SPSO Individual Decisions

C complained about the treatment that they received from the Golden Jubilee National Hospital. C had surgery to address a non-union of the bones in their mid-foot. Just under a year after their surgery, C submitted a complaint to the hospital, noting that the surgery had failed and that they required a second operation due to the non-union of the affected joint in their foot. C said that they accepted that non-union was a known risk of this surgery. However, having reflected on their experience and having discussed their case with another orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system), C believed that the care provided by their consultant was inadequate and may have been a contributing factor in the failure of their surgery. We took independent advice from a consultant orthopaedic surgeon. We found that, whilst there was some confusing communication as to the type of surgery that C would undergo, the consultant's choice of procedure was reasonable and the reasoning behind it was valid. C's case was not straightforward due to a previous failed fusion surgery. We were satisfied that the clinical treatment provided was reasonable and that the actions of the board's staff did not contribute to the failure of the joint to fuse. However, we were critical of the board's decision to discharge C before it was clear that their surgery had been successful. Whilst the outcome would not have been any different for C surgically, ongoing monitoring and review would have allowed for potential issues to have been identified sooner and for the clinical team to have had discussions with C regarding the status of their fusion and their ongoing treatment options. Overall, whilst we found that the clinical care and treatment was reasonable, we were critical of C's early discharge and the quality of the communication from the clinical team. Therefore, we upheld C's complaint.

C complained on behalf of their sibling (A) about the treatment A had received from the Golden Jubilee National Hospital. A had emergency surgery to repair a dissected aorta (a tear in the heart) and a pacemaker fitted. Following A's surgery, they suffered a ventricular fibrillation (abnormal heart rhythm) resulting in cardiac arrest. It was later established that A's ventricular fibrillation had been caused by an incorrectly programmed pacemaker. C complained to the hospital about how this could have occurred. We took independent advice from a cardiologist (a doctor who can diagnose, assess and treat patients with diseases and defects of the heart and blood vessels). We found that A's external pacemaker had been incorrectly programmed and there was a failure to manage the resulting R on T event (when the temporary pacemaker delivers an electrical impulse to the heart at an inappropriate time causing an abnormal rhythm) leading to A's cardiac collapse. We found that the hospital had failed to provide A with a reasonable standard of treatment and upheld this aspect of C's complaint. C also complained that following A's cardiac arrest, A was discharged too early from hospital and had not been provided with clear information regarding their cardiology rehabilitation and aftercare, resulting in a delay in A receiving appropriate follow-up appointments. We found that A's post-surgical out-patient review had been delayed by seven weeks without explanation. We also found that the hospital's post discharge communication practice had contributed to the delay in A receiving appropriate cardiology follow-up and cardiac rehabilitation from their local health board. While we found that A's discharge was reasonable, the hospital had failed to provide A with appropriate cardiology aftercare. On balance, we upheld this aspect of C's complaint.

C complained to us about the care and treatment their spouse (A) received at the Golden Jubilee National Hospital. A was referred to the hospital after being diagnosed with aortic stenosis (where a valve has narrowed and is restricting blood flow). We took independent advice from advisers both in cardiology (studies of diseases and abnormalities of the heart) and in cardiology nursing. C raised concern that A's angiogram (a type of x-ray that uses dye to look at blood vessels) was not carried out reasonably, including the aftercare. We found that A's angiogram was carried out in a reasonable manner and the aftercare was appropriate. We did not uphold this aspect of C's complaint. C also raised concern about an unreasonable delay in arranging A's heart surgery. We found that the hospital carried out appropriate tests to decide whether to list A for heart surgery. We also found that the hospital's decision not to proceed with heart surgery was reasonable, due to the risks involved from A's other health conditions. We did not uphold this aspect of the complaint. Related reading View Decision Report 201903410 as a PDF (24.22 KB) Updated: January 20, 2021

C complained about the care and treatment provided by the Golden Jubilee National Hospital. C underwent knee arthroscopy (a type of keyhole surgery used to diagnose and treat joint problems). Around two weeks later, C developed what was considered to be a surface infection, for which they were prescribed antibiotics and given another appointment for later in the week. Two days later, C attended another hospital's emergency department with pain and swelling. They required further surgery to wash out the joint. C complained that the decision to carry out the knee arthroscopy had been unreasonable, and that the care and treatment provided when they had an infection was unreasonable. We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision to carry out an arthroscopy on C's knee had been unreasonable, as C had severe arthritis and carrying out the surgery was contrary to British Medical Journal Clinical Practice Guidelines. We upheld this aspect of C's complaint. In relation to C's treatment when they had an infection, we found that it was reasonable for the surgeon to consider this to be a superficial wound infection rather than a deep wound infection, and the care and treatment provided for this was reasonable. We did not uphold this aspect of C's complaint.

