Upheld, recommendations

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received from the medical practice during two days when she was at home between being discharged from hospital and going into a hospice. When Mrs A was discharged, hospital staff requested a GP home visit for the following day. However, this request was missed, and it was not until Mrs C phoned the practice that a home visit was arranged. The following day, a hospice nurse visited Mrs A and found that her pain was severe and that she needed to be in the hospice for this to be managed effectively. The nurse phoned the practice for another home visit, so that Mrs A could be given further pain relief before she was transferred to the hospice. However, this request was not identified as urgent, and it took a further call to the practice to prompt the visit. When the GP arrived she did not have appropriate medication with her and had to go to a pharmacist to get some.

We obtained independent advice on this complaint from one of our medical advisers. They confirmed that there were delays in providing a home visit the day after Mrs A came out of hospital. This was because the practice did not pick up the request from Mrs A's discharge letter or from a call from staff at the hospital. The adviser considered that the GP attending on the second day should have had appropriate pain relief with her when she came to the house, as she was aware of the reason for the visit. She also said that the GP had not administered appropriate pain relief. We upheld Mrs C's complaints as there was evidence that the practice had not responded appropriately to calls for home visits and had not provided appropriate pain relief to a patient in severe pain. We did, however, note that they had already identified some of these failings and had put in place systems for improving communication in relation to home visits.

Recommendations

We recommended that the practice:

• put in place a system that ensures that actions identified in patient discharge letters are carried out;
• ensure that they are familiar with, and take account of, Scottish Intercollegiate Guidelines Network Guidance 106: control of pain in adults with cancer to ensure appropriate pain relief is used;
• ensure that where a home visit is required for pain relief for palliative care, the doctor attending has access to the appropriate pain relief prior to attending; and
• apologise to Mrs C for the additional distress caused by the failings identified in our investigation.

Summary

Mrs C complained about the care that her husband (Mr C) received in hospital after a catheter (a tube used to drain urine) was inserted into his bladder. Mrs C also complained about poor record-keeping in relation to the catheter's removal and that the board's correspondence to her contained inaccurate information.

Mrs C said that a member of the nursing staff told her that Mr C had pulled the catheter out, but it did not need replacing as he was passing urine normally. After Mr C was discharged from hospital, he suffered recurrent urinary tract infections for approximately six months. He was referred to a specialist and tests showed that a 20 centimetre section of the catheter had been found in Mr C's bladder, which caused Mr C severe pain.

We considered that it was likely Mr C had pulled part of his catheter out due to episodes of confusion and agitation while in hospital. We took independent advice from one of our medical advisers, who said that this was a very unusual case, and that it was good practice for nursing staff to record when a catheter had been removed. We found that there was no evidence to show that nursing staff had ensured that Mr C's catheter had been removed safely or had monitored him in line with the board's guidelines for urinary catheter care. Our investigation also found that whilst the board had apologised to Mrs C verbally for inaccuracies in their correspondence, including referring to her husband by the wrong name and suggesting that he had passed away, we considered that it would have been appropriate for them to have apologised to her in writing, as she had requested.

Recommendations

We recommended that the board:

• review their guidelines on urinary catheter care and care plans, with a view to including a requirement to record the due date and the date when a catheter is removed in order to ensure continuity of care;
• apologise to Mr and Mrs C for the failings identified; and
• draw our findings to the attention of relevant staff, to ensure appropriate written responses and apologies are given where relevant.

Summary

Mr C complained that hospital staff failed to act on symptoms he developed after surgery and this led to a delayed diagnosis of ocular candidiasis (a fungal infection in the eyes). Mr C had been admitted to the urology ward (where patients with conditions relating to urinary function are treated) with a kidney infection. He also had kidney stones and it was decided that he should have a stent (a mesh tube) inserted, as a stone was causing an obstruction.

Mr C was treated for sepsis (blood infection), but it was then recorded that there was yeast in his blood cultures. He was examined by a microbiologist, who recommended that he was reviewed by an ophthalmologist (eye specialist), because fungal blood infections can sometimes spread to the back of the eye. This is very difficult to treat and can result in the loss of vision or of the eye. A referral was faxed to the ophthalmologist the following day. Mr C remained in the urology ward, receiving injections of anti-fungal medication for his blood infection.

Several days later, it was recorded in Mr C's notes that the vision in his left eye was blurred, which was discussed with ophthalmology the following day. It was noted that they would review Mr C the following week. However, the next day, it was recorded that Mr C's vision had worsened and an urgent ophthalmology review was needed. Mr C's family also raised concerns at that time. He was reviewed by an ophthalmologist that night, and ocular candidiasis was diagnosed. He was transferred to the care of an ophthalmologist two days later, but has lost most of the vision in his right eye and has reduced vision in his left eye.

