Upheld, recommendations

Summary

Mrs C was referred to a hospital gynaecology clinic with a vaginal prolapse (a condition when one or more of the pelvic organs slips down from its normal position). After she was first seen, she was given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and given a follow-up appointment for five months after that. A couple of months before the follow-up appointment was due, however, she developed post-menopausal bleeding (PMB - vaginal bleeding occurring over twelve months after the menopause). Treatment of her prolapse was postponed while this was investigated. Mrs C had biopsies (tissue samples) taken on three separate occasions before having a hysterectomy (surgery to remove the womb) some seven months after reporting the bleeding. Mrs C complained about the length of time between her initial GP referral and her surgery. She also complained about the number of biopsies she had to have and the length of time taken between each biopsy. She felt that her treatment was delayed as a result of failed biopsies.

We took independent advice from a medical adviser, who said that the prolapse was not clinically urgent, but that PMB could be indicative of cancer and needed urgent investigation. A hysterectomy was required to deal with the prolapse, and treatment for PMB would also require a hysterectomy. However, if cancer was found in the PMB treatment, it might also be necessary to remove the ovaries and lymph nodes within the abdomen. With this in mind, we found that while the PMB was being investigated it was appropriate to postpone the prolapse hysterectomy, so that she did not have to undergo two separate operations should cancer be found.

We also found that the biopsies that were taken were inconclusive rather than incomplete. Each biopsy was necessary and completed and reported in a reasonable timescale. Ultimately, the biopsies showed no signs of cancer. We were generally satisfied with the investigation and management of Mrs C's PMB.

That said, from December 2011, the board were required to work in accordance with the national waiting time target of 18 weeks from GP referral to treatment. Although Mrs C was referred before then, we considered that the board should have been working towards the target by the time of her referral. It took 35 weeks for Mrs C to be offered treatment after her referral, and her PMB began 31 weeks after referral. As the biopsies showed that Mrs C did not have cancer, we concluded that, had the board carried out the hysterectomy to address her prolapse in line with the 18 week target, Mrs C would not have developed PMB, and as such would not have required the biopsies and other investigations that she underwent. We, therefore, upheld her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation; and
• ensure that their general gynaecology clinic have systems in place to provide treatment in line with national referral to treatment targets.

Summary

Mr C complained that the board provided inadequate treatment to his adult daughter (Miss A) in a hospital accident and emergency department (A&E) after a fall. Miss A had been taken there after a neighbour found her with a head injury. The doctor who saw Miss A recorded that she was intoxicated with alcohol and had abdominal and chest pain. She noted that Miss A had drunk a bottle of wine, and was difficult to assess and quite uncooperative with questioning. Miss A was initially unwilling to say how she had hurt herself, but eventually said she had fallen in her flat and had gone to the foyer to get help. However, the doctor was not convinced by this.

The doctor noted that Miss A said that the abdominal/chest pain started before she fell and was due to an existing kidney disorder. Miss A refused to have the head injury stitched, so it was cleaned and glued. The doctor arranged for a chest x-ray and routine blood tests. She gave Miss A painkillers and re-examined her after two hours, by which time, the chest and abdominal pain had improved. The doctor recorded that she thought that Miss A had likely suffered a muscular chest injury, and discharged her. Miss A was advised to see her GP in two days to get her bloods rechecked, and to return to hospital if there were any problems. Miss A declined to contact her parents for help to get home.

Miss A returned to A&E later that day, and this time told staff that she had in fact fallen off a balcony. She was admitted and was in hospital for three weeks. A CT scan (a special scan using a computer to produce an image of the body) and x-rays showed that she had suffered a number of injuries.

We obtained independent medical advice on the complaint, and found that, in general, the care provided to Miss A was reasonable. The doctor assessed Miss A in the context of the description she gave of a minor fall, and Miss A had to take responsibility for not saying what had actually happened. If the examining doctor had been aware of how the injury happened, Miss A would have been immobilised and a CT scan would have been requested, which would have shown the extent of her injuries much earlier.

