Health

Summary

Mrs C complained to us that the practice had failed to appropriately monitor her for any side effects of taking nitrofurantoin medication (antibiotic to treat urinary tract infections) for a number of years. She subsequently went on to develop pulmonary fibrosis (lung disease) and liver disease and she felt that these conditions were a direct result of the practice's failure to monitor her medication.

We took independent advice from a GP adviser and concluded that the practice had failed to appropriately monitor Mrs C's liver function and respiratory status over a number of years. The British National Formulary, which is the gold standard reference and guidance regarding medicines, has over the years highlighted advice and more recently issued safety alerts that patients on long term nitrofurantoin medication should be regularly monitored for liver function and respiratory function, although it does not state the frequency. In addition, Mrs C was exhibiting symptoms which are recognised complications of nitrofurantoin medication. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to monitor her medication.The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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 practice regarding the handling and communication of decisions to reduce or remove three medications he was prescribed for chronic pain. The practice had taken steps to reduce these medications, as they considered a continued consumption of a high dosage of opiate medication was placing Mr C at risk of further health problems and addiction. However, Mr C was concerned that his pain was no longer being suitably managed and also that he was not adequately involved in the decision making process.

We took independent advice from a GP adviser. We found that the clinical decision to reduce the medications was correct, and in line with relevant guidelines. We were also satisfied that the decision to remove the prescription for one of the medications was reasonably handled and communicated. For this reason, we did not uphold the complaint about this prescription. However, we considered that the practice had failed to appropriately discuss the decisions to reduce the dosage of the other two medications with Mr C in advance of the reduction. As such, we upheld these two complaints.

Although we upheld the complaints we found that, in response to Mr C's initial complaints, it was clear that the practice had accepted the failings in question, apologised for them, and taken steps to ensure these mistakes would not be repeated. As such, we did not make any recommendations.

Summary

Ms C complained to us about the care and treatment that her late father (Mr A) had received from the practice. Mr A had attended the practice as he was feeling some discomfort in his chest after exertion and increasing fatigue. He was referred to hospital urgently for a chest x-ray. The GP also increased the dose of Verapamil (a medication used for high blood pressure and angina) Mr A was receiving. Mr A had a scan of his heart at the hospital approximately ten days later This showed valve disease in Mr A's heart, which can lead to heart failure. An appointment was made for him to see a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and the Verapamil was stopped and his medication changed. Mr A's condition deteriorated and he returned to the practice several days after the hospital appointment. He complained of chest pain radiating to his back and said that he was no better with the new heart medication. The GP thought that this might be caused by gastric irritation and increased his medication for stomach acid. Mr A died from heart failure the following morning.

Ms C complained about the practice's decision to increase her father's Verapamil. We took independent advice from a GP adviser. We found that Mr A had been referred to hospital because it was considered that he had worsening angina. The GP had consequently increased Mr A's Verapamil, which is a recognised and common treatment for angina. The GP could not have foreseen the echocardiogram result at that time and, therefore, could not have foreseen that increasing the Verapamil was not the best treatment. Mr A's valve disease had not been caused by Verapamil, but is a condition that deteriorates over many years. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the GP did not examine Mr A's chest at the appointment after his hospital visit. We found that the GP should have examined Mr A, as he was complaining of persistent chest pains and had no improvement with cardiac medication, despite recent cardiology confirmation that he had developed new heart failure. We upheld this aspect of Ms C's complaint, although we were unable to say if an examination by the GP would have changed the overall outcome for Mr A.

Finally, Ms C complained that the practice had delayed in processing a medication request for Mr A. The practice had accepted that there had been failings in relation to processing this request and had apologised to Ms A for this. We also, therefore, upheld this aspect of her complaint. We made no further recommendations regarding this, but we asked the practice for evidence of the action they said they had taken.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out an examination of Mr A. 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 be aware of the symptoms, signs and management of unstable angina and should carry out and record an adequate clinical assessment in appropriate cases in line with General Medical Council guidance.

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 to us about the care and treatment her later father (Mr A) received from the cardiology department at Victoria Hospital. Mr A had been referred to the hospital by his GP because he was feeling some discomfort in his chest after exertion and increasing fatigue. When he attended the hospital, Mr A had a scan. This showed significant impairment of the pumping function in his heart.

A letter from the hospital to Mr A's GP also referred to a significant recent increase in the frequency of his chest pain and a corresponding reduction in the amount of effort required to bring on these pains, along with recent chest pain at night. These are characteristic features of unstable angina (a coronary condition which can be predictive of an impending heart attack.) The hospital changed Mr A's medication and made an appointment for him to see a consultant cardiologist the following week. However, Mr A continued to have chest pain and died six days later.

Ms C complained that the cardiology department should have admitted Mr A to hospital given the findings at the initial appointment. We took independent advice from a consultant cardiologist. We found that it had been reasonable not to admit Mr A to hospital and we did not uphold the complaint. However, we found that the cardiology department should have given Mr A and his GP more information about his condition and its management. We made recommendations to the board in relation to this.

