Upheld, recommendations

Summary

Mr C's wife (Mrs C) had hip replacement surgery. She recovered well, but suffered constipation afterwards because of the painkilling medication she was prescribed. After having had no significant bowel movements for more than a week, Mrs C began vomiting and had a painful, hard stomach. Mr C phoned NHS 24 and asked for a home visit from a GP. Mrs C's case was prioritised as serious and urgent and Mr C was told that a district nurse would come within two hours. When the nurse did not arrive, Mr C called NHS 24 again. They investigated and learned that the district nurse would not visit new patients with constipation. Instead it had been arranged for a GP to call Mrs C for a further phone assessment.

Mr C was not happy with this, and was then told that NHS 24 would request an out-of-hours GP to visit within two hours. The out-of-hours GP was, however, required for another more serious call, and arrived about six hours after Mr C's initial call to NHS 24. He gave Mrs C two enemas and a prescription for laxatives. Mr C was advised to monitor his wife overnight and contact her own GP in the morning if she did not improve. As Mrs C did not improve, her own GP visited and immediately referred her to hospital, where she was diagnosed with a perforated bowel that needed emergency surgery. Mr C complained that NHS 24 did not prioritise Mrs C's case appropriately and that she could have been admitted to hospital more quickly had the out-of-hours GP attended sooner.

After taking independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaint. We found that Mrs C's case was treated seriously and given the highest priority, but that NHS 24 should have requested a GP visit rather than a district nurse visit at the start. We were critical of NHS 24 for not gathering relevant information about Mrs C's bowel habits and pre-existing kidney failure, which would have helped staff decide the action to take.

We concluded that, although there was a clear delay in the out-of-hours GP attending, this was partly due to communication problems between NHS 24 and the local health board. NHS 24 and the board had already identified this and had taken action to improve communication. We were satisfied that, although his attendance was delayed, the out-of-hours GP's conclusions and treatment would not have been different had he visited Mrs C earlier. However, we recognised that she would have received the enemas and laxatives sooner and that this might have improved her chances of avoiding a perforated bowel, if it had not already occurred by then. We also recognised that the delays added to the discomfort and anxiety that Mrs C was experiencing.

Recommendations

We recommended that NHS 24:

• apologise to Mr and Mrs C for the issues highlighted in our investigation;
• remind their clinical staff of the importance of establishing each patient's level of renal failure and of taking this into account when progressing their treatment; and
• consider briefing their clinical staff on the need to consider whether patients have passed stools or gas in cases of severe constipation.

Summary

Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, where the on-call doctor thought she might have acute sinusitis (inflammation causing facial pain). Later that month, Mrs C went back to the practice with her sister. She said the medication had not worked. She also had other problems, including being increasingly unable to socialise or attend to her personal hygiene. She was treated for sinusitis, but her symptoms became even worse, and she went back to the practice at the end of the month. She described increasing withdrawal, problems with her eyesight and that she had been off work for a number of weeks. The day after this appointment, NHS 24 were called again, and Mrs C was immediately admitted to hospital for a scan. She was diagnosed with a brain tumour and had an operation to remove it.

Mrs C complained that the GP at the practice failed to pick up on her serious illness and refer her to hospital. She said that as a consequence her life had been put at risk.

We obtained all the complaints correspondence and Mrs C's relevant clinical records and took independent advice from one of our medical advisers, who is a GP. Our investigation found that the GP missed a number of classic features associated with brain tumours. The adviser said that on her second visit to the practice Mrs C was demonstrating enough of these to merit urgent referral. He said that although some of the changes could be interpreted as being associated with depression, in his opinion that would be a secondary consideration in a patient with persistent headache and such a significant change in personality. The symptoms should have alerted the GP to a possible serious diagnosis and she should have made a comprehensive assessment including a detailed clinical examination, then referred Mrs C urgently if she felt that any element was beyond her clinical competence. We made recommendations, noting that the GP had already acknowledged that she had missed an important diagnosis and apologised for this, and that the practice had carried out a significant event analysis.

