Health

Summary

Mrs C's GP referred her to St John's Hospital for a blood transfusion because she was anaemic, had chest pains and was breathless. However, Mrs C said that when she was in the hospital the blood transfusion did not happen. She was discharged and told that an urgent endoscopy (a procedure where a tube-like instrument is put into the body to look inside) and colonoscopy (an examination of the bowel with a camera on a flexible tube) would be arranged for her. Mrs C said that she did not hear anything further and that the following month she was admitted to hospital again. She had a scan which showed a large tumour and she was diagnosed with bowel cancer. Mrs C complained that she was not properly cared for and treated during her first attendance at hospital.

We took independent advice from a consultant gastroenterologist. We learned that Mrs C did not have a blood transfusion because her blood flow was not compromised and she showed no symptoms of active bleeding. While we found it was reasonable to discharge Mrs C home with plans for urgent endoscopic investigations, the board subsequently failed to deal with this as a matter of urgency. We found that this was unreasonable and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay;
• confirm the situation with regards to waiting times for urgent endoscopies; and
• ensure that, in the event that they cannot address the waiting times for urgent endoscopies, alternative scans, such as CT scans on the colon, are made available. This new protocol should be brought to the attention of referring clinicians.

Summary

Mrs C complained to us about the treatment she received when she attended the emergency dental clinic at Wishaw General Hospital. Mrs C was experiencing pain from a left molar tooth and was scheduled to have root canal treatment carried out by her own dentist. Mrs C contacted NHS 24 and explained the problems she was experiencing and they made her an appointment at the clinic the following day. When she attended the clinic she said the dentist read the NHS 24 referral note, asked her a few questions, numbed her mouth, removed a nerve in a tooth, and put in place a temporary filling. When Mrs C returned home, the anaesthetic began to wear off and she looked in her mouth to discover the dentist had treated the wrong tooth and not the one which was scheduled to have root canal treatment. As a result she had to attend another NHS facility for emergency treatment on the correct tooth.

We took independent advice from an adviser in general dentistry and concluded that the dentist had taken note of Mrs C's dental history and the information contained in the NHS 24 referral, and had conducted an appropriate examination of her mouth. We found that the dentist had identified a tooth which was causing pain and that appropriate treatment was provided. We felt it was reasonable for the dentist to have treated the tooth which he had identified as causing a problem. While the tooth which was treated was not the one scheduled for root canal treatment, there was nothing to indicate that the tooth was incorrectly treated. We did not uphold the complaint.

Summary

Miss C's late father (Mr A) had been admitted to Hairmyres Hospital with a suspected mini-stroke and it was decided that he required vascular surgery. However, the vascular surgery was not carried out during that admission of four days, and arrangements were made for him to return to hospital two weeks later. The re-admission date was extended by a further week due to a medical emergency concerning another patient. Mr A suffered a major stroke the day before the planned re-admission date and died before the vascular surgery could be performed. Miss C complained that there was an unreasonable delay in arranging vascular surgery for her father.

We took independent advice from an adviser in vascular surgery. We found that during the initial admission Mr A was not fit for surgery, due to his other health conditions, and that it was appropriate to postpone the vascular surgery for two weeks. When the planned surgery had to be postponed for a further week for another patient who had clinical priority, we found it was appropriate at that time to postpone it. We did not find any evidence of avoidable delays in scheduling Mr A's surgery, and as such we did not uphold the complaint.

Summary

Mr C complained that when he returned to prison having undergone surgery, he was not prescribed with appropriate pain relief.

While in hospital, Mr C had been prescribed dihydrocodeine and paracetamol (pain relief medications). However, on returning to the prison, clinicians prescribed Mr C with co-codamol (a mixture of codeine and paracetamol). The prescription was not issued until after the pharmacy cut-off time and so Mr C only received paracetamol until the following morning when he was given a one-off dose of dihydrocodeine.

We took independent medical advice. The adviser's view was that Mr C had not been provided with sufficient pain relief and that the delay was unreasonable. We accepted this advice and upheld the complaint.

We also found that the board's response to the complaint was contradictory. They had told Mr C at stage one of the complaints process that they would take action to ensure there was not a repeat of the situation. However, when we contacted the board to find out what action they had taken, they said there were no actions taken as the delay was unavoidable. We were critical of this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in prescribing appropriate pain relief and for the contradictory response to his complaint. 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 should receive appropriate medication when returning to prison after surgery.

In relation to complaints handling, we recommended:

• The board’s decision on a complaint should be clear and, if it differs to the view reached at stage one, this should be explained in the response.

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 and Mrs C complained about the care and treatment the practice provided to their late son (Mr A).

