Health

Summary

Ms C complained about the care and treatment provided to her late mother (Mrs A) by the medical practice. In particular, she complained that the practice delayed taking action which diagnosed Mrs A was suffering from pancreatic cancer. We took independent GP advice and found that the practice had acted promptly in referring Mrs A for specialist intervention and that there were no delays in sending the referrals. The medical records detailed that Mrs A was referred to hospital twice under the two-week cancer pathway. We did not uphold the complaint.

Ms C also raised concerns that the practice had failed to investigate Mrs A's abnormal liver function results taken in 2014. The advice we received was that the test results had not shown any deterioration until September 2015 and at that time the practice had acted reasonably in making an urgent referral to hospital. In view of the advice that the practice's response was reasonable, we did not uphold the complaint.

Ms C was also concerned that the practice had failed to take appropriate action on Mrs A's reported weight loss. The clinical records demonstrated that Mrs A had been referred for dietary advice and attended a dietician clinic, and the advice we received was that the referral had been made at an early stage. We were satisfied, based on the medical records and independent advice we received, that the practice responded appropriately to Mrs A's reported weight loss and we did not uphold the complaint.

Finally, Ms C complained that the practice failed to ensure appropriate palliative care was put in place for Mrs A at home. The advice we received was that, based on the medical records, the practice had not delayed in referring Mrs A to palliative care services and that the practice offered reasonable care. We did not uphold the complaint.

Summary

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received at Biggart Hospital and University Hospital Ayr. Mrs C said that staff at Biggart Hospital had failed to treat her mother's deteriorating condition. We took independent advice from a consultant in acute medicine and from a nursing adviser. We found that there had been prompt recognition of Mrs A's deteriorating condition and that the care and treatment provided to her had been reasonable. We did not uphold this aspect of Mrs C's complaint.

During her treatment Mrs A was transferred from Biggart Hospital to University Hospital Ayr. She was subsequently transferred back to Biggart Hospital. Mrs C complained about the decision to transfer Mrs A back to Biggart Hospital given that she had tested positive for sepsis, MRSA (a bacterial infection that is resistant to a number of widely used antibiotics) and E.coli (bacteria found in the digestive system). We found that Mrs A's condition had improved at the time to the point that it was reasonable to consider her transfer back to Biggart Hospital. We did not uphold this aspect of the complaint.

Mrs C also complained that the communication between Biggart Hospital and University Hospital Ayr was unreasonable. We found that there was no clear documentation of communication between the hospitals about the fact that Mrs A had E.coli and MRSA. We therefore upheld this aspect of the complaint.

Mrs C further complained that Biggart Hospital had prescribed her mother a form of morphine, despite the fact that Mrs A had previously had an adverse reaction to morphine. We found that Mrs A's allergies, drug intolerances and drug interactions could have been better documented, and we made a recommendation in relation to this. However, we found that it had been reasonable to give Mrs A small doses of morphine, as the effect on her was being monitored. We did not uphold this complaint.

Finally, Mrs C complained about the medication Mrs A received at University Hospital Ayr. We found that it had been reasonable to try alternative medications given that Mrs A was able to tolerate them. In addition, nursing staff had observed Mrs A for adverse side effects. That said, Mrs A had not been given her routine medication when she was admitted to University Hospital Ayr and the reasons for this had not been adequately recorded. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the lack of clear documentation and communication.

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

• The policy on communication between hospitals regarding patient transfer should be reviewed.
• The computer system for recording allergy information should be reviewed.
• A review policy around prescribing medication on admission, including who is responsible for this if the admitting team are too busy, should be produced.

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 had a family history of DVT (deep venous thrombosis, a blood clot in a vein). During her pregnancy she suffered cramps and pain in her calves. She therefore underwent a scan of her right leg. This scan was clear but because she continued to complain of pain, Mrs C underwent a further scan. Mrs C said that the scan was of her left leg, although the board said it was of her right leg. After Mrs C gave birth, a further scan confirmed a pulmonary embolism (a clot in the blood vessel that transports blood to the heart and the lungs) and a DVT in her left leg.

