Some upheld, recommendations

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs A about care provided by a dentist. Mrs A attended with a painful front tooth and it was decided that root canal treatment was needed to save it. Mrs A had this treatment over two appointments. However, the tooth later broke while she was eating. Mrs A saw the dentist and emergency treatment was provided. Mrs A experienced pain and swelling following this and saw the dentist about this a few days later. At this meeting, there was a breakdown in the dentist/patient relationship. The dentist completed the treatment and Mrs A later registered with a new dentist.

Ms C complained that Mrs A had not been offered options for treatment and that the risks had not been properly explained. She also raised concerns about the dentist's attitude towards Mrs A, and that the dentist had not followed the proper process as they had threatened to deregister Mrs A. Ms C's final complaint was that the handling of Mrs A's concerns had not been reasonable.

We took independent dental advice. The advice we received was that the treatment provided was appropriate and was the only option to save the tooth. However, the adviser highlighted that there was no evidence that the risks of the treatment had been properly explained to Mrs A. There was also a lack of records for one of her consultations. We therefore upheld Ms C's complaint.

The adviser noted that there was no evidence that steps had been taken to deregister Mrs A and we therefore did not uphold this aspect of Ms C's complaint.

We found that the dentist had not included all appropriate information in the response to the complaint and that there were inconsistencies between the complaints handling procedure and the associated staff guidance document. We therefore upheld Ms C's complaint in relation to this.

Recommendations

We recommended that the dentist:

• apologise for the failings identified in this investigation;
• take steps to ensure that patients are appropriately informed of the risks and benefits of procedures;
• ensure that patient dental records are kept in line with the General Dental Council standard; and
• review the complaints handling procedures for staff and patients for consistency.

Summary

Mrs C complained about the care and treatment provided by the board in relation to her varicose veins. She also complained about the board's communication with her.

Mrs C attended an appointment at Wishaw General Hospital with a vascular surgeon to discuss a procedure to treat her varicose veins. She understood she was to undergo a procedure called vein stripping (where the vein is pulled out from under the skin with minimal incision). However, the procedures, performed at Hairmyres Hospital, were radiofrequency ablations (where the vein is heated with radiofrequency energy causing the vein to contract and then close) and stab avulsions (where several tiny incisions are made in the skin through which the varicose vein is removed). Mrs C complained that she should have undergone the vein stripping procedure. Mrs C also raised concerns about the post-operative advice and care provided by the board, in particular concerning dressing and travel.

After receiving independent advice from a vascular surgeon,we upheld Mrs C's complaints concerning communication and post-operative advice. We found that a number of the board's staff gave Mrs C confusing and incorrect information. However, we did not uphold Mrs C's complaint that she should have received the vein stripping procedure. Rather, we found that the procedure performed was the appropriate one for a patient in her circumstances.

Recommendations

We recommended that the board:

• ensure that supporting staff in the vascular surgery department are aware when procedures are updated or changed; and
• ensure that there is a standardised approach to post-operative advice and care for patients following varicose vein surgery.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A) about the care and treatment she had received at Wishaw General Hospital. Ms A suffered a stroke-like episode and was taken to hospital by ambulance. Following medical investigation, Ms A was discharged a few days later with a probable diagnosis of multiple sclerosis (MS). Although her discharge documents detailed this probable diagnosis, Ms A complained that a doctor had made a specific diagnosis of MS and that this was not in line with national guidance which states that MS should not be diagnosed in a general hospital setting. Ms A was also concerned that the medical investigations that were carried out and the delay in referring her to neurology were unreasonable. We also considered whether the handling of and response to the complaint was reasonable.

After taking independent advice from a consultant physician, we did not uphold the complaints regarding medical investigations or neurology referral. We found that the investigations were timely and appropriate for the symptoms that Ms A presented with. We found that board staff had a different recollection of Ms A being advised of the outcome of the medical investigations and that while Ms A was certain that a definitive diagnosis had been provided, staff maintained that this had been probable only. We were unable to determine what had been said at the time in question but found that the medical records made reference to a probable diagnosis of MS. The advice highlighted that Ms A was referred to neurology following discussion with the neurology department which is based at another NHS board. No delay in referral was identified and the board had no control over waiting times for appointments, given that the service is provided out with their area. We did make a recommendation around communication as we found that there were a number of differences between the board's and Ms A's understanding.

