Health

Summary

Ms C complained about the care provided to her late mother (Mrs A) by the practice. Mrs A had attended the practice on a number of occasions with chest pains, confusion, arm weakness and sight problems. Mrs A also had a history of high cholesterol (a fatty substance found in the body that can increase risk of health conditions) and a family history of heart problems. Mrs A later died at home and Ms C felt that the GPs involved in her care should have made earlier referrals to hospital specialists.

We took independent medical advice from a GP. We found that although Mrs A had attended the practice on a number of occasions before her death, she had not reported chest pain for a period of six months and it was felt reasonable that the staff had assumed her previously reported symptoms had resolved. During previous consultations with GPs they had considered a number of diagnoses and prescribed appropriate medication for the symptoms which were reported. There were also attendances at hospital where scan results were reported as being normal. Therefore, we did not uphold Ms C's complaint. However, we provided feedback to the practice that on one occasion, there was a need to make a referral to cardiology for further investigation and to provide Mrs A with safety netting advice. While there was no evidence that this would have prevented Mrs A's death, it may have led to an earlier diagnosis of heart problems and allowed treatment options if required.

Summary

Mrs C complained on behalf of her husband (Mr A) regarding the delay in reaching a diagnosis of prostate cancer during consultations at Perth Royal Infirmary. In response to Mrs C's complaint, the board explained that a number of factors had contributed to the time taken to diagnose Mr A. The board said that Mr A's symptom pattern was unusual, and investigations were initially performed to rule out bladder and kidney cancer. Mrs C was unhappy with this response and brought her complaint to us.

We took independent advice from a consultant urologist (a specialist in the study or treatment of the function and disorders of the urinary system). We found that it was reasonable of the board to first exclude the possibility of bladder or kidney cancer before investigating the possibility of prostate cancer. We also found that the department had carried out appropriate tests prior to Mr A being reviewed by the consultant. We considered that the board had met the waiting time targets and did not uphold Mrs C's complaint. Although we did not consider that the delay in diagnosis was unreasonable in this case, we gave detailed feedback to the board regarding areas for potential improvements in practice.

Summary

Ms C complained that the board unreasonably failed to discover an object left in her nasal tissue after surgery at St. John's Hospital. Ms C said that on removal of stents (splints placed temporarily inside a duct, canal, or blood vessel to aid healing or relieve an obstruction), one stent came away in two pieces. Ms C was alerted at the time that a piece of silicone stent may have been retained. Ms C continued to attend the hospital for treatment of chronic rhinosinusitis (a condition where the cavities around nasal passages (sinuses) become inflamed and swollen for a prolonged period). Sixteen months after the surgery, a scan was carried out which identified that a titanium clip had been retained in the nasal tissue. The silicone stent and titanium clip were removed at the same time Ms C was undergoing another surgery, approximately 12 months after the retained titanium clip was discovered.

We took independent medical advice from a consultant rhinologist (a specialist in conditions affecting the nose). We found that the board unreasonably failed to discover and report on all elements retained in Ms C's nasal tissue after surgery. No investigations were carried out until the scan 16 months after the stents were removed, where it was found that the titanium clip was still in place. After it was discovered, it was over a year before it was removed. We found that there was an unreasonable delay in identifying the retained titanium clip. Therefore, we upheld this part of Ms C's complaint.

Ms C also complained that the board failed to provide a reasonable explanation as to how an object was left in her nasal tissue after surgery. The board accepted that they had not provided a reasonable explanation. The communication regarding this issue was poor. When it was found that a titanium clip had been retained as well as the silicone stent, it was over four months before Ms C was informed of this. No explanation was provided as to why the clip was retained or why Ms C was not informed that this was a possibility. We considered that the board could have been more open and detailed about what happened and why. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified by this investigation. 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:

• A review of practice to consider best practice to secure silicone tubes for dacryocystorhinostomy (DCR) surgeries.
• A review of the process for selecting patients for DCR surgery.
• Clinicians should review their diagnosis when patients do not respond to treatment.
• Learning from this investigation is fed back to relevant staff in a supportive way.
• The process of discussing options and consent to treatment should be clear in its documentation.

