Upheld, recommendations

Summary

Mr C suffered from ongoing problems urinating and tried to treat these himself, but this caused him further problems. He went to A&E at St John's Hospital and the urology department at the Western General Hospital several times. He was prescribed antibiotics for infection and given an appointment for a cystoscopy (an operation using a special telescope to examine the urethra - the tube that allows urine to pass out of the body - and bladder).

Mr C did not attend the appointment, as he said he did not receive the letter and did not know where to go. Another appointment was arranged, but Mr C developed another infection before this. He was prescribed more antibiotics, and although the operation could not be carried out, the surgeon met Mr C to discuss his condition and treatment. Another appointment was made for the cystoscopy, but Mr C was worried about the operation. He wrote to the surgeon about it, and they met again to discuss his concerns and his treatment plan, after which the operation went ahead with a different surgeon. Follow-up tests, however, showed that it was not successful and the new surgeon arranged for Mr C to have an urethrogram (an x-ray examination of the urethra). He planned to follow this up in his clinic, but Mr C was not given a follow-up appointment.

During this time, Mr C made several complaints about his treatment, in particular about medical staff being reluctant to give him ongoing antibiotics, which he thought he needed. He emailed the board's complaints team regularly about his complaints and ongoing health problems. While the board investigated and responded to several complaints, they eventually told him that the complaints team was not able to influence his medical treatment. They said that they would not respond to further complaints about antibiotics, but would investigate any new matters. However, when Mr C wrote to complain that he had not heard back since his urethrogram, the board told him that his complaint was closed and would not be investigated. Mr C asked his MSP to complain on his behalf, but the board told the MSP that the complaint was too old, as the events had happened over six months before. Mr C then complained to us about his medical treatment and the board's handling of his complaints.

We investigated Mr C's complaints and took independent medical advice on his case. As a result of our enquiries, the board acknowledged that he had not been given a follow-up appointment, and they arranged this as a matter of urgency. We upheld Mr C's complaint about treatment, as it was unreasonable that the board had at first failed to arrange this. We also found no evidence that Mr C was sent an appointment letter for his first surgery date, and we were critical of this. Finally we noted a lack of continuity in Mr C's care (with nine doctors involved over a six-month period). Although the first surgeon showed particular care in meeting twice with Mr C to explain his treatment, the lack of continuity meant that Mr C did not fully understand the treatment plan, or the importance of treating his underlying problems as well as taking antibiotics.

We also upheld Mr C's complaints about the board's complaints handling, as they did not correctly follow their complaints handling policy or their unacceptable actions policy. In particular, the board should have tried to clarify Mr C's complaints earlier, and should have told him as soon as they had concerns about the amount of contact he was having with them. We also found that they should have investigated his last complaint about the lack of follow-up appointment, as it raised a new issue that had occurred within the last six months and had not previously been investigated.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings our investigation found, and provide a reassurance that his future requests for medical care will be treated with respect;
• review the processes for arranging urology appointments at the Western General Hospital, to ensure there are clear records of when an appointment is required and when an appointment letter (or replacement letter) has been sent;
• consider identifying a single clinician to maintain continuity of care in cases where the patient may benefit from this;
• remind complaints handling staff of the requirements of the complaints policy in relation to clarifying complaints at the outset and the time-frames for acknowledging and responding to complaints;
• identify and address any training needs for complaints handling staff in relation to supporting vulnerable complainants (including responding appropriately to comments relating to self-harm); and
• review complaints handling processes and procedures to ensure they comply with the unacceptable actions policy.

Summary

Mr C had concerns that action was not being taken to prevent patients, visitors and staff from smoking at entrances to buildings at Monklands Hospital. He tried to report the matter via the contact number displayed on the 'no smoking' signs but no such number existed. When Mr C spoke to staff about the matter they seemed resigned to the fact that smoking outside the premises was an ongoing problem that happened all the time. He complained to the board but their response did not address all the issues he raised, and he brought the matter to us. We upheld his complaint, as we found that the board's response lacked detail and did not address a number of Mr C’s questions.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings which have been identified as a result of our investigation; and
• review their original response and provide Mr C with a further response which addresses the specific concerns which were raised.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Ms A) about the actions of a health visitor in relation to a burn to Ms A's child's arm. The burn was treated at the time by the child's grandmother, who is a healthcare professional. Some weeks later, the child's GP noticed the burn during a routine visit, and asked the health visitor to visit Ms A. During the visit, Ms A explained that the burn had been caused by an accident with a pair of hair straighteners: she had left the hair straighteners on, thinking they were out of reach of the child, but the child had pulled on the cord, causing the straighteners to fall onto the child's arm. The health visitor was not satisfied with this description and, after consulting with the child's GP, the child protection adviser and the duty social worker, she submitted a Notification of Concern to social work.

