Some upheld, recommendations

Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.

Summary

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach.

Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer.

After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the apparent lack of consideration of Mrs C's shrunken kidney, and upheld Mr C's complaint that this was not investigated quickly enough. Investigations concentrated on the biliary tree but found no significant abnormalities other than gallstones. Mrs C's pain was located in the area of her shrunken kidney, which was highlighted in June 2010 and showed again in the November 2011 CT scan. It was established in December 2011 that the biliary tree abnormalities were not the source of the pain. We concluded that there was sufficient cause to refer Mrs C to a urologist at an early stage, rather than to concentrate investigations on the biliary tree abnormalities. We did not uphold Mr C's complaints about how details of his wife's condition were explained in a letter to her and about medication prescribed.

Recommendations

We recommended that the board:

• share our findings with the clinical team so that they may consider reviewing how referrals are managed for patients requiring multi-disciplinary investigations.

Summary

Ms C and Mr C are sister and brother. Their elderly father (Mr A) was admitted to a hospital as an emergency with a suspected urinary tract infection, and was discharged home five days later. Ms C was unhappy that although she held a power of attorney for her father, no senior member of staff contacted her to discuss Mr A's care, in particular the changes that were made to his heart medication. The hospital clinician's view was that Mr A suffered from several illnesses and his admission was precipitated by increasing confusion and reduced mobility. The clinician said that the medicine changes made in hospital took account of Mr A's condition at the time of his first admission. Mr A was readmitted to the hospital about four weeks later and tests confirmed he had suffered a heart attack. He died there three days later. Both Ms C and Mr C said that the hospital withdrew Mr A's life supporting medication during his first admission and they made several complaints linked to this.

We took independent advice from one of our medical advisers, who considered all the clinical aspects of the case. We took account of his advice along with the documentation provided by Ms C and Mr C and the board. The adviser said that life supporting medication was not withdrawn, and that Mr A's age, frailty and his other illnesses had to be taken into account. However, the adviser also said that consideration should have been given to Mr A's future symptom control when he was discharged home after his first admission, so we made recommendations to the board about this. The adviser also said that there was no evidence that a review by a doctor was not independent. Although, therefore, we did not uphold the complaints about Mr A's clinical treatment, we considered that the board had offered unsatisfactory explanations to Ms C and Mr C when they complained and we upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• feedback the learning from this complaint to all staff;
• ensure that when changes in medicine(s) are made to patients with diminished capacity, such changes are discussed with their carers;
• ensure that, when medicines are changed prior to a patient's discharge home, consideration is given for appropriate follow-up or monitoring of the patient;
• ensure that information entered in case records is an accurate reflection of events;
• apologise to Ms C and Mr C for the failures identified in this case; and
• ensure that the rationale for changes in medication is clearly documented.

Summary

Mr C's brother (Mr A) was in hospital for two months before being discharged to a care home. Mr C's other brother (Mr B) had welfare and continuing power of attorney for Mr A. Mr C complained that staff failed to take into account Mr A's communication problems related to his cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and his rapid deterioration while he was in hospital. Staff also failed to notice his legs were swollen or that he had injured his eye. Mr C asked to see a doctor who knew Mr A but as that person was unavailable, the family had to speak with another doctor who was not familiar with him. The doctor suggested an assessment. Mr C said that when this was carried out, Mr A's dementia and inability to recognise threats and dangers to his own safety were obvious. Mr C was also unhappy that nursing staff put items of lightly and heavily soiled clothing in the same bags for taking home to launder.

As part of the arrangements to discharge Mr A from hospital, an occupational therapist and social worker visited his home. Mr C did not agree with their findings, or that the proposed adjustments to the house would enable his brother to live there. The family were, therefore, concerned about Mr A's planned discharge home. The hospital consultant phoned Mr C at home to explain why Mr A was being discharged, but the family were not told exactly when this would happen. On arriving at visiting time one day, Mr B found an ambulance crew taking Mr A to be discharged home. The family said this was not acceptable, and Mr A was returned to the ward. He was eventually transferred to a care home. Again, Mr C said that the family and Mr A's social worker were not told about this in advance and only learned of it in a phone message left on an answering machine. Mr C complained about Mr A’s care and treatment at the hospital. In particular, he complained about the lack of clinical treatment which was provided; a lack of co-ordination by health and social work staff; a failure to properly assess Mr A's needs and a failure to communicate with Mr C and his other brother about Mr A’s welfare and eventual discharge.

