Health

Summary

Mr C complained that the practice failed to appropriately manage pulmonary fibrosis (a lung condition) in his late mother (Mrs A). The condition was first identified in a scan carried out five years prior to Mrs A's death and she regularly attended the practice over the intervening years with symptoms that included breathlessness. We obtained independent medical advice and we identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, we considered that a referral should have been made following the initial scan. We also considered that a referral should have been made a year before Mrs A's death, when an x-ray reported progression of the pulmonary fibrosis.

We found that all tests in between these times were not reported back to the practice in terms that would have prompted referrals. However, we noted that one GP expressed awareness of the condition during this period and made a referral to a geriatric clinic. While we considered it appropriate that further investigation was arranged, we noted that a respiratory referral would have been more appropriate.

We were assured that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. However, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C and his family for the missed opportunities to refer Mrs A to respiratory medicine; and
• reflect on the failings identified in this investigation and ensure that the GPs are familiar with the relevant guidelines and care pathways for patients with pulmonary fibrosis.

Summary

Mr C complained that the practice had failed to act appropriately on his reported symptoms of imbalance. Mr C has diabetes and related diabetic neuropathy (nerve damage). He said that over a long period he had complained to the practice of imbalance and falls but that this had always been attributed to his diabetic neuropathy. Mr C was diagnosed with multiple sclerosis (MS - a disease that effects the nervous system) and told us that he felt GPs at the practice should have picked up on this diagnosis earlier.

In investigating this complaint, we took independent GP advice. We found that Mr C had complained to the practice of imbalance on two occasions. On the first occasion, this was attributed to the existing diagnosis of diabetic neuropathy, and we found this to be reasonable. On the second occasion, six years later, Mr C was thoroughly examined and no features of concern were found. Mr C was told to return if his symptoms changed, but this was the last time he was assessed by the practice. We found that the symptoms which later led to his diagnosis of MS seven years after his initial examination were not present during the previous two appointments and that the practice had acted appropriately. Therefore, we did not uphold Mr C's complaint.

Summary

Ms C complained about the care she received at Forth Valley Royal Hospital after she was admitted via A&E with abdominal pains. While appendicitis was initially suspected, further investigations led staff to believe that Ms C was suffering from problems with her gallbladder. On the second day following her attendance at the hospital, a scan was carried out that showed Ms C's appendix had burst causing an abscess. She was operated on that day but suffered from pleural effusion (excess fluid surrounding the lungs) that had to be treated with a chest drain. Ms C felt that an earlier diagnosis could have resulted in a better outcome.

We took independent advice from a consultant in emergency care and a consultant surgeon. In terms of emergency care, we found that Ms C had received appropriate care and investigation in A&E. However, we found that whilst it was reasonable that staff had considered Ms C was suffering from a gallbladder issue due to her symptoms, junior staff should have escalated the case when her condition worsened and alternative diagnoses should have been considered at that point. We found that there had been a delay of around 12 hours in diagnosing the cause of Ms C's condition as a result of her care not being escalated to senior staff appropriately. We upheld Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that this case is included for learning purposes at the appraisal of the junior doctor;
• ensure the protocol for escalating patient care to more senior staff is highlighted during the induction of junior doctors; and
• carry out an audit of patients under the care of the surgical team with high national early warning scores to determine whether the escalation process is being appropriately followed.

Summary

Mr C complained that the board delayed in determining that he had multiple sclerosis (MS - a disease that effects the nervous system). Mr C said that he has diabetes and had regularly attended a diabetic clinic with the board to review his diabetic peripheral neuropathy (nerve damage). However, Mr C said he had repeatedly complained of poor balance to the board but that they had failed to find that he had MS despite his symptoms.

In investigating this complaint, we took independent medical advice. We found that Mr C had often reported pain to board staff and this was treated in line with diabetic neuropathy. We also found that when Mr C presented with dizziness it was reasonable for the board to rule out any cardiac causes. Our investigation found that when Mr C's condition was noticed to be deteriorating, he was appropriately and quickly referred to a consultant neurologist. Therefore, we did not uphold Mr C's complaint.

Summary

Mr C complained to us on behalf of his constituent, Ms A. He said that on being transferred from a mental health unit outside Scotland to Forth Valley Royal Hospital, Ms A was not provided with reasonable mental health care and treatment, in particular that the diagnosis of personality disorder she had been given did not fit her symptoms. Mr C also complained that Ms A was not provided with reasonable out-patient treatment when she was discharged from the hospital, and that the board did not take reasonable steps to change incorrect information on her discharge documents.

We took independent psychiatric advice. We found that the in-patient care and treatment provided to Ms A was not reasonable. Whilst we found that the treatment strategies offered to her were appropriate, the diagnosis of personality disorder was not sufficiently evidenced and documented. We found that no valid diagnostic assessment tool was used to assess Ms A and that her diagnosis was given without sufficient consideration of her previous diagnoses. We also found that the way this diagnosis was communicated was inconsistent, sometimes being reported as a provisional diagnosis and sometimes as confirmed. We found that there was a lack of documentation surrounding decisions taken about Ms A's care, including the decision not to implement the recommendations of a clinician who gave a second opinion, not to trial certain medications and the decision to change Ms A's lead clinician. We therefore upheld this aspect of Mr C's complaint.

