Health

Summary

C has a family history of bowel cancer polyps (abnormal growths) on the colon and was admitted to hospital on several occasions over many months with abdominal pains and vomiting. C complained to the board that, despite their family and medical history, the board unreasonably delayed to perform a scan, which resulted in a delayed diagnosis of bowel cancer. C also complained that the board failed to accurately report on a scan, as a subsequent review identified the presence of cancer.

The board advised that a scan was not indicated when C first presented to hospital. They also advised that the initial report on the scan was adequate, and it was only when additional clinical information became available (blood test results), that a second review changed the diagnosis.

We took independent advice from a consultant colorectal (bowel) surgeon. We found that there was insufficient consideration given to C's own medical history and that an x-ray taken was not appropriately followed up or acted upon. We concluded that there were several missed opportunities to perform a scan or colonoscopy (an examination of the bowel with a camera on a flexible tube) when C had attended hospital. We upheld this aspect of the complaint.

However, we concluded that the initial report on the scan was adequate. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to take proper account of their medical history and for failing to carry out a CT scan when they first presented to hospital. 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 consultant with overall care for the patient should receive feedback from the case in a supportive way and the feedback is used for reflection as part of their annual appraisal.
• This case should be discussed as a delayed diagnosis and be reported and investigated as an incident in the organisation.

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 about a number of aspects of the care and treatment her mother (Mrs A) received at Victoria Hospital.

We took independent medical advice from three advisers – a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), a consultant gynaecologist (a doctor who specialises in the female reproductive system) and a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus).

Miss C said that a radiologist failed to identify the thickened area in part of her mother's bowel on a CT scan. We found that an opportunity was missed at the time of the reporting of Mrs A's CT scan to identify a tumour in this area, in addition to making the new diagnosis of an ovarian tumour. However, given the limited sensitivity and specificity of unprepared CT scan for bowel tumours, we consider this not to be unreasonable.

Miss C complained that there was a delay in Mrs A's hysterectomy (surgical removal of the uterus) taking place which she said was due to the gynaecologist's leave delaying Mrs A's case being discussed at the multi-disciplinary team meeting. We found that Mrs A was referred for her case to be discussed at the next gynaecology multi-disciplinary team meeting the day after she was admitted to hospital. This was then processed in accordance with the department's normal procedures and Mrs A's case was discussed at the next available multi-disciplinary team meeting. We considered that the consultant gynaecologist's leave was not relevant to Mrs A's care and did not delay it in any way.

Miss C said that following the results of Mrs A's CT scan and the suspicion of cancer, the board should have carried out Mrs A's colonoscopy (examination of the bowel with a camera on a flexible tube) and PET scan while she was still in hospital. We found that Mrs A's colonoscopy was carried out within appropriate timescales, taking into consideration the risks from her previous surgery, her potential pain/discomfort and the likely success of the procedure. We found that Mrs A's PET scan was also carried out within a reasonable time, allowing for tissue healing and resolution of infection to take place following Mrs A's surgery, and in order to produce meaningful results to assist clinical decision-making and patient management. The timescales for these procedures would have had no impact on the treatment provided.

We did not uphold this complaint.

Summary

Ms C complained to us about the time she waited for a psychology appointment from the board. While she waited, Ms C went back to see her GP because she felt her condition had worsened. Several months after her referral to the board, Ms C had a telephone assessment with a psychologist to assess her needs. Some months after that, Ms C was offered a psychology appointment. The board apologised to Ms C for the delay and explained that they were taking steps to reduce their wait times.

We took independent advice from a psychologist. We found that there was an unreasonable delay in carrying out Ms C's telephone assessment. We found that it was unclear why there was such a delay, as it was a relatively routine referral. We found that the delay meant the psychology service was unaware of the worsening in Ms C's condition and they missed the opportunity to offer her an earlier psychology appointment. We found this led to an unreasonable delay in offering Ms C a psychology appointment and we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings 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, who are on the psychology wait list, should be assessed promptly. This would allow the board to identify high-risk patients or identify where there is some other need for urgent treatment (e.g. pregnancy) and help the service to identify appropriate treatment options. It would also enable patients to be given timely information about sources of support/guidance while they wait to be seen; and give the patient reassurance and motivation.

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 on behalf of her late mother (Mrs A) whose hip fracture was not diagnosed until approximately nine weeks into her hospital admission, following a fall at home and a further fall during her first night in hospital. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that Mrs A's hip fracture should have been diagnosed within one week of her admission as there was enough information present to indicate she had a fractured hip and more detailed assessments should have been carried out during this time. Therefore, we upheld this aspect of the complaint.

Mrs C also complained that the board did not take reasonable falls prevention measures as Mrs A fell during her first night of hospital, despite having been admitted post-fall, and with a history of falls. We took independent advice from a nursing adviser. We found that there was no evidence that a falls risk assessment was carried out when Mrs A was admitted to the Combined Assessment Unit and there was no evidence of falls prevention measures being put in place at this time, which was unreasonable. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in Mrs A's care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• Nurses should keep clear and accurate records relevant to their practice, in line with the Nursing and Midwifery Council code.
• Falls risk assessments should be undertaken on patients when indicated.
• When the need for further assessment is identified by therapy staff, this should be notified to appropriate parties and actioned.

