Some upheld, recommendations

Summary
Mrs C told us that she accompanied her daughter to the medical centre to see a doctor, as her daughter had suffered an allergic reaction to silicone. An incident occurred within the premises. Mrs C's daughter was subsequently removed from the practice list for inappropriate violence and abuse towards staff.

Differing accounts of what happened have been given by Mrs C and her daughter compared with those of the practice nurse and practice manager. Mrs C wrote to one of the doctors saying that her daughter had not been abusive towards staff and asked that she be allowed to re-register. After the medical centre cancelled a meeting to discuss Mrs C's concerns, she made a formal complaint to the board as she was concerned that the medical centre were not interested in resolving the issues she had raised. The board explained to Mrs C the complaints process for family health services and acted as an intermediary between her and the medical centre.

The complaint we investigated was about the way that staff treated Mrs C's daughter on the day she attended the practice, and the way in which the medical centre handled the complaint. We found that there was insufficient evidence to support the complaint that staff had mistreated her daughter. However, we established that the medical centre did not respond to the complaint in full in good time, and we concluded that there was evidence of poor complaints handling.

Recommendations
We recommended that the practice remind staff dealing with complaints to:
• respond to all the issues raised and ensure that the letter is clearly addressed, dated and contains relevant information on who has carried out the investigation and issued the letter; and
• respond within the time frame set out in the guidance document 'Making a Complaint about the NHS'.
 

Summary
Mrs C complained about the care and treatment that her late husband (Mr C) received from the board's out-of-hours service and in hospital. Mrs C said the response from the out-of-hours service was inappropriate, as the attendant arrived without batteries and sterile gloves and asked her to provide these. Mrs C also said she was refused an ambulance, and so took Mr C to hospital in her car. As there were no independent witnesses to the out-of-hours service's visit to Mrs C's home, we could not prove what took place. Therefore, in the absence of any direct objective evidence, we did not uphold this complaint.

Mrs C said the board failed to diagnose and treat her husband. We found from looking at the clinical records and after taking advice from one of our medical advisers that, although there were issues with a delayed gastroscopy and poor recording and communication about Mr C's' mobility, we could not conclude that the board failed to diagnose and treat him. We did not, therefore, uphold this complaint, although we made a recommendation related to it.

Mrs C said the board failed to record and/or pass on Mr C's wishes about resuscitation, and that Mr C was later resuscitated after a collapse. The board appeared to accept Mrs C's account that she was not given an indication that Mr C was ill enough for her to advise hospital staff of his wishes about resuscitation. However, when she felt his condition had deteriorated, she told a nurse, although the nurse did not record this or pass the information to medical staff. The board said there would be a review and confirmed to our office that nursing staff had been spoken to. As Mrs C's evidence was not disputed, we concluded that the board failed to record and/or pass on her husband's wishes about resuscitation and upheld this complaint.

Mrs C said the board provided poor general care. We found from looking at the clinical records and taking advice from one of our medical advisers that, while it was clear that the events of Mr C's final days were deeply upsetting for Mrs C and her family, we could not conclude that the board provided poor general care to Mr C. We did not uphold this complaint.

Mrs C said there was poor communication from staff to her and her husband. We found there had been failings in communication and we upheld this complaint.

Finally, Mrs C said the board failed to order a post mortem to confirm the cause of death. We found from looking at the evidence, and taking advice from one of our advisers, that medical staff were confident of Mr C's final diagnosis and, therefore, there was no need for a post mortem. Our adviser agreed with this, in terms of Crown Office and Procurator Fiscal Service guidance and the clinical records. However, our adviser's view was that it was inappropriate for medical staff to presume what Mr C's wishes regarding a post mortem might have been, and that it would have been reasonable for them to have offered Mrs C the option of a hospital post mortem. However, as there was no requirement for the board to order a post mortem to confirm the cause of death in this case, we did not uphold the complaint.

Recommendations
We recommended that the board:
• ensure that clinical records document a patient's mobility, and that such information is communicated to relatives/carers on discharge;
• review their threshold for initiating discussions with patients/carers about resuscitation, given the record of a 'guarded' prognosis in this case; and
• review their practice on when a hospital post mortem should be offered to relatives/carers.
 

