Health

Summary

Following a fall, Mrs C attended the A&E department at St John's Hospital with a painful and swollen left arm. X-rays were taken and Mrs C was diagnosed with a dislocated left elbow. Mrs C's elbow was moved back into position (reduced), she was given a plaster cast and further x-rays were taken. An emergency medicine consultant reviewed the x-rays and did not identify any fractures. Mrs C was discharged the same day.

Mrs C's records and x-rays were later reviewed by an orthopaedic and trauma surgeon at the hospital's virtual trauma triage clinic. The surgeon agreed there were no evident fractures. Mrs C was issued with a follow-up appointment to attend the fracture clinic.

In the interim, Mrs C returned to A&E as her cast had become loose and she was in continual pain. An x-ray was taken which showed the elbow had dislocated again and she had a displaced radial head fracture (a fracture of the bone at the top of the forearm). Mrs C was referred the same day to the Royal Infirmary of Edinburgh for surgery.

Mrs C complained that there was an avoidable delay in staff diagnosing she had suffered a fractured arm.

We took independent advice from advisers in emergency medicine and orthopaedics. We found that Mrs C's injury was managed correctly when she first attended A&E and she was appropriately referred to the virtual clinic for review. We also found that the x-rays taken before Mrs C's elbow was reduced showed a fracture which was missed on review. We noted that the x-rays taken after Mrs C's elbow was reduced were not of sufficient quality to rely upon for a diagnosis and that further x-rays should have been obtained. While the problems Mrs C experienced in terms of her outcome were due to the severity of her injury and not her treatment, if further x-rays had been ordered, it is likely the severity of the injury could have been diagnosed and the injury treated sooner. We therefore upheld Mrs C's complaint.

We accepted the advice we received that the board should give consideration to the implementation of hot reporting (where a report of an x-ray of a suspected fracture is delivered by a radiographer before the patient is discharged from the emergency department). This would be in-keeping with the National Institute for Health and Care Excellence (NICE) guidelines on the assessment and management of non-complex fractures. We also considered the board should review the relevant patient advice sheet given at discharge and the process of scheduling fracture clinic appointments to minimise the risk of administrative errors which we found had occurred in this case. We therefore made recommendations to address this.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in diagnosing her fractured arm;
• ensure that the advisers' comments on the failure to observe the x-ray abnormalities in this case and to order further x-rays of a diagnostic quality are brought to the attention of relevant staff and report back on the action taken;
• give consideration to the implementation of hot reporting as per the NICE guideline (NG38) on the assessment and management of (non-complex) fractures;
• review the relevant patient advice sheet given at discharge to ensure it sets out the process for orthopaedic follow-up and contains appropriate contact details for any concerns the patient may have and provide us with evidence of this; and
• review the process of scheduling fracture clinic appointments to minimise the risk of administrative errors as occurred in this case.

Summary

Mr C complained to us about a delay in the medical practice referring him for a scan. The scan showed a diagnosis of testicular cancer. He had attended the practice on three occasions and it was only on the last attendance that he was referred for the scan. Mr C believed that the scan should have been arranged at either the first or second consultation.

We took independent GP advice. At the first consultation there was a report of a tender right testicle which had been present for two to three days. There was no lump and antibiotic medication was provided with a review the following week if the condition did not settle. A diagnosis of orchitis (inflammation of one or both testicles) was made. Mr C then reattended the practice some 12 weeks later with a report of right testicular discomfort again and repeat medication was provided. Mr C then attended again after a further five weeks and reported right testicular discomfort and a lump. The ultrasound referral was then made, in line with national guidance, which led to the diagnosis of testicular cancer.

We found that the practice had provided a reasonable level of care and that the referral was made at an appropriate time in view of Mr C's reported symptoms. We therefore did not uphold Mr C's complaint.

Summary

Mrs C complained about the standard of treatment provided to her father (Mr A) in relation to dead tissue in his big toe. Mr A was diabetic and suffered from a condition which affected his circulation. Mr A had several admissions to hospital and out-patient treatment, but after several months his condition deteriorated and he was admitted to Hairmyers Hospital with severe disease of the arteries.

A surgeon decided to manage Mr A's condition conservatively (without surgery), but Mrs C said that it was clear he was deteriorating due to an infection. After a week, another surgeon undertook an emergency operation to amputate Mr A's leg above the knee.

Mrs C complained that the board failed to ensure surgery was undertaken within a reasonable time and that this had an adverse effect on the outcome.

We took independent medical advice from a specialist in diagnosing and treating conditions which affect circulation. We found that the standard of care and treatment provided to Mr A was reasonable, that it was appropriate to initially treat Mr A's condition conservatively and that the time taken to perform surgery was reasonable. We also found no evidence that any other intervention would have saved Mr A's leg. We therefore did not uphold Mrs C's complaint.