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 that the board failed to discharge her late husband (Mr A) in a reasonable way. After a period of admission to Borders General Hospital, staff planned Mr A's discharge which was discussed with Mrs C. Mrs C said that staff unreasonably failed to fully consider her concerns about Mr A's discharge and to record these in Mr A's clinical records in a reasonable way. As a result, the couple struggled to cope when Mr A was discharged home and he was readmitted to hospital the following week.

We took independent advice from a nurse. We found that while the decision to discharge Mr A was reasonable, staff communication did not meet Mrs C or Mr A's needs. It would have been reasonable for staff to have fully discussed (and recorded) their concerns about discharge with Mrs C and the consultant responsible for Mr A's care during his hospital admission beforehand. We also found that Mrs C's concerns about Mr A's discharge home were not recorded and the board gave inaccurate information during the complaint process about a meeting Mrs C had with staff. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication. 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:

• Feedback the findings of our investigation in relation to communication to relevant staff for them to reflect on.

In relation to complaints handling, we recommended:

• Feedback the findings of our investigation in relation to complaints handling to relevant staff for them to reflect on.

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 care and treatment they received at Borders General Hospital was unreasonable, including that they should not have been admitted; that they were not advised of the side effects of their medication; and that staff did not adequately explain what the medication was to treat.

We took independent advice from an adviser qualified in psychiatry. We found that it was appropriate for C to be admitted to hospital for assessment and treatment. While we found that there was no evidence of a specific discussion with C regarding the potential side-effects of their medication, we considered that the board's acknowledgement and apology for this in their letter to C to be a reasonable response. We found that, overall, there was good evidence of engagement and dialogue with C regarding their treatment plan and medication, and that the board's prescribing and administering of medication was reasonable. As a result, we did not uphold the complaint.

Summary

Mrs C was listed for a procedure to decompress a nerve in her foot. This procedure was agreed by a consultant but they resigned so Mrs C was transferred to another consultant (consultant 2) whose preferred treatment was non-surgical. Mrs C expressed concern at the treatment proposed for her so she met with a third consultant (consultant 3). It was agreed that she would be listed for surgery. Mrs C understood the procedure would involve removal of a bone spur (bony lumps that grow on the bones of the spine or around the joints) along with decompression of the deep peroneal nerve (a nerve that runs from the leg to the top of the foot). After surgery, Mrs C became aware that the procedure carried out by consultant 3 involved only the removal of the bone spur. Mrs C complained that the board unreasonably changed the original treatment plan agreed for her and that they inappropriately failed to carry out the procedure she consented to. She also complained that the board unreasonably failed to arrange a follow-up appointment with a different consultant.

We took advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that consultant 2's preferred treatment was reasonable although we did note that pre-operative investigation was limited with no apparent x-rays being arranged until Mrs C was seen by consultant 3. We found that consultants can have differing opinions in relation to proposed treatment and therefore, it was reasonable to change the original treatment plan for Mrs C given her care was transferred between different consultants. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to consent for the surgery, we found that the consent form signed by Mrs C and the letter issued by consultant 3 confirming the proposed surgery did not match the surgery she received. It may have been the case that removing the bone spur released pressure on the nerve anyway but this should have been explained clearly to Mrs C. We found that whilst the procedure may have been clinically appropriate, the communication surrounding the procedure was unclear and inconsistent so we upheld this aspect of the complaint.

In relation to arranging a follow-up appointment for Mrs C with a different consultant, we saw evidence that Mrs C had clearly communicated that she was unhappy with the response provided to her complaint and she asked that her follow-up appointments be with someone else other than consultant 3. We saw evidence that consultant 3 wrote to Mrs C offering to facilitate her receiving an opinion from someone else. Mrs C said she did not receive that letter. The board told Mrs C that because she did not have an open referral, she should return to her GP to discuss further treatment options.

We found that it would have been reasonable for the board, as part of its handling of Mrs C's complaint, to offer her the opportunity to meet with a different consultant. Doing so would have demonstrated a willingness to try to better understand and resolve Mrs C's ongoing concerns about her surgery. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to clearly and consistently communicate with her in relation to her surgery and for not offering her the opportunity to meet with a different orthopaedic consultant as part of their final complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• Clearly communicate to Mrs C details of the surgery including the procedure consented to and the procedure actually carried out detailing whether that involved decompression of the deep peroneal nerve.
• Consider offering Mrs C the opportunity to meet with an orthopaedic consultant to discuss her concerns about the surgery.

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, an advocacy worker, complained on behalf of her client (Mr A) about the treatment he received following a cataract operation (a surgical procedure to replace the eye lens with an artificial one). During the surgery a complication occurred whereby the lens unfolded in an unusual fashion. Mr A underwent a number of other procedures and is concerned that these may have been unnecessary had his concerns about his eyes been listened to. The board accepted that a complication occurred during the cataract surgery, however, they consider it was managed appropriately. The board consider Mr A was kept informed of his clinical condition as it evolved.

