Upheld, recommendations

Summary

Mrs C complained that doctors at Monklands Hospital did not examine her mother (Mrs A)'s ear for infection, or do a CT scan (computerised tomography: a scan which uses x-rays and a computer to create detailed images of the inside of the body), when she went to the hospital's emergency receiving unit. Mrs C felt that hospital staff did not take all steps to ensure that Mrs A received the best care.

We looked at Mrs A's medical records, and we took independent advice from one of our medical advisers. We also took into account relevant clinical guidance in Scotland about the diagnosis and management of headache in adults. The guidance referred to 'red flag' features, some of which could have applied in Mrs A's case given what was recorded in her medical and nursing records. We concluded that a CT scan should have been carried out, or at least the relevant hospital staff should have specifically recorded the decision not to perform a CT scan, in line with the guidelines. We also found that hospital staff should have examined Mrs A's ear for infection. We upheld Mrs C's complaints.

Recommendations

We recommended that the board:

• apologise to Mrs C and Mrs A's family for the failings identified in our investigation;
• remind relevant staff, in particular locum consultants who usually work elsewhere in the UK, of the specific national guidelines which are used in Scotland; and
• make reasonable efforts to share the result of our investigation with the staff involved.

Summary

Mrs C complained about the treatment she received when she was admitted to Monklands Hospital to have a blockage in her bowel investigated. This was examined in the operating theatre and the blockage was resolved there and then. However, Mrs C experienced excruciating pain and complained that she was not given an anaesthetic for the procedure. She said the consultant ignored her requests to stop. She also complained that she was asked to sign a consent form on her way to theatre, and she raised concerns about the board's handling of her subsequent complaint.

We took independent advice from a consultant colorectal (relating to the colon and rectum) surgeon. We were advised that Mrs C could have been offered anaesthesia or sedation for the procedure. The adviser noted that Mrs C was already taking strong pain medication when she was admitted, potentially indicating that she may have wished to receive something to control her pain during the procedure. We upheld this complaint.

The adviser confirmed that it was not appropriate for Mrs C's consent to have been obtained on her way to theatre, which the board had already acknowledged. We identified inconsistencies in relation to what happened during the procedure. The board said both that the consultant had stopped when asked by Mrs C, and that they had proceeded with Mrs C's verbal consent, but neither of these scenarios was documented in the operation note. We concluded that the informed consent process was not handled reasonably and we upheld this complaint.

We also upheld the complaint about the way the board handled Mrs C's complaint to them. There was an unreasonable delay that the board had already acknowledged and apologised for. We noted that there were omissions and inconsistencies in the board's response, and that it was overly technical in parts. We also noted that the board had not sought comments from relevant medical and nursing staff who were involved, and that could potentially have added value to the board's complaint investigation.

Recommendations

We recommended that the board:

• bring this decision to the attention of the consultant and team, and ask them to reflect on their decision not to offer Mrs C sedation or anaesthesia;
• review their process for obtaining informed consent, taking account of the failings this investigation has identified and relevant guidance in this area;
• ask the consultant to reflect on their operation note from this procedure with a view to identifying areas for improvement and ensuring that any significant interactions are documented in order to avoid similar future uncertainty;
• review their handling of Mrs C's complaint in order to identify areas for improvement and ensure compliance with their statutory responsibilities as set out in the Can I Help You? guidance; and
• apologise to Mrs C for the failings this investigation has identified.

Summary

Miss C complained to her mother (Mrs A)'s medical practice about how they dealt with Mrs A in the last two days of her life. Miss C then complained to us that a GP failed to diagnose and treat Mrs A's condition; that reception staff wrongly referred her mother to NHS 24 rather than arranging for a house call from a GP; and about the practice's handling of her complaint.

We looked at the practice's file on Miss C's complaint and at Mrs A's medical records, and we took independent advice from one of our GP advisers. We found that Mrs A had a number of risk factors for a heart condition, and we decided that the GP should have taken these into account by reviewing Mrs A's blood pressure and pulse, given the possibility of a heart-related cause for her symptoms. We concluded that the assessment and treatment provided by the GP was not of a reasonable standard. We also concluded, on the balance of the available evidence, that reception staff were wrong to refer Mrs A to NHS 24, rather than offering an emergency appointment at the practice or a home visit from the on-call GP. We also found that the practice's handling of Miss C's complaint was not in keeping with the principles set out in the national NHS complaints handling guidance. We upheld Miss C's complaints.

Recommendations

We recommended that the practice:

• apologise to Miss C for not providing a reasonable standard of care, treatment and service to Mrs A;
• apologise to Miss C for the failure to deal with her complaint adequately;
• provide us with evidence of how practice medical staff learned from this case;
• review the practice protocol for late calls and emergency appointments; and
• refresh their understanding of national complaints guidance and review their complaints procedure to ensure that the procedure, and staff practice in dealing with complaints, is in line with the guidance.

