Some upheld, recommendations

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) that his medical practice had failed to properly assess his symptoms and provide him with further tests to determine his increased risk of stroke. Mr A had attended the practice on a number of occasions with various symptoms. There was a history of heart and circulatory disease in his family and he was concerned that he had had a stroke.

We obtained independent medical advice on the complaint from one of our medical advisers. Although Mr A did subsequently have a stroke, the advice we received was that the symptoms with which he had presented to the practice did not suggest that he had suffered a stroke at that time. The adviser said that his symptoms were reasonably explained by other, more likely, diagnoses. Although we found that Mr A's concerns had not been fully addressed, the practice properly assessed the symptoms he presented with and arranged the appropriate tests. We found that they had acted reasonably and did not uphold this aspect of the complaint.

Mrs C told us that Mr A later did have a stroke and phoned the practice as soon as he realised what had happened. The practice recorded that he said that he was struggling to hold a cup in his left arm and was now having to drag his leg. They recorded that there was no mention of his arm being affected in the previous notes and that he might have suffered a stroke. They arranged an appointment for him later that day. However, Mr A instead went to hospital and was admitted to the stroke unit. We found that, based on the record of the phone discussion with Mr A, the correct course of action in line with relevant national guidance would have been for the practice to phone a blue light ambulance to take him to hospital. If the practice considered that there were good reasons for not doing so, at the very least, they should have recorded the reasons and arranged to examine Mr A immediately. The action they took was not appropriate and so we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology to Mr A for inappropriately telling him to attend an appointment later that day, when it was recorded that he had potentially suffered a stroke;
• make the GP that Mr A spoke to aware of our decision on this matter; and
• confirm that the matter will be discussed at the GP's next annual appraisal.

Summary

Mrs A registered with the medical practice when she moved into a care home. She had several ongoing medical conditions and was seen by GPs from the practice on a number of occasions. A number of months after moving into the care home, Mrs A became quiet and was not drinking enough fluids. Staff contacted the practice and were advised to keep her under close observation. A call back was arranged for a short time later at which time the care home staff reported that Mrs A was much better and was drinking fluids. As they also advised the practice that Mrs A had very strong, foul smelling urine, an antibiotic was prescribed to treat any underlying infection. Later that night, however, Mrs A's condition deteriorated and she was admitted to hospital later that night. She died some days later.

Mrs A's daughter (Mrs C) complained that the GPs had not provided Mrs A with appropriate medical care while she was resident at the care home. In considering this complaint, we took independent advice from one of our medical advisers, who is a GP. Having reviewed Mrs A's medical records, our adviser said that she had received reasonable care and treatment from the practice. The GPs had reviewed and amended her medication, referred her to specialists in old age psychiatry and speech and language therapy, and responded to requests for advice from the care home staff as well as monitoring her general health. We did not uphold this complaint.

However, Mrs C also complained that the practice took too long to respond to her complaint. We reviewed their complaints handling procedure and agreed that the complaint had not been dealt with within their published timescales. We also noted that their complaints handling procedure had not been updated to reflect the introduction of new legislation, so we upheld this complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to respond to her complaint in a timely manner; and
• update their complaints handling procedure.

Summary

Mr C visited his dentist because he had toothache. The dentist found an abscess that was discharging pus from the gumline of the third and fourth teeth on the lower right side of Mr C's mouth. As Mr C was already taking a course of antibiotics prescribed by his GP, the dentist said that he should let the inflammation settle before returning to have the teeth extracted. Mr C returned and his teeth were extracted but the pain and swelling continued. He went for an emergency appointment, and the abscess was found on the first lower right tooth. Mr C was referred to local maxillofacial surgeons (specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) who provided intravenous antibiotics before removing all his lower teeth.

Mr C complained that his dentist did not provide reasonable treatment during the first consultation. He said he was not already taking antibiotics and that these were prescribed when he found it necessary to visit his GP having been unable to secure an emergency appointment with his dentist.

We found clear evidence that the antibiotics were prescribed before Mr C visited his dentist. Based on the information available at that time, we were satisfied that the dentist could not provide any immediate treatment, and we did not uphold this complaint. We were, however, critical that the dentist did not take additional x-rays to identify the true location of Mr C's abscess. The failure to do so delayed treatment by around two weeks and so we upheld the complaint that the care and treatment was unreasonable. However, we were satisfied that the two teeth that were extracted had to come out in any case. We found no evidence to suggest that emergency appointments were requested and refused and did not uphold that complaint.

Recommendations

We recommended that the dentist:

• apologise to Mr C for the delay to the treatment of his abscess; and
• take note of the adviser's comments regarding the need for additional x-rays with a view to identifying any points of learning for future treatment.

Summary

Mrs C raised a number of concerns about the care and treatment that her late mother (Mrs A) received at the Victoria Hospital during two separate admissions. Mrs A was taken to hospital with symptoms suggestive of a stroke. Tests showed that she had a lung tumour, and a biopsy (tissue sample) was taken several days later. She was discharged, but was readmitted four days later having suffered a major stroke. Mrs A died three months later.