However, our adviser also said that there were a few lapses in the standard of care. There was inadequate questioning about the significance of the head injury, particularly in the context of there being a four centimetre laceration to the head. If the doctor had asked about loss of consciousness, persistent headache, vomiting or amnesia memory loss, then responses might have indicated a need for a CT scan. The adviser also said that it was unlikely that a more senior doctor would have discharged Miss A, and there were a few subtle clues missed. These included a mildly raised respiratory rate, the chest and abdominal pain and a raised white cell count.

Although we upheld the complaint this was a decision taken on balance, in view of the fact that the overall care provided to Miss A was reasonable and the doctor was clearly not assisted by the fact that she was given inaccurate information about how Miss A sustained her injury.

Recommendations

We recommended that the board:

• issue an apology to Miss A for the failings identified; and
• make the doctor aware of our findings.

Summary

Following a laparoscopic hysterectomy (keyhole surgery to remove the organs and surrounding tissue of the reproductive system), Miss C began experiencing pain in her back and left leg. She was kept in hospital for five weeks and diagnosed with sciatic nerve damage (damage to the nerves of the lower back area). She told us that she continues to suffer from these problems and has been told that it could take two years for her to regain normal function. She complained that, despite corresponding with the board and attending several appointments, she has not received an explanation as to what caused these problems.

Our investigation found that the board had carried out appropriate investigations to identify the problems Miss C was experiencing and that her pain was likely to be caused by sciatic nerve damage following her surgery. This was a rare complication and not something the board could take particular precautions to avoid. We found that, although the board were not clear about what was causing Miss C's pain and carried out a number of tests to establish this, there was a lack of evidence to show that they had explained why they were carrying out these tests, the conclusion reached, and the likely outcome. For this reason, we upheld this complaint.

Recommendations

We recommended that the board:

• give Miss C a copy of her consultant's letter to her GP; and
• arrange for Miss C to meet with neurology staff to discuss her condition and likely outcome, if she wishes to do so.

Summary

Mr and Mrs C complained that the medical practice inappropriately prescribed their father (Mr A) anti-inflammatory medication on a long-term basis, without also prescribing gastric protection medication. Mr A had sciatica (lower back pain caused by pressure on a nerve) and osteoarthritis (the most common form of arthritis, affecting the joints) in his knees. He had been on a non-steroidal anti-inflammatory drug (NSAID) for a number of years when he attended hospital several times complaining of abdominal (stomach) pain. He was eventually admitted to hospital, where he was found to have a massive gastro-intestinal haemorrhage (severe bleeding in the stomach/intestine) because of a bleeding ulcer. Doctors were unable to control this, and although Mr A had emergency surgery, he did not survive.

Our investigation found that guidance in 2008 said that gastric protection medication should be prescribed with NSAIDs. We upheld the complaints, as we found that from 2008 onwards Mr A should not have been prescribed a NSAID without this protection. We noted that this was in fact picked up at a medication review that year, which noted that Mr A was over 65 and a smoker and was, therefore, at increased risk of stomach bleed. The review said that if the NSAID prescription was continued, gastric protection medication should be added. The NSAID was then removed from Mr A's repeat prescriptions. However, a year later, a NSAID was added to his repeat prescriptions without gastric protection medication. The practice apologised to Mr C for this after Mr A's death and carried out a significant event analysis.

Mr C also complained that the practice failed to diagnose and treat Mr A's ulcer. Mr A had attended the hospital with abdominal pain several times, and they had told the practice about this. We found that the practice were not required to follow this up unless the hospital specifically asked them to do so, and there was no evidence that Mr A attended the practice with abdominal problems until the day before his death. That said, we found that Mr A's abdominal pain, along with the fact that he was taking the NSAID without gastric protection, should have alerted the GP to the probability that the pain was being caused by an ulcer. We found that the GP should have prescribed gastric protection at that time, although it was unlikely that this would have prevented Mr A's death.

Recommendations

We recommended that the practice:

• make the GP who examined Mr A on the day before his death aware of our finding on this matter; and
• issue a written apology to Mr C for the failure to carry out a reasonable and appropriate consultation on that day.

