Not upheld, no recommendations

  • Case ref:
    202002811
  • Date:
    October 2022
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained regarding the treatment that they had received from the board in relation to a pharyngeal pouch (a pocket in the lining of the pipe that carries food from the mouth to the stomach). They complained about issues regarding the surgery they had in relation to this and about the information they were given.

We took independent advice from an ear, nose and throat (ENT) surgeon. We found that C was given reasonable information in advance of their surgery and that it was reasonable to examine a pharyngeal pouch through surgery. It was appropriate that C's pharyngeal pouch was emptied of partially digested food as otherwise it would not have been possible to examine it. It was also reasonable that C was offered a cricopharyngeal myotomy (where a surgical cut is made in the muscle that allows swallowing to weaken it) to treat their pharyngeal pouch, as it is one of the treatment options set out in the relevant clinical guidance. Although an external myotomy was recommended, C was given the option to explore alternative approaches, but the clinicians felt the pouch was too small for stapling. In addition, it was reasonable that C's outpatient appointment with the ENT surgeon was cancelled, given they were unhappy to proceed with the proposed treatment option.

Therefore, we did not uphold the complaint.

  • Case ref:
    202003428
  • Date:
    October 2022
  • Body:
    Fife NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

Following a short psychiatric hospital admission, C presented unwell on several occasions over the course of the next month. C complained that they weren’t sectioned under the Mental Health Act and given appropriate treatment. C’s behaviours at that time had prompted police involvement and the outcome of clinical assessments concluded that these behaviours were not driven by a mental health problem. C disagreed with this and was very distressed to subsequently be subject to a short imprisonment, before a judge ordered that they be admitted to a psychiatric unit.

We took independent advice from a consultant psychiatrist. We found that based on the information available at the time, reasonable conclusions were reached by the clinical team regarding the nature of C’s condition and the cause of their behaviours. We found that the action taken was in line with accepted practice in the circumstances. The clinicians all reached a consistent view as to the nature of C’s presenting condition and none were able to identify an underlying psychotic issue. We considered that C’s condition at that time was significantly different to when they were subsequently admitted to hospital, at which time a psychotic cause had become apparent. We did not uphold this complaint.

  • Case ref:
    202009078
  • Date:
    September 2022
  • Body:
    Lanarkshire NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the follow-up care provided to their late partner (A) who died around four months after suffering a heart attack. The board said that A was followed up by the cardiac rehabilitation service in line with established practice. We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that A's follow-up care was reasonable in the circumstances (of no face-to-face consultations due to the COVID-19 pandemic). We also found that it was reasonable for the board not to follow up on blood tests taken at A&E following A's attendance with chest pain. The board said that the test results showed no evidence of a new cardiac injury. We considered it reasonable to have excluded a new cardiac injury as the cause of A's chest pain, and we were not critical of the care provided. Therefore, we did not uphold these aspects of C's complaint.

C also complained about the conduct of a telephone consultation with a cardiac rehabilitation nurse. A called to report symptoms of breathlessness and C complained that the nurse diagnosed a chest infection and/or anxiety over the phone, and did not arrange for A to be seen. However, the nurse did not recall making such a diagnosis, and their recollection was that there was no apparent indication for A to be seen. We were unable to reconcile the differing recollections, and we considered that the actions of the nurse appear to have been consistent with reasonable practice. C was unhappy that the call was not documented. The board said that the call was not documented as A had been discharged from the cardiac nurse service, and in such circumstances patients are directed to their GP for any advice required. We noted that referral back to primary care for non-urgent symptoms is consistent with established good practice. We did not uphold this complaint.

Finally, C complained that A's post mortem described A as having severe heart disease, and they complained that they had been advised everything was fine following A's heart attack and stent insertion. We found that comparison between findings pre and post death, four months apart, is problematic and can be complicated by a number of factors. We noted that the disease seen at post mortem may not have been present four months earlier and we considered A's care was reasonable based on what was known at the time. We did not uphold this complaint.

