Health

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.

Summary

Mr C complained about the medical practice on behalf of his mother (Mrs A). Mrs A was discharged from hospital and given three new medications. On learning of these new medications, the practice decided to carry out a review of Mrs A's prescriptions, as this would result in her being prescribed 18 different medications a day.

Mrs A's GP phoned Mrs A's daughter (Mrs B) to discuss the medications as they considered that these new medications were not necessary and may cause side effects that would exacerbate Mrs A's existing conditions. Mrs B felt that the GP's manner was callous and uncaring and that the content of the call was inappropriate. Following the call, the practice decided to prescribe the medications in line with the request from Mrs A's respiratory consultant.

However, this call led Mrs A's family to decide that they would change GP practices. Mrs A died before the new practice was able to arrange Mrs A's medications.

On investigation we found that there was some discrepancy in the information available to the practice, caused by a delay in the hospital sending them Mrs A's full discharge letter. This meant that they were not in possession of the consultant's rationale for providing the new medication and had to carry out the review based on the medical history they were aware of.

Our adviser considered the relevant medical records and concluded that it was reasonable for the practice to carry out a review of Mrs A's medications in the circumstances. They also considered the conclusions reached in the review to be reasonable, based on the information available to them at that time.

On reviewing the records we were unable to see any evidence that the content or manner of the call in question was unreasonable. For these reasons, we did not uphold Mr C's complaint.

Summary

Mrs C complained on behalf of her son (Mr A). Mr A was admitted to A&E at University Hospital Crosshouse with a three-day history of stomach cramps, diarrhoea and vomiting. It was suspected that he had gastroenteritis and after his symptoms settled he was to be discharged. However, Mrs C said she spoke with the consultant gastroenterologist responsible for Mr A's care and told them that this had been an ongoing problem. Mr A was kept in hospital for a further six days and then discharged with plans to follow up. Prior to the follow-up, Mr A was admitted to hospital as an emergency and diagnosed with Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). Mrs C complained that during his initial admission, Mr A was not given appropriate care and treatment.

We took independent advice from a consultant in gastroenterology. We found that on Mr A's admission to hospital, a clear history was documented in the emergency department notes of several weeks of recurrent episodes of abdominal pain associated with significant and unintentional weight loss. This history was later repeated by Mrs C. We found that in the circumstances, this should have raised suspicion of a diagnosis other than that of food poisoning, such as Crohn's disease. The adviser said they would have expected a scan of the abdomen or of the small bowel to have been undertaken during the admission or shortly afterwards. Had this happened, Mr A would have been diagnosed sooner. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failures identified during this investigation;
• ensure that the consultant gastroenterologist concerned with Mr A's care during this admission is made aware of the results of this investigation and that this case is discussed at their next formal appraisal;
• satisfy themselves that the consultant gastroenterologist is made aware of the guidance relevant to this case; and
• ensure that information about Crohn's disease is readily available to patients on diagnosis.

Summary

Mrs C complained about the care and treatment received by her husband (Mr A) at Ayr Hospital for a rare type of bladder cancer. Specifically, Mrs C was dissatisfied with surgery performed, the communication with her and Mr A, and the board's response to her complaint.

We took independent advice from a consultant urological surgeon and a consultant radiologist. We found that the surgical treatment and follow-up review were both of a reasonable standard. Whilst we did not uphold the complaint about Mr A's treatment, we identified unreasonable failings in the reporting of a scan which had shown Mr A's cancer had worsened. We found that even had the scan had been reported accurately, it would not have changed Mr A's treatment or outcome. However, Mrs C and Mr A would have known about this much sooner. We also noted that although there was no specific indication for it at the time, it would have been preferable for Mr A's particular case to have been reviewed by the urology multi-disciplinary team and we made a recommendation in relation to this.

In addition, we were critical that the board had not identified the error in the reporting of the scan after Mrs C complained about the matter.

We also considered that the communication with Mr A and Mrs C fell below a reasonable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the inaccurate reporting of the scan;
• reflect on the reporting of the scan and take steps to identify learning and improvement;
• consider routine review by the multi-disciplinary team of follow-up imaging for those patients with bladder cancer at high risk of recurrence;
• share these findings with the staff involved in Mr A's care; and
• share these findings with the staff involved in the investigation of the complaint for shared learning.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) during his admission to Ninewells Hospital. In particular, Mrs C had concerns that the effects of the medication Mr A was prescribed for delirium were not monitored, and that after a fall whilst in hospital he was given a further dose of this medication. She also complained that he had not been reasonably checked and monitored throughout the night. By the time nursing staff came to check his observations the next morning, Mr A had died.

