Health

Summary

Mr C complained on behalf of his daughter (Miss A). He complained that there had been an unreasonable delay in her receiving treatment for a foot injury at Aberdeen Royal Infirmary.

We took independent advice from a consultant orthopaedic paediatric surgeon. We found that an appropriate initial referral and examination of Miss A's foot had been carried out and that an appropriate treatment plan had been instigated, which included the use of interventional radiology treatment (treatment that is used to precisely target therapy to affected areas). However, we found that due to staff shortages there was an unreasonable delay in Miss A receiving interventional radiology treatment at Aberdeen Royal Infirmary. We found that there were a series of cancellations and that it was then decided that Miss A should be referred onto another board for treatment. We found that there was also a delay in sending that referral. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the delay in initiating treatment.

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

• Patients requiring interventional radiology treatment should receive treatment in a timely manner or be referred to an alternative provider, such as another NHS board.

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 provided to her adult daughter (Miss A) at Loch View House, which is a specialist facility for providing care to patients with learning disabilities.

Mrs C raised concern that following her daughter's admission to Loch View House, staff did not take into account that her clinical problems could have been due to difficulties with Miss A's diabetes control. We noted that Miss A was under the care of a consultant psychiatrist during the admission and we sought independent advice from a psychiatric adviser. They considered that the medical records clearly showed that staff had reviewed Miss A's history of diabetes management in the community and had recognised that Miss A's behavioural change might be related to her diabetic control. We did not uphold this complaint.

Mrs C also complained about the way that staff managed Miss A's diabetes throughout the admission. We found that the board had acknowledged issues in relation to the provision of needles, required for administering medication, and had apologised to Mrs C for this. We took independent advice from a nursing adviser on this aspect of the complaint. They were satisfied that the board had put reasonable steps in place to address this issue and that appropriate steps for learning and improvement had been identified. We upheld this complaint, but did not make any further recommendations as the board had already taken action.

Finally, Mrs C expressed dissatisfaction that staff failed to communicate with her adequately about her daughter's treatment. The psychiatric adviser found that the medical records evidenced regular communication with Mrs C and other members of the family throughout the course of Miss A's admission. They added that the records showed a high level of contact, mostly by phone, with detailed discussion and timely responses to concerns raised. The adviser considered that this level of contact was appropriate given Miss A's needs and they noted the entries clearly described the views of the family and the efforts of the clinical team to reassure them where there were differences in opinion over the management of Miss A. We were unable to conclude that the communication was unreasonable and we did not uphold this complaint.

Summary

Miss C complained about the care and treatment provided to her at Victoria Hospital. Miss C complained that when she first presented at the hospital with symptoms relating to an infection in her groin area, she was discharged too early and had to be readmitted later that day. Miss C also complained that the abscess which formed in her groin area was inappropriately drained at her bedside, and that there was a delay in a diagnosis of necrotising fasciitis (a rare infection that destroys the soft tissue of the skin) being made.

We took independent advice from a general surgeon and a consultant physician. We found that Miss C was inappropriately discharged from the hospital on her first admission as she had been newly diagnosed with diabetes and had an ongoing temperature. The advice we received was that it may have been helpful for Miss C to have had input from a diabetologist and earlier surgical management of her skin infection. We also made a recommendation regarding the documentation of timings in medical records as we found this to be poor.

We further found that the drainage procedure carried out at Miss C's bedside was not reasonable as pain relief was not documented, and the signs that were present at this point, namely skin blistering and fluid filled tissues, were not reasonably acted upon.

Finally, we found that there was an unreasonable delay in the diagnosis of necrotising fasciitis as, when there were clear features of this occurring, the appropriate action was not taken in a timely manner. Additionally, the advice we received noted that there was clear indication for surgical incision and drainage at a far earlier point than was carried out and that, had surgical treatment been carried out at an earlier point, necrotising fasciitis may not have occurred. We upheld all of Miss C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for inappropriately discharging her from hospital, inappropriately carrying out a clinical procedure at her bedside and unreasonably delaying in reaching a diagnosis of necrotising fasciitis. 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 entries in clinical records should be correctly dated and timed.
• The board should ensure it has clear guidelines that comply with recognised standards for how to manage skin and soft tissue infections, which include when surgical treatment should be commenced. Staff should be competent to apply them to an acceptable standard.
• In otherwise unwell patients with newly diagnosed diabetes, consideration should be given to seeking input from a diabetologist.
• Surgical staff should be familiar with signs of necrotising skin and soft tissue infections.