Summary

Mr C complained on behalf of his brother (Mr A) that the board failed to diagnose Mr A's testicular torsion (the twisting of a testicle, which shuts off the blood supply and can result in the loss of the testicle) and inappropriately discharged him from the Southern General Hospital. Mr A later had to have a testicle surgically removed. Mr C was also unhappy with the board's handling of his complaint.

We found that, as acknowledged by the board, there was a series of failings when Mr A was in hospital. The main issue was that an on-call urologist (a doctor who treats conditions of the urinary tract) should have examined Mr A in person to exclude or confirm testicular torsion. We also found that hospital staff who were asked to comment on Mr C's complaint agreed that Mr A should not have been discharged without being examined by the urologist and being given an ultrasound scan (a scan that uses sound waves to create images of structures inside the body). A lack of available beds may have been a factor in Mr A's discharge.

We found that the board's investigation of Mr C's complaint was reasonably thorough, and their letter to him acknowledged failings and apologised for them. However, we found that the investigation was missing a statement from the doctor who took the decision to discharge Mr A. This was an important aspect of the events in question because it was this doctor who raised the issue about there being no available beds. In our view, the lack of evidence from this doctor compromised the board's investigation. We upheld all of Mr C's complaints.

Recommendations

We recommended that the board:

• share widely within the urology service the circumstances of Mr A's care;
• discuss the details of this case with the on-call urologist;
• share the circumstances of Mr A's care with the out-of-hours service and the emergency department;
• explain to us why a statement was not obtained from the doctor who discharged Mr A;
• ensure that the details of this case are discussed with the doctor who discharged Mr A; and
• provide us with confirmation regarding the availability of beds in relation to Mr A's discharge.

Summary

Ms C was referred by her GP for her painful right ankle to be reviewed. She complained that she experienced an undue delay in receiving appropriate treatment.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that Ms C's first appointment for treatment with a foot surgeon was just over 39 weeks after her referral. This was longer than the board's waiting time policy. However, in the meantime, Ms C had been sent on a different treatment pathway by being referred to a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb), a consultant orthopaedic surgeon and then finally a foot surgeon. She had also refused appointment times that had been offered and had been quite specific about where she would receive treatment. This all affected her waiting time.

We took the view that it would have been more appropriate, given the terms of her referral, for Ms C to have been referred directly to a foot surgeon and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the overall delay in providing a date for surgery; and
• bring the complaint to the attention of those staff who assess referrals of this type for them to reflect on the advice given.

Summary

Mr C complained that he had not received appropriate care following an operation on his urinary tract. He said that because the consultant had not examined him appropriately at a post-operative consultation, the consultant did not realise that Mr C's condition had deteriorated. Mr C said that meant that he was in significant discomfort until a further consultation six months later, when the problem was identified and he underwent a further operation. He was then taught a technique for self-help which aimed to support the work of the operation, to avoid a further recurrence. Mr C complained that the board had not referred him for this self-help technique after his first operation.

We sought independent advice from a urology consultant. Our adviser noted that there was limited information on file about what happened at the post-operative consultation, but that given the concerns expressed by Mr C (and referred to in the records) it would have been reasonable for the consultant to have examined Mr C in more detail, and undertaken various tests to identify how his condition had changed. Our adviser was critical of this, and of the limited information in the notes from the consultation. However, our adviser also noted that while some consultants may sometimes refer patients to the self-help technique after a first operation, it was reasonable that Mr C was not taught this until after his second operation.

We were critical of the level of follow-up Mr C was given following his first operation, particularly given the concerns he raised during his consultation. We noted that, while the clinical notes provided limited information about what was discussed, we were satisfied that Mr C raised concerns which were not sufficiently investigated. We were also critical of the level of record-keeping.

Recommendations

We recommended that the board:

• highlight the findings of this investigation to the consultant involved, and remind him of the General Medical Council's requirements in relation to record-keeping; and
• apologise to Mr C for failing to provide an appropriate level of treatment during his first post-operative consultation.

Summary

Mrs C complained to us on behalf of her husband (Mr C), following surgery he had at Victoria Hospital. Mr C was given morphine for post-operative pain, administered through a Patient Controlled Analgesia device (PCA - a special syringe allowing pain relief on demand). Over the subsequent 18 hours Mr C administered his own morphine, within limited doses, via the PCA. Nursing staff contacted the Hospital at Night team when they were concerned about the amount of morphine he had received, but he was not seen by a doctor until ward rounds the next morning. Concern over his pain relief led to a referral to the pain team. Mr C was seen by a pain nurse, who stopped his PCA and prescribed alternative, morphine based pain relief. Three hours after his PCA was stopped Mr C started to show clear signs of opiate toxicity (overdose). A doctor was called and he was given medication to reverse the overdose.

We sought independent advice from nursing, anaesthetic and general medical advisers. The nursing adviser was satisfied that nursing staff had appropriately monitored Mr C's condition. The anaesthetic adviser noted that Mr C had shown signs of mild opiate toxicity before his overdose, and that a review by an anaesthetist should have been requested either at those times or when he was seen by the pain nurse. The general medical adviser agreed with this assessment.