Ms C complained that the health visitor acted inappropriately by insisting that social work take action, despite being advised by the child protection adviser and the duty social worker that the child was not at risk. Ms C raised concerns that the health visitor failed to assess the situation appropriately and did not obtain additional information from the previous health visitor or the child's medical practice; that the description of the burn given to social work by the health visitor was inaccurate; and that the health visitor acted unreasonably by failing to inform Ms A before making the referral.

We investigated Ms C's complaint and took independent nursing advice from one of our advisers. We found that the health visitor had followed the appropriate procedures in making the referral to social work, including by appropriately discussing her concerns with the child's GP, the child protection adviser and the duty social worker. Although the health visitor did not follow the advice provided by the duty social worker that a referral was not necessary, we accepted that the decision whether to make the referral was a matter for the health visitor's professional judgment, and we were not critical of this. We also found that the description of the burn which the health visitor gave social work was reasonable in the circumstances. However, we found that the health visitor failed to comply with the relevant policy by not discussing her decision to share information with social work with Ms A, before making the referral. On balance, we upheld Ms C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Ms A for the failings our investigation found;
• review their guidance on child protection referrals, including both internal and national guidance, to ensure that there are clear and consistent steps for healthcare professionals to follow when considering a child protection concern; and
• raise the findings of our investigation with the health visitor for reflection.

Summary

Ms C had been living abroad but returned to Scotland, although she still had connections overseas. She was experiencing difficult personal circumstances and she was referred for psychiatric review. She received mental health care but complained that her treatment was inadequate and that the board failed to provide appropriate support. In particular, Ms C complained that after a referral to psychological services, it took too long for her to be seen; that although she was frequently suicidal, she was not admitted to hospital; and that there was a general failure to respond to her needs which contributed to her acute mental distress. She said as a consequence, this led to her child being taken into care.

We took independent advice from one of our advisers who specialises in mental health. We found that Ms C's initial assessment and plan were appropriate and a psychiatric review took place on schedule. At times of crisis, there was a good response with reasonable follow-up arrangements being put in place. However, although it was not considered that Ms C required compulsory treatment, her management was complicated by her continuing treatment overseas and her travel between the two countries and, at various times, she declined psychiatric appointments.

However, we found there was an extended delay before Ms C was seen by psychological services and so we upheld her complaint about this. The board had already apologised to Ms C for the delay, so we did not make a recommendation about this, but we did make two other recommendations.

Recommendations

We recommended that the board:

• confirm to us the actions they have taken to resolve the delay identified; and
• confirm to us that they are satisfied that they can meet reasonable waiting times for psychological services.

Summary

Mr C complained to us about the care and treatment he had received from a dentist. He had attended the dentist for emergency treatment, who had extracted a badly broken tooth. Mr C was given an antibiotic and advised to return to the surgery for a more detailed examination to be carried out to assess what other dental treatment was required.

Mr C returned to the dentist two days later and complained of pain and swelling. He said that he had been unable to eat. It was noted that a small swelling was present at the border of the lower jaw and there was pus discharging from the area where the tooth had been extracted. The dentist diagnosed a dry socket (an infected wound at the site of an extraction) and Mr C was prescribed another antibiotic and an antiseptic mouthwash. A dressing was not applied, as this was too uncomfortable for him.

Mr C attended his GP on the following day, as he was still in some pain. He was then admitted to hospital later that day with a submandibular (inside the lower jaw) abscess, which was spreading into the tissue spaces. This was leading to extensive swelling, which was threatening his breathing. He was also suffering from a fever. Mr C was admitted in order that the hospital could drain the infected fluid from the abscess.

