Some upheld, recommendations

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.
 

Summary
Ms C was dissatisfied with the handling of her request for travel expenses and disagreed with the decision taken by the Student Awards Agency for Scotland (SAAS) to restrict her travel expenses. She also complained about how the SAAS handled her appeal against their decision not to reimburse the expenses. We found that the SAAS had assessed her travel expenses in line with their policy. However, we also found that they had failed on a number of occasions to correct Ms C's misunderstanding that she was entitled to full travel expenses under the Disabled Student Allowance. When Ms C was advised of SAAS's decision to restrict her travel costs, she withdrew from her course.

We considered that, as a result of not having full information, Ms C was unable to make an informed choice about whether to start her university studies and, as a result, incurred travel costs that she was unable to afford. We upheld the complaint, although we did not uphold the further complaint that the SAAS had failed to investigate her appeal.

Recommendation
We recommended that SAAS:
• reimburse Ms C for the travel costs she incurred as a result of travelling by train to the university, excluding the amount already paid to her. This was to be offset against any outstanding debt.

Summary
Mr and Mrs C complained about a number of aspects of the council's handling of a planning application made by neighbours, including that the council failed to carry out neighbour notification correctly by not notifying Mr and Mrs C; failed to properly advertise the planning application; and failed to provide consistent and correct responses to enquiries. Mr and Mrs C also complained that, although they had provided the council on two separate occasions with relevant grounds for work being halted (on the grounds that the development was not being constructed in accordance with the planning permission), the council refused to take action to halt work on the development.

Our investigation confirmed that there was an error in the advertising of the application, and noted that the council had looked into the matter and identified that this was due to an oversight, for which an apology was offered to Mr and Mrs C. We recommended to the council that action should be taken to improve their process to ensure that there was not a recurrence of the error.

Recommendation
We recommended that the council:
• take steps to ensure that the error in publication of the application has been investigated thoroughly and that action is taken to improve their process to ensure that this does not recur.