Summary
Mrs C was admitted to hospital for removal of her ovaries. Complications arose which resulted in an extended stay in hospital. Mrs C complained that the board failed to provide appropriate care and treatment during the first five months of her stay in hospital, which included an injury to her bowel leading to a colostomy, as well as septicaemia, pneumonia, kidney failure and becoming infected with clostridium difficile. Mrs C also complained that for over a year the board failed to disclose to her that an ovary had adhered to her bowel.

Although there is no question that Mrs C suffered serious consequences as a result of the injury to her bowel, resulting in an extended stay in hospital and the need for ongoing care and treatment, we did not uphold the complaint about care and treatment. We found from looking at the medical records, and taking advice from two of our medical advisers, that it was not possible to say definitively how the bowel injury was caused, but it was a recognised complication of abdominal surgery.

Both advisers said it was unlikely that the injury, as the cause of Mrs C's symptoms, could have been identified sooner, and they were satisfied that the board provided reasonable care and treatment. We did, however, conclude that medical records could have been clearer. There was no documentation in the medical records to confirm that Mrs C was given an explanation of the procedure used during, and the findings and outcomes of, the surgery to remove her ovaries. There was no evidence that this information had been deliberately withheld, but the lack of records was not in keeping with the General Medical Council's Good Medical Practice guidance. Given this, we could not conclude that Mrs C was provided a clear and consistent explanation of events and, therefore, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for their failure to provide a clear and consistent explanation of events;
• remind medical staff in the hospital of the need to maintain clear and thorough medical notes, in line with Royal College of Physicians' guidelines on standards for medical record-keeping; and
• remind medical staff of the importance of recording details of explanations given to patients, in line with the General Medical Council's Good Medical Practice guidance.
 

Summary
Ms C complained on behalf of her late mother (Mrs A) about the care and treatment that she received from her GP practice. Mrs A attended the surgery for a period of two years with repeated complaints of breathlessness, pain in the back and rib cage, and a cough. She made the practice aware of a family history of lung disease and lung cancer. She was treated for numerous chest infections but received little or no relief from her symptons. Mrs A's condition deteriorated and she was admitted to hospital and diagnosed with terminal cancer of the lung, liver and upper chest. Mrs A died shortly after. Ms C complained that the practice failed to properly investigate Mrs A's symptoms within a reasonable time and that they failed to suspect her condition and refer her to hospital within a reasonable time.

We found that the practice carried out reasonable investigations, but that they should have had a high index of suspicion of lung cancer given Mrs A's strong family history and that she was previously a heavy smoker. Our medical adviser said that the practice should have considered referring Mrs A to a respiratory specialist when her respiratory symptoms had persisted for more than six weeks and were unexplained. However, we also found that even if the diagnosis had been made sooner, this was unlikely to have affected the outcome because Mrs A probably had a non-curable disease at presentation. Having said that, an earlier diagnosis might have improved her quality of life because it would have allowed treatments to be explored that might have alleviated some of her symptoms.

Recommendations
We recommended that the practice:
• undertake a significant event audit and review their practice on management of respiratory symptoms to ensure that they refer for specialist advice within a reasonable time; and
• apologise for the failures identified.
 

Summary
Mrs C made a number of complaints about the care and treatment that her late husband (Mr C) received from his medical practice before his death from cancer. She complained that the practice failed to diagnose her husband's illness and order appropriate tests within a reasonable time, or to chase up the result of the tests. We took advice from our medical adviser, and found that it was in fact appropriate for the practice to refer Mr C to a specialist in order that the specialist could carry out further tests. The practice made an urgent referral, which was sent the day after Mr C attended the practice. In addition, there was no evidence that the practice were subsequently asked to chase up the results.

Mrs C also complained that the practice failed to refer her husband to hospital when he was severely dehydrated. We found that the practice had failed to carry out a reasonable clinical assessment. They had also failed to assess Mr C for hydration. We upheld the complaint as, based on the inadequate assessment, it was not possible to say whether Mr C was dehydrated or whether he should have been admitted to hospital.

