Health

Summary
Ms C complained to us on behalf of her client (Mr A) that doctors did not reasonably diagnose that his late wife (Mrs A) had cancer.  In late 2012, Mrs A had breast cancer surgery, during which an extremely large high-grade tumour was removed.  She contacted the practice some seven months later complaining of back pain and spasms.  She also then developed a wheeze and cough.  Between 29 July 2013 and 19 August 2013 she had four telephone consultations with three GPs at the practice, who prescribed and adjusted pain relief medication, and later provided Mrs A with an inhaler.  The day after the last consultation, she contacted NHS 24 because she was having problems breathing.  They arranged for an out-of-hours doctor to visit, who diagnosed pneumonia and said Mrs A should contact her GP.  She did this the same day, and saw another GP from her practice, who referred her straight to hospital because of her history of breast cancer.  She was found to have cancerous growths and a build-up of fluid in her chest.  She was admitted to hospital but died before cancer treatment could be started.

When Mr A complained to the practice they concluded that they did not identify early enough that Mrs A was as unwell as she was, and that it would have been better if she had been more fully assessed.  They said that this might have been partly due to a breakdown in communications, apologised for the standard of care provided and said that they would carry out a Serious Event Analysis (SEA) of Mrs A's case.  Mr A was not satisfied with this, and took the complaint further, latterly with the help of Ms C.  The final outcome was that although the practice agreed that with hindsight things could have been done better, they said that they had found nothing that needed remedy.

I took independent advice from one of my medical advisers, who is a GP.  She said that the medical histories taken during the telephone consultations were sparse and that Mrs A's clinical history should have made doctors suspect that the cancer might have come back.  The surgeon had told the practice that it was not possible to say whether surgery had achieved a long term cure.  Given all the circumstances, my adviser said that Mrs A should have been physically assessed at the time of the first call, and certainly when the pain did not resolve after painkillers were provided.  My adviser had several concerns about the lack of assessment before prescribing treatments, and these are detailed in my report.  She also pointed out although that the SEA report showed some evidence of reflection on and learning from Mrs A's case, the practice also appeared to have suggested that some of the responsibility lay with Mrs A for not explaining just how much pain she was in.

I upheld Ms C's complaint, as I found that a combination of errors led to an unreasonable delay in diagnosing Mrs A's condition.  She should have been seen face-to-face and assessed much earlier, and elements of her care fell below General Medical Council standards.  Although the practice accepted that they did not physically assess her early enough and have introduced a new telephone protocol, my adviser identified some other serious failings, especially around prescribing medication without adequate knowledge of the patient's health.  I was also concerned that in handling the complaint the practice appeared to ascribe some of the blame to Mrs A, which suggests to me that they had not fully accepted that their handling of her case was not of a reasonable standard.  They also appeared to minimise fault on the part of the doctors, and I found the tone of some of their letters inappropriate.

Redress and recommendations
I recommended that the Practice:

• (i)  apologise to Mr A for the failure to identify the recurrence of Mrs A's cancer;
• (ii)  ensure that this complaint is discussed during the next annual appraisals of GP 1, GP 2 and GP 3;
• (iii)  raise awareness amongst all doctors at the Practice of the signs and symptoms of cancer recurrence; and
• (iv)  refer this case to the Board for further discussion with their clinical support group to avoid a recurrence of similar events in future.

Summary
Mrs C complained on behalf of her grandmother (Mrs A) about the time it took to provide Mrs A with treatment.  Mrs A had a long history of incontinence problems, and her GP referred her to the board in August 2012.  In November 2012, Mrs A had her first appointment at Wishaw General Hospital.  In May 2013, tests at a second appointment identified the problem as stress incontinence.  At a third appointment in October 2013 a doctor suggested that surgery might address this, and said that Mrs A would be referred to a specialist consultant.  This, however, did not happen and when by January 2014 nothing had been heard, Mrs A, her GP and Mrs C all contacted the hospital.  Mrs A was eventually referred to a consultant in February 2014, and was placed on a waiting list for surgery.

