Not upheld, no recommendations

Summary

Mr C has a long-standing lung condition. He complained that when he contacted NHS 24 as he was feeling unwell, an out-of-hours GP phoned him back and said that Mr C did not require a home visit and that he was to contact his own GP when the medical practice opened in an hour and a half's time. When Mr C attended the practice, he was prescribed medication and told to return in a week if the symptoms did not resolve. Mr C felt that the out-of-hours GP was wrong to refuse a home visit and complained about this.

As part of our investigation we obtained independent advice from a medical adviser, who is an experienced GP. She said that the out-of-hours GP took an appropriate clinical history and that their decision that Mr C should wait until the practice had opened was reasonable. Although Mr C did need to be seen by a doctor, there was no evidence that his condition was unstable or that an urgent house visit was needed before the practice opened.

Summary

Mr C was unhappy with the steps taken by the practice to assess his medical condition. He asked for an independent medical opinion but the practice refused. Mr C said that the refusal was unreasonable.

Our investigation of Mr C's complaint found that the practice diagnosed his condition and referred him to two consultants for further investigation. Mr C had refused to attend a MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) and he also refused an offer to meet with the practice to discuss his concerns. We were of the view that the steps taken by the practice were reasonable and we did not uphold Mr C's complaint.

Summary

Mr A was diagnosed with a syrinx (cyst) in his spine. This is a rare and complex condition known as syringomyelia. Mr A was concerned that a delay of over a year between diagnosis and surgery had lessened his chances of the operation being a success. Ms C, who is an advice worker, complained on his behalf about this and also about his concerns that this caused his condition to worsen, with increased weakness in his legs, bladder weakness, shaking and nerve pain.

After taking independent advice from one of our specialist medical advisers, our investigation found that there are no national guidelines on the management of syringomyelia. Although we considered that, with hindsight, it would have been better had Mr A's initial referral been passed to a neurosurgeon rather than a neurologist, we did not find that the board delayed unreasonably in carrying out surgery. There was evidence to show that after they received a referral for a neurosurgical opinion, they arranged an appointment for Mr A two months later. When it was drawn to the attention of the board that Mr A had not received the appointment letter, arrangements were made within two months to have him assessed and surgery carried out. Our adviser was of the view that even if surgery had been carried out around the time of the initial referral, it was unlikely that it would have affected Mr A's outcome, due to the natural progression of the condition.

Summary

When Mr C suffered severe chest pains he called an ambulance. The paramedics told him that he was not having a heart attack, but he was taken to hospital for tests. Mr C complained that, despite the paramedics having ruled out a heart attack, he was treated for one upon admission to the hospital. He raised further concerns about a lack of investigation into his chest pain once it was established that he was not having a heart attack, and a lack of follow-up appointments.

We took independent advice on this complaint from one of our medical advisers. The adviser said that paramedics would have carried out an electrocardiogram (ECG - a test to measure the heart's electrical activity and to check for a shortage of blood to the heart muscle). The ECG determines whether the patient is having an ST-elevation myocardial infarction (STEMI heart attack), which suggests a complete blockage of one of the coronary arteries. If such a heart attack is evident, paramedics will take the patient to a dedicated cardiac unit, which may not be the closest hospital. In cases of non-STEMI heart attacks (where the artery is only narrowed or partially blocked), the patient will be taken to the nearest hospital and treated with medication while further tests are undertaken. We found that in Mr C's case, the paramedics ruled out a STEMI heart attack and took him to the nearest hospital. He was still considered to potentially have a non-STEMI heart attack and was treated appropriately for this. Ultimately, tests indicated that he had a chest infection and he was treated accordingly. We were satisfied that the board acted appropriately and in accordance with national guidance for coronary artery disease.

We were also generally satisfied that appropriate follow-up appointments were made after Mr C's discharge from hospital. Although one referral to a rheumatologist was not acted upon, we did not find that this had any significant impact on the overall care provided to Mr C.

Summary

Ms C complained that when her late uncle (Mr A) was a patient in hospital, staff failed to provide him with appropriate care for his pressure sore area and that pressure ulcers developed that affected his deteriorating condition.

As part of our investigation we took independent advice from our nursing adviser. The adviser said that the nursing notes showed that staff arranged for Mr A to be regularly turned, ordered a special air mattress to prevent the development of pressure ulcers, and applied cream. All of these measures were reasonable and considered good practice to prevent the development of pressure ulcers. When Mr A's general condition deteriorated, however, his skin started to break down. We did not uphold the complaint, as we found that staff assessed and monitored the situation appropriately. They took reasonable steps to prevent Mr A's skin from deteriorating and there was no evidence of any failure in the standard of nursing care provided.

