Upheld, recommendations

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.

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.

Summary

Ms C was admitted to Borders General Hospital (hospital 1), then Knoll Hospital (hospital 2) after being involved in an accident. She was given pain relief at the scene of the accident and taken to hospital 1. On arrival, there was a mix-up over patient details and Ms C told us that on that day and the following day, staff tried to give her medication meant for another patient. Ms C told us that this took some time to resolve and, as a result, she said she was not given pain medication in a timely manner or when requested. She also believed she was given an overdose of morphine, which affected her ability to pass urine. She alerted nursing staff who then identified a urine retention issue. Ms C was transferred to hospital 2 the following month. She said that nursing staff there were institutionalised in their attitudes and treated her as if she was an elderly patient. Ms C discharged herself five days later.

We took independent advice on this case from our nursing adviser, who said that pain charts were not fully utilised at hospital 1 to manage Ms C's pain. Although pain was recorded there was no record of any action taken. In addition, Ms C was known to the pain team but they were not alerted until four days after her admission. We also found that although Ms C was already known to have chronic pain, she was not assessed for this in a proactive manner, and that in this instance care was not reasonable. Moreover, we were concerned that her patient details were incorrect. This was rectified and did not result in any medication errors, but could potentially have had more serious consequences. We were satisfied that the nursing care in relation to urine monitoring and that provided by staff at hospital 2 including their attitude was reasonable, and were satisfied Ms C was not given an overdose of morphine. However, in light of the failings identified, we upheld the complaint.

Recommendations

We recommended that the board:

• review how pain is assessed and monitored in Borders General Hospital and how instruments such as early warning system charts are used;
• inform us of the steps taken to ensure patient details are correct; and
• apologise for the failures this investigation identified.