Mrs C complained to the board that despite her many complaints, they did not refer her to haematology (the specialism concerned with the study of blood and blood-related disorders) and that they failed to properly carry out the second scan. In response, the board said that Mrs C should have been reviewed by a senior doctor and probably referred back for a further scan. However, Mrs C still felt that the scan had been carried out incorrectly.

We obtained independent haematology advice and found that although scans were a good diagnostic tool for DVT of the upper leg, they were not as reliable for the calf. We found that an examination had not shown evidence of a clot in Mrs C's lower leg. Furthermore, the scan about which Mrs C complained had been carried out in a reasonable way and Mrs C had been reviewed on three occasions during the five days after this scan. Despite the board's own conclusion, we found that the management and care received by Mrs C following her scan was reasonable. We therefore did not uphold Mrs C's complaint.

Summary

Mrs C complained about the care and treatment provided to her husband (Mr A) during hospital admissions to the Royal Infirmary of Edinburgh (RIE), Liberton Hospital, the Western General Hospital and Ellen's Glen House in the months prior to Mr A's death. Mrs C also complained about communication and the board's complaints handling.

The board arranged a meeting for Mrs C with staff from the hospitals involved, and provided several written responses to her complaints, including an independent clinical review of some of the complaints. The board acknowledged a number of failings, including that significant decisions to complete a 'do not attempt cardiopulmonary resuscitation' (DNACPR) form and a 'verification of expected death' form were not discussed with her or Mr A, that the nursing documentation from Ellen's Glen House was completed to a poor standard, and that all of the medical records from Mr A's admission to RIE had been lost. However, Mrs C was not satisfied with the board's response.

After taking independent medical and nursing advice, we upheld Mrs C's complaints. We found some additional failings in medical and nursing care, including that Mr A was discharged from RIE when he was not fit to be discharged, and that nursing staff did not contact the family or carry out a neurological assessment when Mr A suffered a minor head injury. In relation to Mr A's missing medical records, we were advised that the board's actions in relation to the management of files were relevant but not sufficient.

We also found failings in the board's complaints handling. On several occasions the board agreed to take action, but did not follow through on this, and the independent clinical review provided to Mrs C included inaccurate findings, which were contradicted by the board's later responses. However, in making our decision we acknowledged that the board devoted considerable time and effort to addressing the numerous points Mrs C raised, including meeting with her and writing detailed responses to her concerns.

Recommendations

We recommended that the board:

• feed back our findings to the RIE doctor who discharged Mr A, for reflection and learning;
• confirm that the consultant who put in place the DNACPR without informing Mrs C has discussed this complaint at an annual appraisal;
• demonstrate that there are robust auditing processes in place at Liberton Hospital and Ellen's Glen House, to ensure decisions about DNACPR and nurse verification of death decisions are discussed with patients and/or families;
• discuss the nursing adviser's comments in relation to the treatment of Mr A's head wound with relevant nursing staff, for reflection and learning;
• demonstrate they have taken the action identified in their improvement plan to improve record-keeping (introduction of transfer letters and discussion of the process of filing notes at a quality meeting);
• review training needs of relevant staff in relation to information governance;
• update the management of misfiled and missing records procedure to include reporting responsibilities of staff;
• apologise to Mrs C for the additional failings our investigation found;
• review their systems for tracking actions agreed with a complainant, to ensure they follow up on these; and
• confirm that the failings in the independent clinical review have been fed back to the relevant doctor for reflection and learning as part of their next annual appraisal.

Summary

Mr C complained about statements made by a GP at an adult protection case meeting held in relation to the care of his wife (Mrs A). Mrs A suffered from an illness that affected her ability to care for herself and was in hospital at the time of the meeting, which was organised to discuss the possibility of discharging her home.

