Health

Summary

Mr C complained that dental staff at the practice had failed to deal appropriately with his concerns that his gums continued to bleed after having four teeth extracted. He was on warfarin medication (a medication to prevent blood clots) which meant that he was at high risk of bleeding. He reported this to a dentist, who said that it would be alright and he could leave the practice. When Mr C got home, the bleeding continued and he contacted the practice again and was asked to attend. He saw a different dentist, who also said that he was not to worry and the bleeding would stop. However, the bleeding continued that evening and Mr C had to attend hospital where the bleeding eventually stopped and he was sent home.

We took independent advice from an adviser in general dentistry and concluded that the first dentist was aware that Mr C was on warfarin medication, that they had checked his clotting status prior to the extractions and that they had stitched and packed the tooth sockets following the extractions. The first dentist had also provided Mr C with a detailed post-operative instruction sheet, which provided advice on action which should be taken regarding any bleeding. We did not uphold the complaint.

Summary

Ms C complained about a number of consultations, for different medical complaints, that she had at her GP practice. Ms C also complained that she had been unreasonably removed from the practice list, and she complained about how the practice had responded to her complaint.

We took independent advice from a GP adviser. We found that Ms C had received a reasonable standard of care and treatment, and so we did not uphold this aspect of the complaint. However, we did find a consultation which had happened had not been noted in the clinical records. We made a recommendation to address this.

We found that the practice had followed the correct procedure when removing Ms C from their patient list and that they had responded thoroughly to her complaint. We did not uphold these complaints.

Recommendations

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

• All interactions with patients should be documented, adhering to the standard of record-keeping set out in the General Medical Council's Good Medical Practice 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 care provided to his wife (Mrs A) during out-patient appointments at the cardiology department at Ninewells Hospital. Mrs A was referred to the cardiology department by her GP because of drop attacks (sudden episodes of collapse). Over the following 18 months, Mrs A attended consultations in the department and a number of investigations into her symptoms were carried out. During the period that Mrs A was waiting to be fitted with a cardiac event monitor device (a device to measure the heart's activity), she sustained a stroke and was admitted to hospital for treatment. Tests carried out during this admission indicated that Mrs A was in atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). Mr C complained that the board had failed to provide Mrs A with a appropriate treatment in view of her presenting symptoms and medical history.

We took independent advice from a consultant cardiologist. We found that the board managed Mrs A's condition appropriately, with the exception of the way they handled a referral from her GP approximately five months prior to the date of the stroke. We found that this referral described a change in Mrs A's symptoms and their pattern and the adviser said that the referral should have been considered more promptly and carefully by the cardiologist. The adviser said that further tests could have been considered and that, had these been carried out promptly, atrial fibrillation might have been diagnosed sooner. The adviser said that if atrial fibrillation was diagnosed, then medication would have been started and the likelihood of the subsequent stroke would have reduced. We were unable to conclude that better management would have changed the eventual outcome in this case. However, we upheld the complaint and made recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings to handle the GP referral five months before the stroke in an appropriate manner. 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 carefully assess whether a referral highlights a change in symptoms and their pattern, before promptly considering whether further investigations or actions are indicated.
• Waiting times for routine investigations, such as a patient being fitted with a cardiac event monitor device, should be minimised as far as possible.

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 about the care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints.

During the birth, Mrs C's baby became stuck after delivery of the head due to shoulder dystocia (where one of the shoulders becomes trapped behind the mother's pubic bone) and additional help had to be called to assist the midwife who was attending to her. The baby was delivered following this, but died a few days after the birth.

After Mrs C raised her complaints with the board, they carried out a local adverse event review and also had an external review conducted by a senior midwife from another NHS board area. These reviews identified some failings with regards to aspects of Mrs C's care. However, it was found that these failings did not affect the outcome, which was considered to be unavoidable.

After taking independent advice from a midwife, we upheld Mrs C's complaint about the induction of her labour. We found that there had been delays which affected her access to pain relief and that there had been poor communication. We did not make any recommendations relating to this as these failings had already been addressed by the board.

We also upheld Mrs C's complaint about her care during labour. We found that the board had already identified issues, including the way that examinations were carried out to monitor Mrs C's progress. The advice we received highlighted further concerns about monitoring of blood pressure and listening to and recording Mrs C's preferences during labour. We made recommendations to address these matters.

We did not uphold Mrs C's complaint about the care that was provided to her during the birth of her baby. The advice we received was that this care was timely and that the shoulder dystocia could not have been identified earlier or avoided.

