Upheld, recommendations

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) about the care and treatment of his late mother (Mrs B). Mrs B was admitted to Glasgow Royal Infirmary with pain in her side and was found to have a kidney stone. She began taking medication to expel the stone and was discharged home for review in two weeks' time. When she attended for review, although she said she was still experiencing pain, an x-ray did not reveal any obvious stone. Arrangements were then made for a further examination and she was admitted to the New Victoria Hospital for surgery, following a discussion between Mrs B and the consultant in which Mrs B agreed to this. Mrs B was discharged the day after her surgery but later the same day she was admitted to hospital with pneumonia, moderate to severe hydronephrosis (where one or both kidneys become swollen or stretched as a result of a build up of urine) and multi-organ failure. She died a few days later in the intensive care unit.

Mr A was concerned about his mother's care. He questioned whether her previous medical history had been taken into account, whether she had been given the correct antibiotics and whether she should have been discharged the day after her operation.

In considering this complaint, we took independent advice from a consultant urological surgeon, who specialises in problems of the urinary system. We found that it had not been reasonable to operate on Mrs B and that this had not been in her best interest even though it was what she wanted. Our adviser said that best clinical practice would have been to keep her in hospital, offer her pain-killing medication and establish whether a stone was present as a possible cause of her pain. We noted that at the time of her discharge she had been well and the medication she was given was appropriate. However, Mrs B's medical notes were not clear about what was discussed with her before surgery and the risk (given her previous history) was not clear. We upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• make a formal apology to Mr A;
• ensure that the consultant urologist involved in Mrs B's surgery is made aware of the outcome of this complaint and that it is discussed at their next formal appraisal; and
• confirm to us that they are satisfied that consent forms and other clinical notes contain an appropriate level of detail.

Summary

Mr C complained about poor pain management and lack of information following hernia repair surgery (a procedure to address a bulge or protrusion of an organ through the structure or muscle that usually contains it) at Gartnavel General Hospital. Mr C said that he suffered severe pain because he was not given patient-controlled analgesia (PCA) morphine following the surgery, despite the anaesthetist having discussed his pain management and agreeing to the PCA at Mr C's pre-operation assessment.

Mr C was taken back to theatre the following morning to find out the reasons for his worsening pain, but no complications were found, and his surgery was considered successful. He suffered breathing difficulties which resulted in him being transferred to the high dependency unit (HDU) and then to an intensive treatment unit in a different hospital where he recovered several weeks later. Mr C also said that the cause of his severe pain and respiratory failure was not fully explained to him.

In responding to the complaint, the board said the anaesthetist discussed with Mr C that he would be assessed after the operation to see if a PCA was necessary. However, they also said that the respiratory failure following surgery was precipitated by poor pain control and that earlier establishment of PCA might have altered the sequence of events, although they could not be certain of this. As a consequence, Mr C was advised that in the event of future surgery, PCA and HDU care would be arranged for him because he would have a high risk of respiratory failure again.

We took independent advice on this case from one of our medical advisers, after which we upheld the complaint. Our adviser said that it was reasonable for the anaesthetist to say that the PCA would be put in place after Mr C's operation, if it was needed. However, we were critical that the PCA had not been written up on Mr C's drug chart before he was transferred from the theatre to the ward, so that it would be available if necessary. This was especially important as the record of Mr C's surgery indicated that he had undergone a long and difficult procedure, and it was highly likely that strong analgesia would have been necessary later in the evening. We considered that it was likely that a PCA would have avoided the subsequent problems with his pain relief.

Recommendations

We recommended that the board:

• share our findings with relevant medical staff involved in Mr C's pain management at the hospital in order to ensure lessons are learned;
• apologise to Mr C for the failings our investigation identified; and
• ensure that the medical staff involved in Mr C's care at the hospital record information discussed with patients and their families in line with General Medical Council guidance.

Summary

Mrs C complained that a GP at her medical practice failed to deal with her mental health problems in an appropriate manner. She said that over a two-year period they failed to provide her with a reasonable service for her mental health problems and refer her for specialist support. Mrs C said she asked the GP to refer her to a psychiatrist on a number of occasions and that her counsellor had also made a request for this on her behalf, but no referral was made. Mrs C also complained about how the GP handled the reduction of her sleep medication.

We took independent advice from one of our medical advisers, who is also a GP. We found no evidence that the GP failed to consider Mrs C's requests for referral for specialist support, or failed to refer Mrs C to a psychiatrist in response to her counsellor's request. However, the evidence showed that the practice were copied into a letter from a consultant psychiatrist to Mrs C's counsellor indicating that an appointment would be arranged for Mrs C in the 'near future'. Our adviser said that as the GP continued to see Mrs C for over a year after the letter was sent, and as Mrs C was still having mental health problems and no appointment with the psychiatrist had been forthcoming, it would have been reasonable for the GP to have enquired about this. Our adviser also expressed some concerns about the tone and content of the GP's letter in response to Mrs C's complaint. We were particularly concerned that they referred to Mrs C in the letter as 'patient', which was inappropriate. We were also concerned that the GP took nearly two months to respond to the complaint and that no updates appeared to be sent to her during this time.