There was nothing to indicate the presence of the abscess when Mr C had the tooth extracted on his first visit to the dentist. However, when Mr C attended again two days later, the dentist noted unusual symptoms, including a spreading infection, that did not fit the normal pattern. The development of an abscess of the type Mr C experienced following dental extraction is a very rare occurrence. After taking independent advice from our dental adviser, we found that that the dentist should have arranged an urgent referral to the local maxillofacial surgery department (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) when Mr C had returned complaining of pain and swelling, but had failed to do so. In view of this, we found that the dentist did not provide reasonable care and treatment on that occasion and upheld the complaint.

Recommendations

We recommended that the dentist:

• issue a written apology to Mr C for the failings identified.

Summary

Mr C complained that staff at the Royal Alexandra Hospital, Paisley failed to adequately assess his symptoms following a jarring injury to his neck from a fall in his garden. Mr C raised a number of concerns, including that the doctor who saw him failed to take adequate account of his dystonia (a movement disorder that causes muscle spasms and contractions), failed to arrange an x-ray and failed to ensure he had adequate pain relief. Mr C said it was later identified that his neck was fractured, but said that by then it was too late for it to be treated.

We took independent medical advice from a consultant in emergency medicine. The board indicated that the doctor's assessment of Mr C was appropriate. However, as the board could not locate Mr C's medical records, we could not clearly determine that this was the case. We were very critical of the board's management of Mr C's records.

Our adviser said that in general Mr C's dystonia would have played no part in his assessment and the determination of the treatment he required. However, he said that the doctor who saw Mr C should have considered the impact of his dystonia on his ability to swallow when determining appropriate pain relief. In the absence of a pain score, it was difficult to determine exactly what level of pain relief should have been provided. However, the board acknowledged that their understanding of the medication available to Mr C at home was incorrect and it would appear that Mr C was, therefore, sent home without adequate pain relief.

Further, given Mr C's swallowing problems caused by his dystonia, our adviser said that he would have expected senior involvement in deciding if Mr C should have been admitted for pain relief and we were critical of the board for failing to arrange this.

In terms of the need for an x-ray, the adviser was clear that, given the absence of any direct blow to Mr C's head, an x-ray was not indicated.

Recommendations

We recommended that the board:

• review their practice on the storage of patients' medical records to ensure that records are stored securely in future.

Summary

Mrs C complained to us that the board had given her terminally ill child (child A) a large dose of a muscle relaxant before they were taken off a ventilator. Child A had been receiving a muscle relaxant to improve ventilation (breathing), but was approaching the end of life and care was being withdrawn. We took independent advice from one of our medical advisers, and found that it had been unnecessary to give Mrs C's child a large dose of relaxant immediately before being taken off the ventilator. Our adviser said that this might in fact have hastened child A's death by a short time. The board had also continued to give child A the muscle relaxant after they were taken off the ventilator. This was not in line with the relevant guidance, which said that this should not be done.

Mrs C also complained that staff did not discuss this with her. Although the large dose of muscle relaxant should not have been given, any significant changes that affect the care provided to a child should be discussed with the family/carers. There was a clear failure to do so in this case.

Mrs C made a further complaint that the consultant treating child A did not tell her about this, when she asked him several months later why her child had passed away so quickly. Our adviser found no evidence in the record of the meeting that the consultant told her about the large dose of muscle relaxant. It is imperative that parents are given full and complete information about the care and treatment provided to a child when they request this. There was no evidence that the consultant did so in this case. We upheld all of Mrs C's complaints.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for unnecessarily giving her child a muscle relaxant before they were taken off the ventilator and for continuing the muscle relaxant after ventilation had been withdrawn; and
• take steps to ensure that their guidance on end of life care for children reflects guidance on muscle relaxants from the Royal College of Paediatrics and Child Health.

Summary

Mr C submitted a request to see a prison dentist, saying that he had severe dental pain. Seven days later, Mr C had not received an appointment and he complained to the board. The next day, Mr C had a triage appointment with a nurse, who arranged an urgent dental appointment three days later. At this appointment the dentist found that the nerve in Mr C's tooth had died, and root canal treatment was required.

The board did not uphold Mr C's complaint, as he had received an appointment by the time this was considered and they found the delay was reasonable for a 'routine referral'. Mr C was dissatisfied with this response, and complained to us about the delay in his dental treatment.

