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Mr C complained that he had not been provided with appropriate clinical treatment in relation to his diabetic neuropathy (nerve damage) and a slipped disc in his back. However, during the course of our investigation, Mr C withdrew his complaint.
Mrs C was referred to St John's Hospital for her first maternity appointment. Mrs C complained that during her pregnancy, community midwives failed to provide her with a reasonable level of care and that she was not given antenatal blood screening as she said she required. Mrs C's baby was stillborn.
We took independent advice from a specialist in haemostatis and thrombosis and from a midwife. We found that as Mrs C had a family history of deep veinous thrombosis, she was correctly referred to a specialist clinic for tests. These tests showed no evidence of personal risk for Mrs C and as such no further blood testing was required. However, it was agreed to offer her blood thinning medication after the baby's birth. While Mrs C believed that if further blood screening tests had been carried out she may not have lost her baby, we found no evidence of this. We found that the midwifery care and treatment given to Mrs C had been of a reasonable standard. We therefore did not uphold these aspects of Mrs C's complaint.
Mrs C said that her placenta was lost when it was sent for testing. We found that when the placenta was sent to the laboratory, it was not accompanied by the appropriate paperwork and for this reason it was destroyed. We upheld this element of Mrs C's complaint. The board apologised for this and put new procedures in place to prevent the same happening again.
Mr C complained about the prison health centre's decision not to prescribe him sleeping medication that he had previously been prescribed by his community GP.
The information available confirmed that the prison health centre had checked the medications prescribed to Mr C by his community GP. This confirmed that he had been given a two-week supply of the sleeping medication to take as needed.
We took independent clinical advice. The adviser noted that the sleeping medication should only be prescribed for short periods and long-term use was to be avoided. They also noted that Mr C had been prescribed an appropriate detox whilst in prison and that because of this, the decision to not prescribe the sleeping medication was reasonable. Our adviser also confirmed that Mr C was being prescribed appropriate medications for the symptoms he had reported. We did not uphold Mr C's complaint.
Following a private hernia operation, Mr C was referred to the Royal Infirmary of Edinburgh for pain management. Mr C had various appointments with a consultant over a nine-month period, and required further surgery. Mr C later complained that the consultant had failed to complete appropriate clinical records which fully explained why he needed further treatment. Mr C told us the lack of records had caused him a problem when he went to get insurance when travelling abroad for work.
We took independent clinical advice. We found Mr C's medical records were of the standard, and in the detail, expected of NHS clinical records. We were satisfied the reason Mr C required surgery was appropriately documented. We did not uphold Mr C's complaint.
Ms C, an advocacy and support worker, complained on behalf of Ms A about the care and treatment given to Ms A after she was diagnosed with breast cancer.
Ms A was treated with surgery followed by chemotherapy and radiotherapy at the Western General Hospital, from which she appeared to be recovering well. However, part way through her course of chemotherapy, Ms A was not given a review appointment to establish how she was progressing, as per a local protocol. Ms A maintained that she had been 'lost to the system' and received inadequate care. Ms C also said that the board failed to respond reasonably to Ms A's complaint.
We took independent advice from a consultant oncologist. We found that Mrs A's treatment had been given in terms of national guidelines and had been reasonable and appropriate. While it had been intended to review her part way through her chemotherapy, Ms A was seen a few weeks later and her treatment continued. We did not uphold this aspect of Ms C's complaint.
However, we noted that the board failed to deal with Ms A's concerns about her treatment in a timely manner and we therefore upheld this aspect of Ms C's complaint.
We recommended that the board:
Ms C was referred to the sleep clinic at the Royal Infirmary of Edinburgh. She attended on a number of occasions over the following four years but her symptoms did not improve. She said that a consultant physician contacted her clinical psychologist but provided inaccurate and misleading information which detrimentally affected her future treatment. Ms C also complained about the way the board responded to her complaint.
We took independent advice from a consultant respiratory and general physician. We found that while Ms C's consultant physician provided her professional opinion to other health professionals, she did not provide incorrect or misleading information. We therefore did not uphold this aspect of Ms C's complaint. We noted, however, that the information could have been written more sympathetically and that the board had already spoken to the consultant physician about this. We also found that after Ms C complained, the board took too long to reply to her and their letter provided little explanation. We therefore upheld this aspect of Ms C's complaint.
We recommended that the board:
Miss C complained about the care received by her brother (Mr A) at the Royal Infirmary of Edinburgh following a suspected drug overdose. During his admission, Mr A was drowsy and had slurred speech. Mr A was moved to the acute medical unit and received treatment for a chest infection. He also had a scan to check for a blood clot on the lung. No blood clot was found and Mr A was to be discharged. On the morning of his discharge, he experienced a cardiac arrest and died.
We took independent nursing and medical advice. The nursing adviser was satisfied that nursing staff had noted Mr A's condition but raised concerns that Mr A's oxygen saturation (the relative measure of the amount of oxygen in the blood) was abnormally low during the admission. Whilst nursing staff had noted this, they had not informed medical staff.