Recommendations

We recommended that the practice:

• formally apologise to Mrs C for a failure to properly examine her and then refer her on;
• confirm the actions taken to amend their procedures; and
• provide evidence that the matter has been addressed at the GP's next appraisal.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), who had injured her knee in a heavy fall whilst on holiday. She was taken to a local hospital, where the injury was treated as a sprain. She then returned home and went to the accident and emergency department of Wishaw General Hospital next day. Mrs A was assessed, but the swelling around her knee made a full examination impossible. Mrs A was reviewed there again five days later, and damage to her ligaments was suspected. She was referred to the orthopaedic (dealing with conditions involving the musculoskeletal system) fracture clinic for further assessment.

Mrs A was seen by an orthopaedic consultant, who considered it likely that she had a fracture of her knee cap, so the leg was put in plaster. Mrs A said that she repeatedly returned to the hospital, as the cast was causing her severe discomfort. She also said she repeatedly informed medical staff that her knee felt unstable and 'caved in'. Although Mrs A was first seen in July 2012 it was not until November 2012, when she started physiotherapy, that she was diagnosed with several torn knee ligaments, requiring surgical repair.

Mrs C complained to us that Mrs A’s knee was never properly examined and staff ignored her (Mrs A’s) concerns. She also said Mrs A had suffered needlessly due to the delay in diagnosing her injury and had lost income as she had to take time off work.

We took independent advice from an expert in orthopaedic and trauma surgery. He said that it was normal to wait until the swelling had gone down before attempting to examine a badly injured knee joint. He said, however, that the record of Mrs A's treatment was inadequate and there was no evidence that her knee was properly examined. Our investigation found that while the initial treatment Mrs A had received was reasonable, overall her care and treatment was not of an acceptable standard. We found that although this did not ultimately affect the outcome of her surgery, she had suffered pain and discomfort due to an avoidable delay in diagnosing her injury.

Recommendations

We recommended that the board:

• remind orthopaedic staff of the importance of a thorough, documented examination of an injury as clinically appropriate;
• apologise for the failings identified in our investigation; and
• remind staff of the importance of clear and detailed clinical record-keeping.

Summary

Miss C complained that her dental practice had decided to remove her from their patient list without providing her with treatment for a three month period in accordance with national guidance. She also told us that she made a complaint to the practice in 2012 and that she had not been told the outcome.

We found that, although the practice had the right to give notice of removal from the list, they also had a statutory duty to provide dental treatment for a three month period after their decision. Their final letter to Miss C did not mention this, and so gave the impression that termination would take effect immediately. We also found that the practice did not deal with the previous complaint appropriately and should have told Miss C of the outcome of their investigation into that complaint.

Recommendations

We recommended that the practice:

• remind staff of their obligation to provide dental treatment for a period of three months after their intention to withdraw from a continuing care arrangement and to communicate this to the patient;
• apologise to Miss C for the failure to explain that dental treatment would continue for a period of three months or until she registered at another dental practice;
• remind staff of their obligations under the NHS complaints procedure; and
• apologise to Miss C for the failure to respond to her complaint in an appropriate manner.

Summary

Mr C, a member of the Scottish Parliament, complained on behalf of one of his constituents (Ms A) about the care and treatment she received following an operation at Gartnavel General Hospital. He said that the plans for Ms A's discharge home were inadequate and that there was a failure to ensure that she was technically able to deal with the catheter (a thin tube used to drain and collect urine from the bladder) that was a consequence of the operation. He also complained that there was a failure to review her in a timely manner, that arrangements for reviews were confused, that Ms A's concerns about her operation were dismissed and that the operation had not greatly improved her condition.

The complaint was investigated and carefully considered all the relevant documentation (including all the complaints correspondence and Ms A's clinical records). We also obtained independent advice on Ms A's care and treatment from one of our medical advisers, a consultant urological surgeon (dealing with issues of the urinary tract).

Our investigation showed that the clinical aspects of Ms A's care and treatment were reasonable, as were her discharge plans. We found no evidence to suggest that her concerns about her operation had been dismissed. However, plans to review her were frustrated by confused administration and poor communication between departments which no doubt caused Ms A unnecessary stress and inconvenience at what must have been a difficult time. This was unacceptable and amounted to a service failure, and we upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology to Ms A for the added stress she experienced;
• confirm to the Ombudsman that procedures for making x-ray appointments are now effective and robust, and advise of the actions taken to ensure this; and
• advise the Ombudsman that they are satisfied that the communications problems affecting Ms A's appointments have now been addressed.

