Upheld, recommendations

Summary

Miss C complained that the association had acted unreasonably when they charged her for repairs they carried out after she moved out of her property. Our investigation found that the association inspected the property after she moved out, and the report completed then showed that some repairs were needed. Although it would have been useful if photographs had been taken of the damage, we were satisfied that there was sufficient evidence for them to pursue the cost of the repairs.

Miss C said that she was not given the opportunity to have the work done herself, and that other former tenants had received inspection visits before ending their tenancy. We found that the association were not obliged to do this prior to Miss C moving out, although we noted that doing so might have helped to avoid the problem. They also told us that they would have visited the property if she had contacted them about possible charges. That said, the repairs bill they sent Miss C referred to an incorrect address and did not provide her with information about the repairs she was being charged for. Miss C contacted them about this but the association then did not provide her with a written breakdown of the costs (although they did provide this during our investigation). Although this was a finely balanced decision, in view of these specific failings we upheld Miss C's complaint.

Recommendations

We recommended that the association:

• issue a written apology to Miss C for failing to provide sufficient information and for quoting an incorrect address on the original bill;
• consider reviewing their policy for rechargeable repairs in relation to the evidence required, the information given on the bill and whether a survey should be carried out for all tenants before they move out of a property; and
• consider whether it would be appropriate to reduce Miss C's bill for rechargeable repairs further in view of the administrative failings identified.

Summary

Mrs C complained that she had been refused cosmetic surgery based on an incorrect mental health diagnosis. She also said that the investigation into her complaint was not thorough.

In our investigation, we considered the information provided by Mrs C and the board, along with her medical records, as well as obtaining independent advice from one of our medical advisers. The board said that they had not diagnosed a condition but, rather, had used a particular condition to explain Mrs C's symptoms. Our adviser recognised this but, as the symptoms were used as the reason to refuse surgery, took the view that the diagnosis was implicit. Our adviser also said that the diagnosis was clinically disputable, and so we upheld Mrs C's complaint about this.

We found that the board dealt with her complaint in line with normal procedures, but our adviser pointed out that during their investigation they had not picked up that there had been a significant misinterpretation of the government guidelines about such treatment (the adult exceptional aesthetic referral protocol). We were concerned that they did not identify this, and we also upheld this complaint.

Recommendations

We recommended that the board:

• make a full written apology to Mrs C for the shortcomings we found in relation to her diagnosis; and
• remind relevant staff of the importance of ensuring that reasoning and decision-making in relation to cosmetic surgery is in line with the guidance and exclusion criteria set out in the updated adult exceptional aesthetic referral protocol.

Summary

Ms C had surgery on her foot to treat bunions at Ninewells Hospital. She complained that the operation did not relieve her pain and discomfort, but made it worse, and so the operation was unsuccessful. After treatment, other possible surgical options were discussed with her, but Ms C was anxious about having further surgery without assurances that she would be properly assessed and treated in future. She was particularly concerned that no x-rays were taken before or after her operation.

During our investigation, the board were unable to explain why they took no

x-rays before surgery. We took independent advice from one of our medical advisers, who said that although it was not mandatory, it was normal practice to take x-rays. Because they were not taken, the adviser was not able to say with certainty whether the procedure Ms C had was appropriate. We were also critical of the board for not properly recording Ms C's consent for the surgery. The procedure carried out was different from that to which she consented and we were concerned that Ms C might not have been properly advised of the procedures involved in this or the potential for failure.

Recommendations

We recommended that the board:

• apologise to Ms C for the failures to x-ray her or record her consent as part of the initial assessment of her suitability for surgery; and
• consider whether there are wider implications for the failings identified in this case, and advise us of the actions taken to address this recommendation and any outcomes.

Summary

Mr C, who is a doctor, complained about the Scottish Ambulance Service's response to a call he made to them when his wife (Mrs C) awoke one night with an irregular heartbeat. Mr C reviewed her condition and was concerned that her symptoms indicated she needed immediate medical assessment and possibly treatment. He called for an ambulance, but was not happy with the response. He was taken through the standard triage procedures, despite explaining that he was a doctor and was with the patient. After a discussion with a clinical adviser, a non-emergency ambulance was sent, and Mrs C was taken to hospital.

The service said that they had a protocol for calls from doctors, but as Mr C was not practicing at the time of the call, they treated him as if he were a member of the public, and took him through the normal triage procedures. They also explained that they were in the process of redesigning their triage process for calls from health professionals, and would take this case into consideration during that process.