In addition, we found that the practice should not have told Mrs C that she would be able to accompany her husband in the transport that they booked for him to attend hospital to get his results. The practice could not guarantee this, as space is limited when patients are being transported. We upheld the complaint, as the practice should have told Mrs C this, although we noted that they had already apologised to her for their failure to make her aware of this.

Mrs C also complained that the practice failed to provide palliative care to her husband or to offer any information about palliative care nursing. We found that the deterioration in Mr C's condition was extremely rapid, and that it would have been difficult to foresee this. We were satisfied that the practice's attempts to provide palliative care and to offer information during the short period from confirmation of his terminal diagnosis to his admission to hospital were reasonable. We also noted that the practice had taken steps to improve their delivery of palliative care.

Finally, Mrs C complained that the practice failed to show an appropriate degree of compassion throughout Mr C's illness by making inappropriate and insensitive comments. In response to her complaint about this, the practice said that part of their role in such situations is to be open, honest and realistic. Although we understood why Mr and Mrs C might have found the comments distressing, we did not find them inappropriate.

Recommendations
We recommended that the practice:
• make relevant staff aware of the need to undertake proper clinical assessment where appropriate; and
• draft a protocol for patient transport.
 

Summary
Mr C complained about the care and treatment that his 17-year-old nephew (Mr A) received from the board before his death from sudden unexpected death in epilepsy (SUDEP).

Mr A had had a suspected seizure and had seen a consultant at the board's 'first seizure clinic'. The consultant said that Mr A might have had a seizure, but needed more information. He provided Mr A with his contact details and suggested that Mr A contact him again after obtaining a phone number for a witness to the event, so that the consultant could speak to them about it. Mr C said that Mr A was not aware of the significance of not obtaining a phone number for this person. He complained that after Mr A's appointment there was no proactive follow-up by the first seizure clinic.

Our medical adviser said that it is not standard practice to provide follow-up appointments following a first seizure clinic, as in many cases it will be unnecessary. Treatment is not given if there is no immediate reason to believe that another event will happen. The patient should contact his or her GP if any subsequent suspicious event occurs. Follow-up and treatment will start if considered appropriate. In Mr A's case, the consultant tried to obtain a first-hand witness account to help him decide on this, but could not do so. We, therefore, found that the consultant's actions were reasonable.

Mr A was subsequently admitted to hospital after collapsing. Guidance from the Scottish Intercollegiate Guidelines Network (SIGN) on epilepsy (SIGN 70) says that the diagnosis of epilepsy should be made by a neurologist or other epilepsy specialist. Mr A was given a provisional diagnosis of epilepsy by a general physician at the hospital, referred to a neurologist, then discharged. Mr C complained that the board failed to involve Mr A's parents in discussions about his diagnosis, treatment and advice before he was discharged.

Our medical adviser said that once over the age of 12, the law assumes that a person can make their own decisions about their health care unless there is evidence to suggest they cannot. Health workers are not usually allowed to tell such a patient's parents anything unless the patient has agreed to this. Mr A was aged 17 at the time. Unless the board had evidence to suggest that he could not make his own decisions about his health care, they were not required to involve his parents in discussions about his diagnosis, treatment and advice. Mr C also complained that Mr A was discharged from hospital with no verbal or printed information about epilepsy. He said that no individual or personal assessment was undertaken of Mr A's circumstances and no information was provided about SUDEP.

In general, patients should be fully informed about the risk of any condition and its treatment. Although death from SUDEP is rare, most patients should be given information about it at some point soon after a diagnosis of epilepsy has been made. This will help patients to understand the issue and put it in perspective. However, detailed information about epilepsy and the risk of SUDEP should be provided as part of comprehensive counselling about risks and prevention. This should be provided by or arranged by neurologists after a definitive diagnosis of epilepsy has been made. Mr A had not seen a neurologist.

