Some upheld, recommendations

Summary

Ms C complained about the care and treatment her late father (Mr A) received at the Royal Northern Infirmary. She said the board failed to provide adequate nursing care for her father and unreasonably failed to diagnose his broken collarbone and stroke.

We obtained independent advice on the case from a nurse adviser and a GP adviser. Our nursing adviser said Mr A's fluid balance and food intake, repeat fall assessments and care planning fell short of what should have been in place. However, she said that even if these areas of Mr A's care had been up to standard, the outcome may not have changed. Our adviser said the board's response to Ms C's complaint was poor and she would have expected the board to have recognised their shortcomings, and to have apologised and ensured lessons had been learned.

Our GP adviser said there was documented evidence in Mr A's medical records of a review of his condition after each of his falls by a clinical member of staff. She noted that the documentation of the examination and assessment was thorough and of a reasonable standard. She said the doctor who attended to Mr A noted his on-going confusion, poor mobility and number of recent falls. The doctor identified that Mr A's condition had deteriorated and arranged transfer to Raigmore Hospital for further investigation. The doctor also identified that Mr A may have had a stroke and correctly referred him to Raigmore Hospital for a scan. Our adviser said this was reasonable management and was in accordance with relevant guidelines.

Recommendations

We recommended that the board:

• feed back our decision on this case to the nursing staff involved;
• remind their nursing staff about the importance of falls assessment and care planning; and
• provide Ms C with a written apology for the failings identified.

Summary

Ms C was charged by her dental practice for a missed appointment. Ms C felt this was unreasonable in the circumstances and complained to the practice about this. She was dissatisfied with the practice's response and made further complaints. Following a subsequent visit to the practice she and her daughter were removed from the practice's treatment list. Ms C complained about this and was dissatisfied with the response she received. She complained further and also received a reminder for a check-up despite her having been removed from the practice's treatment list. Ms C complained about these matters but did not receive a response from the practice. She raised her complaints with this office.

We attempted to resolve the matter but this was unsuccessful. Following consideration we decided that the practice's actions in charging Ms C for the missed appointment, failing to send a reminder for an appointment and sending two copies of the letter advising Ms C that she had been removed from their treatment list were not unreasonable. We also found that there was insufficient evidence to determine whether the practice had refused to treat Ms C's daughter due to Ms C's outstanding debt. However, we did decide that the practice's actions in refusing Ms C's request for a meeting to discuss her complaints, the process by which they removed Ms C from their treatment list, their response to Ms C's complaints and their having sent her a reminder for a check-up after they had removed her from the treatment list were unreasonable and upheld these aspects of the complaint.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failures we identified; and
• undertake training with all practice staff in relation to the removal of patients from treatment lists and the practice's complaints procedure.

Summary

Miss C said she attended the practice for a check-up with the dentist and he removed a tooth which had been causing her pain for some time. She said she suffered extreme pain after the extraction and attended the practice again for an emergency appointment with the dentist. Miss C complained that the dentist unreasonably dismissed the pain she was feeling in her gum and unreasonably failed to notice and treat a hole in her gum. She also complained that the practice manager unreasonably failed to answer her questions about her treatment by the dentist in the practice's written response to her complaint.

We obtained independent dental advice on Miss C's complaint from a senior dental practitioner. Our adviser said Miss C's dentist reasonably diagnosed that Miss C had a dry socket (a well-recognised complication of tooth extraction, characterised by increasingly severe pain in and around the extraction site, usually starting 24 to 48 hours post-operatively) and treated it in line with the guidelines and established good practice – suggesting that the pain in her gum was not dismissed.

As we were not present at Miss C's appointment, it was not possible for us to say if there was a hole in her gum which the dentist then failed to treat. Given this and our adviser's view that the dentist's treatment of Miss C's condition was reasonable, we did not conclude that the dentist unreasonably failed to notice or treat a hole in Miss C's gum.

