Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). She complained that when Mrs A had been admitted to Queen Elizabeth University Hospital with shortness of breath and chest pain, she was not provided with proper care. Ms C also complained that Mrs A was inappropriately discharged from the hospital, as three weeks after Mrs A's admission, she was diagnosed with interstitial lung disease (thickening of the tissue between the air sacs of the lungs).

During our investigation, we took independent advice from a consultant physician and found that whilst appropriate tests were carried out when Mrs A was in hospital, there was a delay in her chest x-ray being formally reported. The adviser said that had the chest x-ray been reported sooner, the clinician may have arranged further investigations which could have led to an earlier diagnosis of interstitial lung disease. We therefore upheld this aspect of Ms C's complaint. However, we found that the decision to discharge Mrs A had been reasonable as there was nothing to suggest at that time that she had serious health problems.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mrs A.

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

• The board should ensure that formal reports should be more readily available, particularly for acute or unscheduled patients.

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 and treatment provided to her late mother (Mrs A) by her GP practice. Mrs A had hypertension (high blood pressure) and was prescribed multiple medications for this. Ms C expressed concern that this medication was not reviewed, despite it failing to control Mrs A's blood pressure. Ms C felt that this contributed to Mrs A suffering kidney failure and heart problems.

We took independent GP advice and found that Mrs A had multiple health conditions, and that her treatment and blood pressure control were complex. The adviser noted that some of her medication was serving a dual purpose, such as controlling her blood pressure and fluid overload. The adviser considered that the practice took appropriate steps to monitor Mrs A, including active assessment of her hypertension and regular blood tests. They explained that the number of underlying conditions made it difficult to control Mrs A's blood pressure, but were satisfied that the difficulties were not due to a lack of care on the part of the practice. We accepted this advice and did not uphold the complaint.

Summary

Ms C complained that the board incorrectly diagnosed her as suffering from bi-polar disorder when she was admitted to hospital in 2004. She was also unhappy that they prescribed sodium valproate which she did not consider should be prescribed to someone of childbearing age.

Although this complaint related to issues which occurred some years ago and would usually be considered to be time-barred in terms of a complaint to our office, as the board had reviewed the medical records last year and advised Ms C that the treatment provided was appropriate, we agreed to look at the diagnosis and decision to prescribe.

We obtained independent advice from two advisers, one of whom reviewed the records for the period of Ms C's admission. We were satisfied that a reasonable diagnosis was made in 2004 and the decision to prescribe sodium valproate to Ms C was reasonable. As a result, we did not uphold the complaints.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs B about the care and treatment of her late husband (Mr A). Mr A was admitted to Queen Elizabeth University Hospital with symptoms including severe abdominal pain and weight loss. He underwent tests, including a CT scan, but nothing was found to explain his symptoms. His GP later contacted the hospital as they remained concerned about Mr A's pain, and the CT scan was reviewed. Abnormalities in Mr A's liver and abdomen were suspected, and a further CT scan and liver biopsy confirmed that he had secondary liver cancer. He was referred to oncology and died after two sessions of chemotherapy. Ms C complained that Mr A's cancer was not diagnosed earlier and that there were signs on the first CT scan that were initially overlooked.

The board accepted that there was a delay in diagnosing Mr A's cancer but said the original CT scan report was falsely reassuring. They did not consider that this delay had any bearing on Mr A's prognosis, as Mr A's cancer was advanced and would have been regarded as terminal at the time of the first scan. They noted that the missed diagnosis on the first scan had been discussed at a radiology review meeting and also fed back to the radiologist concerned.

We took independent advice from a consultant radiologist who noted that interpreting the first scan was not straightforward and that the abnormalities were subtle. Nonetheless, they confirmed that these were overlooked, leading to delay in diagnosis. We also took advice from a consultant clinical oncologist, who confirmed that the delayed diagnosis would not have altered Mr A's life expectancy but acknowledged that it would have delayed his access to palliative care services. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mrs B regarding the delay in diagnosing Mr A's cancer, and consequently the delay in him accessing palliative care services.