The medical adviser considered that Mr A had received appropriate care and treatment for the first two days of his admission, but that Mr A's low oxygen saturation should have resulted in a medical review on the evening before discharge. They noted that a possible explanation for the omission of a review was that staff considered his oxygen levels to be low as a result of drug use, rather than his chest infection. The medical adviser noted that staff could have considered administering a medication which temporarily reverses the sedative effects of drugs to help them determine the reason for low oxygen levels. The adviser could not say whether better care at this time would have prevented Mr A's death. However, they considered that the treatment provided to Mr A was unreasonable. We upheld this aspect of Miss C's complaint.
Miss C also complained that staff had failed to respond reasonably to concerns raised by Mr A's family. The medical adviser noted that Miss C had spoken to a doctor on the evening before the planned discharge. The adviser was critical that the doctor had informed Miss C that Mr A was well enough for discharge, when the evidence available at that time did not support this. They considered that there was evidence that staff had shown a lack of appreciation for the family's concerns, and we therefore upheld this aspect of the complaint.
Miss C also complained about the board's handling of her complaint. We noted that the board had met with Miss C and Mr A's family and had also taken steps to investigate the concerns raised by Miss C. We were critical that the board delayed interviewing staff regarding Miss C's complaints and that the board did not update Miss C about the delay in arranging a second meeting. While we noted that the board had responded in writing to aspects of Miss C's complaints, we were critical that they did not conclude their investigation with a definitive final response or inform Miss C in writing of what to do were she not happy with their response. We also noted that Miss C had not received a copy of a substance misuse leaflet that the board had agreed to provide. We upheld this aspect of Miss C's complaint.
Miss C also complained that Mr A's medical records inaccurately stated that his family had given him drugs. We found that the discharge letter did not explicitly state this, but that staff did have concerns that Mr A's family had brought him drugs. The medical adviser noted that there was no suggestion in the letter that any additional drugs caused Mr A harm, and no indication that the letter was directly critical of the family. However, they found that the letter contained a statement that was not supported by the clinical notes and that there was no clear evidence in the records of specific additional drug use, or evidence of involvement of the family related to the drug use. The adviser considered that the statement was unreasonable. We therefore upheld this complaint.
We recommended that the board:
Mrs C complained about the care and treatment given to her father (Mr A) on four occasions he attended A&E at Wishaw General Hospital. She further complained that the board failed to deal with her subsequent complaint in a reasonable and timely way. The board took the view that Mr A had been treated appropriately and that they had dealt quickly and reasonably with the complaint.
We took independent advice from a nurse and from a consultant in emergency medicine. Mr A first attended A&E on three occasions over the course of a month. We found that Mr A had largely been treated appropriately but that when he unexpectedly attended on the second occasion, his case should have been discussed with a consultant and he should have undergone a scan.
On his fourth attendance around a month later, we found that while there were delays in treating Mr A, these were unavoidable as the A&E department was at full capacity. However, we found shortcomings in his triage and that he was not reviewed by the intensive care team. We found this to have been unreasonable as Mr A's diagnosis was unclear and he was seriously deteriorating. Mr A died the day after this admission. We upheld these aspects of Mrs C's complaint.
Although Mrs C also complained about the way her complaint to the board was dealt with, we found that it had been considered in a timely and appropriate way. Staff also met with her family on four occasions. We therefore did not uphold this aspect of Mrs C's complaint.
We recommended that the board:
Mrs C, who works for an advice agency, complained on behalf of her client (Miss A), who said she was suffering from Jarisch Herxheimer's reaction (a physical reaction to the death of microorganisms within the body during antibiotic treatment). Mrs C said Miss A believed that she had not received the appropriate care and treatment from her medical practice. Miss A believed that she had not been prescribed antibiotics appropriately and that the practice had inappropriately interfered with her consultations with hospital specialists.
We took independent medical advice from a GP adviser. The adviser said, and we agreed, that Miss A had been treated appropriately. Jarisch Herxheimer's reaction was an unusual condition and would require diagnosis by a hospital specialist. Miss A had received the appropriate referrals, but the specialists in question had confirmed that Miss A did not have this condition. We found that there was no evidence that the practice had acted inappropriately or that they had attributed Miss A's problems to her mental health.
We found that the care and treatment provided was of a reasonable standard and we did not uphold the complaint.
Mrs C attended Raigmore Hospital with an injury to her ankle. She complained about the care and treatment provided, in particular that there was an unreasonable delay in providing her with orthopaedic treatment.
During our investigation we took independent advice from a consultant radiologist and a consultant trauma and orthopaedic surgeon.
The consultant radiologist considered that an abnormality on Mrs C's first x-ray was missed, and as a result there was a delay in being referred to an orthopaedic surgeon and in a diagnosis being made. In addition, the consultant radiologist considered that the abnormality was also missed on an x-ray taken 15 months later and that had this been noticed, Mrs C may have been referred for imaging earlier than she was.
We found that there were no long-term orthopaedic consequences for Mrs C's ankle as a result of the delays. However, we were concerned that the delays added to Mrs C's distress and that she had continued to suffer pain and discomfort when this could possibly have been avoided.
We considered that a delay between Mrs C being placed on the waiting list for an orthopaedic appointment and being advised four months later that she would not be offered an appointment within the target timescale was unreasonable.
We also found that the delay between Mrs C attending hospital for her injury and being seen in an orthopaedic clinic was unreasonable. However, we noted that action was being taken by the board to address the delays. We upheld Mrs C's complaint.
We recommended that the board: