Health

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received when she was a patient in the geriatric long stay facility at Mearnskirk House. Mrs A became unwell and was treated for a presumed urinary tract infection. Her condition deteriorated and she developed sepsis (blood infection) and jaundice (a condition with yellowing of the skin or whites of the eyes), and later died.

Mrs C suspected that Mrs A's urinary tract infection was from a liver source and raised concerns about the board's response to Mrs A's jaundice. However, the board considered that a urine source was more likely and that the treatment Mrs  A received had been reasonable.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the source of infection often remains uncertain in particular situations, and that treating the sepsis would be the correct priority. We considered that more vigorous medical investigations or interventions would have been disproportionate. We did not uphold Mrs C's complaint.

However, we noted that there was insufficient documentation to demonstrate adequate discussions with Mrs C regarding Mrs A's management plan, particularly surrounding the uncertainty of her recovery. We also highlighted that adequate internal communication was not demonstrated and that communication failings were contrary to Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the care of deteriorating patients. We made recommendations relating to these observations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure of clinical staff to communicate adequately, both with her and with each other. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• As per SIGN 139, patients identified as deteriorating with limited reversibility should have a written management plan which considers and includes discussion with the patient and family (which may include discussion of uncertain recovery and medical plan, preferred place of care and concerns or wishes); and standardised and agreed ceilings of care.
• As per SIGN 139, all communication about patients identified as deteriorating should be formalised and should include a structured handover process which includes all relevant clinical information.

Summary

Mrs C was admitted to Queen Elizabeth University Hospital with severe abdominal pain. She was pregnant at that time and had been referred to the hospital with suspected appendicitis (a serious medical condition in which the appendix becomes inflamed and painful). The hospital carried out an ultrasound scan and considered it was likely that Mrs C had gastroenteritis (inflammation of the stomach and intestines). Her condition deteriorated over the next few days and it was found that her unborn baby had died. Mrs C was taken to theatre where it was identified she had appendicitis and her appendix was removed. She was then admitted to the intensive care unit at the hospital with sepsis (blood infection) and organ failure. Mrs C recovered but later had two further admissions with infections in her abdominal muscles. Mrs C complained that there was an unreasonable failure to diagnose appendicitis and sepsis.

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 there had been a number of failings in Mrs C's care and treatment, including:

• a failure to adequately consider an alternative diagnosis to gastroenteritis in view of rising CRP (C-reactive protein - a blood test marker for inflammation in the body),

• a failure to give adequate consideration to carrying out a CT scan or diagnostic laparoscopy (a surgical procedure in which a fibre-optic instrument is inserted through the abdominal wall to view the organs in the abdomen or permit small-scale surgery),

• the national early warning scoring (NEWS - an aggregate of a patient's 'vital  signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration) that was carried out was not done appropriately,

• a failure to interpret and actively pursue signs of sepsis on the NEWS scores,

• staff should have used maternity early warning score (MEWS) observation charts,

• there was no review by an experienced obstetrician (a doctor who specialises in pregnancy and childbirth),

• the lack of physical examination by experienced doctors,

• there was a delay in carrying out a repeat ultrasound scan and

• the delay in considering a diagnostic laparoscopy or surgery was unreasonable.

We considered that there was an unreasonable failure to diagnose Mrs C with both appendicitis and sepsis and, therefore, upheld Mrs C's complaints. A number of failings had been identified by the board, but we made some additional recommendations for learning and improvement.

Mrs C also complained that the board's investigation into her care and treatment was inadequate. We found that there had been a delay in starting a critical incident review and that there were some failings in the report. We also upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in starting the significant clinical incident investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsandguidance.

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

• In relevant cases, NEWS scoring should be carried out appropriately.
• Deteriorating patients should be escalated to a senior clinician especially in the presence of sepsis. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Significant clinical incident investigations should be started promptly in appropriate cases.

Summary

Mrs C attended the dentist for restorative crowning treatment of one of her teeth, having recently completed a course of private orthodontic treatment. Following completion of the crown preparatory work, Mrs C complained that her retainer felt slack and that there was subsequent movement in one of her teeth between then and her re-attending for the crown fitting a week later. The dentist considered that the movement was an orthodontic relapse issue and did not accept liability for the cost of the remedial orthodontic work required. Mrs C complained that there had been no movement prior to the crown preparatory work and that the movement could, therefore, only be attributed to this work.

We took independent dental advice from a general dental practitioner. We found that the treatment provided by the dentist was carried out appropriately and that this could not reasonably be responsible for the movement of Mrs C's tooth. We noted that any movement was likely to have occurred over a period of months, due to orthodontic relapse, rather than the short period of time between the crown preparation and crown fit appointments. We observed that the dentist's notes from an earlier appointment suggested that the tooth in question was not in a stable position and that relapse had already occurred. Therefore, we did not uphold Mrs C's complaint.

Summary

Mr C complained about the care and treatment he had received at Dr Gray's Hospital. Mr C, who had a history of heart problems, had attended a consultation at the cardiology unit (the branch of medicine that deals with diseases and abnormalities of the heart) where investigations were carried out and he was told there was no cause for concern. However, Mr C suffered a heart attack three months later and had to be fitted with a stent (tube inserted in a blocked artery to keep it open). Mr C felt that the previous investigations must have shown that he was at risk of a heart attack and that preventative action should have been taken.

