Health

Summary

Mr C complained about treatment he received at the Royal Infirmary Edinburgh after suffering a head injury. He raised concerns that the board had failed to identify a fracture to his skull on his first attendance, as they did not carry out a CT scan until he was referred back to hospital by his GP two days after being discharged.

This case was very similar to a complaint we had recently upheld (201508264). In that case, we recommended that the board carry out an audit of similar head injury cases treated at the hospital. As the audit was still in progress at the time of Mr C's complaint, we asked the board to include his case in their consideration. They did so, and repeated what they had told Mr C in their response to his complaint - that they considered the treatment he received was appropriate. They also maintained this position in response to enquiries we made throughout our investigation.

We took independent advice from a consultant in emergency medicine. The adviser told us that the board's failure to carry out a CT scan on Mr C's first admission was unreasonable as the board had recorded that Mr C had a severe and persisting headache and Mr C had suffered a fall from a height greater than one metre. Under guidance from the Scottish Intercollegiate Guidelines Network  (SIGN) and the board's protocol in place at that time, this should have led to a CT scan being arranged. We also found that the board had failed to carry out enough observations of Mr C's level of consciousness. In particular, the board had failed to record that Mr C was reviewed by an experienced doctor before being discharged. SIGN guidelines specify that an experienced doctor should review all head injury patients before they are discharged to ensure that six specific criteria are met. However, this failling had since been remedied by a new procedure implemented following case 201508264.

We were also concerned that, despite a number of these failings being a repetition of those highlighted in case 201508264, the board had failed to identify the failings, either in response to Mr C's complaint, as part of the audit they carried out into his care or when responding to our enquiries. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide appropriate treatment for his head injury. 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:

• All staff should follow the protocols in place with regards to patients with head injuries.

In relation to complaints handling, we recommended:

• The board's investigations at all stages should identify failures in care and, where failings are identified, make proportionate changes to avoid similar mistakes in future.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C attended the practice with symptoms of a hoarse voice, burning and tightness in her chest, decreasing over five days. Mrs C explained to the practice that she was due to go on holiday in three days and queried whether she was fit for travel. The doctor considered that she was suffering from a viral infection, recommended fluids and paracetamol and considered her to be fit for travel. However, in the following days her condition worsened, causing her to attend a hospital's emergency department who prescribed antibiotics. Mrs C was still unwell when her holiday commenced. Mrs C complained that the practice had not provided her with reasonable treatment, which caused her to be unwell on her holiday.

We took independent advice from a GP. Based on the information available at the time, we considered that the practice provided a reasonable standard of medical treatment and that the practice could not have foreseen that Mrs C's condition would worsen, impacting on her holiday. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) at Monklands Hospital. Mr A had terminal cancer and was admitted to hospital after he developed pneumonia (a lung infection). Following admission, Mr A received an x-ray, pain medication, fluids and antibiotics, and test results indicated that he had neutropenic sepsis (a potentially fatal complication of anti- cancer treatment in which the ability of bone marrow to respond to infection is supressed). During the admission, doctors considered whether to transfer Mr  A to the Intensive Care Unit (ICU). It was felt that, due to the severity of Mr  A's presenting illness as well as the background of cancer undergoing palliative treatment (end of life treatment), ICU treatment would not have altered his chance of survival. Mr A continued to receive treatment on the medical ward, and he died the day following admission to the hospital.

Mr C was unhappy that Mr A was not treated in ICU and he felt that Mr A did not receive appropriate care and treatment during the admission. We took independent advice from a consultant in acute medicine. We found that Mr A received rapid assessment and treatment on admission to the hospital and we considered that the care provided was reasonable. We also considered that the board's decision not to treat Mr A in ICU was reasonable in the circumstances. The adviser noted that specialist cancer nurses had been involved in Mr A's care and they considered that the care provided both before and after the nurses' involvement was reasonable. We did not uphold Mr C's complaint.

Summary

Following a fall at home, Mrs C was taken to Wishaw General Hospital where scans were taken. Mrs C was told by a doctor that the scan results suggested that breast cancer, which she had suffered from previously, had returned. Discussions were held with the breast cancer nurse and the oncology (cancer  treatment) department, who were not convinved that the results were evidence of metastases (when cancer spreads from the initial site to a secondary site). Mrs C had to wait until the outcome of further scans over an eight week period before being told that her condition was benign (non-cancerous) and that there was no metastases. Mrs C complained that it was inappropriate for staff to have told her that scans had shown the possibility of metastases.

