Upheld, recommendations

Summary

Mr C complained that his medical practice failed to provide reasonable treatment and advice to him in relation to peripheral vascular disease (PVD), a condition causing narrowing of the arteries. He attended his practice for a number of years complaining of leg pain, which the GP attributed to back problems. In 2011, after a deterioration in his condition, Mr C was admitted to hospital where he learned that he had been diagnosed with PVD in 2005. He complained that he was not told about this diagnosis and was not treated for PVD. He believed that this led to years of unnecessary pain.

We found that, as well as PVD, Mr C had serious back problems that ultimately needed surgery. Our medical adviser said that both conditions could have caused leg pain. At the time of being diagnosed with PVD, however, Mr C was in his forties. Our adviser said that diagnosis at this age was relatively unusual and, as such, Mr C's case should have been investigated, possibly with immediate referral to a specialist. Mr C's GP had prescribed aspirin and told him to stop smoking. On balance, we considered that this would have been reasonable if Mr C was supported to stop smoking and was monitored via regular blood pressure checks. However, we found no evidence in the clinical records that Mr C's GP made him aware of the diagnosis, nor that there was any support provided to help him stop smoking, nor regular monitoring of his condition. We, therefore, upheld the complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mr C for the issues highlighted in our investigation; and
• review and discuss Mr C's case at a practice meeting to identify where improvements can be made to record-keeping and the treatment of future patients.

Summary

Mr C complained when his local medical practice decided to remove him from their patient list. His new medical practice is located some miles from his home and getting to it causes him inconvenience and expense. Mr C said that he did not understand why he had been removed from the practice list.

Our investigation found evidence that the practice had properly explained their decision, and the reasons for it, to Mr C and had then removed him from the list. However, we upheld the complaint because they had not issued Mr C with a warning about his behaviour in the twelve month period leading up to the decision, which they were contractually obliged to do.

Recommendations

We recommended that the Practice:
• revise their policy relating to the removal of patients from practice list; and
• apologise to Mr C for failing to issue a warning prior to removal from patient list.

Summary

Mr C complained that when his late father (Mr A) went to his medical practice in December 2011 they did not fully assess his condition and showed a lack of urgency in following up with his father. Mr A had a history of myeloma (cancer of the bone marrow) and had received treatment, including a stem cell transplant, between 2009 and 2011. In late 2010 and in November 2011 Mr A was told there was no trace of the disease left.

In late November and early December 2011 Mr A started to complain of breathlessness, weight loss, decreasing energy levels and back pain. His son and wife were concerned and persuaded him to speak to his GP on 6 December, as he was due to attend the practice that day for blood tests. Mrs A accompanied Mr A to the surgery and when she realised that Mr A was only due to see the practice nurse for the blood tests, asked that Mr A be seen by a GP.

One of the GPs (not Mr A's regular GP) saw Mr A as an emergency appointment. Although they examined him and made notes, our investigation found that there was no record of the presence or absence of anaemia (iron deficiency) or of the standard observations of pulse, temperature, respiration rate etc that would be expected for a patient reporting the symptoms that Mr A was suffering. The GP diagnosed a chest infection and prescribed an antibiotic. He told Mr A to make a follow-up appointment for seven days time, at which blood tests would be taken if there was no improvement in his symptoms.

Mr A forgot to make the follow-up appointment but six days later his son was so concerned that he tried to speak to Mr A's regular GP but was unable to do so. He did manage to speak to her the following day and she arranged urgent blood tests. The laboratory that conducted the tests were so concerned by the results that they contacted the local out-of-hours GP service that evening. A GP reviewed the results and notified the practice, but considered that a full GP review could wait until the next day. Mr A saw his regular GP, who immediately advised him to go to the local hospital and called ahead to make arrangements for him to be seen there. Mr A was admitted, but died in hospital the next day.

We upheld Mr C's complaint. Our medical adviser said that the GP should have had further blood tests done on 6 December, with a GP review on receipt of the results. The blood test that the practice nurse had taken was to check Mr A's cholesterol level and would not have told the GP anything about his condition or the cause of the symptoms Mr A complained of. The adviser also said that while it might have been reasonable for the GP to prescribe the antibiotic, the fact that he suspected an infective condition should have rung alarm bells in a patient with Mr A's history of myeloma. He thought that the symptoms Mr A was reporting should have triggered a more robust follow-up.

Recommendations

We recommended that the practice:

• issue a written apology to the family of the late Mr A;
• ensure that the GP conducts a significant event audit, to be discussed at his next appraisal; and
• conduct a review of a sample of clinical records to ensure that consultations are appropriate and accurately and fully recorded.

Summary

Mr C was dissatisfied after treatment from two dentists during 2010. He complained by telephone in January 2011. He also sent a complaint by email in June 2011 when the practice approached him for payment of an outstanding bill. Mr C's email was acknowledged by the practice by email three working days later, but as Mr C received no formal response to his complaint he telephoned several times between June and October 2011. He sent a further email in October 2011 which was acknowledged six working days later. Again he received no formal response to the complaints and approached us in January 2012. He complained that the practice had failed to respond appropriately to his complaints.

