Upheld, recommendations

Summary

Mrs C complained on behalf of her client (Mrs A) who was unhappy with the care and treatment she received from her GP practice in relation to a finger injury.

After injuring her finger, Mrs A attended the hospital minor injuries and illnesses unit, but she was discharged. A week later, she attended the practice as she was still unable to bend her finger. The GP examined her finger and prescribed antibiotics. Mrs A returned a week later and a different GP prescribed different antibiotics. Mrs A returned again another week later, and at this appointment she mentioned that soon after the first injury, she had had a second injury which stretched her finger. The third GP then considered that Mrs A might have an injury to her flexor tendon (the tendon that connects the muscles in the forearm to the bones in the finger), and referred her to the orthopaedic clinic as a routine referral. After further investigations, Mrs A was diagnosed with an incomplete tear of the flexor tendon.

After taking independent medical advice from a GP adviser, we upheld the complaint. We found that, although the first two GPs did not know about the second injury, in view of Mrs A's symptoms they should still have considered the possibility of a flexor tendon injury and referred her for specialist assessment. Although the third GP acted appropriately in referring Mrs A to orthopaedics, this should have been an urgent referral, rather than routine. We were concerned that the GPs' failures to refer Mrs A appropriately led to a delay of over three weeks in her treatment, which our adviser said was significant as flexor tendon injuries are normally treated within a few days.

Recommendations

We recommended that the practice:

• issue a written apology to Mrs A for the failings our investigation found; and
• draw our findings to the attention of the GPs involved, for reflection as part of their annual appraisal.

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury.

Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Recommendations

We recommended that the board:

• remind staff in the minor injuries and illnesses unit of the 'Tayside Hand Unit – Trauma Referral Guidelines' (in particular the guidance on assessment of wounds on page 7);
• consider options for improving the tracking of similar referrals in the general medical clinic;
• bring our findings to the attention of relevant staff for reflection and learning;
• issue a sincere written apology to Mrs A, acknowledging the failings our investigation found; and
• remind relevant staff of the need to ensure complaints are fully investigated in line with the complaints procedure and the responses provide full explanations of the matters raised.

Summary

Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses

x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014.

Mr C questioned why early tests and investigations given to Mr A failed to show evidence of his illness and said that there had been delays in providing him with treatment. Mr C said that as a consequence, Mr A had lost time with his family. Mr C also complained that there had been delay in issuing correspondence to Mr A. On behalf of the hospital, the board said that it had been very difficult to diagnose Mr A's illness and that while tests showed that something was wrong, this could have been for a number of reasons; there had been a delay in getting biopsy results but this had been unavoidable. Similarly, they said that there had been a delay in sending out letters because of administrative problems but that this had not affected Mr A's treatment overall.

We took independent advice from a consultant clinical oncologist and found that it had been very difficult to diagnose Mr A's cancer and to establish information by biopsy to determine the type of treatment he needed. This was not unreasonable in the circumstances. However, it had not been reasonable not to have treated Mr A as a suspected case of cancer from the outset and thus provide him with this care and treatment at an earlier date. Because of this delay and confusion in correspondence sent to Mr A, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• provide a formal apology to Mrs A;
• provide a formal apology for the delays in correspondence;
• inform us of the outcome of their administrative review and the steps taken to avoid a similar situation; and
• ensure that the advice provided for this complaint is brought to the attention of those clinicians involved in the case.

Summary

Mr C complained about his treatment when he attended a stroke clinic. He was unhappy that he was sent home the same day, having been assessed and a stroke diagnosis made. He said he lived alone in a third floor flat and the board did not ask how he would get home or check that there was someone there to look after him. He also complained that no follow-up was arranged, particularly in relation to the psychological impact of the stroke, noting that he previously suffered from mental health difficulties.

The board responded indicating that they carried out appropriate investigations to arrive at the diagnosis and sent a results letter to Mr C's GP with a care plan. They noted that Mr C was independent both before and after the stroke and that he had made his own way to the stroke clinic. They assumed, therefore, that he was able to make his own way home. They assured Mr C that a referral would have been made to the appropriate services had the clinical team believed there to be any ongoing physical or psychological problems arising from his stroke.

We took independent advice from one of our medical advisers, who said there was no evidence to suggest that Mr C required admission following his attendance at the stroke clinic. Our adviser considered that the assessment carried out was reasonable in terms of how thorough it was, noting that appropriate recommendations were made to Mr C's GP regarding his future treatment and monitoring. However, our adviser did not agree with the board's position that there were no ongoing psychological difficulties, stating that there was clear evidence of Mr C's previous and current mental health problems at the time of his attendance at the clinic. Our adviser, therefore, considered that Mr C should have been referred to psychology services by the clinic doctor and considered that the care he received in this regard was unreasonable. We also identified a later breakdown in communication which resulted in the neuropsychology department appearing not to have made an onward referral to the mental health team. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings that this investigation has identified;
• arrange for Mr C to be seen again in the stroke clinic for review of his symptoms; and
• highlight to relevant staff the importance of referring stroke patients to psychology services, where appropriate.