We took independent advice on this case from our nursing adviser and one of our medical advisers, who is a GP. The GP adviser identified that a number of aspects of Mrs A's medical care fell below a reasonable standard. At the time of the first admission, more consideration could have been given to the stroke diagnosis and treatment, and there was an unreasonable delay in the lung biopsy being processed although we took the view that the board had since taken reasonable steps to address this. In respect of the second admission, the GP adviser said there was a lack of communication between specialist stroke staff and the family. We also found that, although Mrs A's medication was managed well on a daily basis, there was a need for more strategic consideration of this. There was delay in providing medication to address Mrs A's high calcium levels and her low mood. In addition, medication for nausea was stopped, and there was no reason for this given in the medical records. Our GP adviser was also critical that there were a number of undated entries in relation to blood results.

We noted that the board had acknowledged Mrs C's concerns that Mrs A's dignity was compromised and that on one occasion she was not properly clothed, and our nursing adviser was satisfied with the measures the board took to address this. In relation to the management of incontinence, pain levels, involvement from speech and language therapy and dieticians, along with Mrs A's care planning and rehabilitation work, there was evidence in the medical records to support that the overall nursing care was of an acceptable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• review the comments of our GP adviser on this complaint and reflect on the decision-making processes used by GPs individually and collectively in assessing Mrs A, and provide us with evidence of this reflection having taken place and its outcome.

Summary

Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.

There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.

Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support;
• review his current treatment to ensure that it is appropriate;
• take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and
• take steps to ensure that care management for psychiatric patients is co-ordinated.

Summary

Mr C complained because he had concerns about the safety of the area that he and other prisoners worked in and he did not think the prison had addressed these properly. He also complained that he was not being paid weekly, and because he felt that the prison had not considered his circumstances appropriately when allocating work to him.

In his complaint to the prison, Mr C said he had not received appropriate inductions and he made a number of observations about the work being carried out. He also raised concerns about an incident that had taken in place in which another prisoner was injured. In response, the prison confirmed that all reported accidents were fully investigated and records kept. They told Mr C that he was required to work. We considered that the prison appropriately addressed his concerns about the incident involving the other prisoner. We also considered that it was unreasonable for Mr C to complain about not receiving the appropriate inductions, because he had refused to attend work. However, the prison did not respond at all to his observations of the work being carried out and we felt they should have, so we upheld this aspect of his complaint and made a recommendation.

Prison rules require prisoners to work. However, Mr C had made it clear to the prison that he was not prepared to attend work. The prison provided evidence to show us the steps they had taken to consider Mr C's circumstances before allocating work to him and we found these to have been appropriate. We, therefore, did not uphold Mr C's complaints about this.

Recommendations

We recommended that the Scottish Prison Service:

• apologise for not responding fully to the concerns Mr C raised in his complaint.

Summary

Mr C complained that the Scottish Prison Service (SPS) had failed to clarify his circumstances in relation to his fitness to work and was reported for not working. He was also concerned about the handling of his representations about this.

During our investigation the SPS provided evidence that Mr C had seen a prison doctor, who had deemed him fit to work, although not with machinery, before he was reported for not working. The prison doctor had also considered the risk assessments for the workshed Mr C was allocated to and deemed it to be suitable.

While we were satisfied that in general the SPS had dealt with Mr C's complaints in line with the complaints process, we were concerned that when Mr C had asked for assistance at a number of internal complaints committee (ICC) hearings, this was not always acknowledged on the paperwork. We also noted that three committee members were not always present at the ICC as required. During our investigation the SPS reminded staff of the need to follow the correct procedures in relation to providing the relevant paperwork to a prisoner. They also agreed to remind staff of the need to follow the process when a prisoner requires assistance at a ICC. We, therefore, made only one recommendation.

Recommendations

We recommended that the SPS:

• remind staff of the need to ensure that at least three members are present at the ICC in line with guidance.

Summary

Mr C had suffered prostate problems since his forties and his prostate health was regularly monitored. Until 2011, the tests had shown that although his prostate was enlarged, he was not suffering from cancer. Early in 2011, Mr C's blood test results began to indicate that he might have prostate cancer. Tissue samples were taken but these showed no sign of cancer. Mr C was given an appointment for a review within 12 weeks. However, this was cancelled and Mr C was not seen again until December that year. Following this appointment Mr C was diagnosed with advanced prostate cancer, which was incurable.

Mr C complained that the delay in rescheduling his review appointment was unacceptable. He felt that this happened because staff did not follow departmental procedures properly and because the board failed to appropriately implement a new appointment management system. Mr C said he believed the delay had adversely affected his treatment options and that when he complained the board did not handle his complaint reasonably or appropriately.

