Not upheld, no recommendations

Summary

C attended Dumfries and Galloway Royal Infirmary (DGRI) for a colonoscopy (a procedure where a camera on the end of a flexible tube is inserted into the rectum). During this procedure, polyps (tissue growths) were found and biopsies (a sample of tissue) were taken. C was told that a polyp showed possible signs of cancer. A second colonoscopy was carried out and the doctor attempted to remove the polyp, however the procedure was painful and was stopped. C was discharged home the next day.

Soon after, C had a bloody bowel movement and went to Galloway Community Hospital where they were then transferred to DGRI. C collapsed and was resuscitated, given a blood transfusion and moved to critical care.

C complained that the colonoscopy was not carried out properly, that it was painful and asked whether it should have been done in the first place. C also complained about the decision to transfer them from Galloway Community Hospital to DGRI and about the care they received on arrival at hospital.

We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We considered that the colonoscopy procedure was required as there was evidence C might have cancer. We noted that pain is subjective and the amount of pain relief given to C may not have been sufficient, although it was the recommended dosage. We found that the procedure appeared to have been carried out appropriately.

We also considered that the decision to transfer C from Galloway Community Hospital to DGRI was reasonable. It was possible that C would need surgical intervention which was only available at DGRI. We found that C was promptly assessed and was treated appropriately following their collapse. We did not uphold C's complaints.

Summary

C complained about the care and treatment of their late partner (A) who died from a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs), secondary to a deep vein thrombosis (DVT, a blood clot in a vein). The complaint related to a GP practice run by the board, which A attended feeling unwell. A was given antibiotics for a suspected infection and a sick note for their employer. A phoned the practice the following week, still feeling unwell, and the antibiotic prescription and sick note were extended. A’s condition deteriorated and they died the following day.

C complained that the GP dismissed the recent history of A's long-haul travel and symptoms indicative of a DVT and misdiagnosed A with an infection. They considered that there was a failure to follow the National Institute for Health and Care Excellence (NICE) guidelines for assessing the possibility of a DVT. C also complained that arrangements were not made for A to be seen when they called the practice the following week. They considered A was denied appropriate follow-up care.

We took independent medical advice from a GP. We found that the recorded symptoms that A presented with were consistent with a diagnosis of infection and not DVT. We considered that the GP’s recorded examination, history and working diagnosis were reasonable at that time.

In terms of A’s follow-up phone call to the practice, we were unable to evidence what was said during the call and whether an appointment was requested. We noted that it is common practice for antibiotic prescriptions and sick notes to be extended without seeing the patient, and we considered that the practice’s actions were reasonable based upon the available evidence. We did not uphold C's complaints.

Summary

C brought a complaint to us about the care and treatment given to their late parent (A) at Dumfries and Galloway Royal Infirmary. C complained that there was a lack of communication between staff and the family throughout A’s treatment. In particular, they said that the severity of A’s illness was not explained to A or the family. C stated that the family remained unclear about the specifics of the cancer A had, that there had been no reaction to A’s early symptoms and that A was advised about their diagnosis by phone with no offer of support provided. C also complained that the administration of A’s medication was unreasonable; in particular, that there was inadequate pain control and that no one took overall control of A’s care and treatment. During the board’s own investigation of the complaint, they accepted that A should not have been advised of their diagnosis by phone, and an apology had been given for that. The board had also indicated this was an area for reflection and learning.

We took independent advice from a consultant hepatologist and gastroenterologist (a doctor who cares for patients with benign or malignant disorders of the gastrointestinal tract, liver, pancreas and gallbladder). We found that while there was some learning for the board in relation to aspects of communication, the overall care and treatment given to A was reasonable. While we did not uphold the complaint, we asked the board to provide evidence of the action taken to ensure alternative methods of communicating a diagnosis to a patient had been considered.

Summary

C complained about the council's involvement in respect of the Welfare Guardianship Order (order which allows someone to make ongoing decisions on behalf of an adult with incapacity) application process. C had applied for a guardianship order in respect of their adult child (A). As part of this process, C's solicitor wrote to the council to request the production of a suitability report. The council allocated a mental health officer (MHO) to carry out this task.

Due to a variety of reasons, the production of a suitability report took a significant length of time. C complained as they felt the council and the MHO unreasonably sought to delay and hinder the progress of their guardianship application. They highlighted that the MHO's communication with doctors required to submit incapacity reports and their involvement in an Adult Support and Protection referral as evidence of this. In C's view, the MHO had acted outwith their remit.

We took independent advice from a social worker. We found that the council and the MHO involved in the guardianship process acted reasonably and within their remit. We acknowledged that the process took an unusually long length of time and that this must have been very frustrating for C. In addition to this, we recognised that the MHO and C held very different opinions on A's capacity. However, we were satisfied that it was appropriate for the MHO to provide their professional views and input as part of the guardianship process and that they had carried out their responsibilities appropriately. Therefore, we did not uphold this complaint.

Summary

C complained about the treatment and support provided by a community mental health team run by the partnership. C said that they were not reasonably assessed by appropriate clinicians and that the partnership failed to provide them with a reasonable diagnosis or treatment. C said that their care was mainly provided by a community mental health nurse whom C did not consider to be appropriately positioned to offer diagnosis or treatment. In addition, C considered that it was unreasonable that they were removed from the list while they awaited an appointment for dialectical behaviour therapy (DBT - a type of cognitive behaviour therapy).