Summary

Miss C broke her wrist and was taken to hospital by ambulance, although ambulance staff could not take with her the wheeled walking frame that she normally used at home. In the hospital, Miss C was helped with a wheelchair and later with a wheeled 'patient transporter'. However, she was then told that she could not use this equipment, as her broken wrist would not affect her ability to move around the ward. She was given a walking frame instead. Miss C complained that, due to arthritis and a weak grip, she could not use the walking frame. She found it to be too lightweight and unstable.

We found that the board had made arrangements for Miss C's mobility to be assessed with a view to providing her with assistance. However, Miss C was a very private and independent person, who did not wish to discuss her care or normal living practices with staff. She declined occupational therapy or physiotherapy assessment and staff were unable to fully assess her mobility needs. We were satisfied that the board considered whether Miss C was able to consent to treatment and found that, as she had decided not to undergo assessment, the decisions reached by staff were reasonable and appropriate. We did not find any evidence to suggest that Miss C was refused mobility assistance or that she did not receive a reasonable level of care.

Summary

Mrs C developed skin plaques on her legs. Biopsies (small samples) were taken for analysis, and at first it was thought these might show signs of squamous cell cancer (SCC). However, a hospital dermatologist then decided that this was hypertrophic lichen planus (HLP - which can look like SCC, but is a non-cancerous common skin disease). When, several years later, Mrs C was diagnosed with cancer in a fallopian tube, she complained that the board did not tell her that the initial biopsy reports had been overturned because of a difference of opinion between clinicians. Mrs C said that her family had a history of cancer, and felt that her health was jeopardised because the hospital dermatology department influenced the diagnosis and so she was denied the opportunity to make informed choices about her options at that time. She was also concerned that as a result of having SCC she also suffered from dermatomyositis (a muscle disease involving inflammation and a skin rash), which had not been appropriately diagnosed.

The board acknowledged that this had been a very distressing time for Mrs C and her family, and that diagnosing her skin condition had been challenging. They said, however, that Mrs C had never been diagnosed with cancer on her legs, but with various forms of eczema. Although dermatology clinicians recognised that the complexities and changes in the status of this condition could be perceived as a conflict in diagnosis, doctors who had treated her were very clear that she did not have SCC, and the samples had confirmed this. They said that the cancer diagnosis was not related to Mrs C's skin problems, but to a gene she carried that meant she was more likely to develop certain cancers. After Mrs C complained, and it was clear she was unhappy with the board's response, staff offered to meet her to discuss their response to her concerns, but she declined.

In investigating Mrs C's complaint, we took independent advice from one of our medical advisers, but we did not uphold her complaints. The adviser noted that Mrs C disagreed with the initial diagnosis she received from the dermatology department, but found no evidence of any failure that prevented Mrs C from making informed choices. Neither did he find any evidence that she suffered from dermatomyositis. He said that interpretation of the biopsies that were taken and differentiating between HLP and SCC is extremely difficult, but that the management of her difficult rash and skin lesions was appropriate and timely. It was not possible to verify exactly what staff said to Mrs C about the biopsies, but we found no evidence of a failure to tell her that the results had been overturned due to conflicts of clinical opinion.

Summary

Mr C complained on behalf of his wife (Mrs A) about the care and treatment she received when she attended hospital with an injury to her vertebrae (part of her spine) after falling down stairs. Mr C said the board failed to arrange appropriate pain relief for his wife before she was discharged from hospital, failed to provide her with an appropriate service for fitting her neck brace and did not carry out an independent investigation of his complaint.

After obtaining independent advice from one of our medical advisers, who is an orthopaedic surgeon, we did not uphold Mr C's complaints. The adviser said that Mrs A's medical records showed that her reported pain at the time of discharge was low. He considered it reasonable for the hospital not to supply pain killers and that it would have been reasonable for Mr C or his wife to purchase over the counter any pain killers that she might have needed. The adviser also confirmed that a brace was required for Mrs C’s injury. Although there was some dispute over how the brace came to be badly fitted or who noticed this, the adviser indicated that appropriate action was taken to fix the problem once it was identified. He also indicated that there was no evidence in Mrs A’s medical records of her having any confusion on the afternoon of her discharge, and so it was reasonable that she was given instructions on how to fit and remove her brace. The adviser said that, in his view, Mrs A’s medical treatment was entirely appropriate.