Although we found that the board's response to Ms A's complaint addressed the points raised, a failing in the board's investigation was identified. We found that a member of staff that had been present when Ms A was advised of the outcome of the medical investigations had not provided comments before the final decision was issued. While this did not affect the outcome in this case, we considered that the board should have ensured all necessary comments were obtained before reaching a conclusion on the complaints.

Recommendations

We recommended that the board:

• use this case to highlight the importance of clear, effective communication with patients.

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of Ms A about a GP home visit when Ms A reported severe dizziness and staggering. Ms A was diagnosed with labyrinthitis (an inflammation of the inner ear), but it was later discovered that she had suffered two minor strokes. Mrs C said that the GP should have considered the possibility of a stroke and admitted Ms A to hospital by ambulance. Mrs C also said that it was unreasonable for the GPs at the practice to prescribe statins (medication used to lower cholesterol in the blood) to Ms A.

We took independent advice and found that the care and treatment provided to Ms A at the home visit was reasonable. It was appropriate to diagnose labyrinthitis and there was no clinical evidence at this point to suggest that Ms A had had a stroke. However, there was an unreasonable delay in making a referral to a stroke unit, and there was a failure to carry out a particular examination which would have been reasonable in light of Ms A's symptoms, which included hypertension. In relation to the prescription of statins, we found that this was reasonable in the circumstances.

Recommendations

We recommended that the practice:

• ensure their systems for sending hospital referrals are such that referrals are sent within a reasonable time, and there is no recurrence of unreasonable delays;
• ensure the relevant GP familiarises themselves with guidelines for the management of hypertension; and
• apologise for the failings identified in this investigation.

Summary

Mrs C complained about the care that her late husband (Mr A) received at Monklands Hospital after attending the emergency department. Mr A was to be admitted to a private room but none was available. He remained in A&E until a suitable room was found. Mr A was later moved to a different area in the hospital, where he fell while in the toilet.

Mrs C complained that Mr A waited in A&E for too long. She was also concerned that the toilet where he fell was not properly equipped and that staff had not taken reasonable steps to help him afterwards. Mrs C also considered that his risk of falls had not been assessed and that the recording and investigation of the incident had not been carried out properly. Finally, Mrs C complained that Mr A's bed was not adjusted for his height quickly enough.

After taking independent advice from a consultant in emergency care, we upheld the complaint about Mr A's wait in A&E. We found that he had waited longer than was reasonable in the circumstances and that the board had already apologised for this. We recommended a review of their policy for escalating cases like Mr A's.

We took independent advice from a registered nurse in relation to Mrs C's other concerns. We did not uphold the complaint regarding a falls assessment as the advice we received was that this had been carried out in A&E with no risk identified. We also did not uphold Mrs C's concerns about the toilet facilities as we received advice that these were reasonable. We found that there were two different accounts of events around Mr A's fall and we were unable to determine exactly what had happened within the scope of our investigation, therefore we did not uphold this element of the complaint. We did, however, uphold the complaint about the initial investigation of the fall. The advice we received was that although it was appropriately recorded, there were missed opportunities to resolve Mrs C's concerns locally. We made two recommendations to address this.

Finally, we upheld Mrs C's complaint about the failure to adjust Mr A's bed. The advice we received was that this was unreasonable in the circumstances and the adjustment can be made easily. We made two recommendations to the board in light of this.

Recommendations

We recommended that the board:

• review the escalation procedure for individual patients awaiting specific beds, taking into account the adviser's comments;
• review the training they have in place for early resolution of concerns and complaints;
• ensure mechanisms are in place for staff to access support from more senior colleagues in the ongoing resolution of complaints;
• apologise for the failure to take the falls assessment into account and adjust the bed in a timely manner; and
• ensure staff are aware of the appropriate considerations when making adjustments to beds.

Summary

Ms C, an advice and support worker, complained on behalf of Ms A. Ms A had developed mobility problems and, after an episode of severe dizziness, was admitted to Hairmyres Hospital and discharged a week later. She then attended the movement disorder clinic for further tests and investigations.