Mr C complained that the board had delayed in arranging an appointment for Mr A with a neurologist. The appointment arranged for Mr A was some 17 weeks after he was discharged from hospital. Mr A died before the appointment. Although we did not uphold Mr C's other complaints, we upheld this one as we found the delay unacceptable. Our medical adviser pointed out, however, that the risk of SUDEP cannot be eliminated and it is not possible to say that an earlier appointment at the neurology clinic would have prevented Mr A's death.

Recommendations
We recommended that the board:
• issue an apology to Mr A's parents for the delay in arranging an appointment for him with a neurological consultant; and
• take steps to ensure that patients who have been given a provisional diagnosis of epilepsy are seen by specialists as soon as possible so that a definitive diagnosis can be made and, where appropriate, detailed and specific information can be given.
 

Summary
Ms C was admitted to hospital after a colonoscopy to remove a polyp from her bowel. She was discharged and a further diagnostic appointment was made for some months later. A flexible sigmoidoscopy was to be carried out at that appointment to check for other polyps, and she was advised to take laxatives before attending, to reduce faecal matter. At the appointment, however, she was told that the procedure could not be fully completed due to 'faecal loading'. Ms C was told that she would have to wait 12 months for another appointment. She complained about the nursing care that she received during her stay in hospital and that there was confusion prior to her diagnostic appointment as to what procedure she had been booked for. She also complained that she was prescribed insufficient laxatives, that her procedure was unnecessarily delayed and that the board proposed insufficient follow-up action.

We found the nursing care during Ms C's initial hospital admission to be poor. Her fluid intake was not properly monitored and failed attempts were made to catheterise her, causing her discomfort, when there was no clinical need for this. Although Ms C was given incorrect verbal information about the further procedure, we found that the correct procedure had in fact been booked. The board confirmed that the procedure was delayed, but we were satisfied with their explanation that this was due to the urgent clinical needs of other patients.

We found the prescription of laxatives to be appropriate and, whilst faecal loading prevented a full inspection of the colon, our medical adviser confirmed that the consultant was able to see enough to confirm that no further sinister polyps were present. As such, further review in 12 months was considered appropriate, although the board did not explain this clearly to Ms C.

Recommendations
We recommended that the board:
• use this complaint to remind staff of the importance of accurate recording in records including recording of dignity issues; and
• apologise to Ms C for the failings identified regarding record-keeping, catheterisation, and the fact that their initial response to her complaint did not adequately address concerns about the outcome of her sigmoidoscopy.
 

Summary
Miss C complained about the care and treatment her mother (Mrs A) received in hospital after she suffered severe burns to her body. Miss C said that her mother had made a good recovery from a skin graft. However she believed that an error inserting a needle into Mrs A's left arm caused her mother to suffer a life threatening flesh eating bug (necrotising fasciitis) requiring intensive care treatment and a longer stay in hospital. She said that Mrs A was left with a damaged arm and suffered unnecessary trauma.

The clinical advice that we received from our medical adviser is that necrotising fasciitis is a very uncommon condition and can be difficult to diagnose because it usually presents with oedema (swelling). Mrs A had oedema in her legs, groin and arms. Our adviser said that necrotising fascitis is even rarer as a consequence of inserting a needle, and that in Mrs A’s case it would have been difficult to make the diagnosis earlier. The department of burns and plastic surgery acknowledged that there was a delay in diagnosing the condition, but had learnt from this. The board had also issued an apology. Accordingly, while we appreciated that Mrs A suffered trauma and distress, we considered the delay in diagnosis was not unreasonable given the symptoms that Mrs A had. We, therefore, did not uphold the complaint.

Miss C also complained there was unreasonable delay before a central line was inserted into her mother’s left arm. Our adviser said that it is not appropriate for any junior doctor to have five attempts to insert a cannula, as happened with Mrs A before a central line was inserted. The board conceded that the number of attempts at cannulation was excessive but had learned from what happened to Mrs A. In particular, they had produced a policy to deal with this. While we welcomed the introduction of the policy, and acknowledged that lessons had been learned by clinical staff, we considered there was an unreasonable delay in inserting a central line and we upheld this complaint.

