Health

Summary

Mr C complained about the care and treatment provided to his father (Mr A) at Victoria Hospital. Mr A was admitted to A&E after suffering a transient ischaemic attack (TIA, a mini stroke caused by a temporary disruption in the blood supply to part of the brain). Mr A underwent a brain scan. The doctor discussed Mr A's case with a stroke consultant and Mr A was discharged with planned follow-up in the TIA clinic.

Following discharge, Mr C had a stroke and was re-admitted to hospital later the same day.

Mr C complained that staff had failed to take into account that Mr A's wife had recently died and that he would be returning to an empty home on discharge. The board acknowledged that aspects of the communication during the admission were poor, but maintained that the decision to discharge Mr A was appropriate and in accordance with the protocol.

The board apologised to Mr C for the communication failings and outlined steps for improvement. In particular, the board said that they would discuss the issues with staff involved and that a newsletter would be introduced to A&E to share learning. We made a recommendation in relation to this.

We took independent advice from an adviser in emergency medicine. The adviser considered that the doctor's assessment of Mr A was of a good standard and overall they were satisfied that Mr A was appropriately managed in accordance with the board's TIA protocol. The adviser noted that the doctor who assessed Mr A received input from a stroke consultant before discharge and they were satisfied that the decision to discharge Mr A was reasonable. In view of this, we did not uphold Mr C's complaint.

Recommendations

We recommended that the board:

• provide an update on the production of the newsletter.

Summary

Mr C complained about the care provided to his mother (Mrs A) at Victoria Hospital. Mrs A had recently had a heart attack and had received treatment for this from another health board. Less than two weeks later, Mrs A attended the A&E department at Victoria Hospital and was assessed by a consultant cardiologist. The cardiologist suspected that Mrs A had aortic valve disease (the narrowing of the main valve through which blood is pumped out of the heart to the rest of the body), and decided to withdraw one of the medications Mrs A had previously been prescribed and introduce a beta-blocker (a medication used to treat various conditions including those of the heart). After a period of monitoring took place following the first dose of the beta-blocker, it was decided that Mrs A could be discharged. However, at the point of discharge, Mrs A collapsed and required assistance. Mrs A was readmitted overnight and, after further monitoring took place, she was reviewed by the cardiologist the following day. The cardiologist decided that Mrs A should remain on the beta-blocker and prescribed a further medication used to lower blood pressure, before discharging Mrs A later that day.

Following discharge, Mrs A's condition deteriorated. Mr C then arranged a cardiology review appointment with Mrs A's local health board. At this appointment, a different consultant cardiologist changed the beta-blocker medication to a different medication. Mr C noted that Mrs A's condition quickly improved as a result. Mr C complained to the board that it was inappropriate that Mrs A had been given the beta-blocker medication and felt it had caused the deterioration in her condition. We took independent advice from a consultant cardiologist. The adviser said that the beta-blocker was one of the recommended medications for patients who have had a heart attack, and said it was reasonable that it was given to Mrs A. The adviser was unable to conclude that the medication had affected Mrs A adversely, but, in any case, said that an adverse reaction to the medication could not have been reasonably foreseen. We did not uphold this complaint.

Mr C also raised concerns that the beta-blocker medication given to Mrs A was not re-evaluated prior to discharge, and said that he was not informed of the potential side effects of this medication. The adviser reviewed the records, and found evidence that staff had appropriately monitored Mrs A's blood pressure and heart rate in the period between Mrs A's re-admission and her discharge the following day. The adviser noted that there was no evidence that Mrs A was not fit for discharge, and concluded that the decision to discharge was reasonable. However, based on the records available, the adviser was not able to determine whether the potential side effects of the beta-blocker, together with the benefits and risks of any alternatives, had been discussed with Mrs A. The adviser said that this was a discussion that should have been documented, and was critical of this omission. While we did not uphold this complaint, we made a recommendation to address the issue highlighted by the adviser.

Recommendations

We recommended that the board:

• feed back the adviser's comments to the cardiologist who assessed Mrs A to ensure that potential side effects of medications and the benefits/risks of alternatives are appropriately discussed and documented.

Summary

Ms C complained about the treatment she received for an eye infection from the out-of-hours service at Dumfries and Galloway Royal Infirmary. In particular, Ms C complained that a GP wrongly tried to dissuade her from attending the primary care clinic and that when she did attend, she did not receive treatment and was told she needed to give the antibiotics already prescribed more time to work. Ms C also complained about the board's complaints handling.

