Health

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.

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.