We took independent advice from an appropriately qualified adviser.

C's first complaint related to their diagnosis. While there was a time management issue relating to one of the appointments, the partnership's actions in relation to providing a diagnosis for C was reasonable and in a reasonable timescale. As such, we did not uphold this complaint.

C's second complaint related to the treatment they received. While there was a communication issue in relation to a referral for C, overall the treatment provided by the partnership was reasonable. We did not uphold this complaint.

C's final complaint related to the support the partnership provided to them. We found that the support provided was reasonable while they were being seen by a community mental health nurse. C had also been provided with access to a helpline while they awaited further therapy treatment. As such we did not uphold this complaint.

Summary

C complained about the treatment which they received from the practice. C said that they were ill and had been discharged from hospital following a diagnosis of pancreatitis (inflammation of the pancreas). C saw a GP twice in one month, who diagnosed gastric issues and prescribed Peptac (medication for heartburn/indigestion). C said that they continued to worsen and saw the GP again, who again felt the problem was gastric issues and increased the dosage of Omeprazole (medication for heartburn/indigestion). C said that their condition again worsened and two days later C was admitted to hospital as an emergency where it was found that they had a pancreatic infection, and C remained as an in-patient for some weeks. C felt that their concerns had been dismissed and that, had appropriate treatment been given, their condition would not have been so severe or life-threatening.

We took independent advice from a GP. We found that the practice had provided appropriate care and treatment in view of C's reported symptoms and medical history. There was no clinical requirement that C should have been admitted to hospital at an earlier date. We did not uphold the complaint.

Summary

C, an advice and support worker, complained on behalf of their client (A). A suffered an industrial injury, with a steel beam falling on their head and shoulder. A had been receiving various forms of treatment since, including cortisone injections (an anti-inflammatory steroid injection used to treat a range of conditions), physiotherapy (a therapy to restore movement and function) and surgery. However, A was concerned that they did not receive any treatment for their head injury. A also considered that there were unreasonable delays in providing treatment and that communication with them had been unreasonable.

We took independent advice from a consultant orthopaedic surgeon (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that the treatment received and communication had been reasonable, with the exception of a problem with a referral for physiotherapy, which the board had already identified as part of their own complaint investigation. In addition, there was no evidence that A had complained of a head injury on first attending. We did not uphold C's complaint.

Summary

C complained about the clinical care provided to their child (A) by the board, specifically, that a Chiari malformation (where the lower part of the brain pushes down into the spinal cord) was visible on a magnetic resonance imaging (MRI) scan performed by the board and that the abnormality was not noted until they insisted on a further MRI scan being carried out many years later.

A suffered from a number of symptoms including headaches, tinnitus (ringing or buzzing in the ears), vertigo (a sensation of loss of balance or that objects around you are spinning) and drop attacks (sudden falls to the ground) for a number of years. A had MRI scans performed by the board to try to determine the cause of these symptoms. A had a further MRI scan performed by a different health board and it was found that A had a Chiari malformation.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that it was reasonable to ask only about a possible tumour, and that it would not be possible to make a definitive diagnosis of Chiari malformation from the first MRI images. We concluded that the MRI scan performed then was performed and reported to a reasonable standard. We, therefore, did not uphold the complaint.

Summary

C was an in-patient in a general adult psychiatry ward at a hospital outwith the Lothian NHS board area. A referral was made to transfer C and their baby to the Parent and Baby Psychiatric Unit at St John's Hospital but this was refused. C said that they were finding caring for their baby difficult in an adult environment and complained that the refusal was unreasonable.

We took independent advice from an appropriately qualified adviser. We found that the decision not to approve the transfer was reasonable from a clinical perspective. We did not uphold the complaint.

Summary

C complained on behalf of their late sibling (A). A was admitted to hospital to have their pacemaker and the leads, which attach it to the heart, extracted. There was a 2-3% risk of major bleeding and A signed a consent form for the procedure. During the operation, the surgeon successfully removed one of the pacemaker leads but whilst attempting to remove the final two, A's blood pressure suddenly dropped. This was recognised by the anaesthetist and the major haemorrhage protocol was activated. An emergency call for surgical assistance was placed. Despite chest compressions and fluids, staff were unable to stop the bleeding and A died. When the surgeon had tried to remove one of the leads, a tear had been created in one of the major veins around the heart. C complained that the surgery had not been carried out to a reasonable standard.

We took independent advice from a consultant cardiologist (a doctor that specialises in diseases and abnormalities of the heart). A's pacemaker, at several years old, would be well embedded in scar tissue. There was infection at the site, and the device was pushing through the front wall of A's chest. There were other options for treating this, but laser lead extraction was the best option for a long-term recovery. The operation appeared to have been carried out reasonably, with staff taking prompt and appropriate action when A's blood pressure dropped. There was nothing more the staff could have done to save A's life once the bleed occurred.

We did raise concerns about the consent process. We noted that A had signed a consent form on the day and the risk of major bleeding was noted. However, the board should have used a more detailed consent form with other fields, including alternative treatment options, and that consent should have been obtained prior to the day of surgery as well as the day of it. On balance, we did not uphold the complaint as the evidence indicated that the standard of A's surgery was reasonable.