Upheld, recommendations

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.

Summary

Mrs C's late husband (Mr A) was admitted to Glasgow Royal Infirmary with numerous fractures following a fall. After eight days in hospital, his condition deteriorated and he died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mrs C raised concerns about the orthopaedic, medical and nursing care and treatment provided saying that Mr A had not been given the best opportunity to survive given the failures in care.

We took independent advice from several medical advisers and a nursing adviser. We found that the treatment decisions to reduce the risk of pulmonary embolism were reasonable and that the risks of a pulmonary embolism could not be eliminated completely. Having said that, there was a missed opportunity for a more senior specialised medical review during this period as Mr A's National Early Warning Score (NEWS), a guide used to determine the degree of illness of a patient, was at a level that should have triggered an escalation of clinical care. We also found that there was poor record-keeping, and these failings resulted in unnecessary distress to Mrs C and her husband. In relation to nursing care, we also found record-keeping failings and a failure to alert medical staff of Mr A's deterioration during this period. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure record-keeping by medical staff complies with relevant guidance;
• bring our findings to the attention of relevant medical staff;
• take steps to ensure healthcare professionals comply with the NEWS guidelines or clearly set out the rationale in patients' clinical records for non-compliance;
• ensure record-keeping by nursing staff complies with relevant guidance;
• bring our findings to the attention of relevant nursing staff; and
• apologise for the failings identified.

Summary

Mr C complained about the board after they shared a letter containing sensitive information about him with his school. He said that he had made it very clear that he was not comfortable with information being shared in this way and felt that his confidentiality had been breached.

Mr C then wrote to his doctor, outlining his concerns and explaining that these circumstances had caused him a great deal of distress and anxiety. His doctor responded, apologising if she had misunderstood but had thought that consent had been given by him for this to happen. Mr C remained dissatisfied with this response, as he did not feel that his complaint had been taken seriously.

We found that Mr C's complaint had not been formally investigated through the board's complaints procedure. His doctor had also noted in her records that she intended to seek consent from Mr C at their next appointment. However, the notes for the appointment in question did not contain clarification on whether or not consent had been asked for or given. We took independent advice from an adviser, who stated that they did not consider it to be reasonable to share sensitive information without consent being clearly given and recorded. We accepted this advice and, as such, upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C both for breaching his confidentiality and for the on-going distress and anxiety that this breach has caused him; and
• apologise to Mr C for not properly escalating his concerns and investigating them through their complaints procedure.

Summary

Mrs C complained on behalf of her son (Mr A) about the severe toe pain he suffered since undergoing a total nail avulsion (complete removal of the toenail) in 2013. Mr A had been seen by podiatry staff on a number of occasions following the surgery. As a result of the severe pain, Mrs C said that Mr A had lost his confidence and been unable to undertake his usual activities. Mrs C was concerned that a number of investigations, tests and referrals appeared to be undertaken only when she complained to the board two years after the initial surgery.

We took independent advice from a medical adviser. They said that the treatment decisions were reasonable in light of the main post-operative complications associated with a nail avulsion. However, while the initial referrals, tests and investigations appeared to be carried out within a reasonable time, repeating the surgical and other investigations when previous investigations had not provided a diagnosis to the problem delayed referral onto a specialist pain team. We found this to be unreasonable, so we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• review their processes to ensure referrals to specialised pain teams are made within a reasonable time;
• bring our decision including the adviser's comments to the attention of relevant staff; and
• apologise for the failures our investigation identified.