Some upheld, recommendations

Summary

Mr C complained about the care and treatment he received from a prison health centre in relation to his eye condition. He was concerned that he received various different medications, none of which helped and some of which appeared to worsen his condition. He, therefore, felt that he had been inaccurately diagnosed, and he complained that he was not referred to an eye specialist sooner.

We took independent advice from one of our medical advisers, who observed that Mr C had been seen on a number of occasions by healthcare staff and examined repeatedly. Our adviser noted that examinations did not reveal any serious underlying problems and that this mirrored the subsequent findings of the eye specialist. As such, she did not consider there to have been an earlier indication for a referral to a specialist. We fully accepted this advice and did not uphold this aspect of the complaint.

Mr C also raised concerns about the way his complaint was handled. We noted that he submitted multiple complaint forms on the issue, and the prison health centre continued to try to resolve these informally. The guidance only allows a three-day window for informal resolution, following which the complaint should be formally acknowledged and investigated. This did not happen for several weeks and, seemingly, only upon Mr C's prompting. We identified other failings to follow due process, such as an initial failure to inform Mr C of his right to approach this office. In the circumstances, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the ‘Can I help you?’ guidance; and
• apologise to Mr C for the identified failings in their handling of his complaint.

Summary

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and an extended hospital stay. She complained that the risks of the surgery were not adequately explained and that reasonable steps were not taken to avoid the complications encountered, such as infection. She also complained that the surgery resulted in Mr A developing a foot drop (a condition which impairs the ability to lift the front part of the foot).

We took independent advice from one of our medical advisers who noted that consent forms were completed both prior to Mr A's admission and on the day of the surgery. However, our adviser observed that the forms did not document the potential risks of the surgery. Our adviser stated that it was good practice to list common complications, or those which are rare but severe. In the absence of this, we could not find evidence that the risks were adequately discussed with Mr A and so we upheld this aspect of the complaint.

Our adviser confirmed that the complications encountered were recognised complications of this type of surgery, and did not consider that anything could reasonably have been done to prevent them in Mr A's case. In addition, our adviser considered it unlikely that Mr A's foot drop was related to the surgery. We accepted this advice and did not uphold the remaining aspects of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to improving the process for obtaining consent and, in particular, consider whether the consent form could benefit from revision; and
• apologise to Mr A for the failings in the process for obtaining his consent.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) had received from the board. Mrs A had taken lithium medication for many years for her bipolar disorder. This medication was changed in November 2012 and then changed back to lithium around six months later. Ms C was unhappy with these decisions as she felt they caused her mother to suffer from lithium poisoning, which caused Mrs A to attend Lorn and Islands Hospital. She was transferred to Argyll and Bute Hospital and then was moved between the hospitals again. Mrs A died within two months of her initial admission and Ms C was unhappy with the care her mother had received throughout this period.

We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We did not use the benefit of hindsight in making that decision and we took independent medical advice from a psychiatrist and a geriatrician (a doctor specialising in medical care for the elderly). Their advice confirmed that the original decision to change Mrs A's medication was reasonable in the circumstances, as was deciding to reintroduce lithium. In light of this clear advice, we did not uphold Ms C's first two complaints.

Our medical advice was that Mrs A appeared to have been suffering from lithium toxicity when she first attended Lorn & Islands Hospital, and that it was unreasonable to have transferred her to Argyll and Bute Hospital at that time. Mrs A was then transferred back to Lorn and Islands Hospital for a time before returning to Argyll and Bute Hospital. Our medical advice was that the potential severity of Mrs A's lithium toxicity appeared not to have been recognised during this time and her condition was not investigated sufficiently. We upheld Ms C's complaints about these admissions. However, in terms of Mrs A's final admission to Lorn and Islands Hospital, our medical advice was that care and treatment was by that point reasonable, so we did not uphold Ms C's complaint about that.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings identified in our investigation;
• remind relevant staff (including in A&E) of the possibility for lithium toxicity to occur in older patients at levels within the standard range of prescribed dosage;
• consider whether a shared protocol between Lorn and Islands Hospital and Argyll and Bute Hospital would be appropriate for management of lithium toxicity; and
• raise the medical advice we received about restarting lithium medication at the relevant psychiatrist's appraisal for reflection.