Summary

Mrs C complained on behalf of her son (Mr A) that the university failed to offer guidance and support on his projects during his final honours year. She also complained that the university failed to deal appropriately with her complaint.

We upheld Mrs C's complaints, as our investigation found that there was a lack of documentation to show that Mr A had received adequate support and guidance, and that the project supervisor had not responded to the majority of emails about Mr A's project. We also found that there was a lack of clarity in the way the university had handled the complaint. At the time Mrs C complained, they had a four-stage complaints procedure, which is what they should have used. They had, however, subsequently approved a two-stage procedure and it was this that they tried to use. The university also failed to respond to, or try to clarify, the detail of Mrs C's complaint about adequate guidance and support.

Recommendations

We recommended that the university:

• ensure that the 'usual practice' of students taking minutes of supervision meetings be communicated to students more clearly;
• remind the academic supervisor of the importance of managing email communication with students; and
• ensure that their complaints procedure is adhered to in future and that the quality of responses is monitored.

Summary

An employee of Scottish Water visited Mr C's business premises and advised that he was going to install a water meter. As he had received no prior warning, Mr C at first refused permission for this. However, following discussions with Business Stream, during which he was told that the cost to him would be minimal, Mr C agreed to the meter installation. He was unhappy to then receive a water bill a year later, which he considered excessive as he used no water at his business premises. Mr C complained that it was inappropriate for the water meter to be installed and that he was given insufficient information about the charges he would incur. He said that, had he known about the charges, he would have had the water supply disconnected, as his business does not use water.

We found that Mr C's business had been identified as a gap site (a site that has been receiving water-related services without being charged). It was appropriate for a meter to be installed in line with the Scottish Government's Full Business Metering scheme. However, we were concerned by the lack of information given to Mr C about the metering process. Mr C had asked Business Stream about their charges and they had been unable to provide him with any information. We found this to be unreasonable as, although they could not predict how much water Mr C would use, they should have been able to tell him about their fixed charges.

Recommendations

We recommended that Business Stream Ltd:

• apologise to Mr C for the issues highlighted in our decision letter; and
• credit Mr C's account with an amount equivalent to 50 percent of the total of his first water bill.

Summary

Mrs C's daughter (Ms A) has a history of anorexia nervosa and depression. Ms A was assessed by an on-call psychiatrist after her mother expressed a concern about a deterioration in her mental health. Ms A was allowed to go home and was to be followed up by the crisis care team. The next day, following an incident that concerned Mrs C, police brought Ms A to hospital for assessment. Mrs C attended with her. Ms A was seen by a mental health assessment nurse and a doctor in the early hours of the morning. They offered to admit her to hospital, but she refused and she and her mother returned home. However, later that day, after what Mrs C described as a violent outburst in the presence of the family doctor, police officers brought Ms A back to hospital for a further assessment. The assessing nurse decided not to detain Ms A or to offer to admit her to hospital. The next day, Ms A was detained under a short-term certificate. She was admitted to another hospital and remained there for six weeks. Mrs C was unhappy about the standard of psychiatric assessments Ms A received at the first hospital, particularly the second assessment.

Our investigation found that the first assessment was reasonable and that it was unlikely that Ms A met short-term detention criteria under the relevant legislation. We also found that the follow-up arrangements after her discharge were reasonable. However, in relation to the second assessment, we found that while the critical factors relating to her risk of suicide were assessed and the diagnosis reached was reasonable, there were instances of poor practice. In reaching their decision, the assessing nurse did not make use of all the available information which would have significantly strengthened the assessment and decision making.

Recommendations

We recommended that the board:

• put quality assurance measures in place to ensure that evidence based assessment templates are completed by relevant staff in full and as intended;
• ensure that staff involved in conducting out-of-hours and urgent assessments have (and utilise) access to previous clinical records whenever practicable, especially when considerations of risk are involved; and
• apologise to Mrs C for the failings identified in relation to the second assessment.

Summary

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems.

Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol.

Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition.

