Health

Summary

Mr C complained that the board failed to clearly diagnose his late mother (Mrs A's) pulmonary fibrosis (a lung condition), and failed to communicate the diagnosis and manage the condition appropriately. Mrs A's pulmonary fibrosis was first identified in a scan carried out five years prior to her death. She regularly attended her GP and hospital over the intervening years with symptoms that included breathlessness. We obtained independent medical advice from a consultant respiratory physician, a consultant general physician and a consultant in emergency medicine. We identified that there were missed opportunities to appropriately refer Mrs A to respiratory medicine. In particular, an attendance at an ageing and health clinic did not result in an onward referral despite clear evidence of progression of Mrs A's condition. We were assured, however, that the limited available treatment options for pulmonary fibrosis meant an earlier referral was unlikely to have altered Mrs A's prognosis. Nonetheless, 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 this aspect of the complaint.

Mr C also complained that the board did not respond to his letters of complaint fully and within a reasonable timeframe. We noted that the board's response to Mr C's initial complaint was issued in good time and attempted to address the specific concerns raised. Mr C then wrote to the board on a further two occasions listing several additional questions and outstanding concerns. We noted that the NHS complaints procedure does not make provision for further stages of the process and complainants who remain dissatisfied should be referred to the SPSO. We, therefore, did not consider that the board were obliged to provide the additional level of detail requested by Mr C. However, having agreed to provide a further written response, we considered that the board unreasonably delayed in doing so. We noted that the board had already apologised for the delay. We also considered that they could have responded with greater clarity. We therefore upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failure to clearly diagnose, communicate and manage Mrs A’s pulmonary fibrosis;
• carry out a review of Mrs A’s care and treatment and report the outcome back to us, ensuring that the failings this investigation has identified are fully reflected upon and account taken of the medical adviser's suggested areas for improvement;
• remind complaints handling staff of the importance of responding fully and accurately to complaints, and ensuring that the response represents the board’s definitive position in order that any subsequent disagreement can be appropriately referred to us; and
• remind complaints handling staff that, in circumstances where they choose to engage in further correspondence with a complainant, they should respond in a timely manner and keep them informed of any delays.

Summary

Mr C complained about the care and treatment he received from his medical practice. Mr C had been admitted to hospital to receive treatment for chronic liver disease. When he was discharged from hospital, the medication he was prescribed was a lower dosage than he had been taking previously. Mr C raised concerns that the medication he was prescribed by the practice prior to admission was excessive.

We took independent medical advice. We found that Mr C's medication had changed whilst he was in hospital because his condition had changed. The adviser explained that medications are often reviewed or withdrawn when patients are in hospital settings, yet this does not mean that the pre-existing medication was either incorrect or excessive in dosage. We did not find evidence that Mr C had been prescribed excessive medication and for this reason we did not uphold this aspect of his complaint.

Mr C also raised concerns that appropriate investigations were not arranged when he reported pain in his chest and back to GPs at the practice. Mr C was subsequently diagnosed with osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break), but felt he should have received treatment for this condition sooner. We found that the practice had initially referred Mr C for acupuncture, and that this was because he had a history of pain following a previous injury and had received acupuncture previously. We found this to be reasonable and did not consider that there was a clinical indication that Mr C had osteoporosis until he attended a consultation around three months later. At this consultation, an x-ray was arranged, which confirmed Mr C's diagnosis. The practice then prescribed Mr C two medications to help protect his bones.

We considered that the practice investigated Mr C's condition reasonably and provided appropriate treatment. We did not uphold this aspect of Mr C's complaint.

We noted that the practice had acknowledged that they had not handled Mr C's complaint fully in accordance with the 'Can I help you?' guidance for handling healthcare complaints. While we were critical of this, we found that the practice had undertaken a significant event review and we were satisfied that the practice had taken steps to identify what went wrong and learn from this shortcoming. We therefore made no recommendations.

Summary

Mrs C underwent a hip-replacement operation at Victoria Hospital. During the operation, a suture (a stitch used to close a cut or wound) used to repair the muscles at the back of her hip caught the edge of her sciatic nerve (a nerve in the lower back area). Mrs C said that she had not been told when she consented to the operation that this was a potential risk and that it should not have occurred. Mrs C also raised concerns about the time it took medical staff to find out what happened. It was not until three days after the operation that medical staff recognised that Mrs C had sciatic nerve palsy (foot drop and numbness) and she underwent a further operation six days after the first operation.

We took independent advice from a medical adviser who specialises in surgery. We found failings in the consent process which meant that Mrs C was not in a position to give her informed consent for the procedure. We considered that Mrs C should have been warned of the potential adverse outcome in clear terms and language, even though the risk of permanent nerve damage was very rare. We also found the time it took to identify the sciatic nerve palsy and escalate it to the surgeon to be unreasonable. We therefore upheld Mrs C's complaint.

However, in relation to the standard of operation and surgical error, while we accepted this was a significant failing which had an adverse outcome, our view was that it was not evidence of poor practice or of an unreasonable failing in the surgical care provided.

Recommendations

We recommended that the board:

• review the consent process and related documentation to ensure clinicians properly obtain (and document) consent for procedures;
• bring the failings to the attention of relevant staff and ensure the failings are raised as part of their annual appraisal;
• investigate why the finding of sciatic nerve palsy was not escalated and inform us of the findings; and
• apologise to Mrs C for the failures this investigation identified.

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.