Health

Summary

Miss C complained about the treatment a dentist provided to her over a number of years. We took independent advice from a dental adviser. We found that there was a failure by the dentist to observe decay in three teeth, and possibly other teeth. Consequently, the dentist failed to plan for the management and treatment of the affected teeth. This meant that Miss C's decay profile was wrong, and she did not receive the level of observation and intervention needed, which led to an increase in the risk of decay and a significant impact on the health of her gums. We also found that fillings placed by the dentist were of a poor standard. We concluded that the treatment provided to Miss C was below a reasonable standard and we upheld her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to observe decay, which meant a failure to plan appropriately for the management and treatment of her teeth. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• The dentist should make a payment to Miss C, equivalent to the costs of care and treatment provided (excluding an amount already paid as a goodwill gesture) as redress for Miss C not getting the level of observation and intervention needed.

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

• The dentist should ensure that they have the professional knowledge and skills to understand and act on decay diagnosis on radiographs.
• The dentist should ensure that they have the professional knowledge and skills to achieve proper placement and finishing of fillings within teeth.

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

Mr and Mrs C complained that midwives at Gilbert Bain Hospital failed to recognise that Mrs C had hyponatraemia (low blood sodium levels). Mrs C was given advice to drink more fluids, which made her condition more severe. Mr and Mrs C also complained that the board failed to handle their complaint and the review into Mrs C's care appropriately. In particular, they considered the review wrongly concluded Mrs C had a condition called syndrome of inappropriate antidiuretic hormone production (SIADH - the excessive secretion of antidiuretic hormone resulting in, among other things, water retention and dilution of the blood) when she actually had hyponatraemia. Mr and Mrs C considered the board failed to identify appropriate learning from the review and share it with them.

The board accepted that Mrs C was given inappropriate advice to drink fluids by midwives. However, they said it was unreasonable to expect midwives to have recognised she had SIADH, as it is very rare. The board considered they had undertaken a thorough review of Mr and Mrs C's care and complaint. They explained they had taken learning from it forward by training staff on recognising SIADH.

During our investigation we took independent medical advice from a midwife and from a consultant in general medicine.

The midwife adviser considered that the midwives carried out appropriate observations and tests in light of Mrs C's symptoms. They considered the advice given to Mrs C to drink more fluids was reasonable in light of those symptoms. Therefore, we did not uphold this aspect of the complaint.

The midwife adviser considered that the board undertook an appropriate review into Mrs C's care. However, there was a delay in sharing the action plan with Mr and Mrs C. The general medicine adviser considered it was reasonable that the board diagnosed Mrs C with SIADH following the review. They explained that Mrs C had hyponatraemia, which can have many causes, one of which is SIADH. However, given hyponatraemia is much more common than SIADH, the general medicine adviser considered the board should have trained staff on recognising and treating hyponatraemia as well as SIADH. In light of the failings we found in identifying learning from the review and in sharing it with Mr and Mrs C, we upheld this aspect of the complaint. We made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for failing to appropriately identify the learning from their case and share it with them at the time. 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:

• Reviews should be transparent and any learning should be shared with all those involved in the adverse event, including patients.
• The board should provide a reasonable standard of care to patients with hyponatraemia, whatever its underlying cause, with adequate staff training in place to support this.

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 attended a dental practice for emergency treatment as she was experiencing tooth pain. Ms C complained that the dentist treated the wrong tooth and failed to identify an infection in her wisdom tooth. The practice confirmed that the dentist performed the first stage of a root canal treatment in the tooth that they identified as causing Ms C's pain. They also confirmed that there was no infection present in Ms C's wisdom tooth on the day of her appointment. Ms C was unhappy with this response and brought her complaint to us.

We took independent advice from a dentist and found that Ms C's dentist carried out a thorough assessment of her symptoms. We noted that the dentist treated the tooth that was identified as causing the pain following a series of tests, including an x-ray. We also found no evidence of an infection in the wisdom tooth and, therefore, it was likely that the infection developed after the appointment. We considered that the treatment Ms C received was reasonable and, therefore, we did not uphold her complaint.

Summary

Miss C complained that the plans made for her labour at the Royal Infirmary of Edinburgh were unreasonable. Specifically, that she was refused a caesarean section and induction of labour, and that she was advised not to call an ambulance when going into labour. Miss C also complained that staff included inaccurate information, about a consultation, in correspondence to her GP.

