Upheld, recommendations

Summary

Mrs C complained about the care and treatment of her late mother (Mrs A) when she was admitted to the Royal Infirmary of Edinburgh with a urinary tract infection. Mrs A was also treated for a bacterial infection (staphylococcus aureus) and Mrs C raised concerns that medical staff did not adequately investigate the cause of this infection and relied upon the administration of strong antibiotics, which she considered wiped out her mother's immune system. Mrs A was subsequently diagnosed with a further bacterial infection (clostridium difficle) and, although plans were being made for her discharge from hospital, she suffered a gastrointestinal bleed and died two weeks later. We obtained independent advice from a consultant physician, who advised that most aspects of Mrs A's medical care were reasonable, including the investigation of her infections, the decision to treat with antibiotics and the management of her symptoms. The adviser did not consider that Mrs A's death could have been avoided. However, the adviser did query the initial choice of antibiotic and was also critical of the fluid management. In light of this, we upheld this aspect of the complaint.

Mrs C also complained about the standard of nursing care, including concerns about lack of available staff to provide assistance when required, dementia awareness and continuity of care. We obtained independent nursing advice. The adviser identified significant gaps in the recorded care of Mrs A, and a lack of care planning to meet Mrs A's changing needs. The nursing adviser did not consider it clear that staff understood how Mrs A's dementia affected her or took this into account in her care. We upheld this aspect of the complaint.

Mrs C raised further concerns about the hygiene and infection control measures in place on the ward. The available medical records did not provide sufficient evidence of the specific allegations of poor hygienic practice but we noted that the board had accepted and apologised for poor hygiene standards in Mrs A's care. We also upheld this aspect of the complaint.

Mrs C complained that the record-keeping in relation to her mother's care was inadequate. We received advice that the record-keeping fell below a reasonable standard and so we upheld this aspect of the complaint. We also upheld Mrs C's complaint that communication was inadequate, on the basis of a lack of evidence to show that nursing staff communicated reasonably with the family. In some instances we considered that the board had already taken appropriate action to address the identified failings and, in others, we made some recommendations.

Recommendations

We recommended that the board:

• confirm that the use of appropriate antibiotics will be highlighted to junior doctors as part of their induction process;
• confirm that the findings of our investigation will be reflected upon by the relevant consultant(s) as part of their annual appraisal;
• remind ward staff about the importance of completing fluid intake / output charts;
• apologise to Mrs C's family for the poor record-keeping in relation to Mrs A's care; and
• demonstrate to us that record-keeping on the ward is now of a reasonable standard.

Summary

Mr C was diagnosed with a cataract in his eye and an epiretinal membrane (a thin sheet of tissue over the centre of the eye that can restrict vision). He was referred to The Princess Alexandra Eye Pavilion for surgery to remove the cataract with a separate procedure to follow to remove the epiretinal membrane. On the day of the surgery, Mr C's consultant ophthalmologist was absent due to illness. Mr C was offered the chance to delay the surgery until he returned or to proceed with another surgeon. He opted to proceed.

Mr C experienced complications of surgery that resulted in his retina becoming detached. He found out after the surgery that the surgeon was still a trainee and felt this should have been made clear to him before he consented to the procedure. He also complained that it took several consultations over a number of weeks to diagnose his detached retina.

We obtained independent medical advice on this complaint. We concluded that, whilst Mr C's retinal detachment was not present during the first few post-operative examinations, at one appointment it was noted that the ophthalmologist could not get a clear view of his retina. We accepted the advice that, had an ultrasound been carried out at this point, the detachment may have been identified. This could have led to diagnosis a week sooner than Mr C experienced. We also found that, whilst Mr C's consent for surgery had been properly obtained, it would have been good practice for the board to tell him that a trainee surgeon was going to carry out the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to arrange an ultrasound;
• share this decision with the staff involved in Mr C's care;
• apologise to Mr C for failing to tell him that the surgeon was a trainee; and
• share the adviser's comments on good practice with the ophthalmologists.

Summary

Mrs C complained about a delay in diagnosing her late mother (Mrs A)'s brain tumour. Mrs A attended A&E on six separate occasions over a six month period (five attendances at Hairmyres Hospital and one at Wishaw General Hospital), with symptoms of dizziness, fainting and disorientation. Her third attendance resulted in a hospital admission, where abnormalities with her heart were identified and a pacemaker was fitted. When her symptoms continued and she attended A&E for a fourth time, she was referred to neurology for a routine out-patient appointment. She had two further A&E attendances while she waited for this, with the second resulting in a brain scan, which diagnosed a brain tumour. She was transferred to a hospital in another health board area for urgent surgery but unfortunately this was unsuccessful and she did not regain consciousness. She died ten months later.

Mrs C considered that a brain scan should have been carried out earlier. We took independent medical advice from a consultant in emergency medicine and a consultant physician. We were advised that it was reasonable for a cardiac cause of Mrs A's symptoms to have been pursued initially. However, it was noted that she had new symptoms when she attended A&E for the fourth time, having had her heart problem addressed. We concluded that a brain scan should have been considered at this point. We also identified that there was a further opportunity to diagnose the brain tumour earlier, at Mrs A's penultimate A&E attendance. On this occasion, A&E staff considered that admission was warranted, but the on-call physician decided to discharge her, pending pre-planned follow-up, without seeing her. We were critical of this. We upheld the complaint and made a number of recommendations, including one about record-keeping as the board could not locate the records from one of Mrs A's A&E attendances.