We obtained independent advice on the complaint from a paramedic, who said that the service should have taken greater account of Mr C's assessment of his wife's condition. This would have enabled the clinical adviser to override normal protocols, and request an emergency ambulance for Mrs C. As they did not do this, we upheld the complaint.

Recommendations

We recommended that the service:

• provide an action plan for the re-design of protocols for handling ambulance calls from health care professionals; and
• apologise to Mr C for not handling his call more appropriately, and for not sending an emergency ambulance.

Summary

Mrs C's late aunt (Miss A) had severe chronic obstructive airways disease (a disease in which airflow to the lungs is restricted). Miss A was admitted to Hairmyres Hospital as an emergency with respiratory failure. A doctor reviewed her the next day, and moved her to the medical high dependency unit (HDU). Medical staff recommended that Miss A should have a CT scan (a scan that uses a computer to produce an image of the body). However, Miss A declined this, as she was anxious about being unable to lie down due to her breathing difficulties. A doctor prescribed anti-anxiety medication, and a consultant respiratory physician discussed options with Miss A for helping her undergo the scan. During Miss A's admission, staff also noticed that she was having difficulty swallowing. Medical staff stopped her non-essential medications, and prescribed a mouth wash and thrush treatment. They were concerned about Miss A's nutrition and fluid intake, and arranged for review by a dietician, but Miss A declined nasogastric feeding (where a narrow plastic tube is placed through the nose, directly into the stomach). Two weeks after admission, Miss A was transferred to a different ward, where she died a few hours later.

Mrs C complained about Miss A's care and treatment. She was concerned that medical staff had mocked Miss A for complaining, and had not taken time to understand her anxiety about the scan. Mrs C was also unhappy with the nursing care. She said Miss A was often left in soiled clothing, was not dressed in her clothes that the family had provided, and was often left without drinking water. She also said that Miss A's cards were repeatedly taken down and returned to the locker drawer after the family had displayed them, soiled bedding was left on her bed, and on one occasion she was left without blankets. Mrs C said that communication was poor, and that nurses thought Miss A was refusing medication when actually she was unable to swallow. Mrs C was concerned that Miss A was moved to a side room on one occasion without the family being informed, and was unfit to be moved to a new ward on the day she died.

After taking independent advice on this complaint from a medical adviser and a nursing adviser, we upheld Mrs C's complaint. There was nothing in the medical records to substantiate some of Mrs C's concerns. There was evidence that Miss A's overall care was of a reasonable standard, and doctors and nurses had spent appropriate time with her, discussing her concerns and encouraging her to accept treatment. However, the advisers said that the level of communication with the family about Miss A's treatment and end of life care fell below the level of care they could reasonably expect. Although we were satisfied that most aspects of Miss A's care were reasonable, we were critical of the failure to communicate appropriately with her family and, on balance, upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Miss A's family for failing to communicate effectively with them about Miss A's health and care; and
• raise the findings in this report with the doctors concerned, for reflection.

Summary

Mr C's wife (Mrs C) was referred to Wishaw General Hospital by her GP. She had been experiencing severe abdominal (stomach) pain and back pain. She was known to have an abdominal aortic aneurysm (a weak point in the blood vessels, causing them to bulge or balloon out) but when her GP examined her he felt another mass in her abdomen. Mrs C saw a consultant surgeon, who could not feel the mass and, after checking a recent scan, discharged Mrs C with pain medication. Mrs C continued to experience severe pain. Nine days later she was readmitted to the hospital as an emergency, and was found to have a bowel perforation (a hole in the bowel). As she was not fit for surgery, palliative care (care provided solely to prevent or relieve suffering) was put in place, and Mrs C died five days after being admitted. Mr C complained that, had the surgeon conducted a more thorough examination, the severity of his wife's condition might have been identified and she might have been treated.

We took independent advice on this case from one of our medical advisers, who is a consultant colorectal (bowel) surgeon. We found that the records taken by the surgeon who examined Mrs C were sparse and of poor quality. The surgeon had provided us with a separate written statement detailing the examination and findings, which our adviser found reasonable in the circumstances. However, the lack of contemporaneous notes cast doubt as to how much consideration the surgeon gave to Mrs C's underlying ongoing symptoms. Although we considered it reasonable for Mrs C to be discharged home after the initial examination, we were critical of the board for not arranging urgent follow-up tests to establish the source of her symptoms.

