Not upheld, no recommendations
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Case ref:
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Date:
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Body:
Inverclyde Health and Social Care Partnership
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Sector:
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Outcome:
Not upheld, no recommendations
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Subject:
record keeping
Summary
Mr C, an MP, complained on behalf of his constituent (Ms A) that the partnership mishandled a complaint Ms A made to them about incorrect information in her medical records.
We found that, while the error concerned was extremely serious, it was clear that the partnership had admitted the error, amended the record and made a very sincere and full apology to Ms A. They had also put in place new checking procedures to prevent the same mistake occurring again. We found that there was no evidence to suggest that the partnership's approach to Ms A's complaint was unreasonable. Therefore, we did not uphold Mr C's complaint.
Summary
Ms C complained about the treatment she received from the partnership in response to pain in her right thigh. Ms C had previously underwent a total left hip replacement. After the surgery Ms C attended a physiotherapy (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) appointment due to pain in her right thigh. While Ms C was carrying out the exercises recommended by the physiotherapist, she experienced pain and a tearing sensation on her operated on side. Ms C said that it was unreasonable to have prescribed those exercises so soon after her operation. Ms C said she was not provided with the appropriate advice or precautions to follow.
We took independent medical advice from a consultant vascular surgeon (a clinician who treats disorders of the circulatory system). We found that the exercises prescribed to Ms C were reasonable and found no failings in the treatment offered. There was a record that appropriate precautionary guidance was provided to Ms C. Therefore, we did not uphold Ms C's complaint.
Summary
Mr C, an advocate, complained on behalf of his client (Miss A) about the post-operative care Miss A received at Golden Jubilee National Hospital. Miss A underwent a total hip replacement and was discharged under a week later. Miss A complained that she did not feel ready to return home so soon after surgery and wished to be admitted to a community hospital to recuperate. She was advised that she did not meet the criteria for admission to a community hospital, so she arranged to be transferred to a nursing home. Miss A said that, prior to her discharge, no one had explained to her she would have to pay to stay in the nursing home. She also complained that no referrals had been made for physiotherapy (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) or occupational therapy (a method of helping people who have been ill or injured to develop skills or get skills back by giving them certain activities to do), and said that her recovery time was longer as a result.
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 Miss A's discharge and arrangements for follow-up care were reasonable. We noted that Miss A's concerns had been discussed with her and extra help for when she returned home was offered but declined. Miss A had been assessed as having achieved her rehab goals while an in-patient and was assessed as being safe for discharge home. We did not find any evidence why Miss A would have expected to receive respite care following her surgery. Therefore, we did not uphold Mr C's complaint.
Summary
Ms C complained about the care provided to her late mother (Mrs A) by the practice. Mrs A had attended the practice on a number of occasions with chest pains, confusion, arm weakness and sight problems. Mrs A also had a history of high cholesterol (a fatty substance found in the body that can increase risk of health conditions) and a family history of heart problems. Mrs A later died at home and Ms C felt that the GPs involved in her care should have made earlier referrals to hospital specialists.
We took independent medical advice from a GP. We found that although Mrs A had attended the practice on a number of occasions before her death, she had not reported chest pain for a period of six months and it was felt reasonable that the staff had assumed her previously reported symptoms had resolved. During previous consultations with GPs they had considered a number of diagnoses and prescribed appropriate medication for the symptoms which were reported. There were also attendances at hospital where scan results were reported as being normal. Therefore, we did not uphold Ms C's complaint. However, we provided feedback to the practice that on one occasion, there was a need to make a referral to cardiology for further investigation and to provide Mrs A with safety netting advice. While there was no evidence that this would have prevented Mrs A's death, it may have led to an earlier diagnosis of heart problems and allowed treatment options if required.
Summary
Mrs C complained on behalf of her husband (Mr A) regarding the delay in reaching a diagnosis of prostate cancer during consultations at Perth Royal Infirmary. In response to Mrs C's complaint, the board explained that a number of factors had contributed to the time taken to diagnose Mr A. The board said that Mr A's symptom pattern was unusual, and investigations were initially performed to rule out bladder and kidney cancer. Mrs C was unhappy with this response and brought her complaint to us.
We took independent advice from a consultant urologist (a specialist in the study or treatment of the function and disorders of the urinary system). We found that it was reasonable of the board to first exclude the possibility of bladder or kidney cancer before investigating the possibility of prostate cancer. We also found that the department had carried out appropriate tests prior to Mr A being reviewed by the consultant. We considered that the board had met the waiting time targets and did not uphold Mrs C's complaint. Although we did not consider that the delay in diagnosis was unreasonable in this case, we gave detailed feedback to the board regarding areas for potential improvements in practice.