Meanwhile, in September 2013 new national guidelines had been produced for managing incontinence in women and subsequently the board formed a group to discuss the best way to treat patients like Mrs A.  The group discussed Mrs A's case at their first meeting in March 2014.  They decided that, per the guidelines, rather than her being on the waiting list, they should instead refer her to a specialist centre at another board (Hospital 2) to consider her treatment.  She eventually had surgery in February 2015, some two and a half years after her initial referral.

In February 2014, Mrs C had complained to the board about the delays.  They explained why these happened, acknowledged that they were unacceptable and apologised for this and for the distress caused.  Mrs C was unhappy with their response as it did not say whether anything had been done to stop this happening again.

I took independent advice from two advisers, a consultant physician and a consultant gynaecologist.  The consultant physician said that the delays after the first appointment were unacceptable, and that there was a failure of care when Mrs A was not referred to the specialist consultant in October 2013.  Both advisers found the delay in referring Mrs A to the specialist centre unacceptable, although the consultant gynaecologist confirmed that in Mrs A's case it was entirely correct to follow the guidelines and refer her there for consideration.

I found that there was a general lack of urgency in Mrs A's care, that there were unreasonable delays in investigating and assessing her condition, and that the board did not address these effectively when responding to Mrs C's complaint.  I was particularly concerned that Mrs A was not referred to a consultant in October 2013, and that when handling the complaint the board did not try to find out why this happened.  I upheld Mrs C's complaint and made four recommendations.

Redress and recommendations
I recommended that the Board:

• (i)  conduct a detailed review of the failings around the out-patient appointment of 28 October 2013, particularly treatment time targets and the lack of referral/clinic letter; 
• (ii)  conduct a review of appointment allocation and waiting times for patients within the uro-gynaecology speciality;
• (iii)  apologise and provide an explanation for the delay in referring Mrs A to Hospital 2; and
• (iv)  apologise to Mrs C for failing to provide a reasonable response to her complaint.

Overview
The complainant (Mrs C) complained to Western Isles NHS Board (the Board) that a locum consultant gynaecologist (Consultant 1) had not carried out the operation originally agreed between her and her consultant gynaecologist (Consultant 2).  She was further concerned that Consultant 1 incorrectly told her the agreed operation had been carried out; she later discovered it had not been.

Mrs C also complained that she had been given inaccurate information about her post-operative complications.

Specific complaints and conclusions

The complaints which have been investigated are that:

• Consultant 1 unreasonably failed to carry out a full hysterectomy as agreed with Consultant 2 (upheld);
• Consultant 1 provided inaccurate information about the procedure he had carried out (upheld); and
• the Board provided an inadequate explanation concerning the complications which arose during Mrs C's surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a); in particular, that they did not afford her the opportunity to have the operation she had previously agreed with Consultant 2;
• ensure that the comments of the Adviser, in relation to the issue of consent; are brought to the attention of the relevant staff;
• review the procedures for arranging locum surgical cover, so as to ensure that the locum has the requisite surgical skills and expertise;
• apologise to Mrs C for the failing identified in complaint (b), that Consultant 1 provided her with incorrect information about her operation;
• review their current significant adverse event guidance in light of the Adviser's concerns detailed in this report and share the Adviser's comments with the relevant staff; and
• ensure they have a clear policy in place concerning the transfer of patients from one consultant's care to another.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Ms C) raised concerns about the Medical Practice (the Practice) on behalf of her client (Mrs A).  Mrs A's complaints relate to her son (Mr B) and attempts to register him at the Practice.  Mr B was in prison but was due for liberation on 18 January 2013.  Whilst Mr B was still a prisoner, Mrs A visited the Practice and completed registration forms for him.  She also made an appointment for the day of his release so that he could obtain antipsychotic medication (medicines used to treat mental health conditions) to alleviate methadone (a drug used medically as a heroin substitute) withdrawal.  Mrs A contacted the Practice on 16 January 2013 and confirmed that Mr B's appointment was booked for 18 January 2013.  Also on 16 January 2013, the Practice Manager received a call from Greater Glasgow and Clyde Patient Registrations advising that Mr B was still registered as 'care of HMP' (care of Her Majesty's Prison) and that he could not be registered elsewhere until he was liberated.  The Practice Manager thereafter cancelled the registration on the system and advised two members of staff to update Mrs A and Mr B.  Neither of the staff members provided the update.  Mr B was released as planned on 18 January 2013.  He attended at the Practice for his appointment and was advised that there was none on the system.  The Practice Manager gave him contact details for the community mental health team, community addictions team and NHS 24.  Mr B left the Practice without seeing a GP.  He died from pneumonia (an infection of the lungs) three days later on 21 January 2013.