We took independent medical advice from a consultant obstetrician and found that there was no evidence to show that Miss C was refused a caesarean section or induction of labour. We considered that it was reasonable of board staff to recommend against a caesarean section in this case, given the complications associated with the operation. We also considered that advice given not to call for an ambulance outside an emergency situation was appropriate. Therefore, we did not uphold this complaint.

We were also satisfied that a member of staff had not unreasonably included inaccurate information to Miss C's GP and, therefore, did not uphold this complaint. However, we provided feedback to the board that there appeared to have been some miscommunication regarding the matter.

Summary

Ms C, who is a patient adviser, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A at the Royal Infirmary of Edinburgh. Mrs A attended hospital for a planned coronary artery bypass graft (a surgical procedure used to treat coronary heart disease). After a week of in-patient care, medical staff were satisfied that Mrs A had recovered well and was fit to be discharged. Mrs A became unwell shortly following discharge and was re-admitted to a different hospital with an infection. Ms C raised a number of concerns on behalf of Mrs A, who felt that the care provided by the board was inadequate.

Firstly, Ms C complained that staff failed to monitor Mrs A's condition appropriately. We took advice from a cardiac surgery adviser and a nursing adviser. We found that appropriate monitoring did take place during Mrs A's recovery from surgery and that appropriate records of this were maintained. We did not uphold this part of the complaint.

Ms C also raised concern that staff did not listen to and document concerns raised by Mrs A, and did not keep appropriate records of attempted blood tests. We found no evidence in the records that staff did not listen to and document Mrs A's concerns about her health. We were also satisfied that the medical and nursing records were maintained to a reasonable standard. We did not uphold this aspect of the complaint.

Finally, Ms C complained that Mrs A was inappropriately discharged home with an infection. Ms C raised concern that Mrs A was left waiting for a number of hours in the discharge lounge whilst her condition deteriorated and that staff then failed to readmit her to the ward. We found no evidence from the records of the admission that Mrs A had an infection prior to discharge. However, the advice we received highlighted that Mrs A remained in atrial fibrillation (fast irregular heartbeat) on the day of discharge, and that medical staff should have discussed this, and any potential issues that might ensue, with Mrs A prior to discharge. We found no evidence that Mrs A or her husband had reported that her condition was deteriorating whilst she was in the discharge lounge. However, we noted that the board had advised that the senior charge nurse responsible for the discharge lounge had reminded their team that patients who became unwell should be returned to the ward and they were satisfied that the correct procedure would be followed in future.

We were unable to conclude that the complication Mrs A experienced following discharge was as a result of unreasonable care and treatment from staff at the Royal Infirmary of Edinburgh. However, we upheld the complaint and made recommendations because there was no evidence that staff discussed atrial fibrillation with Mrs A prior to discharge.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to discuss atrial fibrillation, and what she should do if she became more unwell, with her prior to discharge. 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:

• Where a patient is in atrial fibrillation, but is otherwise ready for discharge, staff should inform the patient of any complications atrial fibrillation might present, what to do if they become more unwell, and confirm with the patient that they feel ready for discharge. This discussion should be documented in the patient's records.

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

Mr C complained about the care and treatment his late wife (Mrs A) received during admissions to St John's Hospital, the Royal Infirmary of Edinburgh and the Western General Hospital. In particular, Mr C complained about an unreasonable delay in diagnosing Mrs A's lymphoma (a type of cancer) during those admissions.

We took independent advice from a consultant upper-gastrointestinal surgeon and from a consultant physician. We found that appropriate investigations were carried out into Mrs A's condition. However, we found lymphoma is very difficult to diagnose and that it had presented in Mrs A in a very unusual way. We did find that Mrs A was unreasonably diagnosed with an autoimmune condition at St John's Hospital, based on blood test results that actually suggested inflammation. We found that an opinion from other relevant specialists may have avoided this misdiagnosis. We found that this error may have delayed her diagnosis of lymphoma by one month and we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for misdiagnosing Mrs A with an autoimmune condition. 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:

• Blood test results should be carefully reviewed, with the input of other medical specialists when appropriate.

