Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Miss A that a locum GP working at her GP practice inappropriately prescribed her antibiotic medication which she was allergic to. Miss A suffered a severe allergic reaction to the medication, resulting in an emergency hospital attendance that evening. Ms C also complained that, when Miss A returned to the practice the following day, the GP failed to appropriately examine her allergy rash.

We took independent medical advice and found that the medical records noted that Miss A had previously had a reaction to the medication. As it should not, therefore, have been prescribed, we upheld the complaint. However, it was noted that the GP had already acknowledged and apologised for the prescribing error, which we were assured was down to human error and not systemic in nature. We did not, therefore, make any recommendations in this regard.

In relation to the subsequent attendance, the adviser noted that Miss A had already been examined and treated at the hospital the previous night and that a detailed examination was not required. We did not uphold this aspect of the complaint.

Ms C also complained that the practice had not responded appropriately to the complaint. We noted that the practice passed the correspondence to the GP (who was by then working at another practice) to respond to directly. This resulted in delays. We concluded that the practice should have retained ownership of the complaint and managed it in line with their complaints process. We upheld this aspect of the complaint.

Recommendations

We recommended that the practice:

• write to Ms A and apologise for their failure to properly handle her complaint.

Summary

Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission.

We obtained independent advice from a nurse and a consultant in the care of the elderly. The nursing adviser identified failings in relation to the planning, monitoring and recording of Mr A's nutritional care and hydration and his personal care. They also identified that documentation had not been adequately completed. Mr A appeared to have suffered four falls during his admission. We found it was of concern that Mr A's falls risk appeared to have been ineffectively assessed and there was an unreasonable delay in making a referral to a falls prevention specialist. We also considered that communication with Mr A's family was unreasonable.

While we were unable to conclude that any of these failings were significant contributing factors in Mr A's death, we were satisfied that Mr A's nursing care and treatment fell below a reasonable standard and upheld this aspect of Mr C's complaint.

The medical adviser said Mr A was frail, had a history of heart disease and that there was evidence he had chronic kidney disease. While the advice we received was that a number of aspects of Mr A's medical care and treatment were reasonable, the medical adviser identified issues concerning Mr A's medications. The medical adviser also commented that there was a failure to contact Mr A's family when there was a serious deterioration in his condition. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's nursing care and treatment and communication this investigation has identified;
• feed back the comments of the nursing adviser and the findings of this complaint to the nursing staff involved for reflection and learning;
• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's medical care and treatment and communication this investigation has identified; and
• feed back the comments of the medical adviser and the findings of our investigation to the medical staff involved for reflection and learning.

Summary

Mr C was referred to the neurology department at the Southern General Hospital for the investigation of pain that he had suffered since he was involved in a road accident. Mr C attended at the neurology service for an extended period of time without a formal diagnosis of his condition being made. While we were investigating Mr C's concerns about delay in diagnosis and the way his complaint had been handed by the board, he advised us that he had received a diagnosis from a private health provider.

After taking independent advice from a consultant neurologist, we did not uphold Mr C's complaint about the delay in diagnosis. The advice we received was that while Mr C had a long patient journey, this was not unreasonable in the context of his complex case. The adviser considered that if the board had not carried out all the tests they had before Mr C received his private diagnosis, it was likely that these would still have been necessary before a diagnosis could be reached.

We upheld Mr C's complaint about the way the board handled his concerns. We found that there were some instances where the board's complaint responses did not accurately reflect the information in his medical records. This related to a test which they advised was carried out at a consultation. However, the record of the consultation made no reference to this taking place. We made three recommendations in relation to this matter.

Recommendations

We recommended that the board:

• ensure that the appropriate tests are conducted and documented at consultations;
• apologise for the complaints handling failing identified in this investigation; and
• ensure that complaint responses accurately reflect the medical records.

Summary

Ms C complained about the care and treatment that her father-in-law (Mr A) received when he attended at the board's out-of-hours service at the Royal Alexandra Hospital. Mr A had been suffering from worsening symptoms of a cough and cold. He was examined and diagnosed with a viral illness, considered likely to be flu. Mr A was given advice on what to do if his condition worsened. Later that day, he was admitted to hospital. Mr A died the following day as a result of multiple organ failure due to sepsis (blood infection). Ms C complained about the out-of-hours examination as she felt that Mr A was clearly very ill and further action should have been taken at that time.

After taking independent medical advice, we did not uphold Ms C's complaint. The advice we received was that the examination was reasonable with appropriate advice and treatment being provided on the basis of the findings. The adviser explained that Mr A had not shown any signs of sepsis at the time of the examination and that his condition was significantly different when he was later admitted to hospital. The adviser highlighted that sepsis is a condition that can develop and deteriorate rapidly.

Summary

Mr C made regular visits to his medical practice. He was concerned about symptoms of facial flushing and rash (for which he was seeing a dermatologist at a hospital). After six months, a blood test confirmed that Mr C had diabetes. Mr C complained that the practice failed unreasonably to recognise or suspect that he had diabetes given his symptoms.

We took independent medical advice. We found that had the GPs been made aware that Mr C had symptoms including constant thirst and urination, they should have checked the levels of his blood sugar earlier. However, these symptoms were not noted in Mr C's clinical records. The evidence from the clinical records indicated that the GPs had been made aware of symptoms in relation to Mr C's facial flushing and rash and that it was reasonable they did not consider that diabetes could have been the underlying cause of this. We were therefore satisfied the standard of care and treatment provided was reasonable and did not uphold Mr C's complaint.