  • Case ref:
    201902230
  • Date:
    September 2022
  • Body:
    Highland NHS Board
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary

C complained about the treatment that they and their child (A) received from the board. Over the course of nine months, C and A attended a number of appointments with the board's Child and Adolescent Mental Health Service (CAMHS) in respect of difficulties A was experiencing. C complained about the content and nature of these sessions. In their view, the board failed to progress a neurodevelopmental assessment of A within a reasonable timescale, which C considered was one of the key reasons for the referral. C also felt inappropriate assertions were made about them and their parenting skills. In C's view, they were unreasonably picked on during sessions with CAMHS. As a result of this, C's view is that CAMHS failed A and did not provide them with reasonable care and treatment.

C also complained about a child concern referral that was made by the CAMHS service. C considered this to be inappropriate and that it was done in response to them raising concerns about the actions of CAMHS.

We took independent advice from two advisers: a mental health nursing specialist and a clinical psychologist, both with a background in CAMHS. We found that the care and treatment provided by CAMHS was reasonable in the circumstances. Given the content of the referrals from A's GP and social worker, CAMHS embarked on an appropriate course of treatment and therapy. While we recognised that this did not result in a positive outcome for C or A, we did not consider the board's actions to be unreasonable. Therefore, we did not uphold C's complaints about the care and treatment provided by CAMHS.

  • Case ref:
    201900994
  • Date:
    September 2022
  • Body:
    A Dentist in the Highland NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary

Following the extraction of a wisdom tooth in hospital, C's follow-up care was undertaken by their family health service dentist. C suffered altered sensation following the tooth extraction. Over the course of eight months, C arranged three consultations with their dentist at which the altered sensation was discussed. C was concerned that the dentist's actions had not addressed the altered sensation and raised complaints about this with them and, subsequently, with this office.

We took independent advice from a dentist. We found that the dentist provided reasonable care to C and did not uphold the complaint.

When this report was first published on 21 September 2022, it was incorrectly categorised as being about a medical practice. This was due to an administrative error which we discovered on 20 October 2022, and for which we apologise.

  • Case ref:
    202006236
  • Date:
    August 2022
  • Body:
    Scottish Ambulance Service
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary

C's spouse (A) became unwell with severe lower abdominal pain and vomiting. C phoned for an ambulance and was told by the Scottish Ambulance Service (SAS) that A's symptoms did not warrant an emergency attendance and transferred the call to NHS 24. A's condition worsened over the next couple of days and A was taken to hospital, where they were found to have a perforated bowel (hole in the bowel) and kidney failure. A was given palliative care and died in hospital shortly afterwards.

C complained about the SAS decision not to dispatch an ambulance to A and considered that the call out system failed to save A's life. We took independent advice from a paramedic. We found that the telephone assessment conducted was reasonable and that appropriate questions were asked. From the responses provided, it was reasonably determined that there were no immediately life threatening symptoms that required dispatch of an emergency ambulance at that time. On this occasion, it was reasonable to transfer the call to NHS 24 for secondary triage to allow a more in depth line of questioning to be carried out to try to understand more about presentation of A's complaint. We, therefore, did not uphold the complaint.

  • Case ref:
    202006396
  • Date:
    August 2022
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C underwent a hysterectomy (surgery to remove the womb) and although the procedure was considered successful, C began to bleed from scar tissue soon after the operation. An ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) showed blood clots in C's pelvis and C was kept in hospital in case further surgery was required. C was given blood thickeners and a blood transfusion. C developed a chest infection and suffered from further complications.

C raised complaints about their care and treatment following their initial surgery with Greater Glasgow and Clyde NHS Board. C raised a number of specific concerns about their post-operative complications and their management. C was also concerned about the surgery, or that the post-operative complications had caused the nodule on their lung, which was subsequently identified as lung cancer.