Summary
Ms C complained about the treatment she received from the dentist. Ms C was referred to the dentist as she required sedation during dental procedures. Ms C said she was told by the referring dentist that the tooth, which had a missing filling, was salvageable and could be crowned, however when the tooth was assessed, the dentist felt it was not salvageable. Ms C complained that the actions of the dentist led to an infection, cutting of the bone and was essentially unreasonable.
We took independent advice from a dentist. We found that Ms C's treatment by the dentist was reasonable and found no failings in the treatment offered. When the planned treatment changed, Ms C was brought back from sedation so she would be in a position to consent to treatment. The treatment was carried out in a reasonable manner. Therefore, we did not uphold the complaint.
Summary
Ms C, an advice and support worker, complained on behalf of her client (Mr A) regarding the treatment which he had received from the practice, prior to him being diagnosed with prostate cancer. Mr A had attended frequent consultations with right hip pain and had been referred to physiotherapy (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) on a number of occasions. He was also sent for an orthopaedic (treatment of diseases and injuries of the musculoskeletal system) referral which had not helped. Mr A stopped attending physiotherapy as he received no benefit from the exercises or the painkillers which the practice had prescribed.
We took independent medical advice from a GP. We found that initially it was felt that Mr A had a musculoskeletal problem (injuries or pain in the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) which was reasonable in view of the presenting symptoms. The practice provided appropriate pain relief and made appropriate referrals for specialist opinions in orthopaedics and physiotherapy. It was only when Mr A presented with pain in his upper spine, which triggered a red flag sign, that blood tests were arranged which indicated possible prostatic cancer. This resulted in an urgent referral to the cancer specialists. We had no concerns about the way the GPs at the practice managed Mr A's reported symptoms over the period and there was no delay in making a specialist referral when he reported a new symptom of spine pain. We did not uphold the complaint.
Summary
Mr C complained about the care and treatment provided to his late daughter (Miss A) by unscheduled care practitioners (UCPs) at A&E at Campbeltown Hospital. Miss A had attended the hospital on a number of occasions within a short period of time and reported symptoms of severe pain and sickness. Miss A then attended another hospital outwith the board area and a diagnosis of pancreatic cancer was made. Mr C said that Miss A felt that the UCPs had not listened to her and that had led to a delay in the diagnosis.
We took independent medical advice from a GP. We found that there was no evidence that the UCPs had failed to provide Miss A with a reasonable standard of treatment. She had been attending hospital specialists who were treating her for other medical conditions and that her reported symptoms could reasonably have been connected with the other medical conditions or side effects of the medication she was taking. There was nothing to suggest that Miss A was suffering from the effects of pancreatic cancer when she saw the UCPs. There are usually no symptoms in the early stages of the disease and those symptoms which do develop do so when the disease has reached an advanced stage; by the time of diagnosis, pancreatic cancer has often spread to other parts of the body. We did not uphold the complaint.
Summary
Mr C complained about the care he received from the practice prior to his diagnosis of hereditary haemochromatosis (a medical condition caused by an overload of iron in the body). Mr C experienced various symptoms that he said increased in number and severity over six years until his diagnosis. Mr C raised concerns that the practice should have carried out relevant tests, referred him to relevant specialists and reviewed his ongoing symptoms.
We took independent advice from a GP. We found that appropriate tests were arranged and appropriate and timely referrals were made to various specialities. We considered that a slightly raised blood test result was not diagnostic of haemochromatosis and relates to different conditions. We concluded that the care provided by the practice was of a reasonable standard. We did not uphold Mr C's complaint.
Summary
Mr C complained about a delay in the board diagnosing hereditary haemochromatosis (a medical condition caused by an overload of iron in the body). Mr C experienced various symptoms that he said increased in number and severity over six years until his diagnosis. Mr C raised concerns that the doctors should have investigated further rather than repeating the same tests, and that they missed a condition that would have been easily diagnosed by a simple blood test.
We took independent advice from a consultant in general medicine with a clinical interest in haemochromatosis. We noted that it is quite rare and diagnosis can be delayed in many cases for over five years. Mr C was seen by different clinicians in various different specialities before the diagnosis emerged following a random blood test for ferritin (iron storage protein). There was no family history of the condition and we considered that the symptoms Mr C experienced prior to the diagnosis were non-specific rather than being classical symptoms of haemochromatosis. We also considered that a blood test done a year before the diagnosis would not prompt consideration of hereditary haemochromatosis as a likely explanation. We concluded that staff did not unreasonably delay in considering the diagnosis at an earlier stage. We did not uphold Mr C's complaint.