Not upheld, no recommendations

Summary

Mr C attended the hospital's accident and emergency department (A&E) during the night, as he was concerned that he might be experiencing a repeat of a chest condition he had had some years previously. After discussion with a nurse, he was shown to a phone and advised to speak to the person at the other end, who turned out to be from the out-of-hours GP service, NHS 24. NHS 24 advised him to return home, and that they would phone him within an hour to assess his condition. Mr C felt that his situation had not been taken seriously and he left. NHS 24 phoned him three times at home, but Mr C felt too distressed to answer their calls. In the morning, he saw his GP, who diagnosed a chest infection.

We explained to Mr C that it is NHS policy that someone should only attend A&E if they have an emergency and that, if they need to see a GP outside their practice's opening hours, they should phone NHS 24. NHS 24 then assess, by phone, whether the patient needs to see a GP and, if so, whether they should travel to the out-of-hours GP, or whether the out-of-hours GP should visit them at home. The papers we received from the board showed that, when Mr C arrived at A&E, the nurse considered whether he did need emergency care and spoke to a doctor, who decided that this was a matter for NHS 24, rather than A&E.

We did not uphold the complaint because the hospital appropriately established that Mr C needed to contact NHS 24, rather than themselves, then helped him contact them. We also noted that the board said that, because of Mr C's complaint, if someone arrived at A&E but needed to contact NHS 24, staff now made the phone call themselves, giving NHS 24 the relevant details. NHS 24 would then phone the patient back. They believed this would improve their service for patients, and we welcomed the board's use of a complaint as an opportunity for learning and improvement.

Summary

Mr C complained that there was an inadequate number of toilet facilities on his ward.

Our investigation found that patients spend only a limited time on the ward. In essence, the ward is used for little more than eating meals and making phone calls. Patients spend most of their waking time in other areas, which have ample toilet facilities. Sleeping areas are separate, and have en-suite toilet facilities. We also established that Mr C was able to move between areas to a reasonable extent. We considered this reasonable and we did not uphold the complaint.

Summary

Mr C is unable to cut his own toenails, and complained that the board failed to provide him with an appropriate regular service for this. He explained that delays in having his toenails cut impacted on his mobility and caused him discomfort.

Our independent medical adviser noted that it was reasonable that times between appointments may be affected by staff resource and demand. As Mr C’s complaint was very similar to one that he had made before and the board had already explained the appointment system to him at that time, we did not uphold his complaint.

Summary

Ms C complained that doctors at the practice failed to manage her medication regime appropriately. Ms C was suffering from bi-polar disorder (a condition that affects a person's mood). She was prescribed medication, including lithium (a medicine used to treat mood disorders) and quetiapine (a drug used to treat bi-polar disorder). Her lithium levels were monitored every three months at a special clinic as lithium may interact with other drugs and can cause toxicity (a poisonous effect on the body). She was also monitored by a community psychiatric nurse (CPN) and a consultant psychiatrist every four to six weeks.

On one occasion Ms C went to the practice as she felt she was suffering from toxicity. She saw a locum GP (a doctor in a temporary position at the practice), who did not think that she was but asked her to speak to her CPN to organise a blood test. The CPN told her to go back to the practice, and another doctor did the blood test. The results showed that she was not suffering from toxicity.

After investigating, we did not uphold Ms C's complaint. We took advice from as independent medical adviser, who said that the evidence in the clinical notes showed that it was unlikely Ms C was suffering from toxicity when she saw the locum GP. Although the adviser was concerned that the locum GP asked Ms C to arrange her own blood tests, she considered this to be a misunderstanding about the resources available. In light of this, although we did not uphold Ms C's complaints, we drew to the practice's attention that the adviser had suggested they might wish to consider placing an alert on the notes of patients prescribed lithium, with information on how to obtain urgent blood tests where there is a suspicion of possible lithium toxicity.