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, an advocacy and support worker, complained on behalf of her client (Mr B) who had concerns about the way the medical practice had managed his mother (Mrs A)'s oxazepam medication (for anxiety and to be taken for short periods only). He said that Mrs A had been taking the medication for a number of years and that the practice had recently reduced the medication and, as a result, Mrs A suffered a stroke. She was taken to hospital and died of a further stroke a number of days later. Mr B felt that the stress of the medication reduction caused Mrs A to suffer a stroke.

We took independent advice from an adviser in general practice medicine and found that the practice had managed Mrs A's medication regime in an appropriate manner. Care has to be taken with oxazepam medication as it can cause both psychological and physical addiction. Practices have a responsibility to keep medication under review to ensure that it is still required and if it is not, they must reduce it or stop the medication completely. We found that there was evidence from the records that Mrs A was initially not requesting the medication on a regular basis but recently had made increased requests. This made it necessary to review and reduce the medication to an appropriate level. There was also no evidence that the reduction in medication led to Mrs A suffering a stroke. Therefore, we did not uphold the complaint.

Summary

Mr C complained to us that the practice had failed to provide appropriate treatment to his late wife (Mrs A). Mrs A had been attending a hospital out-patient department for a separate matter and had been advised to make an emergency GP appointment as she was showing symptoms of a cough and breathlessness. Mrs A developed deep vein thrombosis (DVT, blood clot in a large vein) four days after the consultation and later died. Mr C believed that the practice should have referred his wife to hospital at the time of the appointment.

The practice responded that Mrs A was given an emergency appointment following her attendance at the out-patient clinic. However, the reason for the appointment was for anxiety problems and Mrs A only reported symptoms of low mood and that her heart was racing. Mrs A did not report symptoms of having a cough, chest pain, shortness of breath, or pain or swelling in her leg. The practice prescribed anti-depressant medication and diagnosed anxiety problems.

We took independent advice from an adviser in general practice medicine and concluded that, from the entries in Mrs A's medical records, the practice had provided a reasonable level of care. There was no indication that Mrs A had reported symptoms suggestive of DVT and the medication prescribed by the practice was appropriate for symptoms of anxiety and low mood. There was also no indication that a hospital referral was required at that time. We did not uphold the complaint.

Summary

Ms C complained on behalf of her late father (Mr A) about the care and treatment he received from the practice prior to his diagnosis of cancer. Mr A presented at the practice with a swollen jaw and neck and was advised to visit his dentist immediately. Mr A later attended the out-of-hours GP service. The practice received the out-of-hours report that stated Mr A had an upcoming appointment at hospital and that he had been referred to an ear, nose and throat specialist. Ms C later contacted the practice as Mr A had become more unwell and an admission to hospital was agreed. Mr A was diagnosed with cancer and died not long after his diagnosis. Ms C complained that more could have been done by the practice to speed up the diagnosis.

We took independent advice from a medical adviser. They reviewed the records and were satisfied that the practice had provided reasonable care at each point of contact. Mr A had been seen by his dentist and out-of-hours services and was soon under the care of a consultant. Therefore, we did not uphold the complaint.

Summary

Mrs C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Mrs A was unhappy about delays in getting confirmation of an appointment with a consultant ophthalmologist (a doctor who deals with injuries and conditions in and around the eye). Mrs A was also unhappy with ophthalmology advice and treatment provided to her by the board.

The board acknowledged that Mrs A's clinic appointments were cancelled on a number of occasions and they apologised to Mrs A for the inconvenience this had caused. We found that, at the time, the board did not know that Mrs A's appointments had been cancelled so many times until Mrs C complained on her behalf. We found that the board had unreasonably delayed in confirming an appointment for Mrs A with a consultant ophthalmologist, and we upheld this aspect of Mrs C's complaint. The board provided reassurance that they were taking administrative steps and had recruited staff to stop such delays happening again. Given these steps taken by the board, we made no further recommendations in relation to this.

Mrs A was given different ophthalmology advice at her most recent clinic appointment from advice she had been given before. Mrs A felt she should have been given the new advice previously. We were satisfied with the board's explanation that the latest advice given to Mrs A was not a new type of treatment, but was a variation of the standard advice given for her eye condition. We did not uphold this aspect of Mrs C's complaint.