Finally, Miss C complained that there was unreasonable delay before a naso-gastric tube was inserted and that her mother should have been fed in this way much earlier. We did not uphold this complaint. The clinical advice we received from our adviser was that overall the nutritional care and treatment Mrs A received was appropriate and there was no unreasonable delay in inserting a tube.

Recommendations
We recommended that the department of burns and plastic surgery:
• should consider obtaining early advice from general physicians, nephrologists and of intensive care staff where there are problems with fluid balance in patients with complications.
We recommended that the board should:
• establish a policy, including indications, for central venous lines in complicated burns patients;
• provide an update on the review of the West of Scotland Regional Burns Unit Venous Access Policy;
• provide evidence that audits are undertaken regularly to monitor compliance with the board’s guidelines for the prevention and management of adult in-patient falls and that results indicate a reasonable standard of care; and
• ensure that, where appropriate, a daily medical entry is included in the records of all in-patients.
 

Summary
Miss C complained that she was not given adequate information and advice by the board before she had a contraceptive implant fitted. She said that this resulted in an unplanned pregnancy. Miss C was also unhappy with the support given by the board when she discovered that she was pregnant.

We found that the board had given Miss C adequate information and advice before the implant was fitted. A full and comprehensive assessment was carried out and appropriate information was noted. Miss C was told that they could not rule out the possibility that she was already pregnant, as she had recently had a contraceptive failure. They also gave her condoms and told her that she should use these for the next seven days. However, we found that the board failed to tell Miss C’s GP that the contraceptive implant had been fitted, despite having her consent to do so. That said, they had already reminded staff about this and had apologised to Miss C, so we made no recommendation. When Miss C said she was pregnant, however, they failed to tell her about a counselling service that was available so we made a recommendation related to this. There was no evidence that staff acted unreasonably when Miss C told them that she was pregnant, or that they gave her misleading or untruthful information when the implant was removed. In addition, we found that the board dealt with her complaint in line with the complaints process in place at that time and responded to all of the issues Miss C raised.

Recommendation
We recommended that the board:
• consider drafting a protocol for use when a failure of contraception is discovered. This could include discussing any need for counselling.
 

Summary
Mrs C complained that her GP practice removed her and her husband from their list of patients without an appropriate explanation. Mrs C also complained that the practice failed to make sufficient adjustments for her disability in dealing with her complaints. In particular, she said that the practice declined to deal with the matter verbally.

The practice had asked Mr and Mrs C to register with another practice, and later removed them from the practice list. They told Mr and Mrs C that this was because of a breakdown in the doctor/patient relationship, but did not give a more specific reason. We found that in asking them to register elsewhere, the practice had, in effect, already taken the decision to remove Mr and Mrs C from the list, and did not leave any room for negotiation. They should have first warned Mr and Mrs C that they were at risk of removal, and explained the reasons for this. The practice did not keep a written record of the reason why they did not give a warning. Neither did they keep a written record of the grounds for a more specific reason not being appropriate. We concluded that the practice removed Mr and Mrs C from their list without providing them with an appropriate explanation, so we upheld this complaint.

Mrs C also asked the practice to deal with her complaints verbally, due to her disability. We found from looking at the practice's records that they did speak to her by telephone. However, Mrs C was not willing to discuss her complaints in any detail on the telephone. The practice were willing to meet with Mrs C, but before they or Mrs C could take this further, they decided to remove her from their list. After this, understandably, Mrs C did not pursue her complaints with the practice. We took advice from our professional medical adviser, whose view was that the practice acted reasonably in relation to Mrs C's disability while they were dealing with her complaints. We concluded that, from an administrative point of view, the practice did try to make sufficient adjustments for Mrs C's disability, and did not decline to deal with the matter verbally. Therefore, we did not uphold this complaint.

Recommendations
We recommended that the practice:
• apologise to Mr and Mrs C for failing to deal with their removal from the practice list in line with the NHS Regulations; and
• review their procedure for removing patients from the list, to ensure that future actions are consistent with their obligations as set out in the NHS Regulations.