Specific complaints and conclusions
The complaints which have been investigated are that:

• Mr B was unreasonably refused access to a GP (upheld); and
• the Practice unreasonably did not respond to further letters related to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mrs A and acknowledge that they should have seen and assessed Mr B properly on 18 January 2013;
• provide us with copies of their Significant Event Analysis and Enhanced Significant Event Analysis with their reflections on what happened and why this occurred;
• provide us with their written policies on the registration of new patients and the provision of immediately necessary treatment;
• ensure that all staff within the Practice are fully trained on patient registration and provision of immediately necessary treatment;
• apologise to Ms C and Mrs A for their failure to deal with further complaint correspondence appropriately;
• work with the Board to create a new complaint handling procedure and provide a copy to us for review; and
• ensure that all staff are fully trained on the complaint handling procedure.

The Practice have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) regarding the care and treatment her father (Mr A) received while a patient in Glasgow Royal Infirmary (the Hospital).  Mr A died in hospital on 26 November 2013.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• provide reasonable care and treatment to Mr A between 25 October and 26 November 2013 (upheld);
• communicate reasonably with Mr A's family between 25 October and 26 November 2013 (upheld); and
• respond reasonably to Mrs C's complaints about these matters (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• ensure its policies set out clear responsibilities for clinicians to ensure that tests are either reviewed by the requesting doctor, or handed over to colleagues;
• carry out a morbidity and mortality case review  of Mr A's death.  The review should include the actions of the Haematology and Orthopaedic departments and provide evidence that the following points were addressed: the handover procedures followed by medical staff; the care and treatment pathways for the management of patients who fracture their hip whilst on a geriatric ward; the failure to ensure that Do Not Attempt Cardio-Pulmonary Resuscitation was discussed appropriately with the patient or his family; whether the Board's end of life care policies were properly followed; whether Mr A's mental capacity was properly assessed and what procedure should have been followed; review whether there was appropriate and timeous discussion of resuscitation with Mr A's family; review the failure to document in Mr A's records the reason for his ward transfer; review the lack of early Consultant input into case discussions with Mr A or his family;
• include the findings of the morbidity and mortality review in the subsequent appraisal of the consultant responsible for Mr A's care;
• remind all staff of the importance of documenting and signing discussions with patients' families;
• apologise for the failings identified in this report; and
• provide evidence that the actions referred to in the complaint response letter have been implemented.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) complained to Ayrshire and Arran NHS Board (the Board) about the care and treatment he received at Crosshouse Hospital, Kilmarnock (the Hospital) in connection with surgery for the removal of duct stones.

Specific complaints and conclusions
The complaints which have been investigated are that the Board unreasonably failed to:

• obtain consent for the specific procedure that was carried out on Mr C (upheld); and
• remove duct stones at the time of Mr C's first operation (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr C for the failings identified in complaint (a) of this report;
• provide evidence of the action taken as referred to paragraph 16 of this report;
• carry out a significant event analysis of what happened in Mr C's case and report the findings to my office;
• provide evidence that they have addressed the issues of (i) consent being obtained by medical staff not competent to carry out the surgical procedure the patient is being consented for; and (ii) obtaining written consent on occasions other than the day of the patient's surgery;
• ensure that the comments of the advisers are brought to the attention of the relevant staff;
• issue a written apology to Mr C for the failings identified in complaint (b) of this report; and
• provide evidence of the action taken to address the failings identified in respect of the removal of Mr C's residual right sublingual gland.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) complained about the treatment provided to Mr A, after he was admitted to the Aberdeen Royal Infirmary (the Hospital) with severe chest pain.  Mr A was initially treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).  However, approximately two and a half days after his admission, it was diagnosed that Mr A had a dissection flap (tear) in the ascending aorta (a portion of the large trunk artery that carries blood from the left ventricle of the heart to branch arteries).  Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