During our investigation we took independent medical advice from a GP. The adviser considered it was reasonable Ms C was told to allow more time for the antibiotics her own GP had given her to work. The adviser did not consider the care provided to be inadequate. We therefore did not uphold Ms C's complaints about the care she received.

As we considered there were some errors in the board's complaints handling, we upheld this aspect of Ms C's complaint. The board acknowledged that they were not always efficient in responding to and progressing Ms C's wider concerns and said that they were in the process of making improvements to their complaints handling practices.

Recommendations

We recommended that the board:

• apologise to Ms C for the errors made in the handling of her complaints.

Summary

Mrs C complained about the medical practice with regards to the care and treatment provided to her husband (Mr A). Mrs C said that the GP failed to ensure that Mr A's diagnosis of a rare type of cancer was followed up and that had the GP acted differently, Mr A would have been offered earlier treatment.

We took independent medical advice from a GP. We found that the practice had not been told that the diagnosis of cancer was definitive, but rather that it had been communicated as a 'suspicion of diagnosis'. We found that there was no obligation for the practice to record this if it was not definitive. Additionally, we found that it was not the practice's responsibility to ensure that further tests and reviews were being carried out as this was the responsibility of secondary care. Therefore we did not uphold Mrs C's complaint.

Summary

Mrs C complained that staff at University Hospital Crosshouse failed to provide her father (Mr A) with appropriate clinical treatment following his admission with abdominal pain. Mr A was diagnosed with cholangitis (an infection of the tube connecting the liver to the duodenum, the first part of the small intestine immediately beyond the stomach) and an ERCP (endoscopic retrograde cholangiopancreatography, a procedure where a flexible tube is passed into the small intestine) was performed on Mr A four days later. Mr A suffered a retroperitoneal perforation (a small tear in the upper bowel) during the ERCP. Mr A's condition deteriorated and he died.

We obtained independent advice from a consultant gastroenterologist and a consultant general surgeon.

The consultant gastroenterologist explained that an ERCP was the appropriate procedure in Mr A's case, as verified by the British Society of Gastroenterology and National Institute for Health and Care Excellence guidelines. They explained that the procedure was carried out appropriately, was documented as being relatively straightforward and was well tolerated by Mr A. However, they said Mr A suffered a recognised complication of an ERCP. Both advisers said that although Mr A's perforation was not detected as soon as it could have been, the management of Mr A's condition would not have changed with an earlier diagnosis. The consultant general surgeon confirmed that the time taken to diagnose the perforation was not due to poor practice. We therefore did not uphold Mrs C's complaint.

Summary

Mr C complained about the care received by his sister (Miss A) at University Hospital Ayr, in particular that there was a delay in her being scanned and a delay in transferring her to the Beatson West of Scotland Cancer Centre, which is in another board area. Miss A had a history of Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system) and became unwell. Further tests showed that Miss A had tumours in her liver and bone marrow. She died two days after being transferred to the centre.

We took independent medical advice and found that Miss A had been reviewed urgently when abnormalities were identified. We found that she was offered admission to hospital to undergo further tests including a specialist scan. However, it appears Miss A opted to wait for an out-patient appointment. Whilst cancer was not initially suspected we found that the time taken to carry out a specialist scan was reasonable. We concluded that Miss A's care was reasonable and did not uphold Mr C's complaint.

However, we were critical of the board's communication about Miss A's transfer to the centre, which caused Miss A and her family additional distress. The board apologised for this and we made a recommendation to identify any further learning and improvement.

Recommendations

We recommended that the board:

• evidence that they have liaised with Greater Glasgow and Clyde NHS Board to identify any possible learning and improvements in relation to the delayed transfer to the centre.

Summary

Mr C complained to us that when he took his son (child A) to the emergency out-of-hours service, he was not satisfied with the treatment given for child A's swollen eye and temple by the attending GP. The GP diagnosed child A was suffering from a chest infection.

Child A subsequently underwent neurosurgery to remove an abscess (a swollen area within the body tissue, containing an accumulation of pus) from the eye socket and was admitted for over six weeks.

We took independent GP advice and concluded that the GP had provided a reasonable level of care. The GP had noted a history of upper respiratory symptoms for two days (suggestive of viral/cold symptoms) and that both parents had similar symptoms. The GP examined child A's chest, breathing rate and temperature. The GP found that child A was likely to have a chest infection. Child A was given treatment and the family was told to return should they have further concerns. We found that this was a reasonable management plan.