We took independent advice from a consultant ophthalmologist (a clinician who treats disorders and diseases of the eye). We found that Mr A suffered a recognised complication during the cataract surgery and there is no evidence to suggest that his post-operative symptoms were not managed appropriately. However, we did consider that there was an unreasonable delay in performing the second surgery to repair the complication. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the unreasonable delay in dealing with the complication that occurred, which caused Mr A unnecessary and prolonged pain and discomfort. 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:

• All surgeons who perform cataract surgery for the board should know how to deal effectively with the complications of posterior capsular rupture during cataract surgery efficiently and promptly.

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, an advocate, made a complaint on behalf of her client (Ms B). Mrs C complained about the care and treatment provided to Ms B's late partner (Mr A). Mr A had attended Ayr University Hospital after rupturing his patella tendon. He underwent surgical repair of his ruptured patella tendon and was discharged home the following day. Over the next few weeks, there was delay and a lack of clarity over how Mr A was to access follow-up care and treatment. His GP informed him that they had not received a copy of the discharge letter in the post and Mr A did not know who was to arrange a follow-up appointment at his local orthopaedic (specialism in the treatment of disease and injury of the musculoskeletal system) department, which was located in a different NHS Board area from the hospital where he received surgery.

These matters were resolved after discussion with the orthopaedic consultant who treated Mr A. However, Mr A suddenly became very unwell some days after his surgery and died following a cardiac arrest. The cause of Mr A's death was later recorded as a pulmonary embolism (a condition when a blood clot breaks off and ends up blocking a blood vessel in a person's lungs), resulting from deep vein thrombosis (a condition that happens when a blood clot forms in a deep vein, usually in the leg) in his calf.

Mrs C complained that Mr A had not been prescribed with chemical thromboprophylaxis (drugs to prevent thrombosis) on discharge and that his discharge was not handled reasonably or appropriately. In particular, she complained that he was discharged without an appropriate post-operative medical review, and that there was a delay in the hospital issuing the discharge letter and arranging an appointment with Mr A's local orthopaedic department.

The board acknowledged that there was a failure to follow the instructions of the orthopaedic consultant who had operated on Mr A and outlined what steps they intended to take to prevent this happening again. However, they concluded that the choice to discharge Mr A without recommending or prescribing chemical thromboprophylaxis was acceptable.

We took independent advice from an orthopaedic consultant. We found that, given Mr A's individual circumstances, the relevant guidance supported chemical thromboprophylaxis being prescribed to him on discharge. Therefore, we upheld this aspect of the complaint. However, we agreed with the board's position that there was no strong evidence to suggest chemical thromboprophylaxis would have prevented Mr A's pulmonary embolism.

In respect of Mr A's discharge from hospital, we found that patients who live outwith the board area should be given two copies of their immediate discharge letter, one for their own records and one to pass onto their GP. The board were unable to say whether this happened in this case. We concluded that it was likely that the board's policy on providing immediate discharge letters to people who live outwith the area was not followed on this occasion.

The board were also unable to confirm whether Mr A was provided with instructions about how to arrange a follow-up appointment with his local orthopaedic department or whether this was to be arranged by the orthopaedic department. We noted that, once the orthopaedic consultant who carried out the surgery became aware of this uncertainty, they appear to have acted promptly to resolve this. However, we considered that the lack of clarity prior to this to be a failing on the part of the board.

We considered whether it was appropriate for Mr A to be discharged without a review by the orthopaedic consultant. We confirmed that it is normal practice for a patient to be reviewed by a health care professional prior to discharge, and that a nurse-led discharge is commonplace in Scotland. Therefore, we considered it reasonable for Mr A to be discharged without being reviewed by a consultant.

Overall, we concluded that Mr A's discharge from hospital was not carried out in a reasonable and appropriate manner. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for failing to provide Mr A with chemical thromboprophylaxis and discharge him reasonably and appropriately. 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 from outwith the health board area should be discharged in line with the existing policy and provided with two copies of their discharge letter. Patients should be made aware whether on-going appointments are to be arranged by the discharging department or by the patient and their GP.
• Staff should be aware of when it is appropriate to utilise chemical thromboprophylaxis after surgery of this type.

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 attended hospital for a coronary angiogram (a test to find out if a person has any problems with the blood vessels that supply the heart muscle with oxygen and how well the pumping chambers and valves in the heart are working).

Following the procedure, Mrs C was left feeling pain in her right leg and described her right foot as feeling frozen. A procedure was carried out to try and alleviate Mrs C's symptoms but she felt no improvement. Mrs C complained that the angiogram was not carried out to an appropriate standard. In responding to Mrs C's complaint, the board apologised but explained that she appeared to have suffered known complications of the procedure.

We took independent advice from a consultant cardiologist (a specialist that deals with diseases and abnormalities of the heart). We found that Mrs C's procedure was carried out to an appropriate standard. Therefore, we did not uphold the complaint.