Ms C also complained that the practice would not prescribe her extra quetiapine. She was under the impression that her psychiatrist had increased the dose. Having looked at Ms C's clinical notes and the communication between the psychiatrist and practice, the adviser confirmed that the psychiatrist had not further increased the dosage. Ms C also had helicobacter pylori (h-pylori - a bacterium found in the stomach) and complained that the practice had not adequately treated it. The adviser confirmed that the dose and duration of treatment for h-pylori was appropriate.

Summary

Ms C's daughter (Ms A) suffers from chronic back pain following an accident some years ago. Ms C complained on behalf of her daughter that the medical practice failed to do enough to provide her with appropriate treatment.

As part of our investigation, we took independent advice from a medical adviser. He considered Ms A's medical records, her medical history and the care and treatment provided by the practice. He said that the practice had provided an appropriate level of care and treatment, including tests and treatment options. Although Ms A's pain has not been resolved, the adviser took the view that the practice have taken appropriate steps to try and identify the underlying problem and to provide on-going treatment in order to minimise the pain Ms A is suffering.

Summary

Mr C was on holiday when he was taken ill while on a moored boat. He called 999 but was told that as his condition was not life-threatening he should call NHS 24. When he did so, they said they would ask an out-of-hours doctor at a local hospital to call Mr C within an hour. Mr C complained that the out-of-hours doctor would not arrange an ambulance to take him to hospital, and instead gave him the number of local GP surgeries he could contact. Mr C said that he was in great pain and could not walk, but with assistance managed to get back to his holiday home. When he got there, an ambulance was called and Mr C was taken to hospital. Mr C felt the out-of-hours doctor should have arranged an ambulance to take him to hospital in the first instance.

Our investigation found that there was a difference of opinion between the out-of-hours doctor and Mr C about his ability to get off the boat, but the information in the records did not help us resolve this. We took independent advice from one of our medical advisers, who said that there was no evidence to suggest an emergency ambulance was required, and that the out-of-hours doctor had provided appropriate advice. This was that, should Mr C's condition worsen, he should contact the emergency service again. It was also appropriate for the out-of-hours doctor to suggest that Mr C should contact a general practitioner who might have been willing to visit him on the boat.

Summary

Mr C hurt his foot while gardening. He complained that the board did not diagnose that it was fractured despite two visits to a hospital accident and emergency department (A&E). When he first attended A&E, Mr C was recorded as limping but able to bear weight on his injured foot. The records showed that his foot was sore but with a good range of movement. A bad sprain was diagnosed and Mr C was given advice on how to care for his foot.

Mr C then went on holiday for two weeks. His foot had not improved so on the way home he went to another A&E. Again the foot was recorded as having a good range of movement and Mr C was able to put weight on it. A rash was also recorded but was put down to a sweat rash, and it was noted that Mr C told staff that he had done a lot of walking on his holiday. Again a bad sprain was diagnosed. Mr C's foot was not x-rayed during either visit to hospital.

Mr C then went to see his GP as he was still having trouble with his foot and now felt it was mis-shapen. The GP arranged an x-ray which revealed that Mr C's foot was fractured. He was referred to an orthopaedic specialist (a specialist in medicine of the musculoskeletal system) who diagnosed that four of the five bones in Mr C's foot had been displaced. Mr C now has to wear orthotic footwear (special footwear available on NHS prescription) to accommodate his mis-shapen foot. Mr C was also unhappy that the board would only provide two pairs of footwear and would not provide specialist footwear such as Wellington boots; gardening boots; or sandals.

Our investigation, which included taking advice from an independent adviser specialising in emergency medicine, concluded that it was reasonable that

x-rays were not taken and that the fracture went un-diagnosed. The adviser pointed out that there should always be clear clinical indications of the need for examination by x-ray. In Mr C's case no such clear indications were present - he was able to bear weight and although his foot was painful and swollen, it had a good range of movement. The adviser commented that this type of dislocation is a relatively rare injury and so, in the circumstances, it was not unreasonable that it was not diagnosed at the time. On the matter of the orthotic footwear, we found that the board’s guidance reflects national guidance issued by the NHS in Scotland, and that it was reasonable for them not to provide more than two pairs.

