, given this may impair their grief reaction; and grieving families should be contacted with offers of support.
• Significant Event Analysis Reviews should be completed in a timely manner and identify any failings in treatment, as appropriate.

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.