Upheld, recommendations

Summary

Mr C complained about his late father (Mr A)'s care and treatment in Wishaw General Hospital in the period before his death in June 2015.

Mr A had been diagnosed with terminal cancer in 2014 and in late May 2015 he was taken into hospital to have an oesophageal stent (a mesh tube in his throat) inserted. However, the procedure did not take place and only an endoscopy (a procedure where a tube-like instrument is put into the body to look inside) was performed. In June 2015, Mr A was admitted again and during his admission he suffered a number of falls. Mr C complained that Mr A was not provided with appropriate clinical or nursing care.

We took independent advice from a consultant geriatrician and from a nurse. We found that when Mr A was first admitted in May 2015, there were problems with the documentation available to the surgical team. It was brief and did not show that his condition had been considered in detail. Furthermore, we found that although a number of clinicians had been involved in his case, none of them had been involved with Mr A in any detailed or personal way and communication had been poor. On his second admission, our investigation showed that although it had been detailed in his notes, one-to-one care had not been provided to Mr A. Had it been, a third fall may have been avoided. For these reasons, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology for the failures identified;
• ensure that the clinicians involved in the case are aware of the adviser's comments and that they discuss them at their next formal appraisal;
• make a formal apology for the failure to provide one-to-one care observation; and
• review their processes for providing one-to-one care.

Summary

Mr C complained that his GP practice did not offer him an urgent appointment with a doctor after he attended the practice with chest pain. Mr C turned down the offer of an appointment with the nurse as he felt his symptoms were too severe. The duty doctor called him later that day and offered an appointment for the next working day (which was a Monday). Mr C chose instead to attend A&E where it was identified that he had a pneumothorax (collapsed lung). The practice accepted and apologised that Mr C should have been offered an urgent appointment to be seen the same day given his reported symptoms.

We took independent advice from a GP. We were concerned about the procedures in place at the practice for managing patient appointments. There was a lack of evidence to demonstrate that non-clinical staff were adequately trained and supervised in the procedures. We concluded that the care provided by the practice fell below a reasonable standard, and we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• work with Lanarkshire NHS Board to review their patient signposting procedures as a matter of urgency.

Summary

Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take sufficient food by mouth). Mrs A had been admitted to the hospital with high output from her stoma (a stoma is a surgically made pouch on the outside of the body; when the output from a stoma is high, it means that you are losing more fluid and are at a greater risk of becoming dehydrated) and acute kidney injury.

We took independent advice on this case from a consultant general surgeon. We found that Mrs A had initially been treated appropriately. It was likely that the NJ feeding tube was exacerbating the high output stoma. It had been reasonable to allow Mrs A to remove the NJ tube under supervision, as this reduced her anxiety about having it removed. This did not cause an oesophageal perforation (a tear in the tube that takes food from the mouth to the stomach) that she subsequently experienced.

However, we found that Mrs A had been discharged from hospital without evidence that the measures taken in relation to her high output stoma were fully effective and would prevent a readmission with the same problem. During our investigation, the board told us that they were working on guidelines on high stoma output for staff, but these had yet to be finalised. We also found the records of communication with Mrs A and her family were inadequate. In view of these failings, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• provide evidence that guidelines for high output stomas have been developed and circulated to relevant staff; and
• feed back our findings to relevant staff.

Summary

Mrs C, who is an advice worker, complained to the practice about a lack of urgency in acting on Ms A's concerns about a problem with her young daughter's hip. She said that Ms A reported that her daughter's left leg was longer than her right leg and that one of the GPs failed to thoroughly examine her daughter. In addition, it was only after Ms A continued to report her concerns that her daughter was referred to hospital. However, one of the GPs marked the referral as non-urgent and Ms A had to ask the practice again to make an urgent referral. Her daughter was diagnosed as having a dislocated hip.

The practice apologised for the delay and said they had learned from the complaint. They were now aware that they can directly ask for an ultrasound scan of the hip in such circumstances. The GPs were more aware of the signs to look for and would mark any referrals as urgent. The practice apologised for the distress which was caused.

We took independent advice from a medical adviser who noted that the response from the practice to Ms A's complaint was thorough and explained the shortcomings which they had identified. The practice said that their GPs were now more aware of the referral options, the need for urgency and the later signs of congenital dislocation of the hip. However, we identified further failings by one of the GPs in regards to the inadequate examination and recording of findings related to Ms A's daughter and a failure to stress the urgency of the situation in the hospital referral letter, so we upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Ms A for the failings identified;
• discuss the complaint as part of the GP's annual appraisal; and
• explain their criteria for carrying out a significant event analysis and explain why one was not performed in this case.