We took independent advice from a medical adviser on the clinical aspects of Mr C's case, and upheld most of his complaints. We found that the delay in rescheduling the appointment was unreasonable. The board did not give a reason for the delay and our adviser said that they should have explained why he needed the review appointment. Their failure to do so meant that Mr C did not pursue a rescheduled appointment after the original was cancelled. We did not uphold the complaint that his treatment was adversely affected, however, as our adviser said that it was likely that the cancer had already spread outside the prostate and the delay in rescheduling the appointment did not affect Mr C's prognosis or the available treatment.

We upheld Mr C's other complaints. The board could not show that they had implemented their appointment management system correctly, or that they had identified learning from the failures in Mr C's case. Their handling of his complaint was inadequate and there was no evidence that they had since introduced robust complaints handling procedures to stop these mistakes happening again.

Recommendations

We recommended that the board:

• review the urology department procedures, to ensure that patients are informed of the reason for a follow-up appointment and the timescale for this;
• provide us with evidence that they have identified the causes of the delay in manually transferring appointments during the introduction of the Patient Management System to prevent a reoccurrence, including the checks carried out to ensure that all patients were manually transferred at the time;
• provide evidence that the new Patient Management System will alert medical staff when appointments are cancelled;
• provide evidence of the steps they have taken to improve the accuracy of complaint responses;
• provide evidence that all staff have been reminded of the importance of using appropriate language when corresponding about patients;
• audit their new complaints process to ensure complaint investigations are conducted with appropriate rigour and that adequate records of the investigation are be maintained; and provide us with a copy of the findings; and
• apologise in writing for the failings our report identified.

Summary

Mr C complained about the end of life care and treatment provided to his late mother-in-law (Mrs A) in Glasgow Royal Infirmary. Mr C said that the family found it distressing to see Mrs A in the latter stages of her illness, and that the board failed to provide reasonable pain relief and refer her to the palliative care (care provided solely to prevent or relieve suffering) team within a reasonable time. He also said healthcare professionals failed to take account of the views of Mrs A's daughter, who held welfare power of attorney (a legal document appointing someone to act or make decisions for another person), and that there were failures in communication and record-keeping, particularly around the provision of a morphine pump. Finally, Mr C complained about the the way the board handled his complaint, saying that they failed to carry out an objective and transparent investigation.

Having taken independent advice from a medical adviser and a nursing adviser, we upheld some of Mr C's complaints, as we found that while the frequency of communication between healthcare professionals and the family was reasonable, the board did not ask Mrs A's family about power of attorney (particularly in light of Mrs A's incapacity) or formally discuss the medical procedures in advance with Mrs A's daughter. Having said that, we found that the board's records of several conversations with the family about the provision of a morphine pump were reasonable in that they reflected the views of the clinicians concerned. We accepted advice that Mrs A's pain relief and end of life care were generally reasonable and that Mrs A's symptoms were adequately managed by the medication prescribed. We were not, however, satisfied that the board's complaint investigation was carried out in accordance with the NHS complaints procedure, as it appeared from the board's responses that it was done by the members of staff who were the subject of the complaint.

Recommendations

We recommended that the board:

• review their patient profile and documentation and its completion in light of our nursing adviser's comments;
• bring the failures our investigation identified to the attention of the relevant healthcare professionals concerned;
• ensure the relevant healthcare professionals appropriately consider referrals to the palliative care team at the earliest opportunity, in light of our medical adviser's comments;
• bring the failures identified in complaints handling to the attention of relevant staff; and
• apologise to Mr C for the failures this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care she received from the maternity triage service at Forth Valley Royal Hospital immediately prior to the birth of her daughter. Mrs C had phoned the service twice for advice about coming into hospital as she was concerned about the progress of her contractions, and felt she was dissuaded from going to hospital after speaking to a midwife during her second phone call. Around an hour later, Mrs C gave birth to her daughter at home with the assistance of her husband. She suffered heavy blood loss, paramedics attended and she was transferred by air ambulance to another hospital.

We took independent advice on this case from one of our medical advisers, who is a specialist in midwifery. Our adviser was critical of the midwife's actions during the second phone call, as they should have asked Mrs C to attend hospital for assessment of whether or not she was in active labour, given that she had experienced complications during a previous birth. We also found that the maternity triage phone template did not prompt staff to ask women about their previous medical history. We, therefore, upheld Mr C's complaints about the advice Mrs C had received by phone, and the lack of adequate documentation of the advice given.

In responding to Mr C's complaints, the board agreed to make triage staff aware that patients should not feel as if they need permission to attend hospital, and acknowledged that the midwife had not documented any advice she had given Mrs C about coming into the hospital. They also took steps to introduce a new national maternity triage template to ensure that appropriate information is captured, and introduced peer review.

Although we took the view that the board made reasonable improvements to shortcomings in the triage process, we did not find that the structure in place at the time was inadequate. We also concluded that it was not unreasonable for the board to have staffed the maternity triage service with a labour ward midwife, given they are qualified to determine if admission is necessary or not. We did not uphold those aspects of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that the midwife reflects on our adviser's comments as a learning tool;
• ensure midwifery triage staff appropriately document advice they provide; and
• apologise to Mrs C for the failings our investigation identified.