Summary

Ms C's second child was stillborn. She said that for a number of weeks prior to the birth she had expressed concern but had not been listened to. She said that staff at the Southern General Hospital failed to respond appropriately when she told them that her waters had broken, and that she was not properly assessed or seen by a doctor. Ms C believed that these failures led to her child's stillbirth.

We took independent advice from a consultant obstetrician. We found that Ms C's temperature had not been monitored as it should have been and that, after two examinations following the rupture of her membranes, she should have been immediately induced. There was also confusion about the responsibility of her care and, thereafter, there were failures in providing her with information. We upheld these complaints.

Although Ms C further complained about the quality of information she received about her child's post mortem, it was considered that reasonable explanations were given, so we did not uphold this part of her complaint.

Recommendations

We recommended that the board:

• make a formal apology for these failures;
• confirm to us that the recommendations made as a consequence of their Significant Clinical Incident Investigation report have since been carried out; and
• recognise this shortcoming in their apology.

Summary

Mrs C's husband (Mr C) had previously suffered from a brain tumour and had a craniotomy (surgery to remove the tumour). However, his symptoms returned about a year later, and he was diagnosed with another brain tumour. Mr C had another craniotomy, followed by six weeks of radiotherapy. Mr C died a few days after his radiotherapy.

Mrs C raised concerns about the delay in diagnosing Mr C's second tumour, as well as the level of support provided during his radiotherapy treatment. Mrs C was dissatisfied that the GP did not arrange admission to hospital during Mr C's radiotherapy (although she asked about this); that the GP did not arrange district nurses or a care plan for Mr C, or carry out more home visits; and that the GP did not manage Mr C's medication appropriately, or provide reasonable care for his diabetes. Mrs C also raised concerns about the practice's communication. She said the GP never told her or Mr C that his condition was terminal, and refused to answer when she asked how much time Mr C had left to live. She was also unhappy that the GP told her it would be fine to go to work the next day when she asked about this, and Mr C died that day.

The practice apologised to Mrs C for several aspects of their care, including not being more proactive about contacting the hospital on Mrs C's behalf, and for advising that it would be fine for Mrs C to go to work on the day Mr C died. In relation to district nurses, the practice said they had offered this, but Mr C had declined. The practice undertook a significant event analysis, and identified steps to improve their communication about palliative care in the future.

After taking independent medical advice, we upheld one of Mrs C's complaints. Although most aspects of the practice's care and treatment were reasonable, we found the GPs failed to take action in response to a letter from the oncologists suggesting medication to help manage Mr C's aggression, and this was unreasonable. We also found the GP used poor judgment in advising Mrs C that she could go to work the day that Mr C died. However, we accepted that the GP had taken appropriate action in response to Mrs C's complaint, including apologising, reflecting on their practice and carrying out a significant event analysis. We did not uphold Mrs C's complaints about communication, as the prognosis would normally be communicated by the oncologists, and there was also evidence that the GP spoke with Mr and Mrs C about the terminal nature of his illness. We also found it was reasonable for the GP to refuse to give an estimate of how long Mr C had left to live, as the GP could not accurately predict this.

Recommendations

We recommended that the practice:

• bring our findings about the failure to consider the oncologist's suggestion about medication to the attention of the relevant GP for reflection and learning.

Summary

Mr C had some of his medications reduced and stopped soon after entering prison (although he was still on one medication). He was then transferred to a different prison, where he raised concerns about his medication and asked to be put back on his original medication. The board arranged for Mr C to see his psychiatrist from the community (who had prescribed his initial medication). The psychiatrist increased Mr C's current medication, but did not return him to his previous medications. Mr C complained about the board's failure to return him to his previous medication, and their handling of his complaint.