Two months later, Ms A was readmitted to Hairmyres Hospital before being discharged the following week. She was referred to community physiotherapy and visited by them on a number of occasions. She was then referred to out-patient physiotherapy.

Ms C said that had Ms A been allowed to stay as an in-patient for longer and been provided with sufficient support and treatment (as both an in-patient and out-patient), she would have recovered her ability to walk.

We took independent advice from specialists in physiotherapy and in care of the elderly. We found that the standard of physiotherapy provided during both Ms A's admissions to hospital was reasonable, and that the follow-up care was reasonably provided for the second admission. However, there was an unreasonable failure to refer her for appropriate physiotherapy services when she was first discharged from hospital. We found that while the decision to discharge her was reasonable, there were failings in the discharge planning in relation to the provision of physiotherapy in the community. We also were satisfied that the decision to discharge Ms A from her second admission to hospital was reasonable.

Recommendations

We recommended that the board:

• take steps to ensure that all in-patients receiving physiotherapy are appropriately reviewed by the service and, where appropriate, referred for community physiotherapy prior to discharge home;
• bring the failings identified to the attention of the relevant physiotherapy and medical staff involved; and
• apologise for the failings identified.

Summary

Mrs C complained to us about the treatment her mother (Mrs A) received from her medical practice. In particular, she was unhappy with the treatment Mrs A received for pain in her left arm and in relation to choking episodes. She also made a number of complaints about the medication prescribed to Mrs A.

We took independent advice from a GP adviser. We found that, in general, the treatment provided to Mrs A by the practice had been of a reasonable standard. However, although Mrs A had angina, she had been prescribed an anti-inflammatory medication by a GP that is contraindicated in (should not be given to) patients with angina. In addition, Mrs A had incorrectly been prescribed a double prescription of heart medication and iron tablets. Although there was no evidence that Mrs A suffered harm as a result of these prescribing errors, in view of these failings we upheld the complaint. The practice had already apologised for this.

Mrs C also complained that a GP had told Mrs A that she had cancer when she attended a consultation at the practice on her own. We found that the specialist clinician who had previously arranged tests for Mrs A should have previously informed her of the diagnosis. It was reasonable for the GP to assume that Mrs A had already been informed of her diagnosis. We did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained about the practice's handling of her complaint. We upheld this, as we found that the practice had delayed in responding and had not advised Mrs C that she could contact SPSO.

Recommendations

We recommended that the practice:

• ensure that all GPs are aware of the contraindications for the anti-inflammatory medication prescribed; and
• take steps to ensure that responses to complaints are issued within a reasonable timeframe and include signposting to SPSO.

Summary

Mr C, who suffers from chronic back pain, raised a number of concerns about surgery performed on his spine at Aberdeen Royal Infirmary. Mr C complained that he suffered significant blood loss during the operation and that the surgeon failed to record on the operation note that he required blood transfusion. Mr C also complained that the surgeon operated on him using old scan images and that the operation caused nerve damage.

We took independent advice from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). They did not find evidence that the surgeon unreasonably failed to record a blood transfusion on the operation note and noted that it was only after the conclusion of the operation that the requirement for transfusion became apparent. The adviser was satisfied that it was reasonable for the surgeon to operate on Mr C using an old scan, and considered that there was no evidence that the operation caused nerve damage. Although we did not uphold this complaint, the adviser was critical about the level of detail in the medical records and we made a recommendation to address this.

Mr C also underwent operations to replace his hips. He complained that the board unreasonably failed to diagnose his hip condition for five years. The adviser noted the extended process involved in diagnosing the cause of Mr C's pain but found that it was reasonable of the board to have focused their investigations on his back given that he had a known back condition. The adviser did not consider that successive consultant neurosurgeons failed to diagnose Mr C's hip condition and said that it was the responsibility of a patient's GP to first investigate the potential of a hip pathology. We did not uphold this complaint.