We took independent advice from a gynaecology (medicine of the female genital tract and its disorders) adviser. We found that C's care and treatment was reasonable and that C had experienced significant post-operative complications, but that these were appropriately managed. We noted that there was no evidence that C received inadequate consultant input post-surgery, or that C's complications were as a result of the surgery being performed poorly or inappropriately. We found that the board were correct to say that there was no relation between C's surgery and the subsequent health issues that they faced. We also found no fault with the level of physiotherapy support offered to C.

We concluded that C's medical records showed that they were regularly reviewed by a physiotherapist and that the exercises that were provided to C were also reasonable and appropriate. As such, we did not uphold C's complaint.

  • Case ref:
    202101690
  • Date:
    August 2022
  • Body:
    A Medical Practice in the Fife NHS Board area
  • Sector:
    Health
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / diagnosis

Summary

C complained about the care and treatment provided to their late child (A) by their GP practice. A had attended the practice on several occasions over a five month period with persisting chest symptoms. C complained that the practice failed to recognise the severity of A's symptoms or recognise that symptoms were indicative of a serious cardiac condition until A's health had significantly deteriorated. A subsequently suffered a cardiac arrest resulting in them being transferred to another health board for surgery, where they later died.

We took independent advice from a GP adviser. Although we noted that there had been a delay of a few days in responding to A's x-ray report, we found that the practice's care of A was reasonable, with referrals and tests being timeously arranged and in keeping with A's presenting symptoms at the time. Therefore, we did not uphold the complaint.

  • Case ref:
    201909723
  • Date:
    July 2022
  • Body:
    Fife Council
  • Sector:
    Local Government
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Policy / administration

Summary

C complained about a financial assessment carried out in respect of their parent (A)'s, care costs. C complained that the council wrongly determined that in transferring the title to A's property to C three years previously, A had intentionally deprived themselves of capital to avoid paying residential care costs. C disagreed with the council’s decision to treat the value of the property as notional capital when calculating the costs that A owed.

There followed extensive communication between the council, C and C's solicitor. According to C, A had no expectation of going into care when they transferred the property, or at any point in the future. C said that A was a very active, intelligent and healthy individual who had every intention of remaining in the same home for the rest of their life. Nor, as far as C was aware, had A had any thoughts of disposing of some of their assets to avoid paying for care in the future.

  • Case ref:
    201901611
  • Date:
    July 2022
  • Body:
    Glasgow City Health and Social Care Partnership
  • Sector:
    Health and Social Care
  • Outcome:
    Not upheld, no recommendations
  • Subject:
    Clinical treatment / Diagnosis

Summary

C complained about the mental health care and treatment their late sibling (A) received at Gartnavel General Hospital. C complained that A was misdiagnosed and received inappropriate treatment. C complained that A was insufficiently supervised, as they were able to leave the hospital on a number of occasions. C also complained that A was discharged when they were still unwell. C believed there had been a focus on discharging A rather than ensuring their condition improved.

We took independent advice from a consultant psychiatrist. We found that during each admission, A's care and treatment was reasonable and appropriate given their presenting symptoms. We found that the changes in A's diagnosis reflected a better understanding of their symptoms and presentation over time. We did not uphold this aspect of the complaint.

With regard to the complaint about supervision, we found that the level of supervision was appropriate andthat there was no clinical justification for any enhanced observation. We did not uphold this aspect of the complaint.

In relation to the complaint about A's discharge from hospital, we noted that difficult circumstances to do with A remaining in the ward was contributing to an escalation in their presentation. We found that the decisions to discharge A after the first and second admissions were reasonable. There was evidence of discharge planning with appropriate follow-ups being put in place. The decision to discharge after the third admission was more complicated, as A was discharged into police custody after their behaviour escalated. We found that under the circumstances this was reasonable, noting that follow-up arrangements were made with support agencies. We therefore did not uphold this complaint.