We took independent advice from a consultant radiologist. We found that it was reasonable for staff to conclude that intial scan results showed signs which could have been attributable to metastases. We found that Mrs C had symptoms that are considered concerning for metastatic disease from breast cancer. We, therefore, considered that it was appropriate to make Mrs C aware of the concerns around potential metastases. We also found that there was no delay in reaching a definite diagnosis. We did not uphold the complaint.

Summary

Mr C noticed a lump in his chest and he was concerned that it was related to a previous abscess (a painful swelling caused by a build-up of pus) he had suffered with. His GP referred him to Hairmyres Hospital for a scan, where it was found that he had an abscess in the fat under the skin that was unlikely to be tracking elsewhere in his body. Mr C had a procedure to have this abscess drained at the hospital and afterwards he began to feel very unwell. He attended a private hospital and was found to have a very large, deeper abscess that was spreading down under his liver and pushing up to his chest. Mr C complained that the board had unreasonably failed to diagose and treat this abscess.

We took independent advice from a consultant vascular and general surgeon. We found that Mr C's condition was appropriately assessed and investigated when he attended the hospital. The adviser explained that the scan that had been taken did not show any deeper abscess. We noted that Mr C did not have symptoms that suggested a larger, deeper abscess. We found that, although Mr  C would have had the larger, deeper abscess when he attended the hospital, the failure to diagnose was not unreasonable. We did not uphold Mr C's complaint.

Summary

Ms C complained about the care and treatment provided to her late sister (Miss  A). Miss A had attended a routine appointment with a practice nurse for her asthma, and had reported symptoms of a urinary tract infection. The nurse had taken a urine sample and had the on-call GP prescribe antibiotics. Several days later Miss A's condition deteriorated and she was admitted to hospital with sepsis (a blood infection), where she then died. Ms C complained that the practice nurse should have realised how unwell Miss A was and carried out further checks such as heart rate, temperature and blood pressure. Ms C felt that if these had been carried out Miss A would have had appropriate treatment sooner.

We took independent advice from a practice nurse and a GP. We found that there was nothing in the medical record to note what symptoms Miss A presented with or any assessment undertaken, and we considered this to be unreasonable. We found that based on the symptoms described by the practice nurse in her complaint investigation statements, the practice nurse should have undertaken a thorough history of Miss A's symptoms, checked her temperature, pulse and blood pressure, and checked for signs of pain. We upheld this aspect of Ms C's complaint.

Ms C also raised concerns that Miss A's blood test results were not acted upon in the weeks leading up to her death. We found that the blood tests that were being monitored were part of the practice's routine screening for chronic disease, and that any abnormal results were followed up appropriately and were not related to Miss A's later diagnosis of sepsis. We did not uphold this aspect of Ms  C's complaint.

Finally, Ms C complained about the practice's handling of her complaint. We found that the practice failed to handle Ms C's complaint reasonably and that it did not meet the complaints handling guidance in place at the time. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately assess Miss A and for failing to handle her complaint reasonably. The apology should meet the standard 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 should receive full and appropriate assessments, from the appropriate person, based on their reported symptoms. These should be documented in accordance with recognised standards such as the NMC Code of Conduct.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Ms C complained about the treatment she received at Wishaw General Hospital. Ms C became pregnant and had a high body mass index (BMI, a measure for estimating human body fat) when she booked in for a scan. As a result, Ms C was tested for gestational diabetes (diabetes that develops in women who did not have diabetes before their pregnancy) and was later prescribed medication to reduce her high blood sugar levels. This dose was later increased as her blood sugar levels remained high. Ms C was admitted to hospital as her baby stopped growing and had an emergency caesarean section to deliver her baby. After she was discharged home, Ms C developed an infection and her stitches burst. She later went on to develop nerve damage and fibromyalgia (a long term condition that causes pain all over the body). Ms C complained that the treatment she received towards the end of her pregnancy led to nerve damage and fibromyalgia.

We took independent advice from a consultant obstetrician and gynaecologist (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that Ms C was correctly started on medication because of her persistently high blood sugar levels and that this helped with problems associated with gestational diabetes. This was in keeping with national guidelines. We noted that Ms C's high BMI and gestational diabetes were significant risks in pregnancy and wound healing. While Ms C suffered nerve damage and developed fibromyalgia, these were not known to be associated with caesarean section surgery. Therefore, we found that she had been treated reasonably and appropriately. We did not uphold Ms C's complaint.

Summary

Mrs C complained about the care and treatment she received at Wishaw General Hospitial in relation to her fertility treatment. In particular, Mrs C stated that she had been misinformed that the medication she was taking would not affect her fertility.

We took independent advice from a consultant obstetrician and gynaecologist (the medical specialty that deals with pregnancy, childbirth, and the post-partum period and the health of the female reproductive systems and the breasts). We found that the correct investigations in relation to Mrs C fertility problems had been performed in a timely manner. We also noted that it was explained to Mrs  C at an early stage about the contributory factors to the fertility problems she was experiencing and the treatment which would be required. We found that there was no evidence that Mrs C had been misinformed about the cause of her fertility problem and that she had been kept advised of the results of the various investigations carried out as they proceeded. Therefore, we did not uphold the complaint.

Mrs C also complained that the board had failed to adequately address her complaint. We found that the board had handled the complaint in line with their complaint process and had offered the opportunity to meet with senior staff to address any outstanding questions. We did not uphold the complaint.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received while she was a patient in Wishaw General Hospital. Mr C was concerned about both the medical and nursing care Mrs A received, and about the way that the board handled his complaint.

In regards to Mrs A's medical treatment, Mr C questioned the length of time a central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) was in place. Mr C also complained that there was an unreasonable delay by medical staff in reviewing blood test results, and subsequently in Mrs A receiving antibiotics. Mr C believed that, because of poor treatment, Mrs A was denied the opportunity of starting chemotherapy treatment.

We took independent advice from a consultant general surgeon with experience in oncology (cancer treatment) We found that, following Mrs A's admission surgery and further investigations being carried out, it was confirmed that she had extensive, incurable cancer and all further treatment was to be palliative (end of life care). We considered that the length of time Mrs A's central line was in place and the actions of medical staff in prioritising the alleviation of Mrs A's severe pain was reasonable. However, we found that there was a significant delay of several hours in reviewing Mrs A's blood test results and starting appropriate antibiotics. While we found that it was unlikely that the delay in starting antibiotics significantly changed Mrs A's outcome, given her underlying condition and poor prognosis, the delay was unacceptable. Therefore, we upheld this aspect of Mr  C's complaint. The board had already acknowledged that there was an unacceptable delay, due to a breakdown in communication involving both junior and senior doctors, and had noted that this has been addressed with staff.

In relation to Mrs A's nursing care, Mr C was concerned over elements of record- keeping and the frequency and recording of some of Mrs A's observations by nursing staff. We took independent advice from a nurse. We found that certain aspects of Mrs A's nursing care were good however, both advisers noted failings in the quality of the completion of some of Mrs A's records and in the frequency of her observations. Therefore, we upheld this aspect of Mr C's complaint. The board had already acknowledged that these issues were unacceptable and noted that they had apologised and taken action.

Finally, Mr C was dissatisfied with the board's response to the concerns he and his family raised about Mrs A's care and treatment. In relation to a meeting which was held to discuss Mr C's concerns, we identified certain aspects that we found to be unreasonable. For this reason, we considered that the board had not responded reasonably to Mr C's complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for the failings identified including a breakdown in communication causing a significant delay in reviewing Mrs  A's blood test results and starting appropriate antibiotics failings by nursing staff in record keeping; and a failure to respond to concerns raised by Mr C and his family following a meeting. 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:

• Current practices and processes and the working relationship between junior and senior doctors should be improved to minimise the risk of a future similar event occurring. Ensure that the importance of effective handover is emphasised as part of a junior doctor's induction. Ensure appropriate timescales are in place for requesting, performing and documenting results, and actions taken, for investigations such as blood tests.
• Nursing observations should be carried out in line with the board's Medical  Early Warning flowchart and the scoring system should be accurately applied. Nursing care charts and care bundles should be completed accurately and in line with the Nursing and Midwifery Council's guidance on record-keeping. The board should reissue relevant staff with their central line care policy and provide appropriate education to staff to support this. Also, senior nurses should routinely audit compliance with the central line maintenance bundle.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mrs C complained that the care and treatment she received at Raigmore Hospital, in relation to problems with her gallbladder, was unreasonable. She said that on several occasions she attended an out-of-hours GP and the emergency department but her symptoms were not investigated and as a result, when she was diagnosed with cholecystitis (inflammation of the gallbladder), the surgery was complicated and her recovery was difficult.

We took independent advice from a GP, a consultant in emergency medicine, and a surgeon. We found that the care and treatment provided to Mrs C was of a reasonable standard and there was no indication of gallbladder problems at her attendances prior to the diagnosis of cholecystitis. We did not uphold Mrs C's complaint.