Mr C also complained about the way the board communicated with him during their investigation into his chronic pain. Mr C felt that a consultant neurophysiologist (a doctor specialising in disorders of the central and peripheral nervous systems) failed to inform him that he had nerve damage following a consultation. The adviser reviewed the findings of the neurophysiologist and concluded that the clinical significance of the findings was questionable and did not necessarily indicate nerve damage. The adviser was therefore satisfied that it was not unreasonable that the neurophysiologist failed to discuss the abnormality in the findings with Mr C. We did not find evidence that the board's communication was unreasonable and we did not uphold this complaint.

Mr C also raised concerns about the way the board handled his complaint. We found that the board had commissioned an independent clinical review into Mr C's concerns about his treatment but we noted that this investigation was not undertaken in accordance with the complaints procedure. We found evidence of a number of instances where the board did not treat Mr C's concerns as complaints, and we considered that this unnecessarily prolonged the board's handling of Mr C's concerns. We found evidence that only one of Mr C's concerns had been handled through the board's complaints handling procedure, although the board noted that there was a delay in responding to Mr C. The board confirmed to us that the Feedback Team (the department that handles complaints) has since introduced a process to prevent such delays. We upheld this complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• feed back the adviser's comments about the level of recording in the clinical notes in this case to clinical staff in the neurosurgery department;
• issue Mr C with a written apology for the complaints handling failures identified in this investigation;
• ensure that the clinical staff involved in this case receive appropriate support and training in handling complaints in line with the board's complaints handling procedure; and
• provide us with details of the Feedback Team's change in process.

Summary

Mr C complained about the medical and nursing care and treatment provided to his wife (Mrs A) at Victoria Hospital from when she was diagnosed with advanced lung cancer until her death four months later. During this period, Mrs A had three admissions to Victoria Hospital. During her second admission, she was found to have spinal-cord compression and was admitted to the Western General Hospital for five days.

Mr C was concerned about a wide range of medical and nursing issues, including treatment and medication decisions; communication; whether appropriate investigations and tests were carried out within a reasonable time; the decision to transfer Mrs A to a hospice near the end of her life; record-keeping failings; nutrition; and monitoring. Mr C was also concerned that Mrs A had contracted diabetes and pneumonia, which he believed were hospital-acquired infections. He said that the board's failings hastened Mrs A's death. Finally, Mr C complained about the way the board handled his complaint.

We took independent advice from four advisers, who specialise in oncology, respiratory care, palliative care and nursing. In relation to the standard of medical care and treatment provided, we found that this was reasonable.

We were also satisfied that while Mrs A contracted diabetes and a chest infection, these were an accepted complication of the medication prescribed and/or prolonged hospital stay and low immunity, and that there was no evidence any hospital failings led to Mrs A's death.

With regard to the standard of nursing care and treatment provided, we found that while this was reasonable in a number of aspects, there were failings around record-keeping and in relation to completing assessment and monitoring for nutrition, wound management and blood glucose. We therefore upheld this part of Mr C's complaint. We also found failings in the way the board dealt with Mr C's complaint in that there were unreasonable delays.

Recommendations

We recommended that the board:

• inform us of the action taken to ensure compliance and better completion of documentation by nursing staff including action taken to ensure adequate training in light of the nursing adviser's comments; and
• provide a further apology for the failings identified.

Summary

Mrs C complained about the care and treatment she received when she gave birth at Dumfries and Galloway Royal Infirmary. In particular, she said that a pessary used to induce labour was left in too long, she was unable to use the birthing pool and a tear she suffered was not effectively repaired.

We took independent midwifery advice and found that overall, Mrs C's labour and birth had been conducted reasonably. The pessary had been used appropriately and was removed as labour progressed. Stitching of the tear she sustained was completed quickly and though it was recognised that sutures could become loose, Mrs C was referred to an obstetrician as required.

However, it was noted that Mrs C either did not receive or did not understand information given about anaesthetic and how its use had repercussions with regard to the use of the birthing pool. Furthermore the clinical records, which were not of the standard required by current guidance, lacked information. For these reasons, we upheld Mrs C's complaint.

Mrs C also complained about her aftercare. However, we found no evidence to show that this had not been reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified in this investigation; and
• ensure that relevant nursing staff are reminded of their obligations with regard to guidance on record-keeping.