Health

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.

Summary

Mr C complained that the prison health centre unreasonably decided to discontinue his medication when he failed a medication check. Mr C said the prison health centre failed to take account of the fact that he had reported to them that he was being bullied for his medication.

The prison health centre considered that Mr C had not been taking the medication as prescribed and therefore the medication was stopped to maintain his safety. The decision was reviewed by a multi-disciplinary team who assessed that there was no significant clinical risk to Mr C ceasing to receive the medication.

Before we reached a decision on Mr C's complaint, he requested to withdraw his complaint. Therefore, we closed the complaint without reaching a decision.

Summary

Mr C underwent an operation at Ninewells Hospital to remove a skin tag on his penis. He was concerned about the outcome of the operation and the appearance of the resulting scar, and he said that he was left with some disfigurement. Mr C complained that the consultant urological surgeon told him before the operation that the appearance of his penis would improve with surgery and that he was not warned that there was any risk of disfigurement. Mr C also had concerns about the standard of the operation itself, and follow-up care.

We took independent advice from an adviser who specialises in urological surgery. We found failings in the consent process. We found that there was no evidence that Mr C had been warned of the risk of scarring and that the outcome of the surgery may not meet his expectations until the day of the operation. This meant that he had not been given enough time and appropriate information to make an informed decision, particularly in light of his additional needs. We found no evidence to suggest that the standard of the operation was not reasonable and while there were failings in relation to a follow-up appointment, this was addressed by the board.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in this investigation;
• bring the failings identified in this investigation to the attention of relevant staff; and
• review the consent process and related documentation to ensure that clinicians properly obtain, and document, consent for procedures.

Summary

Miss C said her mother (Mrs A) had a complex medical history and was admitted to the Royal Victoria Hospital with reduced mobility and delirium (a temporary state of mental confusion arising from, amongst other things, infection). Mrs A was discharged to a nursing home eight days later. Miss C complained that Mrs A was not medically fit to be discharged from the hospital. Mrs A died several weeks after her discharge.

We took independent medical advice. We found that Mrs A was medically fit to be discharged and that the care package was reasonable. We therefore did not uphold Miss C's complaint. However, there were shortcomings in the way in which Mrs A was discharged. This included communication about Mrs A approaching the end of her life, meaning that Miss C was unprepared for Mrs A's death. We therefore made recommendations in relation to this.

Recommendations

We recommended that the board:

• review the discharge policy and communication with relatives in light of the failings identified;
• raise the failings identified with relevant staff; and
• apologise for the failings this investigation has identified.

Summary

Mrs C complained to the board about the care and treatment provided to her mother (Mrs A) by her GP practice. In particular, Mrs C felt that the practice failed to arrange appropriate investigations in view of the symptoms Mrs A presented with.

Mrs A attended the practice on a number of occasions over a two year period, and presented with symptoms including abdominal pain, vomiting and weight loss. After Mrs A's condition did not improve following an out-of-hours GP assessment, she was admitted to hospital. Several tests were performed during this admission and further tests were carried out in the months following discharge. Following these investigations, Mrs A was diagnosed with gastric cancer and she died a number of months following this diagnosis.

In response to our enquiries, the board provided a copy of a review that they had undertaken. Within the review, the board noted that Mrs A had complained of a number of symptoms, yet on each occasion Mrs A's symptoms could have been explained by non-cancer related causes. The board also noted that Mrs A's weight was relatively stable and various blood tests did not suggest anything sinister, with no evidence of anaemia or other worrying findings. The board concluded that the recorded symptoms did not suggest that a referral for gastroenterology investigation was indicated in accordance with local protocols.

We took independent advice on the case from a GP adviser. Having reviewed the records, the adviser did not consider that the practice had failed to take appropriate action in view of Mrs A's symptoms, and did not find that Mrs A's symptoms should have alerted the practice to a likely diagnosis of gastric cancer. The adviser concluded that the practice provided Mrs A with reasonable care. We accepted the adviser's comments, and for this reason we did not uphold this complaint.

Summary

Mr C complained about delays and communication in relation to his wife (Mrs A)'s hip-replacement surgery at Ninewells Hospital.

After taking independent advice from a consultant orthopaedic surgeon, we did not uphold Mr C's complaints. The advice we received was that while Mrs A's patient journey had been a long one, there were no unreasonable delays in her orthopaedic treatment. After reviewing all the available evidence, no issues were found with the standard of communication.

Summary

Mr C complained on behalf of his wife (Mrs A) about the clinical treatment she received when she attended A&E at the Gilbert Bain Hospital. We took independent advice from a consultant in emergency medicine. The advice we received was that the assessment and treatment of Mrs A was reasonable and that appropriate investigations were carried out, and that Mrs A did not require hospital admission. We therefore did not uphold this complaint.

However, the advice we received said that while written notes made by the doctor caring for Mrs A were of a high standard, one thing that could have been improved was the inclusion of vital signs and we made a recommendation to the board regarding this.

Mr C also raised his concern that the doctor had failed to reasonably interpret Mrs A's chest x-ray. The board accepted that the doctor had failed to appreciate the significance of the radiographic appearance on the base of Mrs A's left lung on the x-ray. They apologised for this and explained that the issue of x-ray interpretation had been discussed with the doctor. The advice we received was that the action taken by the board was reasonable. While we upheld the complaint, given the action taken by the board we made no further recommendations.

Mr C complained that the board inappropriately discharged Mrs A when she attended the hospital, particularly as she had had to re-attend the following day. The advice we received was that Mrs A did not require hospital admission. We did not uphold the complaint.

Recommendations

We recommended that the board:

• draw the importance of including vital signs in written notes to the attention of relevant staff as part of their professional supervision.

Summary

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his son (Mr A). He said that a GP had prescribed oxycodone (opiate medication) over the phone to Mr A on the morning that he died from a medication overdose. Mr C was also concerned that there had been an entry in Mr A's clinical records from his previous GP surgery noting that Mr A was not to be prescribed opiates.

The practice said that practitioners are aware of the need to balance the potential benefits of a drug against any possible harm. The practice were aware of the previous GP surgery concerns that Mr A used illicit drugs and that care should be taken about the strength of any opiates prescribed. Mr A had recently undergone significant surgery and he reported that his pain control was ineffective. It was also noted that Mr A was attending orthopaedics and the pain clinic.

We took independent medical advice from a GP who noted that Mr A had been referred to orthopaedics and the pain clinic and that he was regularly reviewed in either face-to-face consultations or phone contact. When required, his pain relief was increased and this was considered reasonable care. The adviser had no concerns about the actions of the GP who prescribed the oxycodone, as they had taken note of the previous GP practice's concerns about drug misuse and made a reasonable clinical judgement based on the recorded evidence available. We did not uphold the complaint.

While we did not uphold the complaint, we noted that the practice and the previous GP practice operated different electronic record recording systems and that there was a failure of the first practice to transfer all relevant information over when Mr A joined the new practice. We made a suggestion to both practices which may have allowed more clarity, although it may not have altered the GP's decision to prescribe the oxycodone.