Recommendations

We recommended that the board:

• apologise to Mr C for the issues highlighted in our decision letter;
• discuss Mrs C's case with the consultant surgeon at their next appraisal; and
• remind the consultant surgeon and her team of the importance of maintaining detailed medical records.

Summary

Mrs C attended the practice for a routine check-up, and returned several days later for treatment to fill a small hole in her upper left molar. Mrs C assumed that the person who carried out the procedure was a dentist, although they were actually a dental therapist. That evening, the side of Mrs C's face became extremely swollen and next day she had a large area of bruising and was in pain. The following week, an x-ray showed that there was an infection in the tooth, and the practice prescribed a course of antibiotics. The pain settled four days later, and the bruising took another four days to disappear. Mrs C said that a dentist at the practice told her that it had been a very deep filling, which had possibly damaged the nerve, and he would have to remove the crown to treat it. Mrs C was concerned when she saw the extent of the planned work, and that it would cost over £400 to restore the appearance of her tooth.

We took independent advice on this complaint from one of our advisers, who is a dentist. The adviser said that it was reasonable not to carry out an x-ray before the procedure, but that there were communication failures. There was no evidence that Mrs C's consent was obtained in relation to the status of the healthcare professional carrying out the procedure, and during the procedure it appeared that Mrs C was not told about the degree of the decay and possible consequences of future treatment. However, the adviser also said that the treatment Mrs C received when she went back and the proposed course of treatment to address the problems were reasonable. Overall, we upheld Mrs C's complaint as although we were satisfied there was no evidence that the treatment was unreasonable, we found failures in care in relation to communication and consent.

Recommendations

We recommended that the practice:

• ensure the failures identified in relation to communication and consent issues are raised with relevant staff; and
• apologise to Mrs C for the failures identified.

Summary

Mr C complained that the medical practice did not provide his late wife (Mrs C) with appropriate diagnosis, care and treatment over a four-year period. Mrs C suffered from haemochromatosis (a condition where the body absorbs an excessive amount of iron which is then deposited in organs, mainly the liver) and had cirrhosis of the liver as a result. She also had diabetes and other health conditions. Mr C said that the practice demonstrated a lack of personal interest and care, and had not communicated with his wife. Mr C said that they were never told about the seriousness of her state of health, and that she had a life threatening condition. Mrs C died in 2012, and Mr C also said that no-one from the practice contacted him after her death.

We took independent advice on the complaint from one of our advisers, who is a GP. The adviser said that most of Mrs C's care and treatment was reasonable and appropriate. However, the adviser identified a number of failings in relation to her care and treatment in 2011. The practice had not recorded Mrs C's diabetes diagnosis on her medical summary and so she was not entered on their diabetic recall register to attend for an annual review. The adviser said, however, that this failure was unlikely to have resulted in Mrs C coming to any significant harm. The practice told us that they had reviewed this and put measures in place to stop it happening again. The adviser also said that, given Mrs C's medical conditions, the practice should have asked her to come in for review during 2011, and should have reviewed and monitored her medication, particularly in relation to the prescribing of spironolactone (a water pill that helps shift the fluid that gathers in cases of liver disease). The practice had continued to issue prescriptions for over a year, without having seen a safe set of blood results or having discussed the medication with Mrs C, and our adviser said that this was poor medical practice. We were unable to reach a conclusion about what the GPs had said to Mr and Mrs C about the state of her health.

The practice confirmed that they had not contacted Mr C after his wife died, although they said that they usually did try to get in touch with close family members after a bereavement. They apologised for this and said they have now changed their procedures to make sure that they proactively contact the family of a patient who has died.

Having considered the evidence carefully, and taken into account the advice we received, we upheld Mr C's complaint because of the failings our investigation identified.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failings identified in this complaint;
• provide us with evidence of their policy of checking patients' summaries as a routine part of a patient's first diabetic review; and
• provide us with evidence that there is a process in place to ensure that patients' repeat medications are reviewed annually.

When it was originally published in September 2014, this case was wrongly categorised as 'some upheld'.  The correct category is 'fully upheld'.