We upheld Mrs C's complaint about the way her complaint was handled by the board. We found that the timescale for completing the investigation of her complaint had not been met and that Mrs C had not been kept updated during the process. We made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care during induction and labour, and for failing to handle her complaint reasonably. 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:

• Patients should be listened to. Their preferences and concerns should be responded to. Clear and accurate records of this should be kept.
• Blood pressure should be recorded in line with national 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 that that a GP at the health centre had failed to provide her with appropriate treatment during a consultation. She had attended the GP and had reported that a couple of days earlier she had been woken with severe pain on her left side. She wondered whether she had ruptured an ovarian cyst which she was known to have. Ms C said that the GP did not examine her or take her temperature. Ms C said that five days later she began vomiting and was admitted to hospital, where it was found that she had ruptured her bowel.

We took independent advice from a GP adviser. We found that the GP had suspected that Ms C may have ruptured an ovarian cyst and that they did arrange for an appropriate blood test and an ultrasound to be carried out. However, the adviser also said that the GP should have examined Ms C's abdomen and checked a urine sample as she had reported abdominal pain. Although the adviser felt that the GP should have performed a clinical examination, the adviser thought it was unlikely that Ms C had ruptured her bowel at the time she saw the GP as this would normally involve the onset of acute sudden symptoms. Ms C had also reported that her symptoms were improving when she saw the GP. The GP had carried out a Significant Event Analysis and they had recognised that they should have examined Ms C's abdomen. The GP said that they would examine patients' abdomen in future. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide a written apology for failing to carry out an appropriate assessment. The apology should comply with the SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• The GP should ensure that full and appropriate assessments are carried out based on the patient's reported symptoms.

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 was told by dental staff that she would require dental braces. She was subsequently told by orthodontic staff that she would not be provided with braces and she was discharged from the service. Miss C complained that the board failed to provide her with appropriate dental care.

We took independent advice from an orthodontics adviser who explained that the assessment criteria to consider whether a patient qualifies for orthodontic treatment funded through the NHS is covered by the Index of Orthodontic Treatment Need (IOTN). It would be expected that an orthodontics practitioner would provide a grade of IOTN which would substantiate their decision as to whether or not the criteria had been satisfied. We found that in Miss C's case the orthodontic staff had assessed her on a number of occasions as having a low IOTN, which was a reasonable judgement for them to make and had indicated that they had considered the IOTN criteria. As such, Miss C would not have qualified for orthodontic treatment and so we considered that the dental care provided had been appropriate. We did not uphold the complaint.

However, we did note that there was a failure by orthodontic staff to record the actual IOTN grade in the dental records, and so we made a recommendation in relation to this.

Recommendations

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

• The staff should be aware of the requirement to record the IOTN category in order to substantiate whether the criteria for providing orthodontic treatment has been met.

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 attended his dentist over a period of months for treatment for severe tooth pain. The dentist extracted one tooth and referred Mr C to the dental hospital to have a second tooth extracted. When Mr C attended the hospital, they identified a number of issues regarding his teeth. Mr C complained that his dentist had failed to provide the appropriate dental treatment and that, as a result, he had suffered with severe pain over a prolonged period of time.

We took independent dental advice. The adviser noted that the dentist did not keep adequate clinical notes in accordance with the guidance published by the General Dental Council. The dentist also did not appear to carry out some of the more basic investigations available for determining the cause of dental pain, and he did not report the findings of an x-ray he took of his Mr C's teeth, which is a requirement of the Ionising Radiation (Medical Exposure) Regulations (2000). We upheld Mr C's complaint and made recommendations.

Recommendations

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

• The dentist should consider the requirements for good clinical records as stipulated in the General Dental Council Standards and should consider the available guidance for good note taking.
• The dentist should consult Clinical Examination and Record Keeping Standards (FGDP RCS (Eng)), Key Skills in Primary Dental Care (FGDP RCS (Eng)) and the Management of Acute Dental Problems (SDCEP) for guidance on carrying out the more basic investigations available for determining the cause of dental pain and the treatments that are available.
• The dentist should make themselves aware of the requirements for reporting the findings of x-rays under the Ionising Radiation (Medical Exposure) Regulations (2000).
• The dentist should write up this incident as an Enhanced Significant Event Analysis and should include the incident as an agenda item in the next in-house dental practice team meeting so that learning can be shared among the practice.