The signs of opiate toxicity which Mr C displayed in the hours after his surgery were short-lived, and his observations on charts remained reasonable. While nursing staff monitored him appropriately, and it was reasonable to refer him to the pain team, we decided he should have been reviewed by an anaesthetist to identify whether alternative medication was more appropriate. We found that this could have eliminated the risk of an overdose. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• discuss this case in an appropriate multi-disciplinary setting, to identify alterations to current procedures to assist staff in identifying when they should seek an anaesthetic review; and
• apologise to Mr and Mrs C for the failings identified and the distress caused as a result.

Summary

Mr C complained about his treatment when he was admitted to Dumfries and Galloway Royal Infirmary for bowel surgery. He had been diagnosed with bowel cancer and underwent surgery to remove the right side of his colon. He became unwell following surgery, experiencing severe pain, and a scan three days later revealed a leak in the join in his bowel. He was taken back to theatre the same day for corrective surgery. He complained about the delay in diagnosing the complication arising from the initial surgery. He also raised concerns that the potential for this complication had not been explained to him in advance and that his wife was not informed of the severity of his condition prior to the corrective surgery.

We took independent clinical advice from a consultant colorectal surgeon who advised us that the risk of a leak was recorded on the consent form that Mr C had signed, thus suggesting that it had been discussed with him. It was our adviser's view, however, that the possibility of a leak should have been considered more closely and a scan arranged a day earlier. We, therefore, concluded that there was an avoidable delay in identifying the leak and carrying out the corrective surgery. Our adviser told us that earlier surgery would not have altered the clinical outcome, however, we noted that it would have minimised the distress caused to Mr C and his wife. We upheld the complaint. The board had already accepted that they should have given more information to Mr C's wife regarding his condition. They had apologised for this and discussed it with senior staff. However, they had not accepted that there was a delay in identifying the leak and we recommended that our findings in this regard be fed back to medical staff.

Recommendations

We recommended that the board:

• arrange for the learning from this decision to be discussed by medical staff at a relevant departmental meeting; and
• apologise to Mr C for failing to identify his post-surgical complication earlier.

Summary

Mrs C complained about Business Stream's delay in sending bills to her for her business premises. She said that the first correspondence she received from Business Stream was a notice saying that her water was to be disconnected, which was issued over a year after she moved in. There was no water meter in the premises and, when the bills were issued, they were based on the rateable value. Mrs C could have applied for reassessment of her water charges, but the charges would only have been reassessed from when her application for this was received. She considered that the delay in issuing bills to her meant that her water charges were higher.

Mrs C provided us with an email that the previous tenant of the property had sent to Business Stream to inform them that Mrs C had moved in. She also sent us a copy of an email that Business Stream had sent to her, in which they had requested that Scottish Water attend the premises and that she confirm that the contact details provided by the previous tenant were correct. Mrs C did not respond to this email and Business Stream had continued to issue bills for the property to the billing address provided by the previous tenant.

Business Stream told us that, like other utility providers, they require customers to contact them when they take over a premises; however, they also acknowledged that, in Mrs C's case, they should have acted more proactively to close the previous account and open an account for Mrs C as soon as they were advised that she had taken over the premises. We found that Business Stream had failed to take appropriate follow-up action after they received the email from the previous tenant and we upheld Mrs C's complaint.

Recommendations

We recommended that Business Stream:

• issue a written apology to Mrs C for the failure to take appropriate action after they received the email from the previous tenant; and
• reimburse her for 50 percent of the additional charges she incurred as a result of their failure to take appropriate action after they received this email.

Summary

Mr C complained about Business Stream’s charging. His building’s rateable value had changed but the section of their bill that was based on his rateable value still used the old value. This meant that Business Stream’s invoices were higher than they should have been. Following Mr C’s complaint, Business Stream amended and backdated their charges but said, in line with the relevant policy, they could not do this for the whole period in question. Mr C was unhappy with this and brought his complaint to us.

Business Stream provided us with two versions of their policy. Both versions were clear that their initial charges were appropriate. The policies differed in terms of Mr C’s more recent charges. The old version of the policy said that Business Stream should have amended their charges for the whole period, but the more recent version limited this, and Business Stream had based their position on the more recent version of their policy.

The more recent version of the policy was in force by the time they concluded their involvement in the matter, but it had not been in force when Mr C first contacted them about this. Although we considered it clear that Business Stream had taken steps to address Mr C’s concerns, it was also clear that there has been confusion about the relevant version of their policy. Given the difference between the two versions, the fact that Business Stream used the later version materially affected Mr C. We upheld his complaint and made one recommendation.

Recommendations

We recommended that Business Stream:

• consider making an ex-gratia payment in line with our findings that the lower rateable value should have been applied from an earlier date.