However, in terms of the complaints handling, we considered that on balance the practice manager's response did not address all the points Miss C made and was not a full response to her complaint. We were also concerned that the practice manager deemed Miss C's letter of complaint to be for information only and initially failed to issue a response, when the letter's contents indicated that a written response was required.

Recommendations

We recommended that the dentist:

• feed back our decision on Miss C's complaint to the staff involved; and
• provide Miss C with a written apology for failing to provide a full response to her letter of complaint.

Summary

Mrs C complained about the care and treatment she received at Glasgow Royal Infirmary in relation to breast reconstruction following a bilateral mastectomy (surgical removal of both breasts). Mrs C was concerned that her choice of reconstruction was interfered with by the specialist breast reconstruction nurse, that the medical choice of expander breast implants was inappropriate, and that the nurse who had inflated the implants had overfilled them, which led to additional treatment and surgery to address the problems.

During the board's investigation of the complaint, they identified the need to implement a protocol for the inflation process. However, they did not clearly acknowledge to Mrs C that the nurse had overfilled the implants well above the manufacturer's recommended guidelines.

We took independent advice on this case from two of our advisers, one of whom is a specialist surgeon in breast reconstruction and the other a specialist nurse. We did not find evidence to clearly show that Mrs C's decision about reconstruction options was unduly influenced by either the surgeon who was responsible for her care or the specialist breast reconstruction nurse. Whilst we considered that to proceed with implants was not unreasonable, we were critical of the size of expander implants used at her second operation. We were also critical that the higher risk of the implant failing was not discussed with Mrs C. We found that the nurse had overfilled the implants above the manufacturer's guidelines and had not sought permission from the surgeon as she should have done. The surgeon also failed to give clear instructions about the total volume of saline to be put into the implants, and the speed at which the filling was to be done. This was particularly important given Mrs C's previous radiotherapy, which makes the breast skin more vulnerable.

Recommendations

We recommended that the board:

• contact the surgeon to share these findings about the failure to discuss and document the higher risk of implant loss when increasing Mrs C's breast size;
• apologise to Mrs C for failing to inform her of the additional risks associated with a larger implant;
• apologise to Mrs C for overfilling her implants and for not including this information in their complaint response to her; and
• ensure the findings are shared with the nurse and the surgeon and that any training needs are appropriately dealt with.

Summary

Mrs C, who is an advocacy worker, complained to us on behalf of her client (Mrs B) whose mother (Mrs A) had been a patient at Dr Gray's Hospital after being admitted with symptoms of abdominal pain, nausea, vomiting and with an infection. While in the hospital, Mrs B had concerns about her mother's clinical treatment and nursing care. These included a delay in diagnosing that Mrs A had fluid on her lungs and that the staff did not listen to the family's reported concerns about possible fluid build-up; that they did not provide Mrs A with assistance to mobilise; and that staff failed to communicate with them regarding Mrs A's condition and test results. Mrs B was also concerned that the board's formal response did not address all her concerns.

We took independent advice from a clinical adviser and a nursing adviser. We found that although the day-to-day clinical treatment which was provided was reasonable, there was a slow pace to the investigations and there was a clear lack of clinical direction. It was accepted that there were numerous medical specialties involved and that there was some uncertainty regarding a definitive diagnosis. However, there was a lack of any thoughtful or dynamic approach to Mrs A's care. We also found that the nursing care was appropriate but there were failings in communication by both nursing and clinical staff. We also found evidence of poor complaints handling as the board had not addressed all of Mrs C's concerns which were set out in the initial complaint letter to them. They had only generally referred to the communication issues and failed to address any of the concerns regarding the nursing care.

Recommendations

We recommended that the board:

• apologise to Mrs A for the way her clinical treatment was managed and for the subsequent delays to her treatment;
• share our findings with senior clinicians who were responsible for Mrs A's treatment in order that they can reflect on their actions;
• apologise to Mrs A for the failings in communication which we identified;
• share our findings with nursing and clinical staff in order that they can reflect on their actions;
• apologise to Mrs B for the inadequate response to her formal complaint; and
• remind all staff who are responsible for investigating complaints to ensure that all concerns are addressed in the final response.