Specific complaint and conclusions
The complaint that has been investigated is that staff at the Hospital failed to provide Mr A with an appropriate level of treatment following his admission in January 2012 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr A's family for:  the failure to identify that Mr A had aortic dissection when the bedside echocardiogram was carried out on 2 January 2012; and the delay in providing a copy of the bedside echocardiogram to his office; and
• provide evidence that they have taken steps to raise awareness of aortic dissection in their A&E, Emergency Medicine, General Medicine and Cardiology departments.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) raised a number of concerns that his mother in law (Mrs A) had been inappropriately cared for in Perth Royal Infirmary.  Mrs A had been admitted on 15 February 2013, with a sudden loss of mobility.  She was discharged on 13 May 2013, but had not regained the ability to walk.  Mr C said that it was not until later that the family learned Mrs A had suffered a fractured hip.  Mr C said this was not properly diagnosed or treated and that Mrs A was never x-rayed during her stay in hospital.  Mr C was also unhappy with the way his complaints were handled by Tayside NHS Board (the Board), as he felt the internal review process lacked objectivity and dismissed the family's concerns.

Specific complaints and conclusions
The complaints which have been investigated are that:

• the Board provided inadequate care and treatment to Mrs A (upheld);
• the Board's reviews of Mrs A's care and treatment were inadequate (upheld); and
• the Board's handling of and response to Mr C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• remind all staff of the importance of discussing completion of the Do Not Attempt Cardio-Pulmonary Resuscitation form with either the patient or appropriate family members;
• review their processes to provide a failsafe to ensure that vulnerable patients are fully assessed to determine their capacity;
• remind all staff involved in geriatric care of the importance of considering hip fracture in elderly patients with loss of mobility;
• review their procedures to ensure that internal case reviews have objective clinical assessment of the available evidence;
• review their procedures to ensure that where additional medical opinion is required, this is obtained in a formal statement from the clinician;
• review its complaints procedure to ensure that all meetings with complainants are formally noted;
• review its complaints procedure to ensure that complainants are provided with notes of all meetings with Board staff conducted under the complaints procedure; and
• apologise in writing to Mr C for the failure to diagnose Mrs A timeously with a hip fracture and for the identified failures in dealing with his complaint.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) raised a number of concerns over the care and treatment her late brother (Mr A) received from Lanarkshire NHS Board (the Board) following his admission to Monklands Hospital on 27 February 2013.  Mr A was admitted with swallowing difficulties and died on 22 March 2013.

Specific complaints and conclusions
The complaints which have been investigated are:

• the Board provided inadequate care and treatment to Mr A (upheld); and
• there were unreasonable delays in care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their results 'sign off' process at ward level to ensure all results are reviewed before filing;
• conduct a review of their complaints handling to analyse why this result from another health board was not identified as part of their investigation;
• apologise to Mrs C for the failure to diagnose Mr A properly, particularly with the information available from the blood test reported upon after his death; and
• investigate the delay in the time from referral to review by the neurologist and provide staff with advice about how to obtain specialist neurological advice for patients such as Mr A, when a consultant review may be delayed.

Overview
The complainant (Mrs C) raised a number of concerns that her late brother (Mr A) had been inappropriately assessed when he attended his GP Surgery (the Practice) on 29 July 2013.  She complained that Mr A should have been referred to hospital for further tests rather than being prescribed medication for an inflamed stomach.  Mr A died suddenly of a heart attack on 31 July 2013.

Specific complaints and conclusions
The complaint which has been investigated is that on 29 July 2013 the Practice failed to provide Mr A with appropriate medical care (upheld).

Redress and recommendations
I recommend that the Practice:

• issue an apology to Mrs C for the failings identified;
• review  the level of education and training required to carry out the NP role, particularly in relation to clinical assessment and diagnosis;
• review the assessment/supervision and on-going monitoring and appraisal requirements in place for the nurse practitioner; and
• submit a Significant Event Analysis (SEA) which is in the standard format used nationally.

The Practice have accepted the recommendations and will act on them accordingly.