After taking independent advice from a medical adviser, we found that the blood infection was identified appropriately, appropriate treatment was quickly started and a prompt referral was made for an ophthalmologist to review Mr C. However, our investigation found that the junior doctors in the urology ward failed to continue to monitor Mr C's eyes while they were waiting for the ophthalmology review, and we upheld his complaint. We considered that the microbiologist should have provided more information about the need for this. Because of this, there was a failure to assess Mr C by asking about his eye symptoms or examining his eyes. When Mr C started to display symptoms in his eyes, this should have prompted another opthalmology referral at an earlier stage, although we noted that this would not necessarily have improved the outcome for him.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to monitor his eyes; and
• make the relevant staff in the hospital aware of our findings.

Summary

Mrs C complained about the care and treatment a medical practice provided to her father (Mr A). Mrs C raised concern that the GP had not carried out a physical examination of Mr A when she first raised concern that he was confused. Mrs C said that despite her father living alone and having mobility problems, a phone discussion had only taken place where the GP prescribed antibiotics for a suspected urinary tract infection.

Mrs C continued to raise concerns with the medical practice about Mr A’s confusion. The GP then visited Mr A at home and thereafter referred him to a specialist for further assessment as she suspected he was suffering from the onset of dementia. Mrs C remained concerned about Mr A's health and contacted NHS 24. Mr A was subsequently taken to hospital by ambulance and further tests identified that he had suffered a stroke.

As part of our investigation we obtained independent advice from a medical adviser. We concluded that the initial phone consultation carried out by the GP was insufficient. We found that the GP, who was in fact a doctor in training, should have organised a home visit when Mrs C first reported her father's symptoms so that he could be fully assessed and his future management discussed with Mrs C.

Recommendations

We recommended that the practice:

• apologise for the failings identified;
• carry out a significant event analysis of Mr A's case; and
• draw our findings to the attention of the GP in training.

Summary

Mr C's mother (Mrs A), who suffered from Parkinson's disease, was admitted to hospital where she stayed for almost three months. After three weeks, she was transferred to a long-term ward before being discharged to a care home. Mr C said he was told that Mrs A was being transferred due to pressure on beds and would now be under the care of another consultant. He believed, however, that the consultant did not see Mrs A at all during her five week stay in that ward. He also believed that staff failed to ensure that Mrs A took her medication. Mr C also noted there was no walking frame in the ward and was told there was no rehabilitation or occupational therapy there. He had noticed that Mrs A's left hand had become rigid, and believed this was down to a lack of mobility opportunities and failure to provide medication. He also complained about one of the doctors, and that when his mother was discharged she had an injury about which he believed staff had lied to him.

As part of our investigation we took independent advice from two advisers - one specialising in nursing and one in medical care of the elderly. We upheld both of Mr C's complaints. In relation to the overall medical management of Mrs A's Parkinson's disease, the advice we accepted was that in the main the care and treatment provided to Mrs A was reasonable. However, the medical adviser said that there was no evidence that the consultant reviewed Mrs A, and we can only reach a judgement based on the evidence available to us. In this case the evidence indicates that the consultant did not see and review Mrs A as they should have done. Referring to the nursing care provided, the advice we accepted was that while aspects of this were reasonable, there were failures relating to prescribed medication. Although there was no evidence that missing the medication had caused Mrs A harm, we considered that the failure to record why it was not dispensed or to note other actions (such as informing medical staff) was significant.

Recommendations

We recommended that the board:

• bring our medical adviser's comments about the doctor to their attention and ensure that the doctor reviews the clinical care of their patients as per their duty of care towards them and fully records this;
• bring the failures in record-keeping in relation to prescribed medication to the attention of relevant staff;
• amend their policy to outline procedures to be followed when prescribed medicines are not dispensed; and
• apologise to Mr C for the failures identified.

Summary

Mr C's son (Mr A) attended a hospital accident and emergency department (A&E) complaining of left-hand rib pain, and pain in his elbows, right hip and shoulder, left wrist and lower back. An A&E junior doctor arranged for him to have a chest x-ray and reported that there was evidence of a lytic lesion (an area of bone damage, which can be caused by cancer) on one of Mr A's ribs. The doctor made an urgent referral for Mr A to be seen at the chest clinic. The x-ray was later reviewed and formally reported by a senior trainee radiologist. They did not identify a lytic lesion and did not mention it on the formal x-ray report. Based on the x-ray report, the consultant respiratory surgeon at the chest clinic contacted Mr A's GP and advised that there was nothing to be concerned about. He arranged for repeat x-rays in six weeks and did not see Mr A in his clinic. Mr A's condition deteriorated and he was ultimately diagnosed with advanced cancer, probably gastric in origin, which had spread to his bones. Mr C complained that radiology staff provided conflicting interpretations of the x-rays, causing a delay to Mr A's diagnosis.