Mr A had a background of autism and other additional needs. He attended the practice with problems including diarrhoea, sickness and weight loss. The practice initially considered Mr A’s bowel upset was caused by antibiotics. After approximately three months, the practice referred Mr A to gastroenterology for investigations. However, his background health problems made these investigations difficult. Mr A’s condition continued to deteriorate and he was taken into hospital approximately four months later. Mr A was diagnosed with Crohn’s disease (a long-term condition that causes inflammation of the lining of the digestive system), and died despite surgical management.

Mr and Mrs C complained that the practice failed to provide Mr A with appropriate clinical treatment. They said his condition deteriorated considerably, and that his family and carers specifically raised concerns that he was suffering from Crohn’s disease. They also raised concerns that the practice did not appropriately take into account Mr A’s additional needs. Mr and Mrs C also complained that the practice unreasonably delayed in referring Mr A for a gastroenterology opinion.

Summary

Mrs C complained about the practice after she required a CT scan to be diagnosed with pneumonia. She told us that she felt an earlier diagnosis should have been possible, based on her medical history and presenting symptoms.

We took independent advice from a GP adviser. We found that the practice did not fail to identify any signs or symptoms that would have led a GP to reach a diagnosis of pneumonia. The adviser considered that the practice carried out reasonable examinations and, when these failed to provide a diagnosis, took prompt and reasonable steps to arrange appropriate tests to investigate further. This involved arranging for an x-ray and then a CT scan, which provided the eventual diagnosis. For these reasons, we did not uphold the complaint.

Summary

Miss C complained to us that the medical practice had unreasonably notified the Driver and Vehicle Licensing Agency (DVLA) that she had alcohol issues. She said that she had to surrender her driving licence for a period and that she had suffered financially as a result. The practice explained that they had acted in accordance with their policy about advising patients to inform DVLA about alcohol problems and the circumstances where the practice could contact DVLA themselves.

We took independent advice from an a GP adviser and concluded that the practice policy in force was reasonable and that the practice were entitled to notify DVLA in this instance. We did not uphold the complaint.

Summary

Mrs C complained that her late mother (Mrs A)'s medical practice did not take urgent action and advise Mrs A to attend hospital after she reported symptoms related to deep vein thrombosis (DVT, a blood clot). Mrs A collapsed at the entrance of the main health centre at the practice and was taken to hospital. She died shortly after of a pulmonary embolus (a blockage of an artery in the lungs), which is a side effect of DVT. Mrs C was also unhappy that the medical practice had not told her about the incident.

We took independent medical advice and found that the practice acted reasonably in advising Mrs A to attend the practice for assessment rather than going immediately to her local emergency department. We considered that the practice provided a timely appointment for Mrs A to be reviewed. In addition, we considered it was reasonable that practice staff had not contacted Mrs C regarding the incident because Mrs A had collapsed outwith the premises of the medical practice and staff there were unaware of what had happened. In view of these findings, we did not uphold the complaint.

Summary

Mr C complained that the board had unreasonably delayed in providing treatment for his eye condition at Hairmyres Hospital.

We took independent advice from a consultant who specialises in the medical and surgical treatment of eye disease. The advice we received was that there had been no unreasonable delay in the treatment provided to Mr C, but that there had been an unreasonable delay in the following up of Mr C's eye condition. However, we found that this delay had not resulted in deterioration of Mr C's vision. Taking account of the evidence and the advice we received that Mr C should have been followed up more closely, we upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to follow-up his eye condition.

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 us about the care and treatment provided to her late father (Mr A) at Wishaw General Hospital after he was diagnosed with cancer of the oesophagus (the tube that carries food from the throat to the stomach). Mr A had been admitted to hospital for an operation. During the operation a hole in one of his air passages was identified and he was transferred to another hospital outwith the board area. It was decided there that his cancer had spread and was inoperable. Mr A died four days later.

Mrs C complained that there had been delays in carrying out tests and in providing treatment to Mr A. We took independent advice from a consultant upper gastrointestinal surgeon and from a consultant radiologist. We found that, in general, the board had provided reasonable care and treatment to Mr A. However, there had been delays in carrying out two scans that Mr A needed. The board did not have the facilities to carry out these scans and had referred Mr A to another board. There was no evidence that the board had taken any action to escalate the matter when there were delays in carrying out the scans. In view of this, we upheld Mrs C’s complaint, although we did not consider that the delays in carrying out the scans would have influenced the ultimate clinical outcome for Mr A.

Mrs C also complained that the board did not take reasonable action to investigate the possibility of Mr A’s cancer spreading before the operation. We found that the investigations the board had carried out before the operation were appropriate and in line with standard practice. It had also been reasonable for them to carry out the operation. We did not uphold this aspect of Mrs C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to act on the delays in the scans being carried out. 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:

• Ensure that there are adequate mechanisms in place to prevent delays in having scans carried out outwith the 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.