C complained about the treatment which they received at the Golden Jubilee National Hospital. C had undergone a total right hip joint replacement but post operatively reported problems with right foot drop and loss of sensation in the right foot and leg. C was put on medication and referred to physiotherapy but still remained in pain with loss of sensation. C felt that something must have gone wrong during the surgery. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that there was no indication from the clinical records that complications had been encountered during C’s surgery in that the surgery was completed within normal timescales and that blood loss was within expected levels. It was possible that the sciatic nerve (nerve in the lower back area) could have been inadvertently damaged during the surgical procedure but there was no documentation to support such a view. While we did not uphold the complaint, we noted concerns about the standard of the record-keeping regarding the brevity of the actual operation notes and whether sufficient discussions about C’s high body mass index (BMI, a measure for estimating human body fat) level, which would increase risks of any surgery, were discussed with them prior to surgery. The concerns were highlighted as feedback to the hospital who have already amended their procedures in an effort to improve learning. Related reading View Decision Report 201906930 as a PDF (24.52 KB) Updated: November 18, 2020

C complained that their partner (A) was prematurely discharged from the Golden Jubilee National Hospital following cardiac surgery. The surgery was successfully performed with no reported complications. A was discharged home from hospital as staff deemed they were clinically fit for discharge. C was concerned that A had been discharged as they had severely swollen feet. A's health deteriorated, and days after discharge an ambulance was called as A had severe shortness of breath and a high temperature. A was then admitted to another hospital where they were an in-patient for several weeks. We took independent advice from a cardiology consultant (doctor who deals with diseases and abnormalities of the heart). We found that insufficient action was taken to establish the extent of A's heart failure and possible wound infection prior to their discharge from the Golden Jubilee National Hospital, which amounted to a failing in the standard of care and treatment required. We upheld the complaint.

Mr C complained about a number of concerns about the service and treatment he received while in the Golden Jubilee National Hospital. He was admitted to hospital in preparation for receiving a heart transplant. Firstly, Mr C complained about the behaviour and attitude of hospital staff towards him during a grand ward round. He stated that they spoke to him in an aggressive and threatening manner. Although there was no evidence of what members of staff the board spoke to as part of their complaint investigation, we noted that Mr C's medical records contained an entry written by a member of staff not named in the complaint. This case note provided a different account from the one Mr C provided. We did not take a view on which account was the definitive one but concluded that there was not sufficient evidence to confirm Mr C's account. Therefore, we did not uphold this aspect of the complaint. Mr C's second complaint was about the fact that all his teeth were removed in preparation for the transplant surgery. We took independent advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that, based on the medical records, it was appropriate for Mr C's teeth to be removed. This was because Mr C's records showed he had significant dental and gum disease. Following transplant, Mr C would have to take long-term immunosuppressant medication. As a result, such dental issues would present an on-going risk of potentially life-threatening infection. Therefore, the hospital's actions were appropriate, and we did not uphold this aspect of the complaint. Mr C's third complaint was that the board did not investigate and respond to his complaint appropriately or reasonably. We found that there were some areas where the board's investigation and response to Mr C's complaint could have been improved. In particular, we highlighted a lack of records of who was spoken with as part of the complaint investigation. However, we di

Mrs C complained about the treatment provided to her father (Mr A) while he was a patient at the Golden Jubilee National Hospital. Mr A had been admitted for planned surgery and subsequently his health deteriorated. Mrs C said that Mr A reported problems with his leg/foot and that these were ignored by staff. Mrs C felt that Mr A should have been sent to the high dependency ward after the surgery so that he would have been better observed by staff and that his outcome would have improved. Mr A was then housebound, had limited mobility, and a poorer quality of life. We took independent advice from a cardiothoracic consultant (doctor specialising in operations of the heart, lungs and other chest organs). We found that the planned surgery was carried out without complications and that it was appropriate to transfer Mr A back to a ward rather than a high dependency ward as there were no concerns noted. When Mr A did deteriorate, he developed respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide) which was identified by staff and he was then taken to the high dependency ward. Mr A also had other long-standing medical conditions, which were more likely to have contributed to Mr A's deterioration rather than as a result of the surgery he underwent. We did not uphold the complaint. Related reading View Decision Report 201807384 as a PDF (24.02 KB) Updated: September 18, 2019

Ms C complained about the care and treatment her mother (Ms A) received at the Golden Jubilee National Hospital. Ms A had bilateral uniportal video-assisted thoracoscopic surgery (VATS - a type of 'keyhole' surgery where only very small cuts (incisions) are made to the body). Ms C was concerned about the length of time Ms A had to wait for surgery, that surgery was not the appropriate treatment and that further investigations were not carried out before the surgery. We took independent advice from a consultant in thoracic surgery (also known as cardiothoracic surgery. It is the field of medicine involving the surgical treatment of organs inside the chest). We found that all investigations necessary for surgery were performed according to the relevant guidelines and that the type of surgery was reasonable and performed within a reasonable length of time. We did not uphold Ms C's complaint. Related reading View Decision Report 201707842 as a PDF (23.77 KB) Updated: July 24, 2019

