SPSO Individual Decisions

Mrs C complained about a decision taken by the board to cancel her heart surgery and the lack of communication to her about this decision. She was also concerned that her complaint had not been dealt with appropriately because members of the complaints team had been involved with the decision to cancel her surgery. We took independent advice from a consultant cardiologist. We found that there were appropriate reasons for the surgery to have been postponed until an independent review was sought to endorse Mrs C's management plan. However, we found the communication in relation to the postponement of the surgery to be unreasonable. The board apologised to Mrs C that she was not informed beforehand that a further clinical meeting would be held. We also considered that the board should have sought Mrs C's input in relation to the independent review and informed her that there was a possibility it would delay her surgery. We did not find that there had been a conflict of interest in the complaints staff handling of Mrs C's complaint about the cancellation of her surgery. The decision to cancel the surgery was taken by relevant clinical staff involved in her care. We therefore concluded that her complaint was investigated appropriately.

Mrs C complained about the care she received prior to replacement pacemaker surgery at the Golden Jubilee National Hospital. She was concerned that her premedication had worn off before being taken to theatre and that the anaesthetist had missed the vein when cannulating her (inserting a thin tube into a vein). Mrs C was also in great pain when the anaesthetic drug was administered. When Mrs C came round from surgery, the cannula had been transferred to her other hand, and her hair was stained due to the solution used to cleanse the skin prior to the procedure and she had to have her hair cut. Mrs C also said that she had suffered from tinnitus since the procedure. We took independent advice from an anaesthetist. We found that the medical records indicated a safe, uneventful anaesthetic procedure and that there were no failings. We were also satisfied that there was no evidence suggesting that failings by the anaesthetist led to Mrs C developing tinnitus. Related reading View Decision Report 201507776 as a PDF (11.05 KB) Updated: March 13, 2018

Mr C complained that the Golden Jubilee National Hospital did not carry out his knee surgery properly and that his aftercare was of a poor standard. He also had concerns about the consent he gave for the procedure as he was under the impression that his named consultant would mainly be performing it, but found out after the operation that another doctor had carried out the operation under the supervision of the consultant. We took independent advice from a consultant orthopaedic surgeon. We considered that the need for Mr C to have revision surgery within a year was not acceptable and there were likely some failings in relation to the way in which the procedure was performed, so we upheld this part of his complaint. We found that Mr C's consent to the procedure had been reasonably obtained by the other doctor the day before surgery, in that he had indicated that he would be involved with the procedure and had highlighted the risks. In addition, the consent form Mr C signed sets out that the procedure might not be performed by the clinician who had been treating him. In terms of Mr C's aftercare, we concluded that reasonable steps were taken in response to his ongoing symptoms of pain and difficulty walking. We did not consider that Mr C was intentionally misled in this respect and therefore we did not uphold this aspect of his complaint.

Mrs C complained about a number of issues regarding her care and treatment at the Golden Jubilee National Hospital. She was also unhappy about the way in which her complaint was handled. Mrs C was concerned about the lack of action by a doctor between November 2012 and September 2013 which she felt impacted on a decision taken in August 2014 that she required further heart surgery. Mrs C also complained about the actions of a second doctor in dealing with her care given that he was aware of her dissatisfaction with the first doctor. We took independent advice from a cardiologist. We found that the first doctor unreasonably delayed in discussing Mrs C's case at multi-disciplinary team meeting and in reviewing Mrs C, which meant that her symptoms would have persisted unnecessarily causing her distress. We made a recommendation about this. However, we did not consider that these delays would have impacted on Mrs C's need to undergo further surgery. We considered that the second doctor's actions were reasonable and noted that Mrs C had been given an apology about the delays in the management of her earlier care. We concluded that the handling of Mrs C's complaint fell below a reasonable standard because the hospital initially dealt with it outwith their complaints procedure and because of the time they took to complete their investigation. We made a recommendation to address this.

Mrs C was scheduled to undergo a flexible sigmoidoscopy (a procedure whereby the rectum is examined by a camera). She had experienced pain during a similar procedure in the past and said that she requested sedation. Mrs C complained that, when the surgeon arrived, he advised that she would not require sedation and started the procedure. Mrs C experienced pain during the procedure and asked for sedation, however, the surgeon carried on. Mrs C was subsequently diagnosed with a perforated bowel. She complained that her requests for sedation before and during the procedure were ignored. Mrs C also complained that the board failed to answer points raised in her formal complaint regarding the procedure. We took independent medical advice from a consultant general and colorectal surgeon. We found that Mrs C's records indicated she consented to the procedure commencing without sedation, so we did not uphold this aspect of her complaint. However, her care plan noted that she may require sedation during such a procedure so we were critical of the board, as the surgeon proceeded with the procedure despite Mrs C's discomfort and requests for sedation. This went against pre-operative advice given to patients that they can ask for the procedure to be halted at any time and request sedation. We concluded that the surgeon proceeded based on what he considered was best for Mrs C, rather than taking her own views into account. Whilst we were satisfied that the board responded to the questions that Mrs C raised in her complaint, we considered that the response failed to demonstrate that her core concerns had been taken on board and appropriate action taken to avoid similar problems for other patients.

