Health

Summary

Ms C's mother (Mrs A), who was diabetic, injured her toe. Mrs A attended A&E at the Royal Alexandra Hospital a few days later. Mrs A's toe was found to be broken and there was evidence of infection. At that time, Mrs A was keen to avoid admission and she was sent home with antibiotics. After initial improvements in her condition, Mrs A had to re-attend at A&E and was admitted for around two weeks. During this admission, Mrs A became unwell and had to be resuscitated. On her discharge, Mrs A's injured toe was noted to be necrotic (where the cells or tissue are dead). Mrs A was readmitted to the hospital later that month after being seen at the diabetic foot clinic.

Ms C complained about the A&E care provided to Mrs A, the medical care and treatment provided to Mrs A while she was an in-patient, the nursing care, the standard of communication and the approach in the Coronary Care Unit (CCU) to visiting.

After taking independent advice from a consultant in emergency care, we upheld Ms C's complaint about the initial A&E attendance. We found that due to Mrs A's diabetes, a referral should have been made to a specialist foot team. Although the advice we received was that this did not affect the outcome for Mrs A, we considered this to be a failing. The board identified this during their own investigation and we considered that they had taken reasonable steps to address the issue.

In relation to Ms C's concerns about the standard of in-patient medical care and treatment, we took independent medical advice. The adviser found that Mrs A received optimal care and treatment. We therefore did not uphold this part of Ms C's complaint.

After taking independent nursing advice, we upheld Ms C's complaint about nursing. The advice we received was that there were failings in obtaining an appropriate mattress for Mrs A and that there had been some issues around wound dressings. The board had already apologised for this and for an occasion where fluids were administered more quickly than intended. The nursing adviser also noted that a fluid balance chart had not been properly completed. We made a recommendation to address this.

We found that the approach of some of the staff regarding Mrs A's family visiting her in the CCU was not reasonable. The board had identified failings in communication with Mrs A's family and apologised for these. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that fluid balance charts are appropriately completed for patients;
• make all relevant staff in the CCU aware of the nursing adviser's comments on visiting; and
• review the approach to visiting in the CCU in light of the nursing adviser's comments.

Summary

Miss C complained about the care and treatment received by her father (Mr A) during an admission to Queen Elizabeth University Hospital. Miss C said it took an unreasonable length time for Mr A to be reviewed by a doctor in the assessment unit, and that he was not treated for his urinary tract infection (UTI) for several days. Miss C was also concerned that Mr A's catheter became blocked on one occasion, and that it took several hours before this was changed. Miss C said that a doctor told her this had resulted in lasting kidney damage. Miss C also raised concerns that in their response to her complaint, the board gave an inaccurate account of what happened.

The board apologised that Mr A had waited so long to be reviewed, and for a lack of communication during the admission. However, the board said Mr A did not have a UTI on admission, but developed this a few days later (which was treated). The board also considered Mr A's blocked catheter was treated appropriately.

After taking independent medical and nursing advice, we upheld Miss C's complaints about medical care and communication. We found that there was no evidence Mr A had a UTI on admission, and that this was treated reasonably when it developed a few days later. We also found the blocked catheter was treated appropriately, and that there was no evidence that this had caused damage to Mr A's kidneys. However, we considered the delay in Mr A being reviewed was unreasonable, and we recommended the board provide more detail on how this is being addressed. We also found failings in communication, although we noted the board had already acknowledged and apologised for this, which we considered appropriate.

In relation to complaints handling, we found a factual inaccuracy in the board's response (describing the position of the blocked catheter). This appeared to be an error, and we did not consider the overall response to have been unreasonable.

Recommendations

We recommended that the board:

• provide evidence of the action being taken to reduce waiting times for patients in the assessment unit.

Summary

Miss C complained about the care and treatment her mother (Mrs A) received from the Victoria Infirmary when Mrs A attended A&E following a fall. Mrs A was found to have a fractured arm and was admitted to the orthopaedic ward. Four days later, Mrs A was noted to be suffering from hip and leg pain and was found to have a hip fracture that required surgery. Mrs A was transferred to the New Victoria Hospital for rehabilitation, but due to concerns about her condition, was transferred back.

Miss C complained about an excessive delay in transferring Mrs A from a trolley in A&E to a ward. She also complained about Mrs A's medical treatment and nursing care, and that communication with Mrs A's family was poor.