Summary

Mr C complained to us about how the board had handled his enquiries about NHS continuing health care. His mother had been assessed as needing continuing care, but was in hospital in another health board's area. Mr C had written to the board to ask for further information about this. The board did not respond and he had to contact them again. Despite this, he still did not receive a response and in view of this, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board had failed to handle his complaint about this matter in accordance with their complaints procedure. We found that the board had adequately responded to the points Mr C had raised in his complaint. We also found that it had been reasonable for the board to contact his mother's power of attorney to obtain consent to share the details of the investigation with him. However, we found that there had been a delay in responding to Mr C's complaint and we also upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in responding to his complaint; and
• make relevant staff aware of our findings on his complaints.

Summary

Ms C complained about a delay in arranging surgery for her child (Miss A), who suffered from malocclusion (a misalignment of the teeth and jaws) and chronic facial pain. A treatment plan was agreed for Miss A's malocclusion, including a period of braces followed by maxillofacial surgery (surgery affecting the mouth, jaws, face or neck). After 18 months of braces, it was decided that Miss A was ready for surgery and she was placed on the waiting list of a surgeon at the Southern General Hospital. However, no surgery date was offered for about 16 months.

Ms C complained to the board about the delay during this time. They were unable to offer a date for surgery due to demand, and emphasised that the surgery was unlikely to help Miss A's pain. They suggested that Ms C discuss the possibility of an out-of-area referral with the surgeon. Ms C said she asked about this and was told to contact other hospitals herself. Although Ms C found a hospital willing to conduct the surgery, the time-frame for this was similar to the estimate given by the Southern General Hospital at that time, so Ms C decided not to take it. However, Ms C said the Southern General's estimate then shifted several months. Miss A ultimately received her surgery about 17 months after she was placed on the waiting list.

In response to our enquiries, the board said the national treatment time guarantee of 18 weeks referral to treatment did not apply to Miss A, as she was a returning patient. They said they had now engaged another consultant to improve their waiting times.

After taking independent medical advice, we upheld Ms C's complaint. Although we agreed that the national treatment time guarantee did not apply to Miss A, and it was unlikely that the surgery would improve Miss A's pain, we found that 17 months was an unreasonable delay for this kind of surgery. We were also critical of the board's communication, and we said they should have been more proactive about arranging an out-of-area referral for Miss A.

Recommendations

We recommended that the board:

• apologise to Ms C and Miss A for the delay and poor communication in relation to her surgery;
• review how they monitor waiting times for 'follow on' maxillofacial surgery, to ensure that any significant pressures are identified and addressed proactively; and
• review what processes they have in place to support patients with arrangements for out-of-area referrals (where this is due to the board's waiting times).

Summary

Mrs C's mother (Mrs A) received regular dialysis (a form of treatment that replicates many of the kidney's functions) at the Inverclyde Royal Hospital Renal Unit. During one session, Mrs A experienced some pain and bleeding and, shortly after this, nurses noticed a red scabbed area near the dialysis access. Two weeks later, Mrs A experienced a significant bleed from her dialysis access and required emergency surgery. Sadly, Mrs A suffered a heart attack shortly after the surgery and died.

Mrs C complained about the treatment provided by the dialysis unit, and in particular the decision not to refer Mrs A for medical review when the scab was noticed. The doctor Mrs C spoke to handled this as a concern, and arranged a meeting with relevant staff, with a written summary provided. Mrs C then wrote to the board to complain, and they investigated the issues. The board said the nurses did not consider Mrs A required medical review, and they were capable of making this decision. However, the board acknowledged that their documentation was poor and said they were making improvements to this. Mrs C was dissatisfied with this response, and complained to us about Mrs A's care and the board's handling of her complaint.

After taking independent advice from a specialist renal nurse, we upheld Mrs C's complaint. We found that nursing staff should have taken further action in response to Mrs A's condition, including monitoring the scabbed area and documenting this, and referring Mrs A for access review. However, during our investigation the board gave us information on additional action they had taken to improve their dialysis service after Mrs A's experience and a similar incident, and we considered that the board had now taken appropriate steps to address the failings in care. We also found Mrs C's complaint should have been investigated as a complaint as soon as she had raised it, rather than being handled as a concern.

Recommendations

We recommended that the board:

• feed back our findings to the staff involved for reflection;
• feed back our findings on complaints handling to the doctor involved for reflection; and
• apologise to Mrs A's family for the failures identified.