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 he received from the board in relation to his mental health whilst he was in prison. We took independent advice on the complaint from a consultant psychiatrist. We found that the care and treatment provided to Mr C had been reasonable. He had received mental health nursing reviews, a full psychiatric assessment and had also seen a number of other healthcare staff. The management of his medication had also been reasonable. Whilst there had been a delay in arranging for Mr C to see a psychiatrist, we found that this was not unreasonable. He saw other healthcare staff during this period and they discussed his care with the psychiatrist and put interim measures in place. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that staff in the prison health centre failed to provide appropriate treatment in relation to his cellulitis (an infection of the deeper layers of skin and the underlying tissue). We took independent advice on this aspect of his complaint from a GP adviser. There was no evidence in Mr C's medical records that he had cellulitis, although the records showed that he had been treated for scabies. We found that the care and medication provided by the board in relation to scabies had been reasonable and we did not uphold this complaint.

Finally, Mr C complained that the board had failed to respond appropriately to his complaints. We found that Mr C had made a large number of complaints. Whilst there had been some delays by the board in responding to these complaints, these delays had not been unreasonable. We considered that the board had issued a reasonable response to the issues Mr C had raised and did not uphold this aspect of the complaint.

Summary

Mrs C underwent a pubovaginal sling procedure (a surgical procedure used to manage urinary incontinence) and a cystoscopy (a bladder examination using a narrow tube-like telescopic camera) to address her stress incontinence. She was reviewed a few months later, and she reported a loss of sensation and significant distress about the appearance of her scars. She was referred to plastic surgery to see if anything could be done about the scarring.

Mrs C complained to the board about her treatment, and one month later she was advised that her complaint had been forwarded for investigation. Five months later Mrs C wrote to the board to raise concerns about the long wait for a response to her complaint. Upon receiving Mrs C's letter, the board discovered that her complaint had inadvertently been closed five months previously. Some weeks later, the board phoned Mrs C to explain that the complaint had been inadvertently closed and to discuss Mrs C's concerns about the delay in responding and her concerns about her treatment. The board then referred Mrs C to a different consultant urologist, and agreed that they would look into why the complaint had been closed. They also suggested that they would arrange an external review of the case, and they said that they would update Mrs C when they had further information. Despite phoning several times over a period of a further four months, Mrs C heard nothing from the board about her complaint. When she did manage to speak to the board again Mrs C asked to be sent a letter with the findings of the board's investigations. Mrs C did not receive a letter, and she then brought her complaints to us.

Mrs C complained to us about the medical treatment she received and the board's handling of her complaint. We took independent advice from a urologist. We found that the treatment that had been carried out was reasonable, and that it had achieved the outcome of restoring continence, even though there were some problems with loss of sensation. We found that Mrs C's scarring was considered to lie within the bounds of what can be seen following the types of surgery she had underwent. We did not uphold Mrs C's complaint about her treatment.

We were highly critical of the board's complaints handling. We found that there were delays, and that some of the board's communication with Mrs C about her complaint was misleading. We found that the board failed to investigate her complaint as agreed. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for closing Mrs C's complaint in error, for including misleading information in their communication with Mrs C and for failing to investigate her complaint as agreed. This apology should comply with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should ensure that complaints are not closed unless there is clear evidence that this is the correct course of action.
• Key staff should receive refresher training in complaints handling, in particular in relation to managing the expectations of complainants.

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 that staff failed to communicate properly with him when he arrived at Hairmyres Hospital following his wife (Mrs A)'s admission with a suspected stroke. Mr C had told the paramedics who called at his home that he thought the time of onset for the stroke was about 02:00, when he heard Mrs A collapse. When he was with Mrs A in the emergency department, and subsequently on admission to a ward, no members of staff asked him for more information which may have narrowed the potential timing of the stroke. Mr C subsequently learned that thrombolysis treatment (medication to dissolve blood clots), which can limit the damage caused by a stroke, was available but has to be given within a certain timescale to be effective. Mrs A was not given thrombolysis treatment as the clinicians had deemed that there was insufficient information available which would have identified the potential time of onset of the stroke.

We took independent advice from an adviser in acute medicine. We found that, although the staff had taken into account the information provided to the paramedics, they missed the opportunity to question Mr C further as he may have been able to provide information which would have narrowed down the potential timings. The staff took the decision not to provide thrombolysis treatment without speaking to Mr C. We noted that even if they had obtained further information from Mr C it was possible that they may still have decided not to start the thrombolysis treatment. On balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate with him. 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:

• Staff should consider all available sources of information available before deciding whether or not to commence thrombolysis treatment.

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.