In terms of Ms A's out-patient mental health care and treatment, we found that it was reasonable for the staff involved to provide care on the basis of Ms A's diagnosis of personality disorder, and that out-patient care and treatment had been planned in a collaborative way with Ms A in line with treatment for personality disorders.

When considering whether the board had taken reasonable steps to remove incorrect information from Ms A's records, we saw evidence that when the board became aware of this incorrect information, they apologised and arranged for the documents to be replaced with amended versions. We also saw evidence that they took steps to ensure all incorrect electronic records were amended. We considered the steps the board took to have been reasonable in this regard.

Recommendations

We recommended that the board:

• apologise to Ms A for the failings identified in this investigation;
• remind relevant staff of the caution advised when assessing personality disorder traits in patients with prominent mood or anxiety symptoms;
• consider using a valid diagnostic assessment tool (not just a screening tool) to aid diagnosis and formulation of personality disorders;
• remind the relevant staff of the importance of being clear and consistent in documenting any diagnoses and whether such diagnoses are provisional or confirmed;
• remind the relevant staff of the importance of, in cases where clinicians have sought second opinions, the recommendations made being fully considered before being implemented, and, if not implemented, the reasons why not being clearly documented and explained to the patient;
• remind the relevant staff of the importance of ensuring prescribed medication is regularly reviewed; and
• remind the relevant staff of the importance of documenting changes of responsible medical officer or consultant psychiatrist, and the reasons for these changes.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs A regarding the care and treatment she received at Forth Valley Royal Hospital. A scan showed a large abscess on Mrs A's liver. She had undergone surgery to remove her gall bladder three years earlier and it was noted on the scan that one of the surgical clips had become dislodged. It was felt that this was the source of Mrs A's infection and abscess formation. The abscess was initially drained radiologically (a process in which, using radiological imaging, a thin needle is guided into the abscess and a drainage catheter placed). Following two further hospital admissions with recurrence of the abscess, surgical drainage was carried out and the clip was removed. A further admission took place following a small recurrence and the surgical incision was re-opened and the fluid drained again.

Ms C complained that the board failed to appropriately manage the complication arising from Mrs A's earlier surgery. In particular, she considered that a delay in removing the surgical clip resulted in the abscess recurrence and need for multiple admissions . We took independent medical advice from a consultant surgeon who noted that the possibility of surgical clips becoming dislodged was well recognised but rarely caused problems. They considered that it was reasonable for the board to have considered less invasive treatment than surgery in the first instance. They noted that, when this was unsuccessful, it was appropriate to proceed to surgery and remove the clip, which they noted was done within seven weeks of the first admission. They considered this reasonable.

However, the adviser did not consider that the recurrence of the abscess was due to the ongoing presence of the clip, but rather due to inadequate drainage. They noted that the drain was only left in place for four days the first time and five days the second. They considered that the drain should have been left in place for 10 to 14 days initially and that the board could also have considered flushing the abscess cavity to ensure that there was no residual fluid collection. They advised that this could potentially have avoided the need for surgery. In relation to the further small recurrence, following surgery, the adviser noted that the surgical incision had to be widened to improve drainage and they considered that this was as a result of the incision having been too small in the first instance. They considered that a wider incision was required for an abscess of the nature of Mrs A's. We concluded that the complication Mrs A experienced could have been better managed by a longer drainage period and a larger surgical incision. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings identified in this investigation; and
• feed back the findings of this investigation to relevant staff, highlighting the adviser's comments regarding the length of the abscess drainage period and the size of the surgical incision.

Summary

Mr C complained about the way his medication was handled by the prison health centre, in particular that his medication was changed and that his complaints about pain had been ignored.

We took independent GP advice. We found that, when reviewing Mr C's medication, the prison health centre had acted in line with the General Medical Council guidelines on prescribing. We also found that the care provided to Mr C in terms of his pain management was reasonable. We therefore did not uphold the complaint.

Mr C also complained that a doctor based at the health centre had inappropriately stated that he hated migrants. We found no evidence to support Mr C's allegation and were satisfied that the allegation had been investigated by the board, including speaking to the doctor involved. However, we noted that there was no written record of the discussions with the doctor as part of the investigation. We were also satisfied that the decisions made in relation to Mr C's clinical management were based on the advice available to clinicians. As such we did not uphold this aspect of Mr C's complaint.

Mr C was also unhappy with the handling of his complaint. We were satisfied that the board had handled Mr C's complaint in line with the complaints process and therefore did not uphold this complaint.

Recommendations

We recommended that the board:

• provide an update on the action taken to ensure that relevant staff keep a written record of conversations held with clinicians as part of a complaint investigation.

Summary

Mr C complained that the board failed to clearly diagnose his late mother (Mrs A's) pulmonary fibrosis (a lung condition), and failed to communicate the diagnosis and manage the condition appropriately. Mrs A's pulmonary fibrosis was first identified in a scan carried out five years prior to her death. She regularly attended her GP and hospital over the intervening years with symptoms that included breathlessness. We obtained independent medical advice from a consultant respiratory physician, a consultant general physician and a consultant in emergency medicine. We identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, an attendance at an ageing and health clinic did not result in an onward referral despite clear evidence of progression of Mrs A's condition. We were assured, however, that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. Nonetheless, we recognised that earlier specialist intervention would have afforded Mrs A and her family the opportunity to better understand the nature of her condition and be assured that her symptoms were being appropriately managed. We upheld this aspect of the complaint.

Mr C also complained that the board did not respond to his letters of complaint fully and within a reasonable timeframe. We noted that the board's response to Mr C's initial complaint was issued in good time and attempted to address the specific concerns raised. Mr C then wrote to the board on a further two occasions listing several additional questions and outstanding concerns. We noted that the NHS complaints procedure does not make provision for further stages of the process and complainants who remain dissatisfied should be referred to the SPSO. We, therefore, did not consider that the board were obliged to provide the additional level of detail requested by Mr C. However, having agreed to provide a further written response, we considered that the board unreasonably delayed in doing so. We noted that the board had already apologised for the delay. We also considered that they could have responded with greater clarity. We therefore upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failure to clearly diagnose, communicate and manage Mrs A’s pulmonary fibrosis;
• carry out a review of Mrs A’s care and treatment and report the outcome back to us, ensuring that the failings this investigation has identified are fully reflected upon and account taken of the medical adviser's suggested areas for improvement;
• remind complaints handling staff of the importance of responding fully and accurately to complaints, and ensuring that the response represents the board’s definitive position in order that any subsequent disagreement can be appropriately referred to us; and
• remind complaints handling staff that, in circumstances where they choose to engage in further correspondence with a complainant, they should respond in a timely manner and keep them informed of any delays.

Summary

Mr C complained about the care and treatment he received from his medical practice. Mr C had been admitted to hospital to receive treatment for chronic liver disease. When he was discharged from hospital, the medication he was prescribed was a lower dosage than he had been taking previously. Mr C raised concerns that the medication he was prescribed by the practice prior to admission was excessive.

We took independent medical advice. We found that Mr C's medication had changed whilst he was in hospital because his condition had changed. The adviser explained that medications are often reviewed or withdrawn when patients are in hospital settings, yet this does not mean that the pre-existing medication was either incorrect or excessive in dosage. We did not find evidence that Mr C had been prescribed excessive medication and for this reason we did not uphold this aspect of his complaint.

Mr C also raised concerns that appropriate investigations were not arranged when he reported pain in his chest and back to GPs at the practice. Mr C was subsequently diagnosed with osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break), but felt he should have received treatment for this condition sooner. We found that the practice had initially referred Mr C for acupuncture, and that this was because he had a history of pain following a previous injury and had received acupuncture previously. We found this to be reasonable and did not consider that there was a clinical indication that Mr C had osteoporosis until he attended a consultation around three months later. At this consultation, an x-ray was arranged, which confirmed Mr C's diagnosis. The practice then prescribed Mr C two medications to help protect his bones.

We considered that the practice investigated Mr C's condition reasonably and provided appropriate treatment. We did not uphold this aspect of Mr C's complaint.

We noted that the practice had acknowledged that they had not handled Mr C's complaint fully in accordance with the 'Can I help you?' guidance for handling healthcare complaints. While we were critical of this, we found that the practice had undertaken a significant event review and we were satisfied that the practice had taken steps to identify what went wrong and learn from this shortcoming. We therefore made no recommendations.

Summary

Mrs C underwent a hip-replacement operation at Victoria Hospital. During the operation, a suture (a stitch used to close a cut or wound) used to repair the muscles at the back of her hip caught the edge of her sciatic nerve (a nerve in the lower back area). Mrs C said that she had not been told when she consented to the operation that this was a potential risk and that it should not have occurred. Mrs C also raised concerns about the time it took medical staff to find out what happened. It was not until three days after the operation that medical staff recognised that Mrs C had sciatic nerve palsy (foot drop and numbness) and she underwent a further operation six days after the first operation.

We took independent advice from a medical adviser who specialises in surgery. We found failings in the consent process which meant that Mrs C was not in a position to give her informed consent for the procedure. We considered that Mrs C should have been warned of the potential adverse outcome in clear terms and language, even though the risk of permanent nerve damage was very rare. We also found the time it took to identify the sciatic nerve palsy and escalate it to the surgeon to be unreasonable. We therefore upheld Mrs C's complaint.

However, in relation to the standard of operation and surgical error, while we accepted this was a significant failing which had an adverse outcome, our view was that it was not evidence of poor practice or of an unreasonable failing in the surgical care provided.

Recommendations

We recommended that the board:

• review the consent process and related documentation to ensure clinicians properly obtain (and document) consent for procedures;
• bring the failings to the attention of relevant staff and ensure the failings are raised as part of their annual appraisal;
• investigate why the finding of sciatic nerve palsy was not escalated and inform us of the findings; and
• apologise to Mrs C for the failures this investigation identified.