We took independent advice from an A&E consultant, an orthopaedic consultant, a consultant physician, and a nursing adviser. We found that there was an unreasonable delay in Mrs A being transferred from a trolley to the ward, which the board had accepted and apologised for. We also identified an unreasonable delay in Mrs A's hip fracture being diagnosed and that her transfer to the New Victoria Hospital for rehabilitation was unreasonable as there was a lack of evidence to show that she was fit for discharge. We therefore upheld these aspects of Miss C's complaint. However, we found that the nursing care in terms of assessing and monitoring food and fluid intake was reasonable.

Finally, we were critical that there was poor communication with Mrs A's family by both the A&E staff and orthopaedic team, for which the board had apologised. While Mrs A's consent form for the surgery indicated that she was not able to give informed consent, we found no evidence of communication with Mrs A's family in this regard.

Recommendations

We recommended that the board:

• provide information about the action taken to minimise waiting times for patients in A&E before they are admitted to a ward;
• ensure that the A&E doctor involved in Mrs A's care reflects on the adviser's findings at their next appraisal to ensure appropriate clinical assessment takes place;
• ensure that the medical staff responsible for Mrs A's transfer reflect on the adviser's findings regarding fully documenting the reasons supporting a patient's discharge or transfer;
• apologise to Miss C for the failings identified with regard to the diagnosis of Mrs A's hip fracture and the decision to transfer Mrs A;
• remind relevant staff involved in Mrs A's care in A&E and the orthopaedic ward of the importance of communicating effectively with family members and documenting in the clinical records when this has been done; and
• review their consent process for patients who are deemed to lack capacity to ensure where relevant that the views of relatives and carers are effectively taken into account.

Summary

Mr C complained to us that the medical practice had failed to provide appropriate care and treatment to his late teenage daughter (Miss A). He said that Miss A had a lump on the side of her head which, over a couple of years, the doctors had said was a cyst. This turned out to be cancer.

Mr C felt that there had been a delay in reaching the diagnosis and that it was inappropriate that the practice had sent letters directly to his daughter about possibly removing the cyst at an earlier time. He said that he and his wife were not aware of the letters.

The practice responded that the presumption was that Miss A had a cyst, and that the option of removal under local anaesthetic was discussed. Miss A was given the opportunity to consider the excision along with the offer of a second opinion. When the cyst was noted to be increasing in size, Miss A was referred to hospital and cancer was diagnosed.

The practice explained that the diagnosis was unusual for a child of Miss A's age but that their investigation had identified a number of learning points.

We took independent GP advice. We found that based on the recorded evidence, there were no concerns about the way the GPs managed the situation. Initially there were no signs that the lump was sinister and the offer to have it removed was made. Miss A was competent to make the decision whether to have the lump removed at an earlier stage for cosmetic reasons rather than for clinical reasons and she decided not to have it removed. That was a reasonable decision for her and her parents to consider as her parents were involved in Miss A attending the practice at times. It was also reasonable for the practice to write directly to Miss A directly. We did not uphold Mr C's complaint.

Summary

Mrs C complained to us that the medical practice had failed to prescribe her with medication that had been recommended by a private clinician.

Mrs C withdrew her complaint to us and we therefore did not continue our investigation.

Summary

Mr C complained to the board about various aspects of the care and treatment which was provided to his son (Mr A) at the Victoria Hospital. Mr A saw his GP, who sent him to hospital with a diagnosis of viral meningitis. Mr A was discharged after clinicians at the hospital made a diagnosis of a viral infection. He was admitted to intensive care the following day and was diagnosed with meningitis. Mr A died a short time later.

Mr C felt that the clinicians should have acted on the GP's diagnosis and that a lumbar puncture (a medical procedure where a needle is inserted into the lower part of the spine) should have been carried out.

We took independent advice from a consultant in emergency medicine. We concluded that although the GP had made a provisional diagnosis of viral meningitis, the staff involved took full note of Mr A's symptoms, carried out appropriate observations and investigations, and arrived at a reasonable diagnosis before discharging Mr A. Initially some of Mr A's results were abnormal but they improved over the time he was in A&E. We also found that there was no clinical indication to admit Mr A to hospital or carry out further investigations. We therefore did not uphold Mr C's complaint.

Summary

On attending his dentist, Mr C was noted to have dental decay in two of his teeth. It was agreed that this would be removed and his teeth would be filled. Despite this, Mr C remained in pain and he required root canal treatment. The treatment and known risks of such treatment were explained. Mr C experienced one of these risks in that a file broke during treatment and was required to be left in his root canal. Mr C's treatment was completed but he remained in pain.

