Health

Summary

Mr C complained about aspects of his care and treatment which he received at Aberdeen Royal Infirmary. Mr C said that he received inconsistent explanations from staff about the cause of his back pain. He was also dissatisfied with the pain relief which was provided as it did not meet his needs.

We took independent medical advice from a consultant neurosurgeon (surgeon of the brain or other nerve tissue). We found that Mr C had a complex surgical history and a chronic pain condition. We found that although the staff had referred to the cause of Mr C's back pain differently at times, the explanations had the same meaning and that did not mean that his treatment was inappropriate. We also found that there was record of Mr C reporting pain and that the actions of staff by prescribing different painkillers and referring Mr C to the pain clinic were appropriate. We did not uphold the complaints.

Summary

Mrs C complained about the care and treatment which her late brother (Mr A) received at Aberdeen Royal Infirmary. Mr A died suddenly at home, two days after being discharged from hospital. The cause of death was recorded as colonic impaction (hard stool in the colon) and renal failure (kidney failure). Mr A had been admitted to hospital as an emergency with colonic impaction and problems with urination. A manual evacuation of the bowel was carried out under anaesthetic along with trials of catheterisation (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Mr A was discharged with a catheter in situation and arrangements made for a urology review as an out-patient. Mrs C believed that Mr A had received inadequate care in hospital.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that while in hospital Mr A did undergo a number of appropriate investigations such as blood tests; radiographs of the abdomen and chest; bladder scan; suppositories; manual evacuation of the bowel under anaesthetic; and catheterisation. However, on the day of discharge there were signs that Mr A was still unable to manage a normal bowel motion and his urine output was low compared to his normal urine output levels. We found that staff should have arranged a urology review in hospital prior to discharge rather than refer for an out-patient appointment in due course. We also found that arrangements should have been made for urgent review of Mr A's inability to manage a normal bowel motion in the days after discharge from hospital. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to establish the reasons for Mr A's urine retention and to ensure that he had normal bowel movement prior to discharge. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Staff should ensure that, where appropriate, an assessment has been carried out into the patient's ability to pass urine and maintain normal bowel motion prior to discharge.

Summary

Ms C complained that the decision to stop her medication when she arrived at prison was unreasonable. When Ms C arrived in prison, a doctor reviewed her prescribed medications. The doctor discussed the matter with Ms C's community practice and following that, took the decision to stop the medications no longer required. Ms C said that the stopping of her medications left her in severe pain and affected her mental health.

We took independent advice from a GP adviser. We found that appropriate pain relief medication had been prescribed to Ms C and that the decision to stop the other medications was reasonable because there was no requirement indicated for them to be continued. We did not uphold the complaint.

Summary

Miss C complained about the treatment she received from her dentist. She said that she had presented with a small chip on a tooth and that the dentist had put on a small filling which repeatedly fell off. Miss C said that at the time of the filling the dentist ground the tooth down with an implement. Miss C said that when the filling fell out she was left with an unsightly tooth and she continually had to pay for the filling to be replaced.

We took independent advice from a dentist. We found that there was no evidence that the treatment provided was inappropriate or that it was the cause of the filling repeatedly falling out. The records indicated that the dentist had listened to Miss C's concerns about the tooth and explained the potential treatment options. We considered that the problems Miss C reported to the dentist were likely to have been caused by natural wear and tear and that it was appropriate to have offered her the different treatment options. We did not uphold the complaint.

Summary

Mrs C complained on behalf of her husband (Mr A) about the care and treatment he received. Mr A was admitted to Queen Margaret Hospital for surgery to treat a hernia (where an internal part of the body pushes through a weakness in the muscle or tissue near the belly button). He was discharged home on the same day as his surgery. However, Mr A began to experience pain at home that worsened overnight. Early the next morning, Mr A was taken by ambulance to Victoria Hospital. He was found to have suffered a serious complication from his surgery.

Mrs C complained that Mr A should not have been discharged home after his surgery at Queen Margaret Hospital. We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We found that it was reasonable that Mr A was discharged home, as his did not yet have signs of any complication from the surgery and his recovery was as expected. We did not uphold this aspect of the complaint.

Mrs C also complained that when Mr A arrived at Victoria Hospital, he was not assessed at A&E before he was transferred to the surgical assessment unit. We took independent advice from an emergency medicine consultant. We found the board's process is that where a patient has recently undergone surgery, they are transferred straight to the surgical assessment unit if they are clinically stable. We found that the process was reasonable and safe and it did not cause any undue delay in Mr A's care and treatment. We did not uphold this aspect of the complaint.

Summary

Mr C complained about the lack of pain relief provided to his late mother (Mrs A) and that she did not have a regular doctor who saw her during her admission to Castle Douglas Hospital. Mr C also complained about the board's communication with him about the decline in his mother's condition.