Summary

Ms C attended an appointment at her GP practice with a three-week history of constipation, vaginal bleeding and abdominal pain. Ms C was asked by her GP if she could be pregnant and Ms C said she was not. Ms C carried out a pregnancy test that same evening, and it showed that she was in the early stages of pregnancy.

Ms C subsequently had three phone consultations with the practice over the following days. Ms C was advised to contact the Early Pregnancy Assessment Service who informed her that, given her symptoms, she may be having a miscarriage. An appointment was made for her to have a scan the following week. When Ms C attended her appointment, the scan revealed she had an ectopic pregnancy and required emergency surgery.

Ms C was unhappy with the care and treatment she received at the practice. She complained about the attitude of one of the doctors who she felt did not listen to her and treat her with sensitivity. Ms C also said that she was not prescribed antibiotics for a urinary tract infection until she insisted and she was not offered an examination even though she was pregnant.

We took independent advice from a GP. They considered that the care and treatment provided to Ms C at her appointment and during the first phone consultation was appropriate and reasonable. In relation to the second phone consultation which involved the doctor Ms C was unhappy with, there were different versions of what had occurred which we were unable to reconcile. The advice we received was that based on the information provided in the medical records, the doctor's actions in relation to Ms C's clinical treatment were reasonable. However, it appeared that the doctor had not meaningfully engaged with Ms C. We also found that during the third phone consultation with another doctor, that doctor had failed to take into account the relevant guidance on the management of bacterial urinary tract infections in pregnant women and had failed to follow appropriate prescribing guidance. We upheld Ms C's complaint.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failings identified;
• feed back our findings to relevant staff for reflection and learning; conduct a significant event meeting to discuss all aspects of this case; and submit a further significant event analysis for review to this office to include their reflection on communication and prescribing; ensures that the first doctor reflects on his consultation skills and discuss this complaint and, in particular his communication skills, as part of his annual appraisal; and
• ensures that the second doctor reviews the relevant prescribing guidance for the management of urinary tract infection in pregnancy and identifies this as a learning need as part of his annual appraisal.

Summary

Miss C decided to proceed with a surgical procedure (to divert the normal flow of urine from the kidneys and ureters into a specially created stoma) to address urine incontinence when other procedures had failed. As a result of the operation, which was performed at the Southern General Hospital, Miss C said she suffered from urinary infections and altered acid-based metabolism (tendency for the blood to become more acidic than normal that required medication) and that she had not been informed of any possible side effects or complications of the procedure beforehand.

We took independent advice from a medical adviser who specialises in urological surgery. We found that while it was documented that medical staff had several discussions with Miss C about the procedure, they failed to document the details of the consent discussions and it was not possible to determine if the risks were discussed with Miss C and understood by her before the operation. Therefore, we were not satisfied that Miss C was fully informed of the risks and in a position to give informed consent.

Recommendations

We recommended that the board:

• review the consent form to ensure that discussions between patients and clinicians about possible risks and complications are clearly recorded;
• bring the failings in record-keeping to the attention of relevant staff;
• consider the adviser's comments in relation to the use of information leaflets; and
• apologise for the failings this investigation identified.

Summary

Mrs C complained that there was a four-month delay in the board carrying out her six-month follow-up scan at Gartnavel General Hospital to monitor her condition. When Mrs C had the scan done, it showed secondary cancer which she felt could have been avoided had her care plan been properly followed. In responding to the complaint, the board accepted that there had been an administrative error and apologised to Mrs C. They said that the scan would likely have gone ahead had a return clinic appointment been made then and took steps to remind administrative staff of their responsibilities. However, Mrs C remained concerned that the board were unable to explain why the error had occurred and if adequate steps had been taken to avoid the matter recurring.

We took independent advice from a consultant urological surgeon and found that the delay was unreasonable and not in line with local guidance. However, we considered that Mrs C's prognosis would not have been significantly affected had the scan and treatment been done sooner. We concluded that there was a lack of evidence to demonstrate whether or not the form requesting the scan was mislaid by either clinical or administrative staff or whether the urology doctor had in fact completed it in the first instance. Whilst an electronic system is now in place which will assist in reducing the likelihood of paper forms going missing, we made a recommendation to address the matter and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• demonstrate what systems are in place to ensure that scan results are reviewed by the clinician responsible for the patient's care and that further monitoring takes place where appropriate; and
• draw these findings to the attention of the clinical team responsible for Mrs C's care.