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 to the board about the care and treatment she received when she was admitted for elective hip replacement surgery at Dumfries and Galloway Royal Infirmary.

Mrs C recalled feeling pain before the procedure finished, known as breakthrough pain, and complained to us about the level of anaesthesia she was given during surgery. We took independent advice from an anaesthetic adviser, who was satisfied that that both the type and dose of anaesthetic and sedative drugs used were appropriate in this case. They did not find a record of breakthrough pain in the notes, and they could not confirm what action might have been taken in response to this. As the evidence available was not conclusive about the reported episode of breakthrough pain, we could not conclude that there was a failure to document pain and the use of top-up anaesthetic. We did not uphold this complaint.

Mrs C also raised concerns that staff did not maintain reasonable records following the operation, and that the records failed to reflect that she was in pain. We received independent advice from an adviser in general medicine and a nursing adviser. The general medicine adviser was satisfied that the frequency and detail of the entries in the records by medical staff was in accordance with normal practice, and they considered that the record-keeping was reasonable. The nursing adviser found that the nursing records had been maintained to a reasonable standard and were in accordance with the professional code of practice. We concluded that the record-keeping was reasonable and we did not uphold this complaint.

Summary

Ms C complained about the treatment her young daughter (Miss A) received from a doctor when she took her to the emergency department at Borders General Hospital. Miss A had been taken to see her GP the previous day with a suspected chest infection. The GP had prescribed antibiotics and told Ms C to take Miss A to the emergency department if her condition deteriorated. Ms C said that she was dissatisfied with the assessment carried out by the doctor at the emergency department, who recommended that Ms C take her daughter home to allow the antibiotics prescribed by the GP to work. Ms C asked that Miss A have a paediatric review. This was arranged and, after spending some hours in a ward, Miss A was discharged home with a supply of steroid medication. Ms C complained to us that the doctor in the emergency department failed to provide Miss A with an appropriate assessment and a reasonable level of care.

We took independent advice from a consultant in emergency medicine. We found that the doctor in the emergency department had documented a detailed history of Miss A's illness and medical history and that it was reasonable for them to have suggested that Miss A be discharged home to allow the antibiotics time to work. The doctor initially diagnosed that Miss A had a lower respiratory tract infection and had phoned a paediatric doctor for advice before making the decision to discharge Miss A home. The diagnosis was further refined to that of bronchiolitis (a viral illness). When Ms C voiced her concerns, it was arranged for Miss A to spend some hours in a paediatric ward where she was observed and then discharged home with steroid medication and to allow time for the GP prescribed antibiotics to take effect. We concluded that the doctor in the emergency department carried out an appropriate assessment of Miss A and that she received an appropriate level of care and treatment. We did not uphold the complaint.

Summary

Mr C complained that the prison health centre's decision to reduce and remove his prescribed medication was unreasonable and had caused him to be left in pain. The board said that two nurses had witnessed Mr C attempting to withhold his medication and for that reason a decision had been taken by clinical staff to reduce and remove his medication. They said this was in keeping with an agreement Mr C had previously signed which stated that a failure on Mr C's part to take his medication properly may result in it being reduced or stopped.

Our decision, after taking independent advice from a GP adviser, was that the board had acted reasonably and that the alternative medication Mr C had been prescribed was also reasonable.

However, we were critical of the board's handling of Mr C's complaints. They had failed to follow their complaints handing process, and had failed to address all of Mr C's main points of complaint. We made several recommendations to address the failings we identified.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to handle his complaints properly and for failing to reply fully to him.

In relation to complaints handling, we recommended:

• Staff should recognise when a complaint has been made and should be aware of the correct process for dealing with it. Complaint responses should cover all significant points raised in the complaint.

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 his late wife (Mrs A), who suffered from diabetes, received from the board. In particular he complained that when a home visit was made by a district nurse, his wife's podiatry appointment was not brought forward by the board.

During our investigation we took independent advice from a consultant podiatrist. The adviser considered that when Mrs A's diabetic foot ulcer was noted during the home visit, an urgent referral should have been made to the board's multi-disciplinary diabetic foot care service which would have given her access to vascular assessment and a vascular consultant.