Mr C complained on behalf of his late wife (Mrs A) about a decision by staff at the Golden Jubilee National Hospital not to perform a heart transplant on her. Mr C highlighted that Mrs A had been working to lose weight so she could potentially receive a heart transplant. Mr C was concerned that Mrs A was not given the opportunity to be included in the major decision made not to allow her a transplant. We took independent advice from a consultant cardiologist. We found that there was evidence to support that much consideration had been given to the heart transplant and that Mr C and Mrs A had been reasonably involved in the decision making. We did not uphold the complaint. Related reading View Decision Report 201701694 as a PDF (10.89 KB) Updated: December 2, 2018

Mrs C complained that, following a foot operation at the Golden Jubilee National Hospital, she continued to suffer pain and discomfort. During the surgery a bone fractured and had to be fixed by a wire. Mrs C reported continuing problems and was reviewed at both the Golden Jubilee National Hospital and the orthopaedic department of her local hospital, where it was established that she had also suffered a further complication of the surgery where there was a non-union of the bone. Mrs C believed that the original surgery had not been performed properly and that she had not been told of the risks of surgery prior to her operation. We took independent advice from a consultant orthopaedic surgeon. We found that both the bone fracture during the surgery and the subsequent non-union of the bone were recognised, but rare complications, of the surgery. We found that there was no indication that the original surgery was not performed to a satisfactory standard. The fracture was caused when inserting a screw in order to fix a bone into place and we found that it was appropriate to change the fixation method to wire when the bone fractured. The two complications of the surgery which affected Mrs C were not specifically mentioned in the operation consent form as they were rare; however, it was found that the actual risks mentioned on the form were adequate as they had identified the most common types of complications. We did not uphold the complaints. Related reading View Decision Report 201707403 as a PDF (11.24 KB) Updated: December 2, 2018

Mr C had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were busy, they asked another consultant to carry out the tests. Both consultants thought that the other would be responsible for Mr C's ongoing care, so neither of them wrote a discharge letter. While Mr C attended a follow up appointment at the second consultant's clinic, he saw another doctor who referred him back to the first consultant, instead of to the multi-disciplinary team (MDT), which is what should have happened. The first consultant did not see the referral. Mr C and his GP both tried to contact the first consultant to find out what was happening, but it is not clear whether Mr C's phone messages were passed on and his GP's letter was not seen by the first consultant. Eventually, about six months after the scan, Mr C's GP spoke with the first consultant, who then referred Mr C to the MDT for consideration and Mr C was offered palliative radiotherapy. Mr C was told that his cancer was terminal, and he was concerned that the delay may have affected this outcome. He complained to the board about this. In response to Mr C's complaint, the board accepted that there was an unreasonable delay and a failure to communicate with Mr C about his treatment. They apologised for this and said that they had taken action to prevent this happening again. The board had put in place a new protocol for passing care between two consultants, and a message book to ensure phone messages are recorded and signed off by consultants. The board said that the delay would not have affected the outcome in Mr C's case, although they acknowledged that palliative radiotherapy should have been offered sooner. Mr C remained unhappy and brought his complaints to us. We took independent advice from a thoracic surgeon (a

Mrs C underwent cataract surgery to her right eye at the Golden Jubilee National Hospital and had no concerns. However, she then complained about the care and treatment she received following subsequent cataract surgery to her left eye because she was experiencing pain and double vision. Mrs C was concerned that she was not informed prior to the operation that a different doctor would be performing the second surgery, that her left eye was not properly anaesthetised, and about the lack of treatment after she raised her concerns, post-surgery. We took independent medical advice and found that it was reasonable for a different doctor to have performed the second surgery. However, we found that it should have been properly explained to Mrs C when she consented to the surgery that it could be a different doctor. In addition, we found that the consent form did not clearly state all of the known risks and complications of her surgery, which would have been accepted good practice. There was documentation indicating that some form of conversation took place with Mrs C about the risks of post-operative inflammation and the possibility that further surgery might be needed. However, we were critical that it was not clearly completed and recommended the board take further action to address these two issues relating to the consent process. However, we did not uphold Mrs C's complaint on the basis that there was no definitive evidence to support that there was a problem with the anaesthetic or the operation itself. There was a small amount of plaque left behind but we considered it was reasonable not to remove it due to there being an increased risk of complications if removed. We considered that it was reasonable for Mrs C to be discharged to the care of her optician after the operation. We noted that the optician referred Mrs C to a different hospital when she experienced pain and inflammation in her left eye, and that the care plan was to carry out further surgery. We

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

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.

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 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