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 there was a failure to carry out a proper range of diagnostic tests into the possible cause of blood in his late wife (Mrs A's) urine when she was admitted to Southern General Hospital. Mrs A underwent a change of catheter and a urinary tract ultrasound. A cystoscopy (a medical procedure used to examine the inside of the bladder) was also planned, but was not carried out.

We took independent advice from a urological surgeon. We found that the treatment Mrs A received was reasonable. We also found that an ultrasound and a cystoscopy would normally be the first wave of investigations to investigate blood in urine, and in doing so investigate the possibility of cancer. While an ultrasound was carried out when Mrs A was admitted to hospital, we found that the decision not to carry out the cystoscopy at that time was reasonable. However, we found that the subsequent delay in carrying out a cystoscopy was unreasonable. While the advice we received was that an earlier cystoscopy and diagnosis of bladder cancer may not have changed Mrs A's outcome, we were concerned that the uncertainty caused Mrs A, Mr C and their family considerable distress during a very difficult time. Given the delay in carrying out the cystoscopy we upheld this aspect of the complaint.

Mr C also raised a concern that Mrs A was unreasonably discharged from the Victoria Infirmary following an emergency admission due to side effects from opiate pain relief that had been prescribed to her. Following this discharge Mrs A had to return to the hospital and was admitted a few hours later. We took independent medical advice from a consultant physician. We found that it was unreasonable that Mrs A was discharged and that, while relevant examinations were carried out, the relevant investigations were not. In particular, we found that the medical staff caring for Mrs A should have predicted the potential requirement for further naloxone (a medication used to block and reverse the effects of opiates) after the naloxone given by ambulance crew had worn off. Our adviser said that, according to the medical records, Mrs A was discharged after approximately two hours, which they considered to be too short a period in the circumstances. The adviser also considered that inadequate investigations into Mrs A's home circumstances were carried out before discharge. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a written apology to Mr C for the unreasonable delay in carrying out the cystoscopy.
• The board should issue a written apology to Mr C for unreasonably discharging Mrs A from the Victoria Infirmary.

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

• The board should ensure that patients with visible blood in their urine are investigated in a timely manner.
• The board should ensure that, where a patient with renal impairment or multiple medical problems has overdosed on long acting opiates, relevant investigations are carried out.
• The board should ensure that relevant guidelines are prepared on the use of naloxone in adult patients with renal impairment who have overdosed on long acting opiates.
• The board should ensure that a patient's home circumstances are adequately investigated when notification is received from a family member that they are struggling to cope at home.

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 late husband (Mr A). Over the course of a number of years Mr A attended the practice with anxiety and depression. During this time, the practice treated Mr A in primary care, and did not refer him to mental health services. Subsequently, Mr A did not attend the practice with these problems for approximately 18 months. Mr A then contacted the practice and reported persistent thoughts about suicide to the GP who saw him. The GP developed a plan of management, including referring Mr A to psychiatric services. However, the referral was not processed. Mr A committed suicide approximately ten days after his attendance at the practice. Mrs C complained that the practice failed to appropriately refer Mr A to mental health services in view of his presenting symptoms.

The practice said they provided appropriate treatment based on Mr A's symptoms during his earlier attendances. They did not consider a referral was appropriate at that stage. When Mr A returned and described persistent thoughts about suicide, they said a referral was appropriate. The practice acknowledged there was an error in processing the referral, although they noted that it was unlikely Mr A would have received an appointment before his death.

After receiving independent advice from a GP, we upheld Mrs C's complaint. We found there was an administrative failing in not making the referral (as the practice acknowledged). We also found the practice should have scheduled an earlier review when Mr A re-attended the practice. However, we did not consider the practice should have made a referral at any of Mr A's earlier attendances, and we found that the care and treatment provided during this time had been reasonable.

Recommendations

We recommended that the practice:

• confirm that the GP will review the relevant National Institute for Health and Care Excellence guidance and consider identifying this as a learning need in their personal development plan;
• confirm the GP will discuss this case as part of their annual appraisal; and
• apologise for the failings identified in this investigation.

Summary

Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr C complained that the board failed to carry out appropriate falls risk assessments, failed to appropriately manage Mrs A's medication and delayed in obtaining a review for Mrs A following a fall. Mr C also complained that it took an unreasonable amount of time for him to be able to speak to a senior staff member about his concerns.