Summary

Mrs C complained about the care and treatment provided to her late mother (Ms A) at the Royal Infirmary of Edinburgh. Ms A had undergone treatment for early stage lung cancer, and was followed up at six-monthly intervals. Mrs C complained that at a follow-up appointment, Ms A had been told there were no signs of cancer, but a few weeks later was found to have liver cancer. Mrs C said that there was a failure to identify the spread of lung cancer and that Ms A had been given false hope.

We took independent advice from a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that there had been a failure to identify a mass near Ms A's spine on a scan, and that this was unreasonable. However, we noted that it was unlikely that earlier identification of this would have altered Ms A's outcome. We also found that at a follow-up appointment, the clinical examination done was incomplete as it did not include examination of the abdomen. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to identify a mass and the failure to carry out a full clinical examination at the oncology appointment. 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:

• Radiological findings should be accurately reported.
• Full clinical examination should be performed and documented during oncology follow-up appointments in cases of radical lung cancer treatment.

Summary

Mr C complained about the care and treatment his daughter (Ms A) received from the practice. Ms A contacted the practice about severe abdominal pain and was given advice over the phone. Four days later Ms A was admitted to hospital where she had her appendix and part of her bowel removed. Mr C felt that it was unreasonable that the practice did not examine Ms A in person when she called them and that this failure could have led to a potentially serious situation.

We took independent advice from a medical adviser. We found that the practice failed unreasonably to adequately assess and examine Ms A. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in assessment and examination. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.

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

• The doctor involved should reflect on the complaint and findings in their next appraisal.
• The doctor involved should follow the relevant guidance on assessment and management of abdominal pain in women of childbearing age.

Summary

Ms C complained about the treatment she received from the dentist. Ms C was referred to the dentist as she required sedation during dental procedures. Ms C said she was told by the referring dentist that the tooth, which had a missing filling, was salvageable and could be crowned, however when the tooth was assessed, the dentist felt it was not salvageable. Ms C complained that the actions of the dentist led to an infection, cutting of the bone and was essentially unreasonable.

We took independent advice from a dentist. We found that Ms C's treatment by the dentist was reasonable and found no failings in the treatment offered. When the planned treatment changed, Ms C was brought back from sedation so she would be in a position to consent to treatment. The treatment was carried out in a reasonable manner. Therefore, we did not uphold the complaint.

Summary

Ms C complained about the treatment she received from the practice in response to her symptoms of oedema (swollen tissue from retained fluid). Ms C said that she had reported symptoms to the practice on numerous occasions. Ms C said there was an unreasonable delay in responding to her symptoms. During an appointment with a GP Ms C was told to stop a certain medication. Ms C said that during the appointment she was not given proper instructions or after care, i.e. to get her blood pressure checked. A few weeks later, after a severe headache, it was found that Ms C's blood pressure was too high and she required hospital admission.

We took independent medical advice from a GP. We found that Ms C's treatment by the practice was reasonable and found no failings in the treatment offered. The practice considered Ms C's symptoms, taking into account her overall medical hisotry and chronic illnesses when considering appropriate action to respond to Ms C's reports of oedema. Therefore, we did not uphold this part of Ms C's complaint.

Ms C also complained that the board failed to provide reasonable after care, specifically that her blood pressure should be checked. There was no written record or evidence to support the practice's view that appropriate information was provided to Ms C regarding having her blood pressure checked. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified by the investigation. 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:

• The GP meets the standard of good record-keeping.

Summary

Mr C complained about the physiotherapy treatment (the treatment of disease, injury or deformity using physical methods such as massage, heat treatment, and exercise) given to his wife (Mrs A) after her hip operation at University Hospital Hairmyres. Mr C also complained that the board had failed to communicate reasonably with himself and Mrs A about Mrs A's rehabilitation potential.