After taking independent advice from two medical advisers, our investigation found that the lesion was present on the original x-ray but was not reported by the senior trainee radiologist. We acknowledged that the lesion was not clear and that it was not necessarily unreasonable that the radiologist did not identify it at that time. However, clearer abnormalities were missed by radiology staff on further x-rays taken the following month. We were also concerned that the consultant made a definitive decision about Mr A's condition based only on the x-ray report, when there was evidence that he had seen the A&E doctor's conclusions and had possibly reviewed the x-ray films himself. We considered that, based on the information available to him, the consultant should have seen Mr A in his clinic. We found that Mr A's diagnosis was delayed as a result of this. Although we recognised that this would not have affected his prognosis, he could have entered palliative care sooner and his pain could have been managed more effectively.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failings that led to the delay to diagnosing Mr A's cancer;
• ask their radiology and respiratory staff to reflect on this case with a view to identifying points of learning for the future; and
• conduct a serious incident review of Mr A's case.

Summary

Mr C, who is a prisoner, complained that the board had refused his requests to see the prison doctor. Mr C had attended the prison's health centre regularly with approximately two to three consultations every month over a six-year period. He made several requests to see a doctor in 2012. However, he received reply slips either asking for more information or advising that his current medication was sufficient and that a consultation with the doctor was not required. Mr C said that because of this his condition had gone undiagnosed and was effectively untreated.

In their response to our enquiries, the board said that requests to see the doctor are through a nurse referral. They said that in Mr C's case, his requests and care were discussed with the doctor. The doctor decided that he did not need to see Mr C and asked that advice was given to him instead.

Our investigation found no evidence in the medical records that Mr C's condition had gone undiagnosed or that the treatment provided to him was inappropriate. However, we noted that although Mr C was eventually given an appointment with a doctor, this was nearly five months after he first asked for one. We found it is reasonable for a nurse to triage (assess) the need for an appointment with the doctor. However, if a patient insists on seeing the doctor and considers that there has been a change in their condition or requirements, it would not be reasonable to repeatedly block access. We took the view that it would be more productive for the doctor to discuss with the patient the most appropriate way to access health care services in the future; why they had been triaged; how the triage system works; and why the doctor was satisfied that the current arrangements were appropriate. We considered that when Mr C continued to request an appointment with the doctor, he should have been given this earlier so that such a discussion could take place.

Recommendations

We recommended that the board:

• make health centre staff aware of our findings on this matter.

Summary

Mr C had a history of abdominal pain, diarrhoea and constipation. He was referred to hospital and was seen by two gastroenterologists (clinicians specialising in the treatment of conditions affecting the liver, intestine and pancreas) at various out-patient appointments. He was diagnosed as having irritable bowel syndrome (IBS) and bile salt diarrhoea. Mr C complained about the board's investigation of his symptoms, suggesting that the two gastroenterologists gave conflicting opinions as to their cause. However, he was also specifically concerned about a hospital admission when he said he was left for several days without being seen by a gastroenterologist. Once the gastroenterologist attended, he was dissatisfied with the extent of their examination and their findings.

Our investigation included taking independent advice from a medical adviser. We did not find any evidence to suggest that Mr C had been misdiagnosed or that the two gastroenterologists reached conflicting views about his treatment, and we were generally satisfied that the overall treatment of Mr C's condition was reasonable. However, we found that Mr C was not seen by a gastroenterologist for eight days during the hospital admission. There was clear evidence that staff on the ward identified a need for him to be seen by a gastroenterologist at an early stage in his admission. However, despite reassurances that someone from gastroenterology would attend, this did not happen. There was insufficient evidence to say whether this was because the ward staff failed to contact gastroenterology as planned, or because gastroenterology failed to act on requests from the ward. The end result, however, was that Mr C's treatment fell below an acceptable standard. We accepted advice that this would not have had a significant long term impact on his physical condition, but we noted that IBS has a recognised psychological component, and symptoms can be made worse by stress and anxiety. We considered that the delay in being seen by a gastroenterologist would not have helped Mr C's recovery.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in him being seen by a gastroenterologist during his hospital admission; and
• draw our findings to the attention of the staff involved with a view to identifying any improvements that can be made to communication between the wards and the gastroenterology unit.