Recommendations

We recommended that the board:

• provide Mrs C with a written apology for the failings identified in this investigation;
• ensure that all relevant staff are made aware of the outcome of this investigation, including those no longer employed by the board;
• take steps to have this complaint included for discussion at the annual appraisals for all relevant staff, including those no longer employed by the board, to ensure learning opportunities are captured; and
• take steps to ensure that Hairmyres Hospital is complying with 'Records Management: NHS Code of Practice (Scotland)' following the missing A&E attendance records.

Summary

Miss C complained to us about the care and treatment provided to her partner (Mr A) at Hairmyres Hospital before his death. Mr A had been admitted to hospital because of increasing breathlessness. He was diagnosed with heart failure and subsequently discharged from hospital. However, he was readmitted to hospital two days later. It was initially thought that his heart failure had worsened, but when scans were carried out, it was identified that he had pulmonary fibrosis (a rare condition causing scarring of the lungs).

Miss C complained about the delay in diagnosing that Mr A had pulmonary fibrosis. We took independent advice on this aspect of Miss C's complaint from a medical adviser, who is a consultant in general medicine. We found that the findings from the scans and tests carried out when Mr A was initially admitted to hospital were not in keeping with a diagnosis of heart failure. We considered that Mr A should have remained in hospital and undergone further investigations to determine the cause of his symptoms and we upheld this aspect of Miss C's complaint.

Miss C complained that the board had failed to provide Mr A with appropriate medication when he was discharged from the hospital for a second time. We took independent advice on this complaint from a medical adviser, who is a consultant respiratory physician. We found that home oxygen therapy and other palliative options to alleviate Mr A's symptoms of breathlessness and lethargy should have been considered before he was discharged from hospital. We upheld this aspect of Miss C's complaint. That said, Mr A was suffering with severe pulmonary fibrosis, which was rapidly progressing when he was initially admitted to hospital and this would not have altered his prognosis. We also upheld Miss C's complaints that staff had failed to discuss the seriousness of Mr A's condition with him and his family and that he had been transferred between wards on an excessive number of occasions.

Recommendations

We recommended that the board:

• issue a written apology for the failings identified during our investigation;
• make the medical staff involved in Mr A's care and treatment aware of our decisions on Miss C's complaints; and
• remind the medical staff of the importance of communicating effectively in cases that involve severe life-threatening disease and of the importance of recording this communication in the medical records.

Summary

Miss C's young daughter (Miss A) has suffered gastrointestinal problems for most of her life and has had many hospital admissions. Miss C complained that she was treated unprofessionally and made to feel uncomfortable and inadequate by staff at Raigmore Hospital. She said that meetings were held behind her back and she was given very little notice about a multi-disciplinary meeting held to discuss her daughter's care. Miss C complained that the board failed to communicate with her appropriately about her daughter and that her daughter had not been provided with appropriate clinical treatment.

The board apologised if Miss C had been made to feel uncomfortable and said that this had not been their intention. They also said that meetings held to discuss Miss A had been routine and in her best interest; they said that she had been treated appropriately.

We took independent advice from a consultant paediatrician and we found that while Miss A's initial care was reasonable, given her longstanding problems, her admission to hospital to consider her symptoms should have taken place earlier than it did. Also, by the time a specialist dietician became involved in her care, Miss A had dietary deficiencies which had been likely to have been present for some time. We were also critical that some of the dietician notes were not available when we asked for Miss A's full medical record, so we made a recommendation to address this issue.

In relation to the way the board communicated with Miss C, the evidence showed that Miss C was given very little notice of a multi-disciplinary meeting held to discuss her daughter's care. There appeared to have been no effort to arrange a suitable date and time with her and she was put under unreasonable pressure to attend. We also found that she had not been given an explanation for meeting to discuss a child plan for her daughter. We therefore upheld Miss C's complaints.

Recommendations

We recommended that the board:

• make a formal apology to recognise the shortcomings in Miss A's care;
• ensure that the findings of this complaint are fed back to staff;
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)';
• make a formal apology for what happened in connection with the multi-disciplinary meeting, and also for failing to provide reasons why it was intended to hold a child plan meeting; and
• ensure that where discussions take place between professionals, an appropriate record is kept on file.

Summary

Mr C complained that his former GP practice unfairly refused a repeat prescription and removed him from their practice list after he complained about the matter.

We took independent advice from a GP adviser and found evidence to show that the repeat prescription had been lost or mislaid by the practice and this had not been explained by the reception staff to the GP who had been asked to reissue it. It was only at Mr C's persistence that he managed to receive his medication a few days later after attending the practice on several occasions. We also considered that the practice had not investigated and responded appropriately to this aspect of Mr C's complaint.