We asked the board why Mr C's referral was classified as 'routine', given that Mr C was not seen by any healthcare professional until his triage appointment a week later. They explained that requests for appointments were reviewed by healthcare staff, and any requests which were considered urgent were seen by a healthcare professional within 24 hours.

After taking independent advice from our dental adviser, we upheld Mr C's complaint. We found that the board did not follow their guidance on referrals, as Mr C's referral should have been classified as 'urgent' and he should have been seen within 24 hours. We also found that it was unreasonable for the board to classify the referral as routine without actually reviewing Mr C, given that the symptoms he described were in the 'urgent' category.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to properly classify his dental request and the delay in issuing him a dental appointment;
• review their procedures for classifying dental referrals, to ensure that all dental cases are reviewed by a healthcare professional within the time-frames required under the Prison Care Pathway guidance; and
• consider clarifying their guidance on the 'Urgent Care' pathway to make it clear that the 24 hour time-frame refers to the patient seeing a healthcare professional, rather than dental treatment being provided.

Summary

Mr C had an elective arthroscopy procedure (a type of keyhole surgery) on his right knee at Forth Valley Royal Hospital. The surgery took longer than anticipated. Mr C was discharged home the following day but was readmitted with an infection in his knee several days later. He had to undergo two washouts of the knee (a technique that involves flushing the joint with fluid) and was prescribed antibiotics to treat the infection, although Mr C said that hospital staff did not give him several doses of the antibiotics. The board agreed that this had happened. Mr C then complained that the care and treatment he received during and after his knee surgery was unreasonable.

We took independent advice from a consultant in orthopaedic and trauma surgery, who explained that Mr C had suffered a severe complication of a joint infection after surgery, which is a recognised risk but is a rare complication. The adviser said that overall Mr C's care and treatment was appropriate and the failure to provide him with antibiotics on a number of occasions did not significantly alter the eventual outcome of the infection he acquired. Nevertheless, the adviser considered the failure to administer antibiotics was either due to failure by staff to be aware of the potential complications of this, or an indifference to 'getting it right' and was, therefore, a failing by the board in their duty of care to Mr C. We were, therefore, satisfied there was a failure in Mr C's care and treatment.

We noted that a senior charge nurse had apologised to Mr C for the failure to give him antibiotics and that other nursing staff had been spoken to, to ensure that this was addressed. However, we thought that the board should apologise to Mr C as well. The adviser had further commented that although the board's explanation about the duration of Mr C's surgery was reasonable, the operation notes did not mention any particular problems or difficulties. We would have expected the reasons for the length of Mr C's surgery to have been noted, and we made a recommendation about this as well.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to administer antibiotics;
• provide us with evidence of the action they have taken to address the failure to administer antibiotics; and
• ensure that our adviser's comments in relation to the operation notes are brought to the attention of the relevant staff.

Summary

Mrs C complained about the standard of medical care she received when she reported a cough to the medical practice. She said that she reported a persistent cough on two occasions but was not referred for a chest x-ray. At a third consultation, seven months after Mrs C first reported her cough, a locum GP referred her for a chest x-ray and, after further tests, Mrs C was diagnosed with lung cancer.

We took independent medical advice from one of our GP advisers. We found that the practice missed two opportunities to arrange for Mrs C to have a chest x-ray as part of their routine investigations into a persistent cough. We found that the practice failed to reasonably follow the national referral guidance for suspected cancer which all GPs should be aware of and which clarify the significance of a cough in the diagnosis of lung cancer and state that a time-frame of three weeks should be considered a persistent cough.

When Mrs C first reported the cough it had been present for eight weeks, and when she next mentioned the cough it had been present for 13 weeks. The criteria for referral for suspected cancer had been met on both occasions. We found that Mrs C should have been sent for a chest x-ray earlier than she was, so we upheld her complaint, and made a number of recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C and her family for the distress caused by the late arrangement of investigations into the cause of her cough;
• notify the board's clinical support group and ask them to consider whether to undertake a random review of patient consultation records for quality assurance purposes; and
• carry out a reflective significant event analysis with support from the board's clinical support group and provide us with a copy.