Summary

Mrs C's mother-in-law (Mrs A), who lives overseas, was visiting her family when she became unwell with stomach pain and anaemia. The family GP referred her to hospital, where she was treated for severe liver disease complicated by fluid retention (an excessive build up of water in the body) for about five weeks. She was then discharged, with the intention that she should come back later for further treatment. However, when she was seen as an out-patient a few weeks later, she was urgently readmitted because of fluid retention. Mrs C complained about Mrs A's care and treatment. She said that Mrs A's experience in hospital was unpleasant; that because an interpreter was not provided, a family member had to stay with her; and that the family were asked to pay a large bill for Mrs A's treatment. She also complained that the board did not respond reasonably to her complaints.

We took independent advice from three of our medical advisers. After considering the advice, we upheld both of Mrs C's complaints. The hospital investigations had showed that Mrs A had cirrhosis of the liver (scarring of the liver as a result of continuous, long-term damage), with complications of fluid retention, and indicated that this was because of infection with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood). The advisers agreed that there was no evidence of inadequate care by nursing staff or clinicians, nor did they consider that there was an unreasonable delay in providing a bed for her, which was one of Mrs C's concerns. Similarly, there was no evidence of unreasonable communication by nursing staff and clinicians with Mrs C and her family about Mrs A's care and treatment. We noted, however, that it was not confirmed to anyone that Mrs A was suffering from hepatitis C, and that there was no evidence in the records that Mrs A or her family received appropriate counselling about the implications of this. In addition, the board’s policy clearly says that interpretation services should be offered. If these were declined, then the board should have considered an appropriate way of obtaining Mrs A's consent to using family members to translate, and this did not appear to happen. We were critical of the board about these points and, although we recognised that a number of aspects of Mrs A's care and treatment were reasonable, on balance we upheld Mrs C's complaint.

In terms of the board's response, we noted that Mrs C felt that the family should not have to pay for Mrs A's treatment, and that this was still in dispute when we investigated the complaint. We found that the Scottish Governmentprovide guidance in their document of April 2010 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services'. This specifically excludes viral hepatitis from the services and treatment that attract a charge. We also noted that the board's complaints response was relatively brief and did not provide a full summary of Mrs A’s medical problems. Had it done so, and in particular had it mentioned that she had hepatitis C, the board could then have considered the financial implication of the diagnosis under the guidance. Although, therefore, we would not normally become involved in the issue of such charges, we considered this to be relevant in this case and upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• take steps to offer the appropriate counselling to Mrs C's family (including Mrs A);
• ensure that all patients (and, where appropriate, family members) receive counselling in respect of the implications of chronic hepatitis C infection and that these discussions are recorded in the clinical record;
• advise the Ombudsman of the counselling arrangements that are in place for patients diagnosed with hepatitis;
• ensure staff are aware of and follow their policy on communication and support for patients where English is not their first or preferred language;
• ensure that full and appropriate clinical information is included in complaints response letters;
• review this case for payment in view of the guidance 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services' (April 2010) and advise Mrs C and the Ombudsman of the outcome; and
• apologise to Mrs C and Mrs A for the upset this matter has caused.

Summary

Mr C complained that in 2010 the sewer to his factory became blocked, and was not properly cleared for eight working days. As his business was unable to function due to an inability to discharge water into the sewer, the factory had been obliged to close. Mr C's business had then incurred overtime costs while catching up with the backlog of work. Mr C had made six phone calls to Scottish Water's emergency line, and regarded their response as unreasonable.

Scottish Water had refused Mr C’s application for compensation, as they said that the blockages had been caused by waste discharged by the factory. Mr C, therefore, withheld the sum he claimed in compensation from a bill payable to Business Stream. He was pursued by Business Stream for payment between August 2010 and March 2012. In March 2012 he received a letter informing him that Business Stream would no longer consider his complaint and that the SPSO was his only option for further review.

We took independent advice from one of our water advisers who said that while the initial response to the blockages had been reasonable, the problem had taken too long to identify and the correct equipment had not been brought on site quickly enough. In addition, communication with the customer had been poor, with only one update to him during the period.

We cannot order Business Stream to provide compensation to Mr C as we are unable to establish liability for financial loss, which is normally a matter for the courts. However, we upheld Mr C's complaint, because we found Business Stream's actions unreasonable. They had failed to make clear to Mr C within a reasonable timescale that they would not consider his complaint, allowing the matter to remain open for two years. Business Stream had not kept accurate records of meetings with Mr C and at times had requested information from him about the actions of Scottish Water’s contractors. We also found that Scottish Water’s code of practice did not appear to distinguish between domestic and commercial properties, and made a recommendation relating to this.

Recommendations

We recommended that Business Stream:

• apologise in writing for the poor customer service provided; and
• review the case and draw the attention of Scottish Water to the lack of differentiation within their code of practice between business and non-business customers.