After taking independent advice from one of our medical advisers, we upheld Mr C's complaints about care and treatment and about communication with Mr A's family. We found that while the care and treatment provided in relation to Mr A’s physical health, including medication, was reasonable, there were failures in relation to his mental health care needs. These included fully assessing his capacity for decision-making, which was of considerable concern to us. While we found evidence in the medical records of communication by nursing staff with Mr A's family about his discharge planning, the medical consultant's communication with them was limited to one phone call. This was below a reasonable standard, as the communication failed to meet the needs of Mr A or his family in relation to Mr A’s welfare given the complexity of his condition. We found, however, that the assessment and planning for discharge was reasonable. We found evidence that Mr A's family were involved and we were satisfied that the arrangements themselves were reasonable.

Recommendations

We recommended that the board:

• ensure that failings identified in relation to communication and documentation are brought to the consultant's attention and reviewed as part of the consultant's annual appraisal;
• apologise to Mr C for the failures identified;
• bring our adviser's comments about the review of Mr A’s prostate medication to the attention of relevant staff;
• provide evidence of how they are implementing Scotland's National Dementia Strategy with particular reference to communication with the families and carers of patients with cognitive impairment; and
• introduce a policy to ensure that the cognitive function of elderly patients is assessed and, if this is impaired, that capacity for decision-making is also assessed.

Summary

Mr C was under the care of a specialist pain physiotherapist in the board's pain clinic service. He was also referred to, and awaiting treatment from, a specialist pain psychologist there. However, the physiotherapist left her post and later, after two periods of sickness absence, the psychologist did likewise. Mr C complained about the delay in filling these posts and the resultant gap in service provision. During our investigation, we took independent advice from one of our medical advisers, who said that the board took reasonable steps to explain the position to Mr C, to make alternative treatment options available to him, and continue to provide a service in the face of challenging circumstances. We also saw evidence that Mr C had not always fully engaged with his treatment plan, and in the circumstances we did not uphold the complaint. However, although we acknowledged the difficulties the board faced in filling these specialist positions, we considered that they could have acted more promptly in advertising the physiotherapist post.

Mr C also complained about the way in which the board handled his complaint. In particular, he was unhappy that he was told that the psychologist would be returning to work, only to later find that she had resigned. We found that the information shared with Mr C was accurate when it was provided and we did not consider that the board could reasonably have foreseen that the post would later be vacated. We saw no evidence of a deliberate attempt to mislead Mr C, as he alleged. Mr C also complained that the board failed to respond to an email he sent them and to address all the complaint points he raised. The board accepted that an administrative error had led to a response not being sent and apologised for this. We also noted that the board had agreed four points of complaint for investigation with Mr C, but did not appear to have responded to all of them so, in the circumstances, we upheld Mr C's complaint about their complaints handling.

Recommendations

We recommended that the board:

• highlight to relevant staff the importance of timely recruitment to specialist posts in order to minimise disruption to patients’ therapeutic programmes; and
• remind complaints handling staff to ensure they respond to all complaint points that have been agreed with the complainant.

Summary

Miss C's mother (Mrs A) was admitted to hospital. She was very frail and had significant leg ulcers, and needed more care than could be provided at home. After a couple of weeks, Miss C had spoken with a healthcare professional about her mother's planned return home. However, Mrs A was then diagnosed with aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). She was reviewed by a speech and language therapist, who considered that Mrs A's swallowing was unsafe and so she was given a modified diet. A doctor then reviewed Mrs A, and said that she had further deteriorated. She reassessed Mrs A's medication and decided that she should not be given normal quantities of food or drink by mouth ('nil by mouth') because of her difficulty in swallowing. Mrs A died of pneumonia a few days later.

Miss C complained to us that communication from staff was poor; that Mrs A went on to develop a urine and chest infection and that the doctor had, unreasonably, given instructions that should her intravenous antibiotic drip become detached, it was not to be re-fixed. Miss C said that when the drip became dislodged, despite repeated requests, it was not reinserted and Mrs A's medication was withheld. Miss C also said that, while her mother was in hospital, she had emphasised to staff that they needed to ensure that her mother received enough to drink as she knew it was critical that Mrs A did not develop an infection. Miss C said that her mother had been in great discomfort before her death, as she had not been receiving medication and had in fact developed a urine infection that had served to weaken her condition further.