Summary

Miss C complained regarding the care and treatment she received for a benign breast lump in 2011. In 2014, Miss C was diagnosed with breast cancer. The board said that the lump had been benign in 2011 and it was very unlikely that a benign lump becomes cancerous. Miss C said that she had not been provided with adequate follow-up or advice, and that the lump had become malignant. Miss C said the board should accept this was possible and that the lump should have been removed in 2011. Miss C also complained of an excessive delay in providing her with radiotherapy.

We took independent advice from one of our advisers, who is a consultant oncologist. Our adviser said there was no evidence to show benign lumps could become malignant. It was possible that despite the appropriate tests being carried out and the results from these showing no sign of cancer that it had in fact been malignant in 2011. Our adviser said that this did not constitute an unreasonable standard of care. However, the delay in the provision of radiotherapy was unreasonable, since it had breached Scottish Government targets and the board had been unable to provide evidence that they were taking steps to prevent a reoccurrence.

We found that the board had acted reasonably in 2011, both in terms of the tests carried out and the decision not to remove the lump from Miss C's breast at this time. When further tests in 2014 showed it to be malignant, the lump was appropriately removed, but the board unreasonably failed to provide radiotherapy within Scottish Government targets, so we made a recommendation about the delay.

Recommendations

We recommended that the board:

• provide evidence that the review being conducted into radiotherapy provision has addressed the delays experienced in this case.

Summary

Mr C complained about the care and treatment provided to his daughter (Miss A) at Forth Valley Royal Hospital. He was dissatisfied that she was not reviewed by a cardiologist (doctor specialising in disorders of the heart) when she reached the age of two, despite concerns about her heart when she was born. He complained that he was not informed about the change of plan about reviewing her. Mr C was also unhappy that the board's complaints team had access to Miss A's clinical records without his consent, that they took an unreasonable length of time to respond to his complaint, and that they did not respond reasonably to his questions.

We took independent advice on this case from one of our medical advisers who is a consultant paediatric cardiologist. We did not identify clear evidence that Mr C had been told Miss A would be reviewed at the age of two. We considered that the care given to Miss A was in accordance with established good practice, and there was no evidence of a heart defect requiring further review. It would have been difficult for the board's complaints team to respond fully to Mr C's concerns without access to Miss A's clinical records. However, there was no evidence that Mr C was clearly informed of the possibility that relevant health records would be handled by a member of the complaints team (in accordance with national complaints handling guidance and the board's procedures). Therefore, we upheld this part of the complaint.

We considered, on balance, that the board's responses were reasonable and were issued to Mr C without undue delay.

Recommendations

We recommended that the board:

• draw to relevant staff's attention the failings identified.

Summary

Miss C complained on behalf of her late mother (Mrs A). Miss C complained that Mrs A's dressings were not changed regularly enough, that the board failed to communicate with her regarding how ill her mother was and, in particular, that Mrs A had signed a do not attempt cardiopulmonary resuscitation (DNACPR) order. Miss C also complained that after her mother's death, she had asked nursing staff to re-dress her mother and this request had not been carried out. Miss C said the board took an unreasonable amount of time to respond to her complaint.

We took independent advice from one of our nursing advisers. The adviser said Mrs A's dressings should have been more closely monitored, so we upheld this complaint. However, as the board had already acknowledged this and taken appropriate action, we did not make a recommendation.

Our adviser noted that Mrs A was competent and able to make decisions about her own care. The DNACPR order had been properly communicated and administered by staff. It was for Mrs A to decide if she wanted to discuss this with anyone else. We did not uphold this complaint.