Summary

Ms C complained that after reconstructive breast surgery, there was an avoidable delay by staff at the Royal Alexandria Hospital in diagnosing that she was suffering from a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue). She said that she complained several times to staff at the hospital that there was a large protrusion on her waist on the side of the reconstruction and that she was in pain, but that this was not addressed appropriately. Ms C also said there was an unreasonable delay of five months between an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) that showed there was a problem, and a CT scan (a scan that uses a computer to produce an image of the body) that confirmed she had a hernia.

We obtained advice on this case from one of our medical advisers, a general surgeon with a specialist interest in breast surgery. The adviser said that in the 12 months following surgery, the board acted in an appropriate and reasonably timely manner in dealing with Ms C's symptoms, as the likelihood was that the underlying cause of the pain and swelling was commonly recognised complications of her surgery. The adviser said it would not have been acceptable to carry out surgery based on the results of the ultrasound, without a CT scan to help identify the problem.

The adviser confirmed, however, that there was an unacceptable delay between the ultrasound report 12 months after surgery and the CT scan report that confirmed the hernia more than five months later. Ms C suffered a prolonged period of pain and discomfort from her hernia as a result. The adviser noted that Ms C's hernia was recorded by the board as having increased in size during the three months following the ultrasound report. However, he explained that such hernias were generally slow growing, wide necked and very rarely life threatening and that the delay did not change the final outcome in Ms C's case.

Recommendations

We recommended that the board:

• feed back our decision on this case to the staff involved to ensure that a similar situation does not occur in future; and
• provide Ms C with a written apology for the failures identified in our report.

Summary

Mr C's late wife (Mrs C) had cancer and was terminally ill. After one of their daughters phoned the medical practice, a GP prescribed a strong morphine-based liquid painkiller. The family also phoned community services, and a community nurse visited Mrs C at home the following week. A few days later, another phone consultation was held with another GP who ordered an electrocardiogram (a test that measures the electrical activity of the heart). Further visits were made by a community nurse and the family agreed that a 'just in case' box (containing medicines that may be needed to help relieve a patient's unpleasant or distressing symptoms while being looked after at home) should be provided. Early the following month, one of Mrs C's daughters was concerned about her condition and spoke to the duty GP at the medical practice, who advised the family to use painkillers and said that Mrs C would be reviewed the following week. When a GP then visited Mrs C at home, they noted that she was at the terminal stage of her illness, and Mrs C died later that day.

Mr C complained about the way that GPs at the medical practice dealt with Mrs C's medical problems, saying that they did not visit and relied on the community nurses instead. He said that his wife was in severe pain and great distress. For four weeks she was not examined by a doctor and additional medication was not prescribed, as the community nurse was not able to prescribe medication. The family accepted that a 'just in case' box was in the house, but Mr C said that they did not know at what point to give Mrs C the medication and that a GP should have provided an explanation.

We took independent advice from one of our medical advisers, after which we upheld the complaint. We found that the medication and explanation provided were reasonable but that, by not visiting Mrs C, the practice failed to provide her with a reasonable standard of care. This led to a great deal of distress for her family, and made a very difficult time worse for them during the final stages of her illness. The adviser also said that while there was evidence that use of the 'just in case' box was explained to the family, it would have been reasonable for this to have been reinforced and for staff to have checked that the family understood what to do.

Recommendations

We recommended that the practice:

• review their management of patients with advanced cancer in light of our adviser's comments; and
• apologise to Mr C for the failures identified.

Summary

Mrs C, who is an advocacy worker, complained on behalf of a client (Ms B) about the care and treatment that Ms B's late father-in-law (Mr A) received from a GP practice run by the board. Mrs C said they did not provide reasonable care and treatment to Mr A, did not discuss his intended treatment at a home visit and did not reasonably respond to Ms B's complaints.

We obtained independent advice on the complaint from one of our medical advisers, who is a GP. The adviser said that while the care and treatment from the practice was largely reasonable, he was concerned about the care and treatment a doctor provided during the home visit. Mr A's symptoms had deteriorated and the doctor should have examined him, assessed his pain (including the likely causes) and examined his abdomen before giving him an injection. As a result there was a failure to appropriately manage Mr A's pain and distress and to assess whether his care required re-prioritising, including whether he needed to be admitted to hospital.

