SPSO Individual Decisions

Ms C attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable. During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems. We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint. In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Miss C complained about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with acute appendicitis. She complained about a procedure that was carried out when her wound became infected and was reopened on the ward several days after surgery. Miss C complained that excessive force was used during the procedure and that her pain was not adequately managed. She also complained about the level of scarring she suffered, and said that the board failed to explain the procedure or obtain her consent for it, and had failed to respond appropriately to her complaint. We took independent advice from one of our advisers, who is a consultant surgeon. There was no evidence to allow us to comment on how much force was used or about the management of Miss C's pain, although there was evidence of three types of pain relief being prescribed that day. Our adviser said that it was reasonable for the procedure to be carried out on the ward without anaesthetic, as local anaesthetic is much less effective in infected tissue. He also said that it would be expected that staff would consider, as part of the implied consent for the procedure, whether it would be appropriate to provide pain relief in advance. He said that there was no need for this consideration to be documented. We also found that it was unlikely that the procedure was the source of the scarring that Miss C suffered, which was more likely to result from the wound infection. We did not, therefore, uphold her complaint that the procedure was not carried out appropriately. Although our adviser said that written consent was not required for this type of procedure, we upheld Miss C's complaint about failure to explain, as we were concerned that she was not given enough information on how the procedure was to be carried out. We did not make any recommendation as the board had already taken action to address this for the future. Finally our investigation showed that, while the boar

Miss C complained about aspects of the care she received during the birth of her son. She was unhappy with the time taken to allocate her a midwife on admission and to give her pain relief. She was also concerned about the attitude of staff in the labour ward, which she felt was dismissive and unprofessional at times. Miss C had a forceps delivery (where the baby is delivered using a surgical instrument resembling a pair of tongs). She complained that the care provided by the labour ward doctor and the surgeon in the theatre during the procedure was abrupt and overly forceful. In particular she was concerned about the physical damage that she and her son sustained during the birth. We took independent advice on Ms C's complaint from two medical advisers. We upheld her complaints about delays and about unprofessional behaviour on the ward, noting that the board had already apologised for these, although we concluded that her overall treatment was reasonable in the circumstances. We did not uphold the complaint about the staff in the operating theatre, as we found no evidence of failures there, although in relation to this complaint we identified a concern with the quality and accuracy of the board's investigation it, and made recommendations accordingly.

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach. Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer. After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the ap

Ms C fell while away from home and fractured her wrist. At the time she was 70 years old with a history of osteoarthritis (a common form of arthritis causing chronic breakdown of cartilage in the joints). She had a cast applied to her wrist. On returning home, she was seen at a hospital. As the bones had not lined up properly, she had an operation to correct this using a fixator (a device to fix the position of fractured bones). Ms C was unhappy when the fixator was removed, as she was told that the bones were still out of alignment and she would not regain the full function of her wrist and fingers. She questioned whether the bones had been correctly aligned before the fixator was fitted. She further complained that the anaesthesia (pain relief) given to her failed to work and that she experienced a great deal of pain. She said that the operation had not been properly explained to her and that the board had taken too long to deal with her complaint. We investigated the complaint taking into account all the relevant information, including the complaints correspondence, relevant clinical notes and x-rays. We also obtained advice from our medical adviser, who reviewed Ms C's notes and the care and treatment she received. He said that her treatment was entirely appropriate and satisfactory. He said that sometimes anaesthesia could be imperfect, but that this did not necessarily indicate any failure by the doctors. He said that her pain was managed in accordance with accepted practice. The adviser also took the view that the board's explanations to Ms C about her operation were appropriate and reasonable. Taking all these factors into account, we did not uphold Ms C's complaints about her care and treatment. However, there was evidence to suggest that the board took too long to deal with her complaints on these matters.