Summary

Mrs C complained to us that at numerous consultations over a nine-month period, the medical practice failed to provide her with appropriate treatment for her reported pain in her right arm. By the time she was referred for a specialist hospital opinion, a diagnosis of non-Hodgkin lymphoma (a cancer that develops in the lymphatic system) was made. Mrs C believed that the GPs at the practice should have referred her to hospital earlier and that as a result she has had to undergo courses of chemotherapy and radiotherapy.

We obtained independent GP advice. We found that during the relevant period, in addition to the consultations at the practice, Mrs C attended the pain clinic and referrals to other departments. She also underwent an MRI scan and x-rays were taken. The symptoms which Mrs C reported to the practice were not in keeping with a diagnosis of non-Hodgkin lymphoma.

We found that the practice arranged appropriate referrals and also closely monitored Mrs C's pain relief whilst communicating frequently with the pain clinic specialists. We therefore did not uphold Mrs C's complaint.

Summary

Ms C, and advocacy and support worker, complained on behalf of Ms B about the care and treatment received by Ms B's daughter (Miss A). In particular, that there was an unreasonable delay by the board in diagnosing Miss A's genetic condition. Ms C also complained that Ms B was wrongly advised during the new-born period that Miss A, who was born at Raigmore Hospital, did not have the genetic condition. Finally, Ms C complained that the board's replies to her complaints were unreasonable.

We took independent medical advice. We found that there was an unreasonable delay in diagnosing that Miss A had the genetic condition. We also found that Miss A should have been referred for a paediatric cardiology opinion. In addition, the advice we received was that had Miss A been appropriately followed up, the genetic test that became available three years later could have been performed at that time, rather than 12 years after her birth when Miss A was referred to a consultant in clinical genetics.

The board said that they now have an IT database which enables them to identify patients who might benefit from changes in genetic testing, but that due to staffing and workload constraints, they were unable to contact all relevant patients. We found that were patients triaged and followed up appropriately, such a database should not be necessary. We therefore upheld Ms C's complaint that there had been a delay in diagnosing the genetic condition.

We also found that while Ms B was given an assurance during the new-born period that Miss A did not have the genetic condition at birth, it was not possible to exclude a diagnosis at that time. When responding to Ms C's complaints, the board explained they were unable to say why this assurance had been given. We therefore upheld this aspect of Ms C's complaint.

Finally, while the board responded to Ms C's complaints in line with the timescales detailed in their complaints process, we were concerned that they had failed to adequately address all the issues raised. In light of this we upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• apologise for the delay in diagnosing that Miss A had the genetic condition;
• review their policy with respect to checking patients with suspected inherited conditions, to ensure they are appropriately reviewed by a specialist with an interest in inherited conditions;
• consider the adviser's comments regarding the current database and report back on any action taken; and
• ensure that a full response is provided to a complaint and that this addresses all the points in line with their complaints procedure.

Summary

Mr C complained that when he underwent a scan to establish whether there was evidence of gallbladder disease, a finding of atelectasis (collapse of small airway) was noted on the report. However, the finding was not brought to Mr C's attention or that of his GP and Mr C wondered whether the atelectasis required attention or was the cause of his health problems.

The board explained that the finding was not related to the purpose of the referral for the scan. They said that it was an incidental finding related to Mr C's respiratory problems, which were already being treated by the respiratory department.

We took independent clinical advice. We noted that the atelectasis was a finding of no consequence and would not normally require further action. We therefore did not uphold Mr C's complaint.

Summary

Mr C was admitted to Glasgow Royal Infirmary with acute left leg ischaemia (inadequate blood supply). Mr C later self-discharged. Arrangements were made for him to be seen a few weeks later for review and he was prescribed medication.

Mr C attended the vascular clinic on three more occasions and his condition began to improve. He was treated conservatively (non-surgically). On his condition being noted as stable, the plan was to continue to treat Mr C without surgery and to review him again.

However, Mr C said that he remained in severe pain and was disabled. His GP obtained a second opinion for him from a different health board and Mr C was later given vascular surgery. Mr C complained that the board failed to provide him with reasonable treatment.

We took independent advice from a consultant vascular surgeon. We found that Mr C's conservative treatment was in accordance with clinical guidelines and that his symptoms had been treated appropriately. While the threshold for surgery could vary between clinicians, that Mr C had not been given surgery at an earlier date did not represent substandard or unreasonable care. We therefore did not uphold this aspect of Mr C's complaint.

Mr C also complained about the way the board investigated his complaint. However, we found that he was provided with a timely and reasonable response and therefore did not uphold this complaint.