Mr C, who had heart problems, was to undergo elective (non-urgent) surgery in the hospital to improve the blood flow to his heart to relieve the symptoms of angina (chest pain) he was suffering. His wife (Mrs C) complained that his planned transfer from another hospital for this procedure was cancelled five times. Mr C was eventually transferred, but died late the following evening. Mrs C also complained that the hospital's response to her complaint glossed over the reasons for one of her husband's discharges from hospital and was not consistent with the response from the other hospital. Our investigation, which included taking independent advice from a medical adviser who is a consultant cardiologist (heart specialist), found that the reasons for the multiple cancellations of Mr C's transfer were all medically based. The adviser was of the view that each of the cancellations was reasonable, based on Mr C's clinical condition at the time. The adviser said that the procedure was designed to relieve chest pain. However, because of Mr C's other serious medical conditions, even if the procedure been carried out during his first admission to hospital it would have been unlikely to have changed the eventual outcome or to have prolonged his life. This is because Mr C's eventual condition would not have been cured, altered or improved by the procedure. Our investigation also found that the reasons for Mr C's discharge were clear and had been made clear at the time. He was discharged so that another medical condition could be addressed to try to ensure that he was fit enough to undergo the surgical procedure, and we took the view that this was reasonable. Similarly, we found that there was no contradiction in the information provided in the complaint responses. Although we appreciated that this had been a very difficult time for Mrs C and her husband, we were satisfied that the overall care and treatment provided was reasonable. Related reading View Decision Report

Mrs C complained that when her husband (Mr C) was airlifted to hospital after a heart attack, there was unreasonable delay in transferring him from the air transport into the hospital and in assessing his condition. We upheld both Mrs C's complaints. Our investigation found that there was no ambulance available to transfer Mr C into the hospital. The health board and Scottish Ambulance Service were in the process of finalising a protocol under which patients could be transferred on a trolley in such circumstances. However, when Mr C was taken ill the protocol had not been finally agreed or adopted although the equipment required - such as a trolley and protective clothing and equipment - was available. Our investigation identified that responsibility for a patient remains with the service until the patient is received in hospital. The ambulance staff involved in transporting Mr C were paramedics and provided evidence that they had offered to take clinical responsibility for transferring Mr C on a trolley. However, this offer was declined by a nurse from the hospital who was also there. It was about 40 minutes before an ambulance was available to transfer Mr C. In view of the offer made by the paramedics, we considered that it was unreasonable for Mr C to have had to wait this long. With regard to the assessment of Mr C's condition, our independent adviser noted that she would not necessarily expect to find notes of an assessment made while a patient was the responsibility of another body. However, although we noted that responsibility remained with the service until Mr C was received at the hospital, the board had in fact indicated in their response that the nurse had assessed Mr C's condition. We found no evidence, however, that any such assessment was made.

Mrs C, an advocacy worker, complained on behalf of Miss A, who had hurt her leg by tearing her anterior cruciate ligament (ACL) in a skiing accident in March 2010. Miss A was referred to the hospital where she was seen by a consultant orthopaedic surgeon, who arranged for her to undergo ACL reconstruction surgery about seven months after the accident. Screws were used to reattach tendons between her knee and thighbone. Two months after the operation, Miss A fell and hurt her knee again. She went to an accident and emergency (A&E) unit and was referred back to the consultant. X-rays taken at A&E showed that the screw in Miss A's thighbone had become dislodged. However, due to the amount of pain she was in, and the level of swelling, the consultant was unable to carry out a full examination. He noted that Miss A had a good range of movement and concluded that the screw was likely in the soft tissue, holding the ACL reconstruction in place. A few days later, Miss A's pain increased and her knee began to lock. She returned to A&E where further x-rays found that the screw was inside her knee joint. Surgery was arranged to remove it and to re-do the ACL reconstruction. After taking independent advice from our medical adviser, we upheld this complaint. We found that there was very little detail recorded at the time about what procedure the consultant initially performed. However, from the x-ray evidence we were able to establish that the ACL reconstruction had been placed in a less than satisfactory position. We also found that the advice given to Miss A by the consultant after her second fall was inappropriate. Although the x-ray evidence was not conclusive, it was most likely that the screw had migrated into the knee joint, and in any case, it was known that the screw was not in the thighbone. As such, the ACL graft was not performing its intended task and we took the view that revision surgery should have been arranged at that time.