We upheld Mr C's complaint. Our investigation found that the practice's complaints policy and procedure did not comply with relevant NHS legislation and guidance at the time. The guidance said that complaints to family health service providers should be acknowledged within three working days and a full response provided within ten working days. The practice complaints policy said that they would acknowledge complaints within seven working days and respond within 20 working days.

Our investigation also showed that the practice did not comply with their own timescales. Although the two emails Mr C sent were acknowledged, there is no evidence that any of his calls were recorded, acknowledged or responded to. In addition, when we made enquiries to the practice these were either not responded to or the responses were very delayed.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C; and
• review and amend the practice complaints procedure to comply with the requirements of the NHS legislation and guidance.

Summary

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) failed to properly consider his request for compensation for items of property that he said went missing when he was transferred between two prisons.

Mr C said that the first prison accepted that they had mislaid some of his property and offered him compensation. However, as he considered that the compensation offer was less than the value of the missing items he did not accept it. He also said that the first prison did not accept that they had lost other items of his property including jewellery and sunglasses. The second prison said they did not receive these items when Mr C was transferred there.

Our investigation found a discrepancy in the dates of transfer of Mr C’s property between prisons, and that there were two slightly different sets of records for the assessment panel's decision on Mr C’s compensation claim. There was also confusion about the items for which Mr C was being compensated. Although at first it appeared that certain items had been lost and compensation was offered, Mr C said that the lost property was later returned to him. He said that despite receiving the missing items, the SPS did not formally notify him of their return nor did they formally withdraw their offer of compensation.

We upheld Mr C's complaints, although we could not conclude anything about the sunglasses, as there was no record of these on Mr C's property card. We did, however, find that as the first prison had a record of receiving jewellery, but the second prison did not, it was reasonable to conclude that jewellery had gone missing. We also found that the SPS had not properly handled Mr C’s request for compensation in line with prison rules and regulations. We made recommendations to address these failings.

Recommendations

We recommended that the SPS:

• review Mr C's claim for the loss of a chain, pendant and earring, in line with the relevant prison circular; and
• after reviewing the claim, follow up the matter in line with the relevant circular, if appropriate.

When it was originally published on 19 September 2012, this case contained a typographical error. This was corrected on 16 October 2013.

Summary

Mr C complained about the service he received from Business Stream, who supply water to his farm. In July 2011 Business Stream contacted Mr C to warn that his water consumption appeared to be higher than average. He then received a bill of over £2,600 for nearly 3.8 million litres of water. A week later this had increased by a further £400 after a second meter reading. It turned out that there was a leak, but there were no visible signs on the surface as the water was leaking directly on top of a field drain. Mr C later discovered that Business Stream had not read the meter since December 2009. He was unhappy and felt that, had they done so, the leak would have been discovered sooner.

Business Stream accepted that they had not read the meter in line with their licence conditions. Mr C then proposed that they prioritise readings where they are missed, and that they share the consequences of their failure to read his meter appropriately. Although we agreed that the customer must bear some responsibility we found that, had Business Stream read the meter sooner, they could have identifed the leak earlier and stopped the situation getting worse. We upheld Mr C's complaints.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for failing to read the meter;
• consider changing their system so that when an actual meter reading is not completed either a subsequent attempt is made or the next scheduled estimated read is changed to an actual one so that potential problems can be identified sooner; and
• reconsider Mr C's proposals in the light of their failure to read the meter.

Summary

Mrs C complained about the orthodontic treatment that her son (Mr A) received. (Orthodontics is the branch of dentistry dealing with the prevention and correction of irregular teeth.) Mr A attended an appointment with the orthodontist and Mrs C completed an NHS form so he could be considered for NHS treatment. The orthodontist found that Mr A's teeth were not misaligned enough to qualify for NHS funding but carried out work privately on his front teeth. Mrs C complained that she was not told that Mr A would be treated privately. She said that she did not agree to this and that she only became aware of the decision when she relocated to England and found that the orthodontist had withheld Mr A's clinical records because the bills were unpaid.

We found that Mr A should not have been considered eligible for NHS treatment. However, the orthodontist should in that case have obtained written consent from Mrs C for private treatment to be carried out. The decision to provide the treatment was confirmed in writing to Mr A's dentist, and the orthodontist said that it was discussed with Mrs C during the appointment, along with the associated costs. However, we found no evidence in the records to show that this was discussed with Mrs C. Neither did we find evidence that consent was obtained, or that any payment was taken once treatment commenced. We also found that it was inappropriate for the orthodontist to withhold Mr A's clinical records. We made recommendations to address thse failings.