After taking independent advice from an experienced psychiatrist, we did not uphold Mr C's complaint about medication. We found there was no clinical reason to restart Mr C's previous medications, particularly as several of these medications are addictive and not for long-term use. We also noted that Mr C's psychiatrist from the community had reviewed his medication and agreed with this.

In relation to the board's complaints handling, we found the board had taken appropriate action in response to Mr C's complaints by arranging review by his psychiatrist from the community. However, on two occasions the board did not respond to Mr C's complaint to confirm what was happening and check that he was satisfied with this, as required by their complaints procedure. Therefore, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the need to acknowledge or respond to all complaints within a three working day timeframe.

Summary

Miss C's MP complained to us on her behalf. Miss C was admitted to Aberdeen Royal Infirmary with an infected appendix, which was removed. She complained about aspects of her nursing care, including that she was not provided with anything to eat or drink on the day of her admission. She also complained that she was not given sufficient information on discharge. In addition, she was unhappy with the time the board took to respond to her complaint and she said their response contained inaccuracies, including the board's view that she was given tea and toast on the evening of her admission.

We took independent advice from one of our nursing advisers, who observed that there was no record of any food or fluids being given to Miss C on the evening of her admission. She said if tea and toast were provided she would have expected this to have been recorded. We upheld this aspect of the complaint.

While the adviser noted that, in light of Miss C's anxiety, the board could perhaps have provided her with extra information and reassurance, she considered that a reasonable level of information was provided to her at the time of her discharge. We did not uphold this aspect of the complaint.

We noted that there was a considerable delay in the board responding to Miss C's complaints correspondence. It appeared as though they had overlooked the complaint. We also noted that information relevant to their investigation was not contained within their complaint file, including notes of key discussions. Further, they failed to address all the points of complaint Miss C raised and some of the information they provided in their response did not appear to be supported by the available evidence. We, therefore, upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• remind nursing staff of the importance of good record-keeping;
• remind complaints handling staff of the importance of issuing full, evidenced and timely responses to complaints;
• remind complaints handling staff that complaint files should contain a complete record of their investigations, including notes of relevant discussions; and
• apologise to Miss C for the complaints handling failures this investigation has identified.

Summary

Mrs C developed deep vein thrombosis (DVT, a blood clot in one of the deep veins in the body) after having surgery at Forth Valley Royal Hospital. Mrs C was readmitted to hospital, where the diagnosis was confirmed and she was started on a medication to treat DVT. After she was discharged, Mrs C's GP referred her to an out-patient clinic at the hospital (the Clinical Assessment Unit), as Mrs C's legs were swollen and she was suffering pain. Mrs C was reviewed by a doctor, but not admitted to hospital. Mrs C then received an appointment for a scan at another hospital out-patient clinic (the Day Medicine Unit). When she arrived, the staff were not sure why she was there, and said she did not need a scan. However, a doctor reviewed Mrs C and arranged for her to be seen by a consultant vascular surgeon, who then took over Mrs C's care.

Mrs C complained about her overall care and the confusion about her appointment at the Day Medicine Unit. Mrs C was concerned that her DVT may have developed in her first hospital admission (and been misdiagnosed as an infection), that she may have been discharged too early after her second admission, and that she should have been given a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) or referred to a surgeon earlier.

The board apologised for a number of failings. The board took a number of actions to address the issues raised by Mrs C's complaint, including developing a ward checklist for checking the use of anti-embolism stockings (specially fitted elastic stockings used to compress the lower leg and reduce the risk of blood clots); developing a patient information leaflet on DVT; arranging for certain types of DVTs to be referred for a CT scan and discussed with a vascular surgeon as a matter of routine; reviewing the patient pathway for the provision of specialist hosiery; and establishing a seven-day service for management of DVTs within the Day Medicine Unit.