Summary

Mrs C's mother (Mrs A) was admitted to Queen Elizabeth University Hospital. Mrs A had a number of health conditions and had recently been treated with antibiotics for infected leg ulcers and had chronic leg swelling.

Mrs A spent two months in the hospital and was discharged after clinical staff considered that she was medically stable. Shortly after discharge, Mrs A had a fall at home and was re-admitted to hospital.

Mrs C complained that the board did not provide appropriate pressure ulcer care for Mrs A. In particular, Mrs C said that staff left wounds on Mrs A's legs undressed for a number of hours and failed to appropriately elevate Mrs A's legs to promote healing.

We took independent nursing advice. We found no evidence in the records that failings in care had occurred. For this reason, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that staff inappropriately discharged Mrs A from hospital. Mrs C specifically raised concerns about the level of physiotherapy input, Mrs A's nutritional status, that a home visit was not carried out prior to discharge and the medication with which Mrs A was prescribed on her discharge.

We took independent advice from an specialist in geriatric medicine. The adviser considered that Mrs A had received an appropriate level of therapy from a range of specialties before discharge and considered that the decision to discharge was reasonable. The adviser had no concern about the medication prescribed at discharge and was satisfied that the board's considerations in relation to a home visit were reasonable.

In relation to nutrition, the adviser considered that Mrs A had received appropriate care from dieticians, but noted that the board had mischaracterised Mrs A's nutritional status in their complaint response. We did not uphold this aspect of Mrs C's complaint, but we made a recommendation in respect of their complaints handling.

Recommendations

We recommended that the board:

• apologise to Mrs A's family for the inaccuracy in the board's complaint response letter.

Summary

Ms C, an advocacy and support worker, complained on behalf of Ms B. Ms B's concerns related to the medical and nursing care received by her mother (Mrs A) at Southern General Hospital. Mrs A had been diagnosed with lung cancer that had spread to her liver. She was admitted to hospital as she was suffering from pain, shortness of breath and confusion. A plan was made for Mrs A's transfer to a special cancer treatment centre but she suffered a fall and fractured her hip before this could take place. An incapacity certificate was completed and after assessment, surgery was carried out to Mrs A's hip, but her condition worsened. Mrs A was transferred to a hospice, where she died.

We took independent advice from a consultant in acute and respiratory medicine. We did not uphold Ms C's complaint about the standard of medical care. We found that the decision to proceed with surgery was reasonable in the circumstances of the case and that whilst pain had been poorly controlled for Mrs A, this was despite the best efforts of the team caring for her.

We also took independent nursing advice. The advice we received highlighted issues with the assessment of Mrs A's risk of falling. We found that Mrs A's cognitive difficulties and other factors had not been properly taken into account, resulting in an inadequate falls prevention care plan at the time of her fall. The advice we received also highlighted issues with the assessment of Mrs A's mobility. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• ensure that all relevant issues, including documented cognitive difficulties, are properly accounted for during the falls risk-assessment process;
• ensure that mobility assessment documentation is appropriately completed and reviewed; and
• ensure that completed incapacity certificates are accompanied by a treatment plan when appropriate.

Summary

Ms C complained that the board failed to provide her with appropriate orthopaedic surgery. She also complained that they did not provide her with appropriate clinical treatment when she reported health problems following the surgery.

Ms C had an initial operation to treat a bunion affecting her right foot. The operation was not successful and she elected to undergo further (revision) surgery. Following this surgery, Ms C's condition appeared to improve. However, over the subsequent years she experienced further problems with her foot, including pain and discomfort. Ms C also felt that this triggered other health problems. During this time, the board attempted to treat these problems with orthotics (supports) and also referred Ms C to their pain management clinic.

Ms C raised concerns about the revision surgery, including that the surgeon had left a bone in her big toe too short. Ms C also said the surgeon did not provide appropriate care when the problems arose with her foot, that they were unresponsive, and did not communicate with her about her situation. The board said that the shortening of the bone in Ms C's foot was inevitable as a result of the two operations, and within reasonable limits. They considered the surgery had been performed appropriately. The board also said they considered the follow-up care was reasonable.

After receiving independent advice from an orthopaedic surgeon, we did not uphold Ms C's complaints. We found that the evidence did not suggest there had been a failure in the operation. We also found that the medical records suggested timely care with appropriate review from the clinicians involved in Ms C's care. We noted the difficulty of judging communication from paper records, but considered that there were no failings evident in respect of this aspect of Ms C's care.

During the course of this investigation, we noted that the board's consent documentation, while appropriate by the standards of the time, would not comply with contemporary practice. We also noted some limitations in record-keeping by the board. We made recommendations to address this.

Recommendations

We recommended that the board:

• remind staff of the importance of adequate record-keeping; and
• review the relevant consent form to ensure it is appropriate.