Ms C also complained that a doctor discussed the decision not to resuscitate Mr A whilst he was in a very critical condition. We recognised that this would have been distressing for the family, but given the seriousness of Mr A's condition, it had been reasonable to discuss the issue of resuscitation. We did not uphold 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 provide Mr A with adequate information about his diagnosis and guidance as to what to do if he deteriorated whilst awaiting review. 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:

• Patients given a diagnosis of unstable angina or severe but stable angina should be clearly informed of the diagnosis and should have clear guidance about what to do if their condition deteriorates whilst awaiting review. This information should also be shared with their GP.

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

Miss C complained on behalf of her mother (Mrs B) about the care and treatment provided to her late father (Mr A) following his admission to Victoria Hospital with a painful hip. Mr A, who had prostate cancer, underwent a hip replacement. The oncology (cancer) consultant who had been caring for Mr A went on leave for a number of weeks. During this period a scan found that Mr A's cancer had spread and he was later admitted to a hospice where he died a short time later. Miss C complained about the care and treatment Mr A received following his admission to hospital. In particular, that Mr A had not been informed that his cancer had spread significantly and that his life expectancy was much shorter than he had previously thought.

We took independent advice from an oncology consultant. We found that, during the period Mr A's oncology consultant was on leave, there was no record of him being informed that his cancer had progressed significantly and that his life expectancy was reduced. We also found that the delay in referring Mr A to the oncology team and informing him of the progression of his cancer appeared to have been caused by a lack of senior oncology cover when Mr A's oncology consultant was on leave. However, we noted that had the oncology medical team been contacted earlier it would not have changed Mr A's management as there had been no further treatment available to him. We also found that, in terms of palliative care, there had been no impact on his management as he had continued with his medication. We upheld Miss C's complaint. Whilst we noted that the board had already accepted that there had been a delay in informing Mr A of his cancer progression and had apologised for this failing, we made a further recommendation.

Recommendations

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

• If a consultant goes on leave there should be adequate supportive cover.

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 was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD - a group of behavioural symptoms that include inattentiveness, hyperactivity and impulsiveness) by a private specialist, and she reported a very positive response to the medication prescribed. She had previously been seen by a consultant psychiatrist at Queen Margaret Hospital, who noted longstanding symptoms of anxiety.

Mrs C saw the psychiatrist again following receipt of the private opinion but the psychiatrist did not agree with the ADHD diagnosis and was not willing to support the recommended medication prescription. As Mrs C's GP practice would not agree to prescribing this medication without the support of her NHS psychiatrist, she was required to pay for it privately.

The board offered Mrs C a second opinion from another consultant psychiatrist, who confirmed her ADHD diagnosis and supported the prescribing of the recommended medication. Mrs C complained that the initial psychiatrist unreasonably failed to diagnose her ADHD and did not follow relevant ADHD protocols.

We took independent medical advice from a consultant psychiatrist, who considered that it was reasonable for the first psychiatrist not to have followed specific ADHD diagnostic protocols at Mrs C's initial out-patient appointment. We found that the psychiatrist's management plan following this consultation was appropriate and that it allowed for review of Mrs C's diagnosis, and specific diagnostic protocols to be considered, at future appointments.

However, the board were unable to provide any written record of Mrs C's follow-up consultation with the psychiatrist. We found that the psychiatrist appeared to only have phoned Mrs C's GP to recommend referral for a second opinion. They did not document the call and no clinic letter was produced. Therefore, we considered that there was an absence of adequate medical documentation to support the psychiatrist's diagnosis and, in particular, their rationale for disagreeing with the medical opinion of the private specialist. We upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the psychiatrist's failure to appropriately document details of their consultation with her, including their rationale for disagreeing with a specialist opinion.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:

• Clinicians should ensure that they adhere to General Medical Council Good Medical Practice guidelines on record keeping and, in particular, they should clearly document their clinical rationale where there is a difference of opinion.

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 transferred to the practice from another practice and, on first attendance at the new practice, was prescribed Sertraline (an anti-depressant medication used to treat anxiety). However, he suffered side effects as a result of this prescription. He was of the opinion that this would have been immediately obvious to the doctor he saw, had they checked with his previous GP, as Mr C had previously been prescribed this medication and had suffered side effects. He was also unhappy with the manner and tone adopted by the doctor. He complained about these matters to the practice and was further concerned by the tone and content of the response he received, which he considered to be confrontational and unprofessional.

Mr C brought his complaints to us. He complained that the practice unreasonably failed to consider his medical history before prescribing Sertraline and that the prescription of Sertraline was inappropriate due to the potential side effects. We took independent advice from a GP. We found that, in order to justify immediately prescribing Sertraline, rather than first trying therapies that did not require medication, the doctor should have documented a pressing clinical need or sought further evidence from Mr C's previous practice to ensure that this was appropriate. However, we found no evidence that this took place. Therefore, we upheld these two aspects of Mr C's complaint.

We also considered that the tone and content of both the clinical records and the practice's complaints responses, both to Mr C and to us, was inappropriate. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to sufficiently evidence the decision to prescribe him Sertraline and for failing to communicate appropriately with him. 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:

• Records should fully evidence any clinical decisions.
• Records and communication should be factual, neutral, and professional in tone and content.

