Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment her father (Mr A) had received at the Queen Elizabeth University Hospital before his death. We took independent advice on the complaint from a consultant in acute medicine. Mr A had been diagnosed with cancer and Ms C complained that he had been discharged from the hospital on two occasions, despite the fact that he was still very ill. Ms C also said that there had been a delay in carrying out a biopsy. We found that it had been reasonable to discharge Mr A on the first occasion and that there had not been an unreasonable delay in carrying out the biopsy. However, it had been unreasonable to discharge Mr A on the second occasion, as he had not been medically reviewed for at least two days at that point, despite concerns being raised about his fitness for discharge.

We also found that medical staff should have been clearer about Mr A's poor prognosis and likelihood of death. Some of the communication with his family had not been reasonable and as a result, they not been prepared for his death. The board had already apologised to the family for this. There should also have been better communication between the oncology and respiratory teams and a more realistic assessment of Mr A's fitness for chemotherapy. In view of these failings, we upheld this aspect of Ms C's complaint.

Ms C also complained about the nursing care Mr A had received. We took independent advice on this complaint from a nursing adviser. Although there were problems with replacing Mr A's water, we found that the nutritional care and personal care provided to Mr A had been reasonable. Whilst a nurse had incorrectly told Mrs B that her father was nil by mouth, the nurse had then phoned her back to apologise for this. We also found that the pain relief provided to Mr A had been reasonable and we did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mrs B for the failings in relation Mr A's discharge from hospital on the second occasion; and
• provide evidence that the failings identified in this investigation have been fed back to the staff involved in Mr A's medical care.

Summary

Mrs C complained about the treatment provided to her by the board at two appointments regarding her breast implants at Cannisburn Plastic Surgery Unit at Victoria Infirmary. Mrs C complained that at the first appointment she had not been offered a chaperone and had not been introduced to the trainee doctor who was present during her appointment. She also complained that at the second appointment the doctor had examined her without discussing her problems first. Mrs C said that she had not been offered appropriate medical treatment for the problems she had been having with her breast implants and she further complained about the way the board handled her complaint.

During our investigation we took independent medical advice from a consultant plastic surgeon. We found that, while Mrs C and the consultant's accounts of the first appointment differed, it was not recorded whether any discussion regarding a chaperone took place. This was contrary to national guidance issued by the General Medical Council in relation to intimate examinations. We therefore upheld this aspect of Mrs C's complaint. During our investigation, the board had implemented local guidance regarding these issues which we considered reasonable, but we also recommended an apology be given to Mrs C.

With regards to Mrs C's second appointment, we did not identify evidence to suggest that the appointment was not carried out in a reasonable manner. We found that Mrs C had been offered appropriate clinical care for the issues she was having with her breast implants. We also found that the board had made efforts to deal with her complaint in a timely manner. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation.

Summary

Mr C complained that the staff at Glasgow Royal Infirmary failed to appropriately assess and treat his mother (Mrs A) when she was referred there by her GP. His concerns included that the consultant in acute medicine who treated Mrs A made a diagnosis of temporal arteritis (where the temporal arteries, which supply blood to the head and brain, become inflamed or damaged), despite there being no supporting evidence from investigations or tests. Mrs A was discharged home that day. Mr C also complained that the staff at the hospital failed to appropriately monitor and manage Mrs A's blood pressure readings when she was admitted the following day.

We obtained independent medical advice from a consultant physician in acute and internal medicine. The adviser explained that Mrs A was referred to the hospital by her GP as they felt she might have temporal arteritis and it would, therefore, have been reasonable for the consultant to have considered this condition as part of the list of possible diagnoses. The adviser explained that after examination and consideration of Mrs A's history and blood test results, the consultant, correctly, did not consider Mrs A to be suffering from temporal arteritis. However, the adviser said that Mrs A should have been admitted to the hospital and treated for her high blood pressure and failure to do so sat outside the scope of standard practice. Mrs A was subsequently admitted to the hospital the following day as a medical emergency. We upheld this part of Mr C's complaint.

The adviser said the board did not unreasonably fail to take into consideration the effect of the reintroduction of Mrs A's existing high blood pressure medications when assessing her fall in blood pressure, and that it would have been reasonable to start Mrs A on her blood pressure medication in the circumstances. Therefore, we did not uphold this part of Mr C's complaint.

Recommendations

We recommended that the board:

• provide Mr C and Mrs A with a written apology for failing to admit Mrs A to hospital for treatment of her high blood pressure; and
• feed back the failings identified to the doctor involved for reflection for future practice.

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.