Summary

Ms C complained about care and treatment her mother (Mrs A) received from her medical practice. Ms C was concerned that the practice missed opportunities to enable an earlier diagnosis of lung cancer. She felt that an earlier diagnosis could have helped prevent Mrs A's death. Ms C also raised concern about the way in which a GP handled a conversation about possible future resuscitation.

We took independent medical advice from a GP. We found that the practice had provided a reasonable standard of care in response to the various symptoms Mrs A had presented with in the year leading up to her cancer diagnosis. We did not identify any clear evidence to show that the conversation about resuscitation was handled inappropriately, and considered that it was reasonable to have this conversation with Ms C and Mrs A. The practice reflected on Ms C's concerns in any case and took steps to improve the way in which their staff deal with such conversations with patients and their families. We did not uphold Ms C's complaints.

Summary

Mrs C complained about the care and treatment provided to her late father (Mr A). Mr A was admitted to Dr Gray's Hospital where staff identified that he had suffered a stroke. Over the course of approximately four months, he had three further admissions. During the course of the admissions, Mr A's condition deteriorated. Mrs C raised concerns about pain Mr A was experiencing in his abdomen and back, and swelling in his leg. During the fourth admission, a scan revealed cancer. Mr A died approximately one week later.

Mrs C complained that the board unreasonably delayed reaching a diagnosis that Mr A was suffering from cancer. She also complained that the board failed to appropriately diagnose a deep vein thrombosis (DVT), which was identified during one of the admissions.

The board apologised and acknowledged that they had been slow to investigate pain Mr A was experiencing in his back and abdomen. They did not consider that earlier identification of the cancer would likely have impacted on Mr A's outcome, and that treatment would have been palliative. The board considered there had not been a delay in identifying the DVT.

After receiving independent advice from a consultant in acute medicine, we upheld Mrs C's complaints. We found that the symptoms Mr A had experienced were unusual, but should have alerted the board to the possibility of cancer at an earlier stage. We noted that the cancer was aggressive in nature and early detection would not have likely altered Mr A's outcome. We found that the board did fail to recognise the DVT in this case. We were critical of the limited records regarding checks for DVT. Finally, we had some concerns about delays in the board's handling of Mrs C's complaints.

Recommendations

We recommended that the board:

• apologise for the failings this investigation has identified;
• feed back the findings of this investigation to the relevant staff;
• remind the relevant staff of the guidance surrounding assessments and checks for venous thromboembolism, including DVT;
• develop an action plan to improve assessments and checks for venous thromboembolism, including DVT; and
• apologise for the failings in complaints handling this investigation has identified.

Summary

Mr C complained about the care and treatment provided to his late father (Mr A) while he was a patient at Aberdeen Royal Infirmary. Mr A had a complex medical history and he was admitted to hospital with ischemia (inadequate blood supply to an organ or part of the body) and sepsis (a blood infection). Several weeks later, he was discharged to a community hospital from where he was discharged home. He died the following day. Mr C complained about aspects of Mr A's discharge to the community hospital including communication.

We took independent medical advice. We found an unreasonable failure by staff to carry out comprehensive multi-disciplinary discharge planning. We also found that Mr A was transferred to a community hospital when he did not have capacity, which was against his family's wishes and without relevant documentation. We also found that there had been a breakdown in communication which meant that medical staff wrongly informed other staff about the family's wishes in relation to discharge. We upheld the complaint.

Recommendations

We recommended that the board:

• review what happened in light of the adviser's comments and reflect on relevant guidelines to ensure that processes in relation to discharge of complex patients are adequate;
• bring the failings identified to the attention of relevant staff; and
• apologise for the failings identified in this investigation.

Summary

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about the practice's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner.

We took independent medical advice. It was noted that, prior to her six to eight week assessment, the health visitor had measured Miss A's head circumference and the measurement had crossed over the top centile. This should have been a cause for concern and should have prompted a referral for further investigation. However, the health visitor had not taken action to alert the practice. The adviser considered, however, that the GP carrying out Miss A's six to eight week assessment should reasonably have looked at the growth charts and sought to satisfy themselves that Miss A was developing normally. They did not do so. We upheld the complaint.

However, the GP had already apologised for not personally examining the growth charts and arranging further action. The practice had reflected on the case and confirmed that they were now checking measurements and centile charts at the six to eight week assessment. We considered this action to have appropriately addressed the identified failings and we had no further recommendations to make.

Summary

Ms C, who works for an advocacy and support service, complained on behalf of Ms A about a health visitor's monitoring of her infant daughter (Miss A). Miss A was diagnosed with hydrocephalus (an abnormal build-up of fluid in the brain) at around four months old. Ms C complained that this should have been picked up sooner.

We took independent medical advice from a health visitor, who considered that there were failures to appropriately record and interpret Miss A's head circumference, resulting in missed opportunities to identify the steep growth rate and make an appropriate referral for further investigation. In particular, it was noted that the measurement at Miss A's six to eight week assessment had crossed over the top centile and, in line with the board's policy, should have prompted referral. We concluded that the health visitor did not take appropriate action to monitor Miss A's development and we upheld the complaint.

Recommendations

We recommended that the board:

• provide training to relevant staff on the guidance in place for monitoring, recording and analysing growth measurements;
• take steps to ensure that health visitors receive adequate clinical supervision and are able to access support in cases such as this; and
• apologise to Ms A for the identified failure to appropriately monitor Miss A's development.