The adviser noted that swollen/puffy eyelids can be common in children with viral illness due to them rubbing their eyes. If there was no evidence of a pus collection, then it was reasonable for the GP to adopt a 'watch and wait' management plan. We found that as the symptoms described could be consistent with a viral illness, it was not unreasonable that the GP did not diagnose the abscess during the visit. We therefore did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment she received at Ninewells Hospital after having her jaw joint replaced with an artificial joint. Prior to then, Mrs C had been under the care of an oral medicine consultant who had tried a range of non-surgical methods to manage the pain she was having in her jaw joint. Mrs C was then referred to a specialist surgeon, who recommended surgical replacement of the joint. Mrs C proceeded with the surgery but suffered complications that resulted in the artificial joint being removed for several months and replaced with a different type.

Mrs C was concerned that the risks of surgery had not been properly explained to her, about the sourcing of the artificial joint, that special equipment to detect nerves was not used during the surgery, and that there was a delay in identifying problems with the replacement joint.

We took independent advice from an oral and maxillofacial (the speciality concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon. We found no failings with the standard of surgery performed or the type of artificial joint used. We also considered that Mrs C's ongoing problems were reasonably reviewed with no undue delay in providing treatment.

However, we considered it unreasonable that there was no evidence to show that a discussion took place with Mrs C at any out-patient appointment with regard to all the benefits and recognised risks associated with the surgery. The only records of such discussions were during a phone call, where not all the risks were documented, and on the day of Mrs C's surgery, where it was unclear what had been explained to her. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise in relation to the failings identified in the consent process;
• review the service's process for obtaining informed consent to ensure it is in line with General Medical Council consent guidance; and
• consider providing written patient information on the jaw joint surgery.

Summary

Mr C complained that the Scottish Ambulance Service (the ambulance service) did not ensure that someone attended his home to make sure he was safe after he took an overdose of paracetamol. When the ambulance crew arrived, they could not or did not gain access and left the house without taking further action. Mr C was later helped by a neighbour to attend A&E. Mr C said he was in a vulnerable situation and that the failings by the ambulance service were potentially life-threatening.

Mr C also complained about the way the ambulance service handled his complaint, including the time it took them to respond.

We took independent advice from a specialist in the training and supervision of healthcare professionals including paramedics. We found inconsistencies in the accounts of the staff involved and it is not clear why contact was not made with Mr C. The ambulance service failed to record their findings and action taken at the time. The evidence indicated a communication breakdown between the ambulance crew and ambulance control centre. We found that the ambulance service should have escalated the situation to the police in order to gain more information and access to the property.

In relation to the handling of Mr C's complaint, we found evidence indicating confusion amongst staff about who should deal with the complaint and how it should be dealt with. We were critical that Mr C's complaint to the ambulance service was initially managed as a concern and that it took over three months for the ambulance service to start an investigation. We also found that complaint staff did not reasonably inform Mr C about the delays and the reasons for these.

Recommendations

We recommended that the ambulance service:

• raise the failings identified with relevant staff;
• confirm that the guidelines being developed for dealing with similar incidents have been implemented and communicated to all staff;
• ensure ambulance crews record adequate information on patient report forms;
• provide an update on the actions taken to improve complaints handling; and
• apologise to Mr C for the complaints handling failures.

Summary

Miss C complained about the care and treatment she received at St John's Hospital. She had been diagnosed with skin cancer and had an operation in the hospital to remove the cancer. She said that, after the operation, the anaesthetist refused to give her further pain relief without having seen her when she asked for this.

We took independent advice from an anaesthetist. We found that Miss C had been seen by the anaesthetist when she requested additional pain relief and that their decision that she had already received appropriate and adequate pain relief was reasonable. We did not uphold this complaint.

Miss C also complained that there was an unreasonable delay by nurses in providing her with pain relief she had requested later that day. We found that there had been an unreasonable delay in providing the pain relief and upheld the complaint. However, we were satisfied that the board had apologised for this and had taken action to prevent such delays occurring in the future.

Miss C also complained that the surgeons had not discussed her concerns with her at an appointment, as the board's response to her complaint said they would. We found that the board had written to Miss C to say that they had shared her concerns with the surgeons and they would discuss the matter at her next appointment. However, Miss C's concerns were not discussed at the appointment, as they had not been shared with the surgeons. We also upheld this aspect of Miss C's complaint. However, we were satisfied that the board had apologised to Miss C for this and had offered to arrange a further meeting.

Finally, Miss C complained about the board's handling of her complaint. We also upheld this complaint, as we found that there had been an unreasonable delay in responding, although the board had apologised for this and had provided us with evidence that they had taken action to prevent such delays in the future.