Summary

Ms C said she was discharged from hospital and issued with medication. She complained that she had visited her GP nine days later to ask for a further prescription but he had told her that the hospital discharge form said she had been issued with sufficient medication on discharge. To check this, the practice called the hospital and a nurse confirmed that Ms C had been issued with the quantities of tablets stated on the discharge form. The GP, therefore, refused to issue her with a prescription.

Ms C phoned the ward and spoke to a nurse who told her that the amount of tablets she had received on discharge had been wrongly recorded and that the nurse would phone the GP to explain the mistake and ask him to issue her with a prescription. We did not uphold the complaint about the practice, as we found that the health board had accepted full responsibility for the error on the discharge form and that the GP had acted reasonably and appropriately.

Summary

Mr C fractured his leg in several places. He was admitted to hospital and had an operation. The consultant reviewed Mr C the next day. Mr C had a change of plaster cast and was advised not to put weight on his leg. Mr C's medical records noted the following day that he was not complying with the non-weight bearing instructions. He was discharged several days later.

Mr C's first out-patient appointment early the next month was cancelled and he was seen towards the end of that month. An x-ray taken at that appointment showed that the tibia (large bone in the leg) was misaligned. The board told Mr C that the consultant's opinion was that the misalignment was likely to have been the result of Mr C bearing weight on his leg contrary to advice. Mr C told us that this unreasonably blamed him for problems with his leg. Mr C sought an acknowledgement that things went wrong during his operation and an apology from the board. He said that as a result of the board’s failures, he will suffer pain permanently.

Our investigation included taking independent advice from one of our medical advisers. We found that the operation was performed to a reasonable standard and that it was likely that a number of factors, including the severity of the fracture, led to the misalignment. Mr C was concerned about the misalignment, but the advice we received and accepted is that it was within reasonable limits. We also found evidence in Mr C's medical records that he was not complying with the advice to put weight on his leg, and we were satisfied that the board's response reflected what was in these records. We appreciated why Mr C was unhappy with the way in which the board's first response was worded, but found that they had later assured him that they were not accusing him of wrongdoing but, rather, had recognised that he could not comply fully.

Summary

When Mrs C 's mother (Mrs A) became unwell, Mrs A's carer contacted Mrs C, who went to her mother's house, and a doctor from NHS 24 (the out-of-hours service) visited. He examined Mrs A and wanted to admit her to hospital but his notes recorded that she strongly refused. He prescribed an antibiotic (a drug used to treat bacterial infection) after asking Mrs C if she knew if her mother had any drug allergies. He also advised Mrs C to get in touch again if her mother's condition deteriorated. He later discovered that she was allergic to the drug he had prescribed, and contacted Mrs C to arrange an alternative. Mrs A, however, died during the night. Mrs C disagreed that her mother had refused hospital admission and felt that the doctor should have known of Mrs A's previous experience of the drug.

Our investigation found that the doctor could not have known of Mrs A's allergy as he did not have access to her emergency care summary. This consists of basic information about a patient (including allergic reactions) and is available in the out-of-hours centre but not in the out-of-hours doctors' vehicles. The doctor was in his vehicle when asked to attend Mrs A. It was clear he took prompt and appropriate action to check her summary when he reached the out-of-hours centre, and to then arrange alternative medication. We took independent medical advice from one of our advisers, who said that the doctor's other actions, such as his examination of Mrs A, were also appropriate. We could not say for sure whether Mrs A had refused to go to hospital, as the accounts were so different. However, we did not uphold the complaint, as we found no grounds to suggest that the doctor's care and treatment (including his decision not to admit Mrs A to hospital) were unreasonable.