Health

Summary

Mr C complained to us that he, his wife and daughter were removed from the practice's list. National Services Scotland (NSS) wrote to Mr C to say that his GP practice had asked NSS to remove him, his wife and their daughter from their patient list because of a breakdown in the doctor/patient relationship. Mr C said it was not clear why they had all been removed and that he had not been given a warning. Mr C believed it was because of a complaint he had made previously to us about the practice. As a result of the decision, Mr C and his family were distressed and left without the care of a GP practice while they found a new practice.

We took independent advice from a GP adviser. The advice we accepted was that there was no evidence that the practice had complied with their contractual regulations and General Medical Council guidance. We found that there had been an appointment between Mr C and practice nurses that was difficult for all concerned and that aspects of the appointment were challenging for staff. However, having reviewed in detail the witness statements and the entries in Mr C's medical records, we were not satisfied that it was reasonable for the practice to remove Mr C without first warning him that his behaviour was causing staff concern and giving him an opportunity to help restore the professional relationships.

We found that the practice had failed to give him an open and transparent response on their reasons for having him removed and that, as a result, he was concerned that he was removed because he had made a complaint. It is also of concern that the practice failed to take all reasonable steps to restore the professional relationship. We were not satisfied that the professional relationship with the practice had broken down to such an extent following the appointment with practice nurses that it affected the standard of clinical care provided, and so we found it to be unreasonable that Mr C was removed from the list. Similarly, there was no evidence that it was reasonable for the practice to remove his wife and child too. We upheld both complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for unreasonably removing him, his wife and his daughter from the practice list. 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:

• Staff should comply with the guidance and regulations on responding to staff concerns about patient behaviour.

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 wife (Mrs A) received at Aberdeen Maternity Hospital after she became unwell following delivery of their child by caesarean section. Three days after the procedure, Mrs A required emergency surgery for a perforated bowel, resulting in a temporary ileostomy (where an opening is made in the abdomen to allow waste to pass out of the body) and further surgery to reverse this, which caused her a difficult and protracted recovery period. Mr C raised concern that they had been told by a doctor that the complications had arisen because the bowel had been accidently stitched to the caesarean section wound.

We took independent advice from a consultant obstetrician and a consultant general surgeon. We found that the consent form Mrs A signed, with the assistance of a doctor, agreeing to the caesarean section was not fully completed and did not warn her of the rare but recognised risk of bowel injury, which we were critical of. We also considered that it was likely that the bowel had been caught at the time of stitching, which meant that it was unlikely an adequate check of the wound was carried out by a second doctor at the time of the procedure. We upheld the complaint and made a number of recommendations to address these failings.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the failings identified in relation to the consent process and her caesarean section. 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 undergoing an elective caesarean section should be fully informed of the possible complication and risk of bowel injury and give clear, informed consent.
• All relevant sections on the consent form should be fully completed.
• The doctor who performed the surgery should reflect on the clinical incident at their appraisal to identify any training needs to ensure the matter does not recur.

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, who works for an advocacy and support agency, complained on behalf of her client Mr A. Mr A's late wife (Mrs A) had been diagnosed with lung cancer. Mrs A began to suffer severe neck pain which subsequently spread to her shoulder and arm. Mrs A was admitted to Dr Gray's Hospital at the request of her GP. Given that a recent scan of the shoulder had shown no problems, a further x-ray or scan was not requested by clinical staff at the acute medical assessment unit. Mrs A was discharged home the following day. Mrs A's pain continued and a few days later she was admitted to Aberdeen Royal Infirmary. X-rays and a scan were performed which showed that Mrs A's cancer had spread to two cervical vertebrae (neck bones) and to the brain. Mrs C complained that the board had failed to provide Mrs A with adequate care and treatment during her admission to Dr Gray's Hospital.

The board acknowledged that Mrs A should have been referred to the oncology team and that a neck x-ray should have been performed. They apologised for the delay in diagnosis and that they did not recognise or control the cause and nature of Mrs A's pain. The board explained that they have taken action following this complaint, including using the National Cancer Treatment Helpline, as well as considering direct referral to the oncology team. They explained that they are working to maintain the awareness of these mechanisms to prevent a recurrence through information on their intranet and documentation in induction packs. We have asked the board to provide evidence of these actions.

We took independent advice from a consultant in acute medicine. The adviser's view was that the possibility of the cancer spreading to the cervical vertebrae or the spinal cord should have been considered. The adviser said that Mrs A's pain should have been managed as a possible malignant spinal cord compression (an issue that develops when the spinal cord is compressed by bone fragments, a tumour, an abscess or other lesion. This is an issue that is usually treated as a medical emergency). The adviser's view was that there should have been a discussion with oncology and that the use of steroids and an MRI scan should have been considered. The adviser stated that they would expect doctors working in an acute medical assessment unit to recognise this and perform this role. In light of this, we upheld the complaint.

Recommendations

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

• The board should have a malignant spinal cord compression protocol.
• All clinical staff within the Acute Medical Assessment Unit should be made aware of the malignant spinal cord compression protocol.
• Clinical staff within the Acute Medical Assessment Unit should learn from this case.

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 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.