We took independent advice from a nursing adviser. We found that Mrs A's pain was assessed appropriately during her admission and the pain relief provided to her was reasonable. Mrs A was reviewed by doctors during her admission and the input from medical staff was reasonable. We also found that the board's communication with Mr C was reasonable. Therefore, we did not uphold the complaints.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) by the practice before his death. In particular, she said that he was given a specific medication in tablet form althought it was known that he had swallowing problems, that communication from the practice had been poor and that Mr A had had sepsis (a blood infection) which had gone undiagnosed.

We took independent advice from a GP. We found that Mr A was taking many different medications all in tablet form and there was no information in his medical records to indicate that he had a problem swallowing medication. We also found that the records showed appropriate communication and no evidence that Mr A had sepsis.

We did not uphold the complaint.

Summary

Mrs C complained about the nursing care and treatment given to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. She also complained that communication by the board was poor.

Mr A had a complicated medical history. As he began to experience an increase in symptoms, he was admitted to hospital. Mrs C said that when she visited she found him in an undignified state. Later, she found that he had six stitches to a head wound, about which she had not been informed.

We took independent advice from a registered nurse. We found that the assessment taken on Mr A's admission noted that he could not properly answer questions to elicit information about his mental state, and that despite this, no further enquiries were made into whether or not he could be experiencing delirium, as was required. Similarly, despite his low score about his mental state, which should also have triggered a falls prevention plan and care plan, this did not happen. Mr A went on to fall twice, the second fall required him to have stitches. Furthermore although Mr A also appeared to be suffering delirium, the prescribed care for this was not evidenced in the nursing records and there were gaps in his care. We also found little record of conversations with Mrs C and she had not been told about his head wound until she visited him.

Given these failures, we upheld both aspects of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the identified failures in Mr A's care and treatment.
• Apologise to Mrs C for failing to communicate in a reasonable and appropriate way. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients admitted to hospital should have falls risk assessments carried out in line with the Board's Falls Management Policy and assessments identified following review, carried out promptly. Nursing care provided to patients should be in line with the Nursing and Midwifery Code, particularly in relation to the importance of good record-keeping. Patients should receive medication as prescribed and this should be documented appropriately.
• Family members and carers, as appropriate, should be kept up-to-date about a patient's treatment and condition. Where specific and reasonable requests for meetings/discussions have been made, these should take place and be recorded.

Summary

Mrs C complained about the treatment her mother (Mrs A) received when she attended the emergency department at Dumfries and Galloway Royal Infirmary having experienced a fall, and loss of mobility in her legs. Mrs A was discharged from hospital the same day. The following day, Mrs A was unable to mobilise and was admitted to hospital, where it was later discovered that she had suffered a stroke. Mrs C was unhappy that Mrs A was discharged, and complained that the opportunity for mitigating treatment for Mrs A's stroke and for further observation was lost. Mrs C said Mrs A had been visited at home by her GP the week earlier and that the GP said Mrs A might have had a slight stroke. Mrs C was unhappy that Mrs A's GP had not been consulted.

We took independent advice from a medical adviser. We found that the medical treatment Mrs A received was reasonable, and that, on the basis of tests appropriately carried out, stroke was not expected as the cause of Mrs A's mobility problems. We considered that, in the circumstances, stroke mitigating treatment would not have been appropriate and would not have altered the outcome for Mrs A. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the board's handling of her complaint. We found that Mrs C's complaint was not acknowledged or responded to within the correct timescale. We found that the board had already acknowledged these shortcomings, had apologised, and had explained the action they were taking to address them. Mrs C also raised some issues that were not addressed in the board's response. We found that a clearer explanation could have been given for the reasons for Mrs A's discharge. Therefore, we upheld this aspect of Mrs C's complaint.

Summary

Ms C complained about the care and treatment her husband (Mr A) received from the board at University Hospital Crosshouse. Ms C complained that there was a delay in diagnosing and treating Mr A's squamous cell carcinoma (a type of cancer of the skin's cells). Mr A had been under the care of the board, as he had a suspicious area of damage on his tongue. Mr A was later diagnosed with cancer in his tongue, which had spread to his neck. Mr A's cancer appeared to have been successfully treated with surgery and chemo-radiotherapy (where drugs and high-energy waves are used to treat cancer cells), however, Mr A's cancer was later found to have returned and spread further. Mr A died of widespread cancer later that year.

We took independent advice from a consultant ear, nose and throat (ENT) and head & neck surgeon. We found that there was an unreasonable delay in telling Mr A he might have cancer in his tongue and in carrying out surgery on Mr A's tongue, once the decision to treat it had been made. We also found that when Mr A later complained of pain in his shoulder, this should have been noted in his medical records and it was not. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in Mr A's care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

What we said should change to put things right in future:

• Patients suspected to have cancer should receive prompt treatment once the decision to treat has been made.
• The board should ensure that there is appropriate recording of reported symptoms at clinic appointments.