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's father-in-law (Mr A) attended the Emergency Department (ED) at Victoria Hospital with severe facial injuries following a fall from a bicycle. He was reviewed by a doctor and transferred to oral and maxillofacial surgery (OMFS - surgery which treats diseases and injuries of the mouth, head, neck, face and jaws) for treatment of the cut to his face, then discharged.

Within the following week, Mr A attended two out-patient appointments at Queen Margaret Hospital to check his wound and remove the stitches. While waiting for the second appointment, Mr A collapsed at the hospital. Medical and nursing staff attended, but no record was made. They told Mr A to visit the ED after his out-patient appointment. However, Mr A remained quite unwell and the family returned to the hospital to ask for help. An ambulance was arranged to take Mr A to Victoria Hospital where a scan showed that he had a skull fracture and bleeding inside the skull. Mr A died shortly afterwards.

The board undertook a Rapid Event Investigation which found failings in the clinical care and processes. They said that there was no communication about head injury care when Mr A was transferred from the ED to OMFS. This meant that nursing staff did not carry out neurological observations (observations of the brain and nervous system), and Mr A was not given information about head injuries when he was discharged. Mr A was also given the wrong advice following his collapse in the hospital, as he should have been taken to the minor injuries unit for further assessment and transfer to Victoria Hospital. The board apologised for the failings found. The family felt that the board's response was unreasonable, and Mr C brought the complaint to us.

Mr C complained that the medical care and treatment provided to Mr A throughout his attendances at Victoria Hospital and Queen Margaret Hospital was unreasonable. We took independent advice from consultants in emergency medicine and OMFS. We found that regular neurological observations should have been taken while Mr A remained in hospital (either in the ED or OMFS) and he should have been given information on head injuries on discharge. Whilst we acknowledged that the board had taken appropriate action to address some of the failings, we were concerned that some of the Rapid Event Investigation recommendations were not specific and clearly linked to the failings found, and two recommendations had been marked off as complete without any evidence of action being taken. In light of this, we upheld Mr C's complaints about medical care and treatment.

Mr C also raised concerns that the nursing care provided to Mr A at Victoria Hospital was unreasonable. We took independent advice from a nurse. We did not find any evidence that nursing staff had missed any concerning signs or symptoms, and we found that the nursing care provided to Mr A was reasonable. Therefore, we did not uphold Mr C's complaint about the nursing care provided to Mr A.

Mr C also complained that the board's response to the complaint was unreasonable. We found that, although it could have been more clearly written at points, the board's response was reasonable. We did not uphold this part of Mr C's complaint.

Recommendations

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

• Patients with an injury to the head should receive neurological observations, regardless of where they are cared for.
• Patients with an injury to the head should be given head injury information on discharge from the ward.
• Recommendations arising from a review of a patient's care should clearly identify changes to prevent the situation reoccurring.

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 raised a complaint about the care and treatment he had received from his dentist when he had two teeth removed and two new teeth added to his existing denture. Mr C later found his denture to be too loose fitting and returned to his dentist. Mr C had clips fitted to make his denture more secure, however, he still felt that it was too loose and was advised by his dentist that a new denture was the only other option. Mr C was unhappy with his treatment and brought his complaint to us.

We took independent advice from a dentist. We found that the dental treatment Mr C received was reasonable and in accordance with usual practice. However, we found issues with patient communication and record-keeping. Mr C was not given a full explanation of his treatment at the outset or advised of the all the possible options and outcomes. We also found that dental records did not mention the advice that the dentist had given to Mr C. On balance, we found Mr C's treatment to be unreasonable and upheld his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not outlining all his options to him at the start of treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Refund Mr C the money he paid for the clips to be fitted.

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 care that her late mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. Mrs A was admitted for emergency treatment of a bowel issue and after some time in the intensive care unit, she was moved to the high dependency unit (HDU). Mrs A's condition deteriorated while she was in the HDU and she later died. Ms C was concerned about the standard of both medical and nursing care that Mrs A received. Ms C also complained about the level of communication with family members and the way that the board dealt with her concerns.

We took independent advice from a critical care consultant and a nursing adviser. We found that the care and treatment provided to Mrs A by both medical and nursing staff was appropriate and reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

However, we found communication with the family during Mrs A's time in hospital to be unreasonable. The nursing adviser noted that staff will refer to the 'ceiling of care' indicating the level of intervention that is appropriate for that particular patient. We considered that the records made of discussions with Mrs A's family were insufficient as they did not document enough information about ceiling of care and to what extent this was discussed. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had already identified areas for improvement.

In relation to complaints handling, we found that there had been a short delay in issuing a final response to Ms C and that the board had not arranged an extension or apologised for this. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had made improvements to their approach to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in responding to her complaint. 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:

• Communication with patients and their families should be in line with the General Medical Council's Good Medical Practice guidance, particularly sections 33 and 49. Ceilings of care should be discussed, agreed, documented and reviewed with all involved (patient, medical and nursing staff). The board should consider using a separate section within the notes to document discussions with relatives or carers.

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.