The adviser, when commenting on the care given during the home visit, also referred to the podiatry care Mr C's wife received when she was admitted to Western Isles Hospital. In particular, the adviser commented that there was no record of a vascular assessment having being carried out and that this represented a failure in assessment by podiatry.

Recommendations

We recommended that the board:

• ensure podiatrists and district nursing teams have the competencies required to provide assessment for patients with diabetes and acute foot conditions;
• ensure all health care professionals are aware of the available guidance for diabetic foot conditions;
• ensure the pathways and signposting for urgent referrals are in place and implemented;
• consider the adviser's comments on referral to an acute multi-disciplinary diabetic foot care team and report back on action taken;
• ensure clinical data is available across the organisations; and
• issue Mr C with an apology for the failings identified in this investigation.

Summary

Mr C complained about the care and treatment provided by the medical practice to his late wife (Mrs A), who suffered from diabetes. In particular, he complained about the treatment of Mrs A's ulcers, decisions made by the practice during home visits and the practice's initial decision to refuse a home visit. Mr C also complained about the practice's response to his complaint.

During our investigation we took independent GP and nursing advice. The advice we received from the GP adviser was that the care and treatment given to Mrs A was in line with NHS guidance on the management of diabetes, and the decisions taken by the practice during home visits were reasonable. The advice we received from the nursing adviser was that the nursing care provided by the practice was reasonable.

We found no evidence that a home visit had been refused by the practice, but that the practice had been hesitant to visit given that a home visit had been carried out within 24 hours prior and the complaint remained the same. The advice we received and accepted from the GP adviser was that in these circumstances it had been reasonable to question the necessity for another home visit.

The practice had accepted that there were inaccuracies in their response to Mr C and in their clinical records. We therefore upheld this aspect of Mr C's response.

Recommendations

We recommended that the practice:

• formally apologise to Mr C for the upset caused to him and his family by their response.

Summary

Mr C complained that, following a collapse in the street where he vomited blood, his son (Mr A) was taken to Ninewells Hospital where he was discharged after treatment for a head injury. Later that day Mr A was again found collapsed in the street and he was again taken to Ninewells Hospital where he died that evening. Mr C noted from the post-mortem report that the cause of death was recorded as a massive gastrointestinal haemorrhage (bleed) and said that had this been identified during the first visit to hospital then the outcome may have been different.

We obtained independent advice from a consultant in emergency medicine about the treatment provided during the first attendance at hospital. We found that the assessment of the cause of Mr A's collapse was reasonable. We also found that the assessment of his head injury was reasonable. However, we found that an insufficient risk assessment had been made when considering Mr A's reporting of vomiting blood and as such he should have been admitted to hospital on the first attendance or kept in for a longer period of observation. However, even if this had been case we could not say with certainty that the outcome would have been different, but we acknowledged that Mr A would have had an earlier review by clinical staff. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation; and
• share our report with the relevant staff so that they can reflect on their actions.

Summary

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his wife (Mrs A). He said that Mrs A had been seen by two GPs at the practice within three days with complaints of severe abdominal pain and dehydration, and that she had not taken food or fluids for a week. Mrs A deteriorated and was admitted to hospital where she underwent surgery for a small bowel obstruction. Mr C believed that the GPs at the practice should have realised that his wife was in severe pain and that she should have been admitted to hospital as an emergency.

The practice told us that on initial assessment, taking into account the medical history and examination findings, the GP did not believe there was any indication for a hospital admission at that time. The GP felt it was reasonable to diagnose a possible flare of diverticulitis (a common disease of the digestive system). The GP prescribed appropriate medication and gave advice to contact the out-of-hours service if required. The second GP visit was due to Mrs A not taking her medication due to nausea and the inability to swallow. The GP was inclined to agree with the first diagnosis and decided that Mrs A could be managed at home if she could tolerate her medication. Advice was given to assist taking the medication but that a hospital admission would be considered if Mrs A was unable to comply with the treatment plan.

We took independent medical advice from a GP and concluded that the practice had provided a reasonable level of care. It was felt that at both consultations the GPs had carried out an appropriate history and examination of Mrs A. In particular there was assessment of her abdomen so as to rule out any acute problem necessitating emergency hospital admission. The prescribing appeared to be appropriate and the working diagnosis of a flare-up of pre-existing diverticulitis was not unreasonable. In addition, Mrs A was not showing symptoms or signs which necessitated emergency hospital admission. We did not uphold the complaints.