We took independent advice from a cardiac consultant. We found that the previous investigations were appropriately carried out and reported on and it was reasonable for the clinicians to have diagnosed that Mr C had mild and stable angina (chest pain). The clinicians involved could not have predicted that Mr C would go on to suffer a heart attack after such a short period of time. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment he received at Woodend Hospital. Mr C had suffered knee problems for a number of years and had been refused surgery as his Body Mass Index (BMI - weight health calculation) was too high. Mr C lost a substantial amount of weight and reduced his BMI. Mr C was then reviewed by a consultant who said that they would not consider surgery unless he lost at least a further three and a half stone in weight.

We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that Mr C had previously been given a target BMI which he reached. However, when Mr C was reviewed by the consultant, they felt that Mr C needed to achieve an even lower BMI before they would consider surgery. We considered that Mr C had persevered with his weight loss attempts and that it was then unreasonable for the consultant to have decided that Mr C continue to lose a further substantial amount of weight. Therefore, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for asking him to lose a further three stones in weight before staff would consider surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should review the decision as Mr C had reached the target BMI for consideration of surgery.

Summary

Mr C complained about the care and treatment that his wife (Mrs A) received from the board's gastroenterology department (the branch of medicine which deals with disorders of the stomach and intestines) at Aberdeen Royal Infirmary for her abdominal problems. A number of tests were carried out and it was considered that she had probable small bowel Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system).

We took independent advice from a consultant gastroenterologist. We found that Mrs A's case was complex. Whilst there had been a short delay in her seeing a consultant, this was not unreasonable. That said, we found that there had then been an unreasonable delay in carrying out an urgent colonoscopy (examination of the bowel with a camera on a flexible tube) that had been requested for her. However, in their response to Mr C's complaint, the board said that this had been reviewed and action had already been taken to prevent similar delays. We also found that given staff were aware of Mrs A being atypical for a Crohn's disease patient, alternative / additional diagnoses, including a psychological diagnosis, should have been considered, documented, discussed and treated earlier in the course of her assessment. Staff should have concentrated more on controlling Mrs A's symptoms and considered more active treatment for irritable bowel syndrome type symptoms. In view of these failings, we upheld this aspect of Mr  C's complaint.

Mr C also complained that the board's response to his complaint was unreasonable. Given the symptoms Mr C had described in his complaint to the board, we found that the board should have explored what further treatment should be provided to Mrs A and referred to this in their response. Given the failure to do so, we also upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in carrying out an urgent colonoscopy, failing to concentrate on controlling Mrs A's symptoms and failing to explore what further treatment could be provided to Mrs A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leafletsand-guidance.
• Review Mrs A's treatment to ensure it is appropriate.

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

• In cases similar to Mrs A's where a patient's presentation with Crohn's disease is atypical, staff should consider alternative/additional diagnoses.

In relation to complaints handling, we recommended:

• In complaints, where complainants have raised concerns about the lack of treatment being provided, the board should explore what further treatment should be provided and refer to this in their response.

Summary

Mr C complained that the dentist unreasonably failed to diagnose the cause of his facial pain. Mr C said that he attended his dentist but was told there was nothing wrong with his teeth. He continued to see his GP about his facial pain and several medical investigations were carried out. Fourteen months after Mr  C had attended his dentist, he saw a specialist who found out that he had a long- standing infection.

We took independent advice from a dental adviser. We found that the treatment decisions and management of Mr C was reasonable in the circumstances, as was the failure to diagnose an infection. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) by the practice. She complained that Mrs A's symptoms and medical and dental history were largely ignored. Mrs C felt that Mrs A's life was cut short as a result of poor care and treatment by the practice.

We took independent advice from a GP. We found that the care and treatment provided to Mrs A by the practice was of a reasonable standard. We found no evidence that the practice had failed to act on abnormal results or that the practice failed to arrange appropriate investigations and referral to secondary care. We did not uphold the complaint.

Summary

Mrs C complained about the medical care and treatment her late mother (Mrs A) received when she attended the Victoria Hospital. In particular that more could have been done by the cardiac service to investigate Mrs A's symptoms and diagnose her.

We took independent advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that there had been some shortcomings in relation to aspects of communication, however, this did not impact on Mrs A's condition. We found that overall the care and treatment Mrs A received had been reasonable. We also noted that the timing of the cardiac tests less than two weeks after a referral from a GP demonstrated good practice and a responsive organisation. We did not uphold Mrs C's complaint.

Summary

Mr C complained about the care and treatment he received at Dumfries and Galloway Royal Infirmary. Mr C received an injection into his hip for pain relief but the needle was placed in the wrong place causing Mr A pain. Another consultant had to remove the needle and gave a further injection in another place. Mr C said that he continues to suffer pain from the procedure and that he had been unable to return to work.

We took independent advice from an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that adequate consent had been obtained from Mr C and that he was advised of the potential risks and the possibility that the procedure may not be successful. We noted that Mr C had suffered a rare but recognised complication of the procedure. The supervising consultant had to take over when difficulties were encountered and this is normal practice. Therefore, we did not uphold Mr C's complaint.