Mr C attends hospital regularly for treatment. On one of those occasions a member of staff handed him an envelope containing letters that Mr C had given another member of staff to read. The envelope was addressed to Mr C but it was open. Mr C was concerned because the letters contained personal information about him. He complained to the board but was dissatisfied with their response and complained to us. When we investigated, the board said they had asked staff about this after Mr C complained but no-one could remember anything about the envelope and there was nothing documented in his file. There was no further information or evidence available, and in the absence of such evidence we could not uphold the complaint as we could not say for certain whether or not the envelope was open when it was left for Mr C. Related reading View Decision Report 201105188 as a PDF (11.12 KB) Updated: March 13, 2018

Ms C, an advice worker, complained about the care and treatment provided to Ms A. Ms A had a very complex medical and surgical history. This included a pancreatic and renal (pancreas and kidney) transplant in 2002, during which surgeons also removed Ms A's appendix. The operation note contained details of the procedures relating to the transplants, but did not refer to the removal of the appendix. In July 2010, Ms A was admitted to hospital with abdominal pain. Following clinical examination, blood tests and a scan, clinicians provisionally diagnosed appendicitis. They operated on Ms A to remove her appendix, but surgeons could not find it. They were not aware that the appendix had been removed in 2002, and Ms A said that she had not been told about it at that time. Ms C complained that the board’s failure to tell Ms A about this or to properly record it in her medical records led to an unnecessary operation. In August 2010, Ms A was transferred to another hospital and underwent further procedures. Shortly after one procedure, Ms A requested help from two nurses to go to the toilet. Only one nurse helped. Ms A was unable to manoeuvre and fell to the floor. She suffered a haematoma (an accumulation of blood) in her leg, which burst causing loss of blood. Ms A said this would not have happened if two nurses helped her as she requested. As a result of her fall, Ms A said that she had to undergo further surgery and suffered significant physical and mental distress. We found that the board’s failure to record the removal of Ms A’s appendix in 2002 was unreasonable. This was compounded by the failure to tell Ms A or her GP that her appendix had been removed. Had the surgeons in 2010 known that Ms A’s appendix had been removed and thus ruled out acute appendicitis as a diagnosis, the intended appendix operation would have been prevented. We also found that the board failed to explain the record-keeping omission when responding to Ms C's complaint. On the issue of Ms A’s re

Mrs C complained about aspects of the care and treatment provided to her late mother (Mrs A) in hospital after she fell at home in a sheltered housing complex. Mrs C said that there was difficulty in receiving accurate information from staff about her mother's condition and whether she was going to be taken to theatre. In addition, Mrs A had gone eight days without food; and the family could not understand how Mrs A could die of pneumonia in hospital two weeks after a simple fall with no injuries. We took advice from two medical advisers who established that Mrs A was an elderly lady in poor health. On looking at the board's care and treatment of Mrs A, we found that she had a number of pre-existing medical conditions, which meant that she did not have the physical reserves to cope with the complications that followed her fall. Our advisers confirmed that Mrs A received appropriate care and treatment while in hospital and that it was necessary for her to be fasted in order to manage her condition, and, therefore, we did not uphold this complaint. We did, however, find that there were failings in the way in which medical staff communicated with the family, and delays in the handling of Mrs C's complaint.

Mrs C complained that doctors were insensitive in the way that they told her husband (Mr C) that he had terminal cancer. We acknowledged that it must have been extremely distressing for Mr C to receive the news that he had terminal cancer, particularly as this was the only hospital appointment that he attended alone. However, our medical adviser said that it was appropriate to be frank and open in such circumstances. We found no objective evidence that doctors were insensitive in the way that they communicated Mr C's prognosis to him. Related reading View Decision Report 201101161 as a PDF (13.53 KB) Updated: March 13, 2018

Mrs C complained to us about aspects of her care and treatment by a hospital gynaecology department. We did not investigate the complaint as we decided it was out of our jurisdiction under Section 7 of the Scottish Public Services Ombudsman Act 2002. Related reading View Decision Report 201101464 as a PDF () Updated: March 13, 2018