On the matter of the sleep medication, it was clear that the guidance in this area was that such medication should be for short-term use and that the doctor was correct to explore the reduction in Mrs C's dosage.

On balance, however, we upheld Mrs C's complaint as we concluded that the GP failed to deal with her mental health problems in an appropriate manner.

Recommendations

We recommended that the practice:

• feed back the failings identified to the GP to ensure that a similar situation does not happen in future; and
• provide Mrs C with a written apology for the failings identified.

Summary

Mrs C was suffering from pain in her thigh some time after having a hip replacement, and her GP referred her for an x-ray. The report of the x-ray noted that there was no abnormality, but that there were also no previous images available for comparison as Mrs C's earlier x-rays were taken in another NHS board area. Mrs C was later seen by a private doctor who considered that the x-ray did show an abnormality that needed investigation. Further x-rays showed a problem with the replacement hip and a possible fracture, and Mrs C needed two more operations to fix this.

She complained that the board had failed to identify the abnormality in her

x-ray. The board took the view that the x-ray did show a subtle abnormality, but that without previous images to compare this to, it was difficult to tell if it was significant. They explained that a new system had since been introduced which made it easier to view x-rays taken elsewhere in Scotland.

After taking independent advice from one of our medical advisers, who is a consultant in radiology, we upheld Mrs C's complaint. The adviser reviewed Mrs C's x-ray and took the view that whilst the abnormality was relatively subtle, it was visible and could have been considered potentially significant for Mrs C. The adviser explained that it would have been appropriate to refer Mrs C for further investigations on the basis of the x-ray.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure to identify and report the abnormality in her x-ray; and
• provide a copy of our decision letter to the reporting doctor to allow him to reflect on Mrs C's case and discuss any learning points at his next appraisal.

Summary

Mr C sent a wash bag to the prison laundry but did not receive it back. He said it appeared that his laundry bag had been stolen and he submitted a compensation claim. The Scottish Prison Service (SPS) rejected Mr C's claim and said that any property held in use by a prisoner was entirely at his or her own risk, as stated on their property card. Mr C complained to us that the SPS's decision-making in respect of his claim was unreasonable.

It was clear from the evidence obtained that the only means by which Mr C was able to have his clothes washed in the prison was to use their laundry service. From the point at which he placed his belongings in his laundry bag and they were removed from his possession, along with his completed laundry sheet, he could not reasonably be expected to be responsible for their return. The prison provided the laundry service and were, therefore, responsible for returning Mr C's belongings to him. We took the view that it was unreasonable for the prison to rely on the disclaimer on Mr C's property card to absolve themselves of any responsibility for returning his belongings to him.

We found that the SPS did not have a system in place to adequately track prisoners' laundry, failed to fully investigate Mr C's claim and reach a conclusion on what happened to his laundry bag and failed to take responsibility for his laundry by applying the property card disclaimer. We concluded that their decision-making in respect of Mr C's claim for lost laundry was unreasonable.

Recommendations

We recommended that the SPS:

• feed back our decision on Mr C's complaint to the staff involved;
• reconsider Mr C's claim for loss of property taking into account the points contained in our decision on his complaint; and
• provide Mr C with a written apology for the failings we identified.

Summary

Mrs C lived in a small residential development. The site consisted of multiple plots and various planning consents were in place for individual developments. It was served by a shared access track with planning conditions in place requiring the developer to upgrade the track surface and drainage before building work started.

Mrs C complained that development progressed at the site without the access track being upgraded. The council took a pragmatic view that it was appropriate for the final surfacing work to be done after all work on the site was completed. However, in the meantime, the track surface became badly damaged and no interim maintenance work was carried out. Initially the council had worked with the main developer to ensure the track was maintained, but the developer sold on a number of their plots and no longer considered themselves liable for the access track.

We took independent advice from one of our planning advisers and found that the pragmatic view taken by the council about final completion of the track was reasonable. However, we were critical of their failure to ensure that interim maintenance work was carried out. In particular, we found that the original planning conditions were poorly worded and made no provision for interim maintenance of the track. Furthermore, we considered that the council did not fully explore who was liable for the planning conditions after the developer sold on their plots and failed to take steps to work with the responsible party to ensure access to the site was maintained.

Recommendations

We recommended that the council:

• review their use of planning conditions in cases involving unadopted road access to multi-owner developments to ensure that a clear record is obtained as to the proposed construction, the council's approval, and the timing of the work;
• consider using conditions to ensure that satisfactory schemes of long-term maintenance of private access roads are submitted and approved by the planning authority;
• review their position as to who is responsible for discharging the outstanding conditions relating to the access track, with reference to the adviser's comments on section 145(2) of the 1997 Act; and
• having clarified who is responsible for the access track, work with the responsible party to ensure interim maintenance work is carried out on the access track.

Summary

Mrs C complained to the council that her son's school had not responded appropriately to a playground incident. She said she should have been contacted but instead her son was sent home with a note in his bag. The council investigated but did not uphold Mrs C's complaints, and she was not satisfied with their response.

Our investigation reviewed how the council had investigated and responded to her complaints. We found that, although they provided a reasonable explanation to Mrs C's initial complaint, their final response (at stage two of their complaints process) was confusing and the conclusions reached did not clearly follow from the explanations given. We upheld Mrs C's complaint.

Recommendations

We recommended that the council:

• apologise for incorrectly stating that the council did 'not uphold' elements of the complaint at Stage 2 of the complaints procedure.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), who experienced a sudden and severe headache while on holiday visiting her daughter. Mrs A's daughter arranged for an ambulance to take Mrs A, who has a history of migraines, to A&E at Dr Gray's Hospital.

A junior doctor reviewed Mrs A and referred her to a senior doctor to determine whether a CT scan (a scan that uses a computer to produce an image of the body) would be necessary. The senior doctor reviewed Mrs A a few hours later, decided this was not required and discharged her, advising her to seek help if her condition worsened or did not improve. Mrs A said the doctor told her that it would be safe for her to fly home the next day, but the doctor did not recall saying this. Mrs A flew home the next day and arrived feeling very ill. A few days later she was admitted to hospital where, after further investigations, she was diagnosed with a brain aneurysm (a bulge in a blood vessel in the brain).

Mrs C complained about the care and treatment Mrs A received at A&E. She said that Mrs A was misdiagnosed and her symptoms were not taken seriously due to her history of migraines. She also complained that the doctor inappropriately advised Mrs A that it was safe to fly.

After taking independent advice on this complaint from a medical adviser, we upheld Mrs C's complaint. We found that the senior doctor had failed to properly investigate Mrs A's symptoms in line with relevant guidance and so missed the diagnosis of a brain aneurysm. In relation to whether the doctor had advised Mrs A that it was safe to fly, there was no evidence of this in the medical records and so we could not make any finding.

Recommendations

We recommended that the board:

• issue a written apology to Mrs A, acknowledging the failings our investigation identified; and
• raise the failings we found with the doctor involved for reflection and learning as part of their annual performance review.

Summary

Mr C complained that he waited too long to see a prison dentist after a crown fell out. He said that he had twice asked to see the dentist and had explained that he was suffering some pain. In response to Mr C's complaint, the board said that they did not consider his dental problem to be an emergency and that his needs would be met by a routine appointment, for which he was placed on a waiting list. Mr C then complained to us as he was concerned the root would be beyond repair if he waited any longer for an appointment. Although he then received treatment, Mr C continued to pursue his complaint with us as he felt he had waited too long for treatment and did not want this to happen again.

We took independent advice on this case from a dental adviser. Although Mr C had asked for an emergency appointment, our adviser considered that he had been appropriately categorised as needing routine dental care even though he had some pain. We found this to be in accordance with guidance to which the board referred when treating prisoners. However, we upheld his complaint as we found that it was four weeks before the crown was re-cemented. We considered this wait to be unreasonably long, and not in accordance with the seven day timescale set out in the guidance for treating routine patients. We also found that there was no documented information to show that Mr C was given advice about pain management while waiting for his appointment. We noted that the Scottish Government will shortly be publishing national guidance for a robust framework for oral health improvement and dental services in Scottish prisons, and made our recommendations in the light of this.

Recommendations

We recommended that the board:

• apologise to Mr C for the unreasonable delay in being seen by the dentist and for the lack of pain relief advice; and
• consider developing a policy for dental care within the prison when the Scottish Government's national guidance is published.

Summary

Mrs C had a hip replacement a few years ago which initially seemed to be successful. In early 2013, Mrs C attended her medical practice with pain in her thigh that was preventing her from bending to put her shoes on or driving. She was prescribed painkillers for a possible muscle or ligament injury and advised to rest. Mrs C's pain continued and she was sent for an x-ray which was reported as normal by a radiologist (a specialist in x-rays). The pain got no better and Mrs C was referred to a specialist. Some months after initially attending the practice, Mrs C contacted them to ask for a referral to a private hospital. Later that month, the practice arranged crutches for Mrs C as she was struggling to walk, and she was seen by the private consultant a few days later. He considered that the x-ray showed a possible issue and made suggestions for further investigations at an NHS hospital. These were carried out the following month and showed that Mrs C's replacement hip had become loose, causing the thigh bone to fracture. Mrs C complained that the practice failed to diagnose the cause of the pain in her thigh.

We took independent advice from one of our medical advisers, who is a GP. The adviser reviewed Mrs C's medical records and said that although the x-ray was normal, the fact that she continued to suffer from pain and visited the practice on several occasions should have prompted them to carry out further

x-rays, particularly when she had to be given crutches to walk. We, therefore, upheld her complaint.

Recommendations

We recommended that the practice:

• ensure that GPs familiarise themselves with the diagnosis and management of hip fracture, paying particular reference to the need to reassess patients who may clinically present with a fracture but have a negative x-ray;
• carry out a significant event meeting to discuss this clinical incident and any lessons that can be learned; and
• apologise to Mrs C for failing to take reasonable steps to diagnose the cause of her pain.