Summary

Mr C's son (Mr A) had a history of symptoms of weakness, numbness and pins and needles, and had previously been seen by neurology consultants. When he had an episode of tiredness, slurring of speech and right-sided weakness, Mr A called an ambulance and was taken to A&E at the Victoria Infirmary. He was examined but was discharged as he had a history of similar symptoms, which had already been investigated, and his condition had improved since he called the ambulance. The next day, Mr A went to his GP, who thought that he might have had a transient ischaemic attack (TIA - a 'mini-stroke'). The GP referred him urgently to a TIA clinic, and he was offered an appointment for eight days later. A couple of days after visiting the GP, however, Mr A was in some distress and Mr C took him to A&E at another hospital, where he was admitted and diagnosed with a stroke. Mr C complained that A&E doctors at the Victoria Infirmary had not treated his son properly when he went there with stroke symptoms.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaint. Our adviser said that the doctor was brief in his approach, and placed too much emphasis on Mr A's history of intermittent symptoms, which distracted from the fact that he had features of a TIA. We were critical of the A&E doctor's failure to take a detailed and accurate history from Mr A, and to make use of the history recorded by the ambulance staff and A&E nurse, which would have pointed to a TIA.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and Mr A for the failings our investigation identified; and
• ensure that the findings of this investigation are raised with the doctor concerned for reflection.

Summary

Mr C complained about the care and treatment that his late wife (Mrs C) received over a four-year period. Mrs C suffered from haemochromatosis (a condition where the body absorbs an excessive amount of iron which is then deposited in organs, mainly the liver) and had cirrhosis of the liver as a result. She also had a number of other medical conditions. Mrs C died in 2012.

Mrs C had been an out-patient at a liver clinic at Gartnavel Hospital since 2009. Mr C was concerned about a number of issues, including that medical staff had not sufficiently considered causes other than alcohol as the reason for his wife's liver condition and had not considered her need for a liver transplant. He also said that Mrs C's consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) had never warned Mr and Mrs C about the seriousness of her condition and her prognosis (forecast of the likely outcome). We took independent advice from one of our medical advisers, who is a consultant in gastroenterology and hepatology (liver disease). The adviser said that Mrs C's medical records showed that she had asked to be seen at the liver clinic less often. Her doctors had agreed to this because she was also regularly attending a specialist hepatology clinic. The adviser said that Mrs C had not been a suitable candidate for a liver transplant at the time, and that it was appropriate for the consultant to have discussed with her whether alcohol was a contributing factor in her illness. The adviser found no evidence of a marked deterioration in Mrs C's condition while under review by the hospital. The available evidence did not show exactly what she was told, but having seen the medical records our adviser took the view that the potential severity of her condition would have been explained to her. Overall, we found no failings by medical staff in their care and treatment of Mrs C.

In 2012 Mrs C was admitted to the Royal Alexandra Hospital with shortness of breath and a pleural effusion (a collection of fluid next to the lung). She discharged herself six days later, as she and Mr C were unhappy with her care and treatment there. Among Mr C's concerns were that Mrs C was left unattended, particularly when she needed to use the toilet, and that nursing staff were unsupportive and had failed to treat skin sores. He also said that he was not told when Mrs C was transferred to another ward, and no-one could tell him where she had been moved to.

Our adviser said that the records showed that Mrs C was correctly diagnosed and that appropriate investigations were carried out after she was admitted. The adviser also said that it was appropriate, given Mrs C's liver condition, to have transferred her from an acute medical ward to a gastroenterology ward.

We obtained independent advice about the nursing care from our nursing adviser, who said that an entry in Mrs C's nursing notes on the day of admission gave the impression that a nurse lacked empathy towards Mrs C. The evidence also showed that Mrs C had fallen while on the ward and that nursing staff had not explored the reasons behind her fall or completed an incident form, which would have helped assess how the risk of further falls could be reduced. The nurse who completed the falls risk assessment form had also failed to record that Mrs C had fallen before, and the nursing admission assessment form wrongly said that she had no breathing problems and was fully mobile and independent. There was evidence from the nursing records that nursing staff were communicating with Mr and Mrs C. There appeared, however, to be no system in place for recording information about transfers, which is why Mr C was unable to locate his wife when she was transferred between wards. As we found a number of failings in relation to Mrs C's nursing care in the Royal Alexandra Hospital, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings in respect of Mrs C's nursing care whilst she was a patient in the Royal Alexandra Hospital;
• ensure that the comments of our nursing adviser, in relation to communication and record-keeping, are shared with the nursing staff involved with Mrs C's care whilst she was a patient in the Royal Alexandra Hospital and provide evidence of this; and
• provide evidence that the Royal Alexandra Hospital has robust information systems in place in relation to inter-ward transfers.

When it was originally published in September 2014, this case was wrongly categorised as 'some upheld'. The correct category is 'fully upheld'.