After taking independent advice from a medical adviser, however, we did not uphold Miss C's complaints about her mother's care and treatment. Our investigation found that the care and treatment provided was reasonable, as was staff communication with Miss C, although they could have explained the meaning of 'nil by mouth' better. Our adviser said the records showed that Mrs A's leg wounds were appropriately treated, and her pain managed, and that there had been care from a multi-disciplinary team including physiotherapy, occupational therapy, dieticians, medical and nursing staff. The records were of a good standard and contained daily entries of the care and treatment given. We did, however, identify some shortcomings in the way the board dealt with Miss C's complaint in that there were a number of inaccuracies in their response.

Recommendations

We recommended that the board:

• satisfy themselves that when a patient is to be 'nil by mouth', the situation is clearly explained to, and understood by, those concerned; and
• emphasise to all their staff the importance of responding to complaints in accordance with their stated policy.

Summary

Mrs C's elderly mother (Mrs A) suffered from angina (heart pain) and high blood pressure. She fell at home and was taken to hospital. Although doctors found no bony injuries from her fall, they decided to keep Mrs A in hospital until her mobility improved. When visiting their mother a few days later, Mrs C and her brother found her in a deep sleep and unresponsive. It was suggested that Mrs A had had a stroke. However, when a consultant reviewed her, he suggested she might be having an adverse reaction to pain medication (tramadol - an opiate drug) that she had been prescribed. Mrs A was given another drug to reverse the effects of the tramadol. Although Mrs A's condition initially improved, she developed heart arrhythmia (abnormal heart rhythm) and collapsed and died thirteen days after being admitted to hospital. Mrs C complained that it was inappropriate for her mother to be prescribed tramadol and that the board's staff failed to take timely action when it was evident that she was sensitive to this medication.

During our investigation we took independent advice from a medical adviser. We did not uphold the complaint that the medication prescribed was inappropriate. The adviser explained that elderly, frail, patients can be at risk of chest infections, and opiates such as tramadol relieve rib pain and allow patients to cough properly, decreasing the risk of infection. However, they can also increase sedation and depress breathing. The risks are lower with tramadol than with other such drugs, however, and we found that it was appropriate for this to be prescribed, particularly as Mrs A was not known to have a sensitivity to the drug. Our investigation found, however, that Mrs A's deterioration was caused by a reaction to the tramadol, which could have been identified earlier. We were not critical of a junior on-call doctor who had investigated the cause of Mrs A's symptoms and had sought advice from two senior colleagues. However, we considered that the initial presumption that Mrs A had had a stroke may have led to some lack of consideration of other causes, such as tramadol sensitivity, and we upheld Mrs C's complaint that the board did not act quickly enough in this respect. We found that the subsequent twelve-hour delay before diagnosis would not have had any long-term impact on Mrs A's health, and that there was no link between the prescription of tramadol and her death. However, we recognised that the delay in identifying this issue caused additional distress to Mrs A and her family.

Recommendations

We recommended that the board:

• ask the clinical team to review Mrs A's case and our comments with a view to identifying any points of learning.

Summary

Miss C was detained in hospital under mental health legislation for nine days, and was assessed by a mental health team in the community after she was discharged. Miss C complained that while in the hospital, she was very bored, and had nothing to do. She said that she started to smoke just to pass the time. She also complained that the board failed to offer or provide the help that she needed after she was discharged, including accommodation away from her family home.

We upheld Miss C's complaint about her stay in hospital. Our investigation found that, while there was evidence that the hospital provided a programme of ward activities for patients, there was no evidence that Miss C was invited to participate, or that she was invited but declined to participate. Nor was there evidence that she had any planned one-to-one sessions with staff as she should have. In relation to the help provided after her discharge, we found that medical staff acted reasonably and in accordance with her wishes. We did not uphold this complaint, as we were not persuaded that there was an unreasonable lack of help.

Recommendations

We recommended that the board:

• ensure that staff encourage patients to participate in available ward activities, to record in a patient's records when this has occurred and whether the patient accepted or declined the invitation to participate; and
• ensure that staff are made aware of the need to provide patients with access to planned one-to-one sessions with staff, for the frequency and duration of these sessions to be negotiated and agreed and for this information to be clearly recorded in the patient’s careplan.

Summary

Mrs C complained that the GPs treating her late mother (Mrs A) failed to fully investigate her symptoms and take timely and appropriate action. She also complained that one of the GPs refused to refer Mrs A to the gastroenterology clinic (a clinic specialising in medicine of the digestive system) for further investigation.

