Health

Summary

Mrs C complained about the care and treatment she received at Ninewells Hospital after having her jaw joint replaced with an artificial joint. Prior to then, Mrs C had been under the care of an oral medicine consultant who had tried a range of non-surgical methods to manage the pain she was having in her jaw joint. Mrs C was then referred to a specialist surgeon, who recommended surgical replacement of the joint. Mrs C proceeded with the surgery but suffered complications that resulted in the artificial joint being removed for several months and replaced with a different type.

Mrs C was concerned that the risks of surgery had not been properly explained to her, about the sourcing of the artificial joint, that special equipment to detect nerves was not used during the surgery, and that there was a delay in identifying problems with the replacement joint.

We took independent advice from an oral and maxillofacial (the speciality concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) surgeon. We found no failings with the standard of surgery performed or the type of artificial joint used. We also considered that Mrs C's ongoing problems were reasonably reviewed with no undue delay in providing treatment.

However, we considered it unreasonable that there was no evidence to show that a discussion took place with Mrs C at any out-patient appointment with regard to all the benefits and recognised risks associated with the surgery. The only records of such discussions were during a phone call, where not all the risks were documented, and on the day of Mrs C's surgery, where it was unclear what had been explained to her. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise in relation to the failings identified in the consent process;
• review the service's process for obtaining informed consent to ensure it is in line with General Medical Council consent guidance; and
• consider providing written patient information on the jaw joint surgery.

Summary

Mr C complained that the Scottish Ambulance Service (the ambulance service) did not ensure that someone attended his home to make sure he was safe after he took an overdose of paracetamol. When the ambulance crew arrived, they could not or did not gain access and left the house without taking further action. Mr C was later helped by a neighbour to attend A&E. Mr C said he was in a vulnerable situation and that the failings by the ambulance service were potentially life-threatening.

Mr C also complained about the way the ambulance service handled his complaint, including the time it took them to respond.

We took independent advice from a specialist in the training and supervision of healthcare professionals including paramedics. We found inconsistencies in the accounts of the staff involved and it is not clear why contact was not made with Mr C. The ambulance service failed to record their findings and action taken at the time. The evidence indicated a communication breakdown between the ambulance crew and ambulance control centre. We found that the ambulance service should have escalated the situation to the police in order to gain more information and access to the property.

In relation to the handling of Mr C's complaint, we found evidence indicating confusion amongst staff about who should deal with the complaint and how it should be dealt with. We were critical that Mr C's complaint to the ambulance service was initially managed as a concern and that it took over three months for the ambulance service to start an investigation. We also found that complaint staff did not reasonably inform Mr C about the delays and the reasons for these.

Recommendations

We recommended that the ambulance service:

• raise the failings identified with relevant staff;
• confirm that the guidelines being developed for dealing with similar incidents have been implemented and communicated to all staff;
• ensure ambulance crews record adequate information on patient report forms;
• provide an update on the actions taken to improve complaints handling; and
• apologise to Mr C for the complaints handling failures.

Summary

Miss C complained about the care and treatment she received at St John's Hospital. She had been diagnosed with skin cancer and had an operation in the hospital to remove the cancer. She said that, after the operation, the anaesthetist refused to give her further pain relief without having seen her when she asked for this.

We took independent advice from an anaesthetist. We found that Miss C had been seen by the anaesthetist when she requested additional pain relief and that their decision that she had already received appropriate and adequate pain relief was reasonable. We did not uphold this complaint.

Miss C also complained that there was an unreasonable delay by nurses in providing her with pain relief she had requested later that day. We found that there had been an unreasonable delay in providing the pain relief and upheld the complaint. However, we were satisfied that the board had apologised for this and had taken action to prevent such delays occurring in the future.

Miss C also complained that the surgeons had not discussed her concerns with her at an appointment, as the board's response to her complaint said they would. We found that the board had written to Miss C to say that they had shared her concerns with the surgeons and they would discuss the matter at her next appointment. However, Miss C's concerns were not discussed at the appointment, as they had not been shared with the surgeons. We also upheld this aspect of Miss C's complaint. However, we were satisfied that the board had apologised to Miss C for this and had offered to arrange a further meeting.

Finally, Miss C complained about the board's handling of her complaint. We also upheld this complaint, as we found that there had been an unreasonable delay in responding, although the board had apologised for this and had provided us with evidence that they had taken action to prevent such delays in the future.

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.