Summary

Ms C complained on behalf of her daughter (Ms A) about the treatment Ms A received at the Western General Hospital. She said that the reporting of a scan was unreasonable, and that the arrangements for follow-up appointments after this scan and an operation carried out some nine months later were unreasonable. Finally Ms C was unhappy with the board's handling of her representations.

During our investigation, we took independent advice from a consultant neurosurgeon and a consultant neuroradiologist, after which we upheld Ms C's complaints. In responding to the complaints, the board had accepted that the written report prepared after the scan failed show that there was a significant abnormality and they had apologised for this error. They had suggested improvements as a result, and our adviser said that these should be implemented.

We also found there was a delay in Ms A receiving a follow-up appointment after the scan, for which the board had also apologised. The advice we received was that Ms A's clinical pathway had not changed as a result of this, but it did lead to a considerable delay in telling her about her new diagnosis. The adviser also said that there was no delay in the follow-up appointment after Ms A's operation but we were concerned that she was not provided with the findings reported at the time of her operation during her in-patient stay in hospital. We were satisfied that there was no delay in arranging a further scan after her operation.

The board had apologised that Ms A had not received details of the oncology (cancer) team including the clinical nurse specialist in a timely manner. As a result of these communication problems the board had taken action to improve coordination of neurology patients and their care by establishing a new multi-disciplinary team. Finally, they had accepted failings in their handling of Ms C's complaints and had taken action as a result.

Recommendations

We recommended that the board:

• report back to us on the action taken to implement the improvements proposed; and
• ensure the staff involved in this case are made aware of the importance of ensuring findings reported at the time of the operation are appropriately reported to patients and/or their relatives.

Summary

Miss C complained that the care and treatment she received for her hand after a cycling injury were unreasonable. She raised a number of issues, including that the consultant orthopaedic surgeon, who she saw nearly four weeks after her injury, failed to operate and refer her to physiotherapy at that time. Miss C also complained that the physiotherapy she received after the board did decide to operate, two and a half months after her injury, was unreasonable. She said the physiotherapist only checked her progress and explained what exercises she should do.

We obtained independent advice on this case from two of our medical advisers, a consultant trauma and orthopaedic surgeon (adviser 1) and a consultant physiotherapist (adviser 2). Adviser 1 explained there were different ways to treat hand fractures and that professional opinions on how best to do this could vary. He said that the extent of Miss C's injury was such that, on balance, surgery should have been considered when she initially presented with her injury. Because of this, we upheld the complaint and were critical of the board. However, adviser 1 said that by the time Miss C saw the consultant, the advantages of early surgery had been lost and it was then not unreasonable to see if conservative treatment was successful. Although early surgery would have shortened the time from injury to recovery for Miss C, it was unlikely to have affected the final result. Adviser 1 also explained that a referral to physiotherapy nearly four weeks after injury would not have achieved anything, and had no adverse impact in Miss C's case. Adviser 2 noted that when Miss C did receive physiotherapy treatment, she had good assessment, a comprehensive exercise programme, sensible advice on self-management between treatments and regular reviews on progress.

Recommendations

We recommended that the board:

• feed back our decision on this complaint to the staff involved; and
• provide Miss C with a written apology for the failings identified.

Summary

After losing a lot of weight, Mr C was referred for plastic surgery to remove excess skin around his abdomen (abdominoplasty). He had a psychological assessment and was told he would have one procedure. After the surgery at St John's Hospital he reported discomfort and problems and felt that the surgery had created other problems with the appearance of his skin. He had additional 'revision' surgery to correct some of the problems caused by the initial operation. However, he complained the surgery was not successful and he was still suffering from side effects. He was unhappy that the board were no longer willing to offer him further plastic surgery.

We took independent advice from our plastic surgery adviser, who said that Mr C's surgery appeared to have been successful. The second operation had been carried out to tidy up elements of the initial surgery, and would be considered part of the same procedure. He pointed out that before an abdominoplasty it was often difficult to be sure whether one procedure would be sufficient. He also said, however, that if the board had a reason for turning down Mr C's request for further surgery, they should have explained this clearly to him.

We found that while there did not appear to be any problems with the surgery itself, Mr C was not being offered further treatment and had not had a full explanation of why this was. We upheld his complaint and made a recommendation.

Recommendations

We recommended that the board:

• review the potential need for further surgery and ensure this is fully discussed with Mr C. Following this, if Mr C requests an independent second opinion the board should make the appropriate arrangements for this.

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's handling of assessments of Mrs A's child in relation to diagnosing autism spectrum disorder (ASD).

Mrs A first reported concerns about her child when they were about two years old, as she felt they had some developmental issues. When the child was between four and five years old, community paediatrics undertook two formal assessments for ASD, both of which concluded that the child did not have ASD (although showed some ASD traits). Mrs A was dissatisfied with these results and sought the opinion of a private psychologist, who also considered her child had some ASD traits, although did not fulfil all the diagnostic criteria for ASD. Over the next nine years, the child continued to have developmental problems and was in on-going contact with health professionals and social workers. The child was also referred on several occasions to the children's reporter, including for non-attendance at school and for lack of parental care. While Mrs A asked on a number of occasions for a further assessment of ASD, the board considered that this had already been ruled out, and did not agree to offer a second opinion.

When the child was ten, Mrs A's solicitor obtained an independent psychologist's opinion for the children's reporter hearing, which found that there had not been appropriate assessments of ASD to date. Mrs A then asked her GP for a second opinion from a different NHS board, and the GP arranged an admission to a hospital outside the board area. As a result of that admission, the child was diagnosed with ASD. In view of the different diagnosis, the board undertook a significant event review (SER). The board also planned to meet with the hospital team which had diagnosed ASD, to discuss the case, although this had not been done at the time of our investigation.

Mrs C complained about the board's failure to undertake appropriate assessments and their handling of Mrs A's complaint. After taking independent medical advice from an experienced psychiatrist, we upheld Mrs C's complaints. Our adviser said that, although the initial assessment for ASD was reasonable for the time, further assessments should have been done when the child continued to have problems over the next few years. The adviser also said that the board should have given Mrs A a second opinion when she asked for one. However, the adviser said that the SER conducted by the board in response to the complaint was reasonable. In relation to the complaints handling, we found that the board had delayed unreasonably in responding to Mrs A's complaint, as well as failing to keep her updated, or respond to her requests for updates on several occasions.

Recommendations

We recommended that the board:

• arrange a meeting with the other board's team that diagnosed ASD, to discuss the differences in diagnosis in this case (as planned during the SER process);
• issue a written apology to Mrs A for the failings our investigation found;
• bring the failings identified in our investigation to the attention of relevant complaints handling staff; and
• remind complaints handling staff of the need to update complainants regularly where the complaint exceeds 20 working days, and to ensure that the full response is issued without undue delay.

Summary

Ms C, who was a patient of the community mental health team, complained that she had been discharged from the service contrary to advice given to her by phone, which was that her case would remain open so that she could arrange support, as needed, related to her employment. The board said a work development officer told Ms C she would be discharged after a period of five weeks. We were unable to reconcile the two very different accounts of this conversation. We found no supporting evidence that the board had reasonably followed their operational procedures which said that discharges from the service were planned with the patient, with advice on staying well and appropriate contact numbers for support organisations clearly communicated. We also found no evidence that a written copy of the discharge summary had been sent to Ms C's GP as it should have been. We recommended that the board review the discharge process.

We found that two mistakes had been made in the response to Ms C's complaint. Firstly the person named as having spoken to Ms C whilst she was attended her appointment had not done so. The second error was a reference to Ms C's employment being temporary rather than probationary. In view of the communication errors we asked the board to apologise to Ms C.

Recommendations

We recommended that the board:

• ensure that patients, GPs and other agencies are being given clear information at the point of discharge in line with the stated operational policy; and
• apologise for failing to communicate effectively with Ms C in relation to her discharge and and for the inaccuracies identified within the response to her complaint.

Summary

Miss C was concerned about a large lump in her mouth, and arranged an emergency dental appointment, where she was given antibiotics and advised to see her regular dentist. By the time Miss C saw her regular dentist a few days later her face was quite swollen. Miss C was advised by her regular dentist to have root canal treatment (RCT) on the infected tooth, noting that Miss C had started this treatment a year earlier but had cancelled the appointment to complete the treatment and not made another.

The dentist administered an anaesthetic to start the treatment, but this did not take effect, so asked Miss C to return the next day. When Miss C returned, the dentist administered the anaesthetic and started RCT. However, by the next day Miss C's face was extremely swollen and she was in considerable pain. She attended another emergency appointment and was immediately referred to hospital, where the tooth was removed and the abscess drained.

Miss C complained to us about the care and treatment she received. In particular, Miss C was concerned that the dentist did not take an x-ray, or attempt to remove the tooth or drain the abscess in her mouth.

After taking independent dental advice, we upheld Miss C's complaints. We found that the dentist should have attempted to drain the abscess, or referred Miss C on if she was not comfortable attempting this. We also found that the dentist should have taken an x-ray before starting RCT. Finally, we found that the dentist's record-keeping was not of a reasonable standard, as there was no proper description of the diagnosis or treatment plan.

Recommendations

We recommended that the dentist:

• issue a written apology to Miss C, acknowledging the failings our investigation found; and
• reflect on the findings of our investigation, as part of their on-going professional development.