We took independent advice from a senior physiotherapist. We found that Mrs A had been provided with reasonable physiotherapy. The advice we received from the senior physiotherapist was that there were two treating physiotherapists which was excellent practice. We also found that the decision not to provide physiotherapy following discharge had been reasonable and that the communication about Mrs A's rehabilitation potential had been reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the pressure area care given to Mrs A. We took independent advice from a nursing adviser. We found that the pressure area care given to Mrs A was unreasonable. In particular, that there was a lack of risk prevention strategies implemented when Mrs A was admitted to reduce her risk of developing pressure damage; when the first damage to Mrs A's skin was identified no care plan was put in place to reduce further risk of damage; and when Mrs A's ulcer developed into a grade three pressure ulcer (grade four is the highest form of damage) the relevant guidance was not followed. We also found that the nursing communication with Mr C had been unreasonable and that there was no evidence of a care plan being initiated to address Mrs A's weight loss. We also noted that that the nursing records were unreasonable Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings identified in pressure area care. The apology should meet the standards set out in the SPSO guidelines on apologyavailable at www.spso.org.uk/leaflets-and-guidance.

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

• Nursing staff should ensure risk assessments for pressure ulcer prevention are accurate. SSKIN care bundles should be followed appropriately to reduce the risk of a patient developing a pressure ulcer.
• Patients with pressure ulcers should have an individualised care plan implemented to further reduce risk of deterioration to the skin.
• Nursing staff should ensure the Healthcare Improvement Scotland standard for prevention and management of pressure ulcers is followed.
• Ensure that there is appropriate communication with patients and/or their families during a patient's stay in hospital.
• Patients with a pressure ulcer should have appropriate nutritional assessments undertaken and receive effective nutritional care, which is in line with relevant guidance.
• Accurate records should be maintained in line with Nursing and Midwifery Council code of record-keeping.

Summary

Ms C, an advice and support worker, complained on behalf of her client (Mr A) regarding the treatment which he had received from the practice, prior to him being diagnosed with prostate cancer. Mr A had attended frequent consultations with right hip pain and had been referred to physiotherapy (treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) on a number of occasions. He was also sent for an orthopaedic (treatment of diseases and injuries of the musculoskeletal system) referral which had not helped. Mr A stopped attending physiotherapy as he received no benefit from the exercises or the painkillers which the practice had prescribed.

We took independent medical advice from a GP. We found that initially it was felt that Mr A had a musculoskeletal problem (injuries or pain in the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back) which was reasonable in view of the presenting symptoms. The practice provided appropriate pain relief and made appropriate referrals for specialist opinions in orthopaedics and physiotherapy. It was only when Mr A presented with pain in his upper spine, which triggered a red flag sign, that blood tests were arranged which indicated possible prostatic cancer. This resulted in an urgent referral to the cancer specialists. We had no concerns about the way the GPs at the practice managed Mr A's reported symptoms over the period and there was no delay in making a specialist referral when he reported a new symptom of spine pain. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided to his late daughter (Miss A) by unscheduled care practitioners (UCPs) at A&E at Campbeltown Hospital. Miss A had attended the hospital on a number of occasions within a short period of time and reported symptoms of severe pain and sickness. Miss A then attended another hospital outwith the board area and a diagnosis of pancreatic cancer was made. Mr C said that Miss A felt that the UCPs had not listened to her and that had led to a delay in the diagnosis.

We took independent medical advice from a GP. We found that there was no evidence that the UCPs had failed to provide Miss A with a reasonable standard of treatment. She had been attending hospital specialists who were treating her for other medical conditions and that her reported symptoms could reasonably have been connected with the other medical conditions or side effects of the medication she was taking. There was nothing to suggest that Miss A was suffering from the effects of pancreatic cancer when she saw the UCPs. There are usually no symptoms in the early stages of the disease and those symptoms which do develop do so when the disease has reached an advanced stage; by the time of diagnosis, pancreatic cancer has often spread to other parts of the body. We did not uphold the complaint.