Our adviser found that the lack of information in the notes taken at the time did not give a full picture of Mrs C's condition on the night in question. However, he was of the view that with the information now known - that Mrs C had concussion - the management of her condition would have been the same even had the concussion been diagnosed at the time. Mrs C was discharged with a small amount of medication and with advice to return to A&E if her condition worsened. The adviser said that this would have been appropriate. He was also of the view that Mrs C's ongoing problems would probably have occurred even had the concussion been diagnosed at the time. We did, however, uphold Mrs C's complaint because no valid reason was recorded in the notes for the GP not having conducted a full assessment and examination at the time.

Recommendations

We recommended that the board:

• apologise for the failings identified during our investigation; and
• review a sample of notes to establish the quality of record-keeping of the staff involved.

Summary

Mr C's late wife (Mrs C) was diagnosed with cancer in June 2011. He complained that staff at the practice failed to take account of the seriousness of her condition and to take follow-up action. Mr C raised concerns about the way in which his wife's medication was given; a failure to document phone conversations; a failure to admit Mrs C to hospital when a provisional diagnosis of gastroenteritis (inflammation of the stomach and intestines) was made; and a failure to monitor her calcium levels. Mr C complained that, by the time Mrs C was admitted to hospital in October 2011, she was hallucinating. He believed that his wife had suffered more than she needed to as a consequence of the practice's failures or inaction.

In considering Mr C's complaint, we obtained independent advice from one of our medical advisers. Our investigation found that once Mrs C was diagnosed with cancer, her care was primarily the responsibility of the hospital and hospital staff. It was clear from hospital records that the practice was kept up to date with Mrs C's condition, and it was also clear that when requested, the practice took appropriate action. Our adviser confirmed that, in his experience, not all patients wanted to hear further from their GP, or to discuss matters with them, at what can be a busy and difficult time.

On the matter of administration of medication, we found that although Mr C was unhappy that his wife was given her medication in tablet rather than liquid form, the adviser said that there was no record on file confirming that this was required.

On the issue of Mrs C's non-admission to hospital when gastroenteritis was suspected, the adviser said that the records confirmed that this was discussed with Mr and Mrs C and it was noted that she was 'OK' to stay at home. Mr and Mrs C were given advice that if her condition worsened, they should phone NHS 24.

We found that Mrs C's calcium levels were not taken, and as she was vomiting, the adviser was of the view that when completing blood tests, this test should also have been carried out. He said that if her calcium levels were high, it might then have been possible to reduce them, and in turn this might have led to a reduction in Mrs C's sickness.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failure to monitor Mrs C's calcium levels.

Summary

Miss C attended the dental practice complaining of pain in her lower left five tooth. She said that she specifically pointed this out to her dentist. The dentist recorded in the notes that the lower left seven tooth was mobile with a discharge of pus coming from the buccal aspect (cheek side of the tooth). The dentist then extracted the lower left seven tooth.

After around 20 minutes, Miss C returned to the practice and complained that the wrong tooth had been extracted. The dentist recorded that the lower left five tooth was mobile and then removed it. The dentist also recorded that she had apologised to Miss C and explained that the lower left seven tooth was not treatable by any means other than extraction.

In her complaint to us, Miss C understood that the dentist said she would not charge her for this extraction. Our investigation found that the notes completed at the time said that the lower left seven tooth was to be extracted, so we could not say for sure whether the wrong tooth was extracted. However, Miss C clearly thought that it was the lower left five tooth that was to be extracted. We found that the dentist did not obtain consent appropriately and did not communicate with Miss C effectively.

In responding to Miss C's complaint, the dental practice said that the dentist was aware of the crucial importance of securing valid consent prior to any treatment and would not have proceeded with the removal of the lower left seven tooth unless she believed that Miss C understood and agreed to this treatment. We concluded, however, that this was not the case and upheld Miss C's complaint that the practice had provided incorrect explanations as to why the tooth had been removed.

Recommendations

We recommended that the practice:

• issue a written apology for the failure to obtain consent appropriately for the extraction of the tooth and for failing to communicate effectively with Miss C; and
• make the dentist aware of our finding on this matter.