Mr C complained that he did not receive appropriate or reasonable treatment. We took independent dentistry advice. We found that while it was regrettable that the instrument broke, this was not indicative of poor treatment and was a known risk, as was the possibility of continuing pain. We therefore did not uphold Mr C's complaint.

Summary

Mrs C complained about the management of her husband (Mr A)'s cardiology care by staff at the Victoria Hospital. Mr A suffered a heart attack and later developed heart failure. Mrs C was also concerned about how staff had communicated with the family and the standard of the nursing care Mr A received. In addition, Mrs C felt that her complaint had not been dealt with appropriately.

As Mr A had a number of attendances at the emergency department, we took independent advice from a consultant in emergency care, a consultant cardiologist and a nursing adviser.

The advice we received was that the management of Mr A's cardiac problems was reasonable, although the cardiology adviser highlighted that the co-ordination of Mr A's care could have been better, an issue that the board themselves had identified during their consideration of Mrs C's complaint. We made recommendations to the board in this regard but did not uphold this part of Mrs C's complaint.

We upheld Mrs C's complaint about communication. We found that the board had already identified and apologised for some communication issues. The advice we received was that there was a lack of evidence that Mr A and his family had been provided with information about his initial signs of heart failure. We made recommendations to address the failings identified.

We upheld Mrs C's complaint about nursing care as we found that a number of failings in the care provided had already been identified. The nursing adviser was critical of an incident where there was failure to maintain Mr A's dignity. We made a number of recommendations in relation to this part of Mrs C's concerns.

Finally, we upheld Mrs C's concerns about the handling of her complaint by the board. The board acknowledged that they had not dealt with the complaint in line with their timescales and had not kept Mrs C updated. They advised that this had been addressed going forwards.

Recommendations

We recommended that the board:

• consider how this case could be used to promote learning on the importance of co-ordination of care;
• provide an update on the co-ordination of care since the time of this complaint;
• apologise for the failure to provide information on heart failure at the relevant time;
• take steps to ensure that appropriate information is provided to patients and their families about medical conditions and that this communication is clearly recorded in the notes;
• consider using this case for staff learning and development to highlight the importance of maintaining patient dignity;
• ensure that staff involved in the failure to maintain patient dignity reflect on this complaint at appraisal;
• provide evidence that action has been taken to address the issues identified during their investigation of the complaints raised in this case; and
• provide supporting evidence that steps have been taken to prevent future communication and complaints handling failings.

Summary

Mrs C complained to us that the medical practice failed to provide her mother (Mrs A) with appropriate clinical treatment for her reported symptoms. Mrs C said that by the time Mrs A had been referred to hospital, she was found to have severe sepsis (blood infection). Mrs C said the GPs did not examine Mrs A fully and failed to admit her to hospital sooner.

We obtained independent GP advice. We found that the GPs who visited Mrs A had on a number of occasions said to Mrs A that her blood tests and presentation were concerning and that hospital admission or further investigation was advised. However, we found that Mrs A declined the offer of a hospital admission on three occasions.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) by staff at Ayr Hospital. She complained that full diagnostic tests had not been carried out when Mr A was in hospital on two occasions, and that signs of heart failure had been missed by staff. Mrs C also complained that Mr A had been prescribed with medication for his previously diagnosed Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) without a full examination and consultation, and that the medication he was given caused adverse side effects. Mr A was discharged with a full care package and died shortly afterwards.

During our investigation we took independent medical advice from a consultant physician and a specialist Parkinson's disease nurse. We found that whilst the clinical treatment provided to Mr A had generally been reasonable, the board failed to consider a diagnosis of pulmonary embolism (blood clot in the lungs) and carry out the diagnostic test for this. Therefore we upheld this aspect of Mrs C's complaint.

We also found that when Mr A was prescribed with medication for Parkinson's disease, he was not appropriately assessed by the Parkinson's nurse and that there was no documented justification for the prescription. We also found that side effects were not appropriately discussed with Mr A or his family, and that prescribing guidelines were not appropriately followed. Given this, we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified by this investigation;
• draw the adviser's comments regarding the alternative diagnosis of pulmonary embolism, and the carrying out of the diagnostic test, to the attention of the relevant staff;
• apologise to Mrs C for the failings identified by this investigation;
• consider implementing in-patient guidelines for staff regarding the care of people with Parkinson's disease in an acute setting, in order to provide a framework to help with assessment and drug choice; and
• consider implementing assessment and prescribing competencies to support nurses working in this setting, to ensure they have the correct knowledge.