The board had said that the doctor gave assurances that, to the best of his recollection, he had provided a full explanation to Mr A before giving him the injection. However, we found no evidence of this in the papers the board sent us, and it was not clear when a statement could have been made, as we could see no evidence that the board consulted the doctor after Ms B complained. The General Medical Council guidance on consent requires doctors to explain proposed treatment and check that their explanation has been understood. We found no evidence to support the board's assertion that either of these things happened.

The evidence also showed several failings by the board in handling the complaints. They did not treat an initial complaint made by Mr A's wife as a formal complaint, they did not update Ms B on the progress of their investigation of her complaints and they did not tell her that she had a right to bring her complaint to us. We also noted that the board's complaints handling procedure did not accurately reflect the current NHS Scotland guidance on acknowledgment letters, investigation reports or timescales.

Recommendations

We recommended that the board:

• bring our decisions to the attention of the doctor and ensure that he reflects on our adviser's conclusions at his next performance review meeting;
• ensure the practice provide Ms B and her family with a written apology for failing to adequately assess Mr A at the home visit;
• ensure the practice provide Ms B with a written apology for failing to ensure that Mr A was given an adequate explanation of his treatment at the home visit and consent obtained;
• review their complaints handling procedure to ensure it is compliant with current NHS Scotland Guidance 'Can I help you?'; and
• provide Ms B with a written apology for failing to properly handle and investigate her concerns.

Summary

Mrs C's daughter (Ms A) was admitted to Forth Valley Royal Hospital after taking an overdose of a mixture of medications, including venlafaxine (an anti-depressant) and propanolol (a beta blocker, used to treat conditions such as heart problems, blood pressure and anxiety), which are absorbed into the system slowly. She had called an ambulance herself and was taken to the emergency department, where she was seen immediately by a staff nurse. She was assessed before being seen by a trainee doctor. Ms A was groggy and her blood pressure was low. She was treated with intravenous fluids (fluids put directly into a vein). Blood tests and an electrocardiograph (a test that records the electrical activity of the heart) were also arranged. Over the following hours, Ms A's blood pressure remained low. Around seven hours after being admitted she began to have seizures and breathing difficulties. Her condition deteriorated further and the intensive care unit was asked to review her. Shortly afterwards, Ms A's heart stopped. Attempts were made to resuscitate her and she was treated with glucagon (medication used to increase blood sugar levels, which can be used in the treatment of propanolol overdose). This failed to improve her condition, however, and she died.

Mrs C complained that staff did not provide glucagon until it was too late. She considered that, had this medication been provided earlier, Ms A might have survived. She also complained about the board's record-keeping. The board said in response to her complaint that glucagon is not the first line of treatment for propanolol overdose and, as Ms A had been responding to intravenous fluids, it was not considered a necessary treatment for her at the time.

After taking advice on this complaint from one of our medical advisers, who is a consultant in emergency medicine, we upheld both of Mrs C's complaints. The adviser reviewed Ms A's medical records, and said that she had not been responding adequately to the intravenous fluids and that glucagon should have been considered far sooner. Although we found evidence that clinical staff consulted TOXBASE (the national poisons information database) we were critical that there was a delay in doing so. We found that Ms A's overdose would have been treated differently had the guidance been consulted and followed earlier in her admission. We were also critical of the board's record-keeping. Important information about medication had been lost from Ms A's records and there was no documented record there of staff having consulted TOXBASE.

Recommendations

We recommended that the board:

• provide a copy of our decision letter to the doctor to ensure that he is fully aware of the outcome of our investigation and discuss any learning points with him at his next appraisal;
• apologise for the lack of appropriate record-keeping in this case; and
• remind all nursing and medical staff of the importance of maintaining accurate contemporaneous records.

Summary

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital.

Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Recommendations

We recommended that the board:

• provide the Ombudsman with a copy of the board's own implementation plan relating to the national standards for dementia care implemented in 2011;
• undertake an audit of current practice of skin care in the hospital and report back to the Ombudsman;
• provide the Ombudsman with a copy of an action plan to illustrate learning from this complaint in relation to the prevention and management of pressure ulcers;
• provide the Ombudsman with a copy of an action plan to address the failings identified in relation to medical records;
• apologise to Miss B and Miss C for the failings identified;
• review their processes to ensure that they meet relevant standards;
• remind physiotherapy staff of the need to maintain full and accurate records in line with the Chartered Society of Physiotherapy guidance; and
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned, and report back to the Ombudsman.