We identified that the practice had not followed General Medical Services (GMS) contractual guidance, nor their own policy, when they removed Mr C from the practice list without issuing a warning. We concluded that the practice failed to address Mr C's concerns in a professional manner and that they resorted to unreasonably removing him from the practice list causing him unnecessary distress and inconvenience.

Recommendations

We recommended that the practice:

• review their process for recording missing prescriptions and ensure that information is shared with the appropriate GP who has been asked to re-issue a prescription;
• share these findings with the staff involved and remind them of the importance of providing full and accurate responses to complaints;
• apologise to Mr C for the failings identified with his prescription;
• apologise for failing to issue Mr C with a warning prior to removing him from their practice list in accordance with GMS contractual guidance; and
• ensure all relevant staff are fully aware of the GMS contractual guidance and their own policy before removing a patient from the practice list.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A). Mrs C raised concerns that hospital staff at Dr Gray's Hospital unreasonably arranged to transfer Mrs A to Turner Memorial Hospital. Prior to the transfer, Mrs C had been treated in Dr Gray's Hospital for her existing chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). Mrs C said Mrs A had suffered diarrhoea on the day of the transfer and looked unwell.

The board said Mrs A's transfer had been reasonable. They said there was no evidence of diarrhoea prior to transfer, and Mrs A had been appropriately transferred.

After receiving independent advice from a geriatrician, we upheld Mrs C's complaints. We found that staff had unreasonably transferred Mrs A. In particular, we considered that Mrs A's condition was unstable, and her transfer was not subject to an appropriate level of consideration. We also considered that the board did not comply with the 'Can I help you?' guidance in answering Mrs C's complaint. We made a number of recommendations to address these concerns.

Recommendations

We recommended that the board:

• apologise to the family for the failings identified;
• confirm that the staff responsible will discuss this issue as part of their annual appraisal;
• remind staff of the importance of adequate record-keeping; and
• remind relevant staff of the complaints handling requirements under the 'Can I help you?' guidance.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Aberdeen Royal Infirmary. Mr C accepted an apology and explanations from the board for a number of his concerns, but Mr C was not satisfied with the board's response to his concern relating to his wife's DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) status. Mr C was not satisfied that the hospital staff in the gastroenterology department had followed the DNACPR policy and disputed the accuracy of a record which stated that a doctor had discussed the decision with him and his wife. We took independent advice from a consultant physician who was critical of the failure to complete a DNACPR form and the low level of detail in the medical notes surrounding the decision. We upheld this part of Mr C's complaint.

Mr C also complained that the board had taken a number of months to provide him with a written response to his complaint and had exceeded their target response time. Mr C was also concerned that the board had not sufficiently investigated his complaint and he was not satisfied with the response that the board had given him. We acknowledged that, in investigating Mr C's complaint, the board had met with him on two occasions and that this had contributed to the delay in providing a response. However, we remained critical about the individual delays that contributed to the time it took the board to respond, and found that the board had failed to keep Mr C updated on the progress of their investigation into his complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to adhere to the DNACPR policy;
• provide evidence that staff in the gastroenterology department have been reminded of the importance of completing DNACPR forms where appropriate;
• provide evidence of any audit or quality improvement work which has monitored the completion of DNACPR forms in the gastroenterology department since staff were reminded to complete the forms;
• apologise for the failure to keep Mr C updated on the progress of their investigation into his complaint and failure to respond to his emails; and
• advise staff responsible for investigating complaints to update complainants in line with 'Can I Help You?' guidance.

Summary

About six weeks after the birth of her child, Mrs C attended her GP practice with bleeding and abdominal pain. She was treated with antibiotics. She was reviewed several times over the next few months, and a urine test and vaginal swab were carried out, with further antibiotics prescribed. Mrs C was then referred to gynaecology as a private patient, and subsequent investigations showed there were retained products of conception (pieces of placenta) left after the birth. Mrs C complained about the delay in referring her, and said she was only referred after telling the GPs she had private medical insurance.

The practice explained that the cause of Mrs C's bleeding had been unclear. Mrs C had had a CT scan (a scan which uses x-rays and a computer to create detailed images of the inside of the body) after the birth which had returned a normal result (suggesting there were no retained products of conception). In relation to the delay, the practice noted that on one occasion the GP asked Mrs C to come back in one to two weeks, but Mrs C did not return until six weeks later. Mrs C said this was the first available appointment, but the practice said there were a number of earlier appointments available with the same or different GPs. The practice gave us a copy of their audit records, which showed the appointment was booked only a few days before the date of the appointment.

After taking independent medical advice from a GP, we upheld Mrs C's complaint. The adviser said that the GPs should have arranged an ultrasound in view of Mrs C's symptoms of unexplained bleeding for six weeks after birth, and they should have referred Mrs C to gynaecology earlier. However, we agreed that part of the delay was caused by Mrs C returning in six weeks, rather than two (which may have been due to a misunderstanding or miscommunication).

Recommendations

We recommended that the GPs concerned:

• apologise to Mrs C for the failings our investigation found;
• familiarise themselves with postpartum complications and consider identifying this as a learning aim; and
• reflect on our findings as part of their next annual appraisals.

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.