Mr C complained that he was given conflicting advice about what happened to his wife (Mrs A) after she had undergone a coronary procedure to address the narrowing of her arteries. Mr C was unhappy that the doctor did not reflect the seriousness of Mrs A's condition in his reports despite him being taken aside and being advised that she had a 50 percent chance of survival. Mr C was also unhappy that the doctor maintained that there were no changes to Mrs A's electrocardiogram (ECG - a test that measures the electrical activity in the heart), despite Mrs A having very low blood pressure and a low heart rate. In response to the complaint, the hospital said that the doctor performed a technically difficult procedure which unfortunately was associated with a complication, which was treated effectively by placing a second stent (an artificial tube) to open up the artery. The hospital advised Mr C that he was told at the time that his wife's condition was not stable and that the doctor was of the view that his reports were an accurate reflection of the events that had taken place. They also said that one of the ECGs was normal and a further one carried out the following day showed inflammation which was not felt to be serious. After taking advice from our medical adviser, we considered that the doctor's discharge summaries sufficiently detailed the seriousness of the complication that had resulted. We also agreed with the hospital's interpretation of the ECG readings and that it was not unreasonable of the doctor to conclude that there were no changes to the first ECG. That said, we were of the view that it appeared that Mrs A had sustained a mild heart attack, but there was insufficient evidence overall to support that Mr C was given conflicting information about his wife's condition. Related reading View Decision Report 201104353 as a PDF (11.57 KB) Updated: March 13, 2018

Mr C complained that a hospital unreasonably cancelled his late partner (Ms A)'s heart bypass surgery scheduled for May 2010. He also complained that the hospital did not take appropriate remedial action following a report commissioned by the Procurator Fiscal's Office. Our investigation found that Ms A, who had a history of heart and other health issues, had a second heart attack in February 2010. She was assessed and was first admitted for heart bypass surgery in April 2010, in late May 2010. Although the surgery was successful, Ms A developed complications and died five days later. Our investigation found that the hospital cancelled all elective (non-emergency) surgery in early May 2010 due to the sudden death of a senior colleague of the team who died in the unit on the day Ms A's surgery was scheduled. The hospital decided to cancel elective surgery as members of staff in the unit were affected by their colleague's death. We took advice from our medical adviser, a cardiothoracic surgeon (a specialist in surgical treatment of organs found inside the chest). Our adviser said that due to the unusual circumstances it was not unreasonable to decide to cancel elective surgery. Our adviser reviewed Ms A's medical notes and was of the opinion that there had been no deterioration in her condition between her discharge and her readmission for surgery. He was of the view, therefore, that the delay had no bearing on the eventual outcome. Throughout the complaints process the hospital assured Mr C and our office that a 'careful assessment' had been made of the conditions of all the patients who were discharged that day, including Ms A. Our findings did not support those assurances. Our adviser described the discharge entry in Ms A's notes as 'perfunctory and brusque'. We were concerned that the note contained no references to any examination of Ms A, to test results, or to any standard observations such as pulse, temperature, respiration rate etc. Although we did

Mr C's 86-year-old mother (Mrs A) was admitted to The Golden Jubilee National Hospital for hip surgery. Following surgery, she was returned to the ward for bed rest and was noted to be a little confused. The hospital said that they explained to Mrs A that she should not mobilise and to use her call bell if she needed assistance. They said that she seemed to understand this advice. During the night, Mrs A fell out of bed and dislocated her hip which then required further surgery. Within half an hour, she fell out of bed again and was then placed in an alarmed bed. Since her falls and surgeries, Mrs A’s recovery has been protracted and her long term prognosis is poor. Mr C complained that his mother was not properly monitored following her surgery. Our investigation confirmed that although Mrs A's first fall could not have been anticipated, the hospital did not take appropriate action after a second fall. We found that the hospital also failed to send Mr C a copy of the appropriate incident report after he requested it. Recommendation We recommended that the hospital: • apologise for failing to send Mr C a copy of the appropriate incident report and that they provide one. Related reading View Decision Report 201101279 as a PDF (18.68 KB) Updated: March 13, 2018

Mrs C complained that the clinicians at Ayr Hospital provided inadequate treatment to her late sister (Mrs A) who required cardiac surgery, and that Mrs A should have been transferred to The Golden Jubilee National Hospital for urgent surgery at an earlier date. She also raised issues about poor communication with the family and the way in which the board handled the complaint. After taking advice from one of our medical advisers, we established that Mrs A received appropriate treatment. We also found that the level of communication and complaints handling was adequate. Related reading View Decision Report 201002232 as a PDF (13.54 KB) Updated: March 13, 2018