On the matter of the complaints handling, the evidence showed that the orthotist (person specialising in the use of devices to support or control part of the body) concerned was not part of the team who carried out the investigation of Mr C’s complaint. Her only involvement in the investigation was to provide a statement of her account of events and to verify that it was accurately reflected in the board’s decision letter. We considered this to be entirely reasonable.

Summary

In December 2011, Miss C attended a hospital accident and emergency department (A&E) with an injury to her little finger. She was reviewed and

x-rayed, and diagnosed with a probable dislocation at the first knuckle in the finger. The x-rays showed a small fragment of damaged bone, suggesting damage to the ligaments on the sides of the joint and some damage to the soft tissues around the finger. Miss C's finger was immobilised by strapping, and she was reviewed at the fracture clinic the next day. The doctor there confirmed that she had a type of fracture that occurs when a fragment of bone tears away as a result of physical trauma, and said that her finger should be immobilised for three weeks. Two weeks later Miss C was reviewed by another doctor. He said that two joints in her finger were becoming stiff and referred her urgently for physiotherapy. She saw a physiotherapist that day. Miss C said that when the physiotherapist manipulated her finger she felt sudden and immediate pain, and after a minute of treatment fainted with the pain. She went to A&E again several days later complaining that the physiotherapy treatment led to an injury to her finger. She complained to us that because of this she needed a further operation which resulted in her finger becoming permanently injured.

As part of our investigation, we took independent advice from a medical adviser. The adviser said that the action taken was correct for a patient three weeks after an injury in which the joints and fingers have become stiff. They noted that the clinical notes for Miss C's attendance suggest that there was stiffness and, crucially, do not mention any abnormal positional deformity in the joint that would suggest the possibility of a secondary deformity developing. Leaving the fingers stiff for longer would have increased the risk of permanent stiffness. We concluded that the doctor's referral to physiotherapy without first taking an x-ray was reasonable, and noted that it was not possible to determine when Miss C sustained the injury about which she complained.

In March 2014, the NHS board involved in this case told us that they had identified further evidence which meant we were able to investigate further. We issued a public report of our findings on 18 February 2015, under reference 201401376. The decision below is not, therefore, the final decision on this complaint and is retained here for archive purposes.

Summary

Mrs C, who is an advocacy worker, complained on behalf of the partner of Mr A that the board failed to provide Mr A with an appropriate level of treatment. Mr A was admitted to a hospital's acute medical assessment unit with chest pain. He was transferred to the care of cardiologists (specialists dealing with disorders of the heart) who noted that he had severely high blood pressure. He was treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).

An echocardiogram (an instrument for diagnosing heart abnormalities that uses reflected ultrasonic waves to show the structures and functioning of the heart) was carried out at Mr A's bedside on the day of his admission. Two days later, he was sent for a further echocardiogram. This showed the presence of a tear in the ascending aorta (a portion of the large artery that carries blood from the left ventricle of the heart to branch arteries). A CT scan (a procedure that uses x-rays to define normal and abnormal structures in the body) was performed the same morning confirming the diagnosis of aortic dissection. Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

We took independent advice from one of our medical advisers, who said that aortic dissection is a rare condition and it is not unusual for the diagnosis of it to be missed. This is because unless a CT scan or, as in Mr A's case an echocardiogram, is performed there may be no specific pointers away from the presumed diagnosis of acute coronary syndrome. For most patients, it is relatively unlikely that a chest CT scan would be performed on a routine or even random basis. Although the fact that Mr A was at risk of aortic dissection was not picked up from the first echocardiogram, there was no recording of this and it was possible in any case that the tear developed after this had taken place.

Mr A had to wait for his operation because it was the holiday period and there was only one surgeon on call, who was in the middle of an operation. We found that it was not unreasonable that the cardiac surgeon completed the operation he was performing, before operating on Mr A. It was also likely that Mr A would have died before an operation could have been performed if he had transferred to another cardiac surgical centre. Mr A was in the acute phase and needed a very high-risk operation. In addition, we considered that Mr A had received the correct medication to lower his blood pressure and relieve his chest pain.

We found that overall, the actions of the doctors were reasonable and appropriate and we did not consider that there were any unnecessary delays.