During our investigation we took independent advice from a nursing adviser. The adviser considered that the overall care in relation to falls assessments, monitoring, care and falls prevention was unreasonable. They also found significant failings in how Mrs A's medication was managed.

The board accepted that it took an unreasonable amount of time for Mr C to speak to a senior staff member about his concerns. They also accepted that there was a delay in having Mrs A reviewed following her fall. The board also accepted that there were significant failings in how Mrs A's medication was managed. The board identified learning as a result of the complaint.

In light of the independent medical advice we received, we upheld all of Mr C's complaints. Although the board had taken steps to address the complaint, we made recommendations in light of our findings.

Recommendations

What we asked the organisation to do in this case:

• The board should issue a formal apology to Mr C for the unreasonable level of care provided to Mrs A in relation to falls assessments, monitoring and care.

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

• The board should ensure that patients at very high risk of falls should be considered for referral to a falls co-ordinator or falls specialist.
• The board should ensure that in future situations similar to Mrs A's a medical review is requested sooner.

In relation to complaints handling, we recommended:

• The board should ensure that senior charge nurses, and other frontline staff, have the skills and confidence to undertake early resolution of complaints.

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 raised concerns about an investigation relating to events at Stratheden Hospital. Following our enquiries, Mrs C met with representatives of the Health and Social Care Partnership, who agreed to explore her complaints further. We therefore did not continue our investigation.

Summary

Mr C complained to us about the care and treatment provided to him by the board in relation to treatment for his leg problems, and their communication with him. Mr C said that after a course of foam sclerotherapy (a procedure where medicine is injected into the blood vessels, making them shrink) for varicose veins in his legs, he was in a lot of discomfort. He said that he was told at a scan a month later that he had deep vein thrombosis (a condition when a blood clot forms in a vein located deep inside the body) but that he was not given appropriate treatment for this. He also said that he had been told contradictory things regarding the clot in his leg.

During our investigation, we took independent medical advice from a consultant vascular surgeon. We found that although the treatment that was given to Mr C was reasonable, there were two occasions on which follow-up scans should have been arranged but were not. We upheld this aspect of Mr C's complaint. We also found that the board had acknowledged that communication with Mr C had been poor, and that the lack of documentation of communication evidenced this. We upheld this aspect of Mr C's complaint.

Mr C also complained to us about the board's complaints handling, specifically that it took a long time for them to issue their final response to his complaint. The board accepted that they had failed to respond to Mr C's complaint in a timely manner and we therefore upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise to Mr C for failing to provide him with appropriate follow-up appointments after his scans.
• The board should apologise to Mr C for failing to communicate appropriately with him about the causes of his leg pain.
• The board should apologise to Mr C for failing to respond to his complaint in a timely manner.

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

• Follow-ups should be arranged for two weeks after a duplex scan shows a clot in the gastrocnemius vein.
• Details of appointments should be clearly recorded.
• Communication could be supplemented by a printed leaflet.

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 provided to him by the board in relation to a hip replacement procedure he had undergone at Borders General Hospital. Specifically, Mr C complained that during the operation, board staff had failed to correctly place the replacement, which resulted in several years of pain and a further operation to correct the replacement. Mr C also complained that there were unreasonable delays in investigating the cause of his ongoing pain after the original hip replacement surgery.

During our investigation we took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence to suggest that Mr C's hip replacement had been incorrectly placed at the first operation. Therefore we did not uphold this aspect of Mr C's complaint. Additionally, whilst we recognised the long time that Mr C was in pain for and the many appointments he had with orthopaedic services, we found that appropriate tests and investigations were carried out at each stage and opinions of other clinicians were sought. We did not uphold this aspect of Mr C's complaint.

Mr C further complained that the board failed to address all of the issues he raised in his complaint to them. On review of the complaints documentation, we found that the board had provided Mr C with a thorough response to his complaint and that they had provided further clarification both verbally and in a letter when Mr C requested this. Therefore, we did not uphold this aspect of Mr C's complaint.