Mrs A was a long-term sufferer of coeliac disease (a condition in which the small intestine fails to absorb and digest food) and was reviewed on an annual basis at a gastroenterology clinic. She also had a skin condition which was linked to the disease, and suffered long-standing back pain. Although Mrs A was prone to constipation because of the medication she took for her conditions, from mid-2010 she had told the practice that she had increasingly severe constipation, sometimes for four to five days. The advice she received from the practice was to increase her laxatives (medication taken to cause or encourage bowel movements). Blood tests taken in early April 2011 returned abnormal results, which the practice attributed to the infective skin condition Mrs A had at the time. They referred Mrs A urgently to the dermatology department (the department dealing with skin conditions). In early May, the department told the GPs that they should seek a further opinion on Mrs A's condition. Mrs A was referred to the gastroenterology clinic that month, where tests revealed that she had inoperable bowel cancer. Mrs A died the following month.

We upheld two out of three of Mrs C's complaints. Our investigation, which included taking independent advice from one of our medical advisers, found that there were delays in fully investigating Mrs A's symptoms and making timely and appropriate referrals for specialist advice. Mrs A had a long-term medical condition, and was taking medication that affected her bowels. Our adviser said that her initial symptoms in 2010 should not, therefore, have triggered a specialist referral. However, when these symptoms continued, and increased in severity despite a significant increase in her laxative medication, this should have triggered action from the GPs. The adviser was of the view that while it was reasonable for the GPs to address the issue of the infective skin condition, they appeared to do so to the exclusion of any other possible underlying condition and did not take a proactive and holistic approach. Although the adviser noted that, even if they had acted more urgently, the outcome for Mrs A was likely to have been the same, we upheld this complaint as we found that there was unreasonable delay in referring Mrs A to a specialist.

One of the complaints referred specifically to how quickly the GPs dealt with blood test results. The adviser was of the view that the results were dealt with in a timely manner, although the referral which followed was to the wrong specialism. Therefore, on balance we did not uphold that complaint. Another complaint was that one of the GPs refused to refer Mrs A to the gastroenterology specialist. Our investigation found no evidence that the GP actually refused to refer Mrs A to this specialist. However, we found that the fact that all the GPs focussed their attention on the skin condition had the same effect, and so we also, on balance, upheld this complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified;
• conduct a significant event audit of this case, with any findings and recommendations to be discussed at the GPs' next annual appraisals; and
• undertake a review of a sample of patient records to ensure that clinical note taking complies with the standards set by the General Medical Council's 'Good Medical Practice: Providing good clinical care'.

Summary

Mr and Mrs C complained about care that the board provided to their son (Mr A). Mr A was placed in foster care in an area away from the family home. The doctor who had been treating Mr A at home referred him to the new area's child and adolescent mental health services team (CAMHS). Mrs C complained that she and Mr C were not involved in the subsequent process.

We upheld this complaint. Our investigation found that there was no opportunity for Mr and Mrs C to express their views to the team despite the fact they maintained parental rights. We also found that CAMHS did not communicate with Mr and Mrs C until a third party prompted them to do so. We also upheld a complaint that mental health care arrangements for Mr A were not reasonable. We found that, although the board had attempted initial unsuccessful engagement with Mr A, his views had not been clearly sought at any stage. We noted that, during a meeting, those involved considered that Mr A was 'reluctant' to engage with CAMHS, but did not initiate a follow-up plan (which should have included obtaining Mr A's views clearly). Five months passed before Mr A was contacted again with the offer of an appointment, which he accepted.

We did not uphold a complaint that staff unreasonably failed to contact Mr and Mrs C when Mr A was admitted to hospital, as we found that they had acted reasonably by accepting that Mr A's foster parents, who had attended hospital with him, were acting as the responsible adults. Mrs C said that Mr A had been asking for her and Mr C, but we found no evidence that staff at the hospital were aware of this, as this information came from Mr A's foster carers rather than the medical records.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for not involving them in Mr A's transfer to CAMHS;
• review the procedures within CAMHS following referrals, to ensure parents have the opportunity to exercise their parental rights, where appropriate, and that parents are advised of outcomes and communicated with appropriately;
• ensure all the staff concerned, and the CAMHS team as a whole, are reminded of the need to maintain detailed minutes during professionals' meetings and to ensure the terms of a referral are considered fully; and
• review CAMHS processes to ensure that the views of the child or young person concerned are taken into account in a timely way.