Recommendations

We recommended that the dentist:

• arrange for copies of Mr A's clinical records to be provided to his new dentist and/or orthodontist on request;
• waive any outstanding fees associated with Mr A's treatment; and
• apologise to Mrs C for the issues highlighted by our investigation.

Summary

Mr C had ulcerative colitis (a type of inflammatory bowel disease) and attended a specialist appointment at Hospital 1. He was told that he would be reviewed at a follow-up appointment in three weeks. Mr C's wife (Mrs C) complained that no follow-up appointment was arranged. Mr C's condition deteriorated and he was referred to the accident and emergency department of another hospital (Hospital 2). He was admitted and treated with intravenous drugs (drugs administered into a vein). The drugs had no effect and Mr C was identified as needing an operation. Mrs C said she was told that her husband would require two further operations after that, and that this might have been avoided had he been treated sooner.

Mrs C complained that the board did not provide Mr C with reasonable care and treatment before his surgery. She also complained that they did not take reasonable action to address a known issue with follow-up appointments and that they delayed in responding to her complaints correspondence.

We upheld all Mrs C's complaints. Our investigation found that although an initial follow-up appointment was made, later planned appointments were not confirmed with Mr C. In relation to the complaint about Mr C's treatment, our medical adviser considered that the initial prescribing of steroids was appropriate. However, as Mr C's condition worsened, he should have been admitted for a course of intravenous drugs. Delays to the follow-up appointment meant that by the time treatment was provided by Hospital 2, it was too late for it to be effective. Taking all the evidence, and the advice of our medical adviser, into account we concluded that Mr C would have required the three operations at some point. However, the delay to the follow-up appointment meant that all the surgery was required sooner than it would have otherwise been, resulting in limited time for Mr C to prepare for the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for the issues highlighted in our investigation;
• provide us with details of the service manager for medicine's review findings and any action proposed as a result of the review; and
• take steps to ensure that all patient referrals and follow-ups are acted upon in accordance with the relevant standards.

Summary

Mr C had an overactive bladder muscle and, supported by his consultant, requested treatment with Botulinum Toxin A (Botox A) to help control his condition. The board refused Mr C’s request, and he complained to us that the refusal was unreasonable as he was aware of the treatment being made available to female patients.

Mr C also complained that the board gave him an unreasonable explanation that such drugs should only be used for patients who have extremely severe symptoms and who have accepted the associated risks. Mr C said that the board failed to take into account the severity of his symptoms and acknowledge his acceptance of the risks as he had twice previously paid to have the procedure carried out privately.

Our investigation found that the board did not deal with Mr C’s request in line with their own policies. In addition, the board acknowledged that different sets of practice had developed within urology and gynaecology, which required further review. For these reasons, we decided it was unreasonable of the board to refuse Mr C’s request and so we upheld this complaint.

We thought the board’s explanation that Botox A should only be used for patients who have extremely severe symptoms who have accepted the associated risks was not, in itself, unreasonable. It was a matter of clinical interpretation whether Mr C’s symptoms were extremely severe, and we understood the board’s explanation that it was not possible for Mr C to have accepted the risks, as the risks were unknown. However, the urology staff who had treated Mr C for several years considered him to be an ideal candidate for Botox A, and supported his attempts to get the treatment. Also, Mr C had received successful Botox A treatment twice in a private hospital. In addition, the explanation provided in the board’s response to Mr C’s consultant’s request for treatment was not consistent with their unlicensed medicines policy. Taking all of this into account, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our investigation;
• consider Mr C's and his consultant's request for Botox treatment in line with the current version of the unlicensed medicines policy; and
• remind management and clinicians of the unlicensed medicines policy, and ensure that the policy is referred to and followed in relevant cases.

Summary

Mrs C was diagnosed with breast cancer and agreed after discussion with medical staff that she would have chemotherapy followed by breast conserving surgery. Mrs C completed her chemotherapy treatment, but shortly before her planned surgery (some six months after her diagnosis) she found out the full extent of the disease and decided to have the breast surgically removed. Mrs C complained that healthcare professionals did not communicate the full extent of the disease to her or report it fully within a reasonable time. She said that as a result, her treatment plan was initially based on the incorrect belief that breast conservation was possible. Mrs C also raised a number of concerns about the board's complaints handling.

We took advice from our relevant medical advisers and found that there were failures in the board's management of Mrs C's breast cancer, and that the process to ensure that healthcare professionals communicated effectively with each other and with Mrs C was not followed. Although we considered that the board's failures made no difference to the treatment and outcome for Mrs C, they did cause her additional stress at a very difficult time. We also found some aspects of the board's complaints handling was inadequate in that there were delays and the board failed to keep Mrs C informed.

Recommendations

We recommended that the board:

• review their practice on management of patients with breast cancer to ensure it meets Scottish Intercollegiate Guidelines Network guidelines, particularly in relation to the multidisciplinary team process;
• review their complaints process to ensure it meets the requirements of the NHS complaints procedure; and
• apologise to Mrs C for the failures identified.