We took independent advice from a GP adviser. The adviser noted that Mrs A was a patient who did not have capacity to make decisions about her care, which meant that the GP was responsible for deciding on the appropriate medical treatment to safeguard or promote the physical or mental health of Mrs A. The adviser considered that the statements made by the GP were supported by the medical records and were, therefore, accurate. The adviser explained that an adult protection meeting is a forum in which care providers share information and that in this context, it was appropriate for the GP to share their concerns with the meeting. We did not uphold this complaint.

Mr C also raised concerns about a letter the GP had sent to him following the meeting. In particular, Mr C felt that the letter inferred that he had mistreated Mrs A. We found that the letter from the GP sought to explain the GP's reasons for the statements made in the previous meeting. The adviser did not consider that the letter inferred that Mr C had mistreated Mrs A, and overall felt that the letter was appropriate. We therefore did not uphold this aspect of Mr C's complaint.

Finally, Mr C expressed concern that the practice had not communicated with him reasonably in relation to arranging a meeting to discuss his complaint to them. We found that Mr C had spoken to the practice manager about a meeting, yet we noted that this did not take place. We considered that both Mr C and the practice manager had different expectations about who would take the next step to arrange a meeting. It was not possible for us to determine what was said and agreed in this conversation, and for this reason we did not uphold this aspect of Mr C's complaint.

We also considered how the practice had handled Mr C's complaint. Although we were satisfied with many aspects of the complaints handling, we found that the practice's complaint correspondence did not provide information about the support available through the Patient Advice and Support Service (PASS), and did not provide information about how to contact us should Mr C remain dissatisfied. We therefore made a recommendation in relation to this.

Recommendations

We recommended that the practice:

• take steps to ensure that complaints are acknowledged and handled in accordance with the practice's complaints procedure.

Summary

Mrs C complained that one of the board's clinicians failed to provide her late daughter (Ms A) with appropriate treatment.

Ms A suffered from epilepsy and cerebral palsy. The clinician prescribed a particular medication for Ms A due to an increase in her seizures. Over the following months Ms A attended A&E at a number of points due to seizures and was seen by the board's A&E clinicians. Approximately 18 months later Ms A was taken to hospital where it was identified that she was suffering from end stage renal failure, and she later died.

Mrs C said that she raised concerns about the prescription of the particular medication to Ms A, which she linked to Ms A's death. She said the board should have further monitored Ms A. The board considered that the care and treatment had been appropriate, and said that there was no link between the medication and Ms A's deterioration.

After obtaining independent medical advice we did not uphold Mrs C's complaint concerning the board's clinician. We found that the board's clinician had followed national guidance regarding the medication and that the decision to prescribe this was reasonable in the circumstances. We found no link between this medication and Ms A's outcome.

While we did not uphold the complaint Mrs C brought to our office, we found evidence that clinicians within the board had not acted on high blood pressure readings taken from Ms A on two A&E attendances. We made a number of recommendations to the board regarding this issue.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise for failing to act on Ms A's high blood pressure readings.

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

• The board should ensure that staff are aware of guidance that recordings of high blood pressure should be acted upon.
• The board should ensure that the circumstances of this case have been fully considered for wider learning at a significant review level.

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 said that until the age of 14 months, his son (child A) attended A&E at the Royal Hospital for Sick Children on several occasions. Mr C said that staff unreasonably failed to investigate child A's symptoms at these attendances and did not provide a correct diagnosis. Mr C believed that child A had had a lung infection since birth until the point at which he began to recover.

We took independent advice from a medical adviser who specialises in paediatrics. We found that there was no indication that either a chest x-ray or the prescribing of antibiotics during child A's attendances were necessary and that the care and treatment given to child A was reasonable. The adviser noted that children under one often have symptoms of viral upper respiratory tract infection during nearly half of their first year, and that the diagnosis and treatment decisions at each attendance at hospital were reasonable. We therefore did not uphold Mr C's complaint. However, we found that there were shortcomings in relation to assessment of risk factors and made a recommendation to address this. We noted these did not have an effect on the outcome of the standard of care received.

Recommendations

We recommended that the board:

• ensure the shortcomings identified in this investigation are addressed with relevant staff through training and supervision (where appropriate) and through audits.

Summary

Ms C complained about the care and treatment provided by the physiotherapy service at Stonehouse Hospital, and that a scan had not been recommended despite her severe back pain.

We took independent physiotherapy advice and found that the initial assessment carried out was inadequate and had not followed the board's local guidance on lower back pain. We upheld this aspect of the complaint and made a number of recommendations to address these failings.

Whilst we found that a scan would not have been appropriate, we were critical that the reasons for this were not clearly explained to Ms C. We did not uphold this aspect of the complaint, but made a recommendation to address the lack of record-keeping in this respect.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings identified in this investigation.

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

• The physiotherapist should be reminded about the importance of good record-keeping which should include a detailed history and comprehensive discussions with the patient.
• Conduct a review of current local physiotherapy assessment management of chronic low back pain alongside the board's local low back pain guidance and national guidance.
• Draw the findings of this report to the attention of the physiotherapist involved.

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 at Hairmyres Hospital failed to provide him with appropriate care and treatment.

Mr C became unwell with sepsis (an infection of the blood) following an operation to treat an abscess on his abdominal wall. He was discharged with arrangements to have his wound cared for by district nurses. Mr C was later readmitted with symptoms of pain, swelling and wound discharge and was discharged the same day. Mr C then went on to develop a hernia some months later.

Mr C raised specific concerns that the operation to treat his abscess was carried out too late in the evening. He said the surgeon did not take into account information relayed concerning a scan that he had undergone. Mr C also said a surgeon opened his wound with a scalpel to further drain it while he was on the ward. Mr C attributed his subsequent health problems to the way the board handled his condition. The board said Mr C's condition was identified accurately, and that he received appropriate surgery. They considered Mr C's subsequent problems were not due to any deficit in care.

We took independent advice from a surgeon. We found that overall, the board had provided appropriate treatment. In particular, we found that the surgeon carried out the correct operation, including taking into account Mr C's scan, and that this was not carried out at an inappropriate time. However, we did find that there was an unreasonable delay in Mr C receiving surgery, as this occurred several days into his admission. We found that the board should have made a decision and operated on Mr C at an earlier stage. We therefore upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in surgery identified in this investigation; and
• consider steps they can take to reduce the impact of avoidable delays on treatment in the future.

Summary

Mr C complained about the treatment his wife (Mrs A) received at Raigmore Hospital. Mrs A had ongoing problems with both of her knees and underwent physiotherapy treatment and surgery. Due to post-operative complications and continuing problems with her right knee, Mrs A had to undergo further treatment.

Mr C complained that there had been unreasonable delays in providing Mrs A with appropriate treatment and that Mrs A's surgical treatment was not of a reasonable standard. Mr C was also dissatisfied with the way that the board dealt with his complaint.

We obtained independent medical advice and we found that the time Mrs A waited for knee surgery exceeded national standards with no exceptional circumstances to justify this. We upheld this part of the complaint.

We found that the surgical treatment Mrs A received was appropriate and of a reasonable standard, and that the orthopaedic treatment was within the range of accepted good practice. We did not uphold this aspect of the complaint.

We found that the board took an unreasonable amount of time to respond to Mr C's complaint, and that they did not address all of his concerns. We upheld this aspect of the complaint.

We noted that the consent form Mrs A signed for her surgery should be updated to reflect current guidance on obtaining consent in relation to ensuring there is an appropriate section to document risk. We made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mrs A for failing to provide treatment for her within the appropriate timescale.
• The board should issue a written apology for the failings in their response to Mr C's complaint.

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

• The board should take action to meet the 18 weeks referral to treatment time standard for knee replacement surgery for at least 90 percent of patients.
• The board should ensure that consent forms signed by patients comply with current guidance on obtaining consent in relation to ensuring that there is an appropriate section to document risk.

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.