After taking independent medical advice, we upheld two of Mrs C's four complaints. We found that, while most of the care and treatment provided was reasonable, the overall approach to Mrs C's care was fragmented, with a number of different doctors and departments involved. This meant that Mrs C received inconsistent information about her condition and care. We also found the board failed to provide the correct anti-embolism stockings and gave inconsistent information about the medication prescription in Mrs C's discharge letter. While we accepted that the action identified by the board in response to Mrs C's complaint was reasonable, we recommended they demonstrate to us that this action is completed within the timeframes they gave.

Recommendations

We recommended that the board:

• demonstrate to us that a consistent pathway for the provision of specialist hosiery has been established;
• review the pharmacy process for checking discharge letters and prescriptions to ensure that any discrepancies in the instructions are clarified appropriately; and
• demonstrate to us that the arrangements for DVT management by the Day Medicine service are in place, including raising staff awareness and updated documentation.

Summary

Mr C complained on behalf of his daughter (Mrs A) who injured her head and neck in a sporting incident. Mrs A was taken to A&E at Forth Valley Royal Hospital and admitted to the orthopaedic ward. X-rays were taken of her neck and finger, and an MRI scan (magnetic resonance imaging scan, used to diagnose health conditions that affect organs, tissue and bone) was taken of her neck. Medical staff did not consider she had a significant head injury and she was discharged after three days. Mrs A continued to suffer symptoms from her accident and was referred to a specialist a few months later. A head MRI was taken which showed she had suffered a head injury and she was referred to the neurology department. Mrs A was diagnosed with post-concussion syndrome. Mr C complained about the delay to Mrs A's diagnosis and expressed his concern that this may have affected her recovery.

We were critical of a number of aspects of Mrs A's care. We took independent medical advice from three advisers (a consultant in orthopaedic and trauma surgery; an emergency medicine consultant; and a nurse). We found that Mrs A's symptoms should have prompted a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) of her head in line with national guidance. We also found that Mrs A's condition was not monitored adequately in A&E, nor were her neurological symptoms adequately monitored in the orthopaedic ward. We were critical of a lack of record-keeping, which prevented us from commenting in detail with regard to a number of points Mr C had raised.

Recommendations

We recommended that the board:

• provide evidence of action taken in response to Mr C's complaint;
• issue a written apology to Mrs A for the failings our investigation found; and
• take steps to increase staff awareness of SIGN 110 (guidelines for the early management of patients with a head injury, written by Scottish Intercollegiate Guidelines Network), including the requirement for regular neurological monitoring and the indications for CT scans.

Summary

Mrs C had been admitted to Dumfries and Galloway Royal Infirmary for pelvic floor repair, as she had a prolapse of the wall between her vagina and rectum. She said that she was only told that she might need a vaginal hysterectomy (surgery to remove the womb through the vagina) on the morning that the surgery was to be carried out. She then had a vaginal hysterectomy later that day. Mrs C complained about the action taken in relation to consent for the procedure. We took independent advice from one of our medical advisers, who is an experienced consultant gynaecologist. We found that it was unreasonable that Mrs C was only told about the possibility of such a significant procedure on the day of the surgery and that she was given little time to consider this. We considered that Mrs C should have been told about the possibility that she needed a vaginal hysterectomy at an earlier stage, and we upheld this aspect of her complaint.

Mrs C also complained about the procedure that was carried out. Although we had concerns about the consent process and considered that Mrs C should have been told about the possibility of a vaginal hysterectomy earlier, we found that it had been appropriate for this to be carried out.

Mrs C also complained about the pain relief she had received after the operation. We found that the pain relief had been reasonable. Finally, she complained that the standard of medical and nursing record-keeping was unreasonable. Although there were some missing/incorrect dates and times in the documentation, we found that the notes were of an acceptable standard. Consequently, we did not uphold these aspects of her complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to ensure that the possibility of a vaginal hysterectomy is discussed at an early stage with patients who are to undergo pelvic floor repair; and
• issue a written apology to Mrs C for the failure to mention the possibility of a hysterectomy to her at an earlier stage.