Regarding Miss C's request for her mother to be re-dressed, we noted that the nurse Miss C spoke to had assured her this would be done by mortuary staff. When the mortuary were contacted, however, they did not believe it would be appropriate for them to carry out this request and passed it on to the undertaker. We were critical that the board had assured Miss C that this request would be carried out. However, the adviser's view was that the decision taken by the mortuary staff was reasonable and was taken to ensure Mrs A's dignity. We did not uphold this complaint.

The board had explained that the reason for the delay in responding to Miss C was caused when staff continued to request information from a doctor who no longer worked for the board. For that reason, we upheld the complaint and made one recommendation.

Recommendations

We recommended that the board:

• reflect on why staff were not alerted to the fact that the doctor had left the board, and how this might be avoided in future.

Summary

Ms C complained about the care and treatment she received from her GP practice. She had an operation to fit a catheter, during which she sustained an injury to her bowel. This injury was not identified at the time and she subsequently experienced a lot of pain. She consulted the practice and a number of tests were carried out but the damage to her bowel was not diagnosed. It was not detected until she was admitted to hospital two months after her initial surgery. Further surgery was carried out to correct the damage. Ms C complained about the practice's failure to diagnose the bowel injury. She also complained that the practice refused to prescribe two drugs that had been recommended by hospital specialists; that they failed to appropriately treat her urine infections and that they failed to provide the hospital with details of her medical condition prior to an emergency attendance.

We took independent advice from one of our GP advisers. Our adviser considered that the tests the practice carried out were reasonable and that the damage to Ms C's bowel would have been difficult to diagnose. However, as Ms C's pain was not resolving and no cause for this pain was identified, the adviser considered that further assessment should have been arranged. She stressed the importance of keeping a wide differential diagnosis in mind when investigating unexplained symptoms in patients (a systematic method of diagnosing a disorder that lacks unique symptoms or signs). We accepted the advice we received and upheld this complaint. We recommended that this should be fed back to the doctor concerned.

We did not uphold Ms C's other complaints. Our adviser noted that the practice had not prescribed the two drugs recommended by specialists as they were concerned about potential interactions with other drugs Ms C was taking. Our adviser considered that this was reasonable and in line with safe clinical practice. She also noted that the urine tests in question had produced no evidence of infection and that no treatment was, therefore, required. Finally, she noted that the practice spoke with the hospital and faxed details to them prior to Ms C's emergency attendance. We therefore concluded that the actions of the practice were reasonable in this regard.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C, acknowledging the failings identified; and
• confirm that the doctor in question will discuss our findings as part of their yearly appraisal and ensure that they reflect on the importance of keeping a wide differential diagnosis in mind when investigating unexplained symptoms in patients.

Summary

Mr C received treatment from the board's mental health team over a number of years. He complained to the board about the accuracy of his diagnosis and about frequent changes to his medication. He also questioned whether he should have been prescribed anti-psychotic medication as he felt this had an adverse effect on his condition.

The board met with Mr C to discuss his concerns, but they did not respond to him in writing due to concerns about the impact this may have had on his mental health. Mr C complained about the lack of a formal response to his complaint. He also asked us to investigate his concerns about his medication regime.

We sought independent advice from a medical adviser who is a mental health specialist. We found that the board appropriately assessed Mr C's symptoms and took into account information provided by him when prescribing medication. His medication was altered on a number of occasions as a result of this, but in each case we were satisfied that the board worked in line with national guidance.

We were critical of the board's handling of Mr C's complaint. We acknowledged their concerns about the impact of a written response on his mental health, but we found their approach to be inconsistent because Mr C's consultant had written to him with a detailed report on his condition. We felt that a formal response from the board would have been appropriate and that their communication generally could have been better.

Recommendations

We recommended that the board:

• review their practices for monitoring side effects for patients being treated for schizophrenia and ensure that they are working in line with national standards;
• apologise to Mr C for their poor handling of his complaint; and
• review their handling of Mr C's complaint with a view to improving the quality and consistency of their communication with patients with mental health issues.