During our investigation we took independent medical and nursing advice. We found that the effects of the delirium medication were well monitored and that tests were carried out to ensure that there were no rare side effects. Therefore we did not uphold this aspect of Mrs C's complaint. The medical adviser suggested, however, that given Mrs C's concerns, the clinical team could have considered trialling a different medication. They also suggested that while overall the monitoring was reasonable, it would have been good practice to perform a test to check that Mr A's blood pressure did not fall significantly on standing. We made recommendations to address these points.

We found that after Mr A fell on the ward, he was not given any further dose of medication, but was checked thoroughly by medical staff and then reasonably monitored by nursing staff. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• draw the adviser's comments regarding the consideration of trialling alternative medications for confusion if families voice concern, and of documenting these considerations, to the attention of the relevant staff; and
• draw the comments of the adviser regarding the monitoring of blood pressure to the attention of the relevant staff.

Summary

Mr C was diagnosed with kidney cancer and underwent an operation at Ninewells Hospital to remove one of his kidneys. Mr C felt that, had staff acted appropriately in response to his emails, his cancer may have been diagnosed sooner and he may not have had to undergo the procedure.

Mr C said that he had reported a decline in his health in an email to the neurology department. He said that had staff reviewed him in the neurology clinic following this, his kidney cancer may have been diagnosed sooner. We took independent advice from a consultant neurologist. They did not consider that the content of Mr C's email indicated that he needed to be reviewed in the neurology clinic or that he needed clinical attention at this time. In view of this, we did not uphold this complaint. Although the adviser was satisfied that staff had not failed to provide treatment to Mr C, they noted that staff had not responded to Mr C's email to advise him that he did not require clinical review. They were critical of this and suggested steps the board might consider taking.

Mr C also raised concerns about the board's actions following a further email, in which he reported further symptoms. The adviser found that, in response to this email, the board had advised Mr C to see his GP, which we considered to be reasonable. We noted that Mr C was subsequently reviewed in the neurology clinic and a blood test performed. The adviser found that the results of the test indicated that Mr C had elevated levels of one of his liver enzymes and that the board had written to Mr C's GP regarding this, which the adviser considered to be appropriate. We therefore did not uphold this aspect of Mr C's complaint.

We found that Mr C's GP had arranged an ultrasound test of Mr C's abdomen to explore whether the increased liver enzyme levels were significant to the condition of Mr C's liver. The adviser noted that this ultrasound scan identified a lesion on Mr C's kidney, which was confirmed as cancerous. We did not consider that the care provided to Mr C by staff in the neurology department had caused a delay in diagnosing his kidney cancer. We found that the cancer was not related to the abnormal blood test or Mr C's neurological condition, rather it was an incidental finding based on an ultrasound scan.

Mr C expressed concern at the delay between the diagnosis of the cancer and the date he received treatment. We sought independent advice from a consultant urologist. They noted that the board had missed the timescales for cancer treatment by two days in this case. However, given that the delay was short, we did not consider that this was an unreasonable failing in care. We did not uphold this complaint.

Mr C also complained that the board had not investigated his complaint impartially, as the clinician who investigated Mr C's complaint was the educational supervisor of the clinician he had complained about. We noted that the guidance on complaints handling did not state any requirement in relation to this matter, and in the circumstances of the case we considered that the board had not failed to investigate impartially. While we did not uphold this complaint, we found that the board had taken a significant length of time to respond to Mr C's complaint. While we noted that various complexities of the case contributed to this, on balance we considered that the delay was disproportionate. We also found that the board had not addressed an important aspect of Mr C's complaint in their response. We were critical of this and made a recommendation.

Recommendations

We recommended that the board:

• feed back the comments of the adviser to staff in the neurology department to ensure that staff appropriately respond to patient correspondence;
• consider whether it would be appropriate to introduce guidelines regarding email communication in light of the adviser's comments; and
• feed back to staff the importance of ensuring that complaint responses address the concerns raised.

Summary

Miss C's father (Mr A) attended his medical practice with urinary problems. Tests and investigations indicated prostate cancer had spread to his bones and Mr A was admitted to Ninewells Hospital. His condition deteriorated significantly due to sepsis (a life-threatening bacterial infection of the blood) and he died two days later. Miss C complained about clinical failings in relation to investigations and treatment decisions by nursing and medical staff, including that Mr A's deteriorating condition was not recognised within a reasonable timeframe.

We took independent advice from a nursing adviser, a specialist in urology and a specialist in nephrology (the study of the kidney). In relation to the standard of nursing care provided, including communication, we found that in the main this was reasonable. We therefore did not uphold this aspect of Miss C's complaint.

With regard to the medical care and treatment provided, we found that medical staff had unreasonably failed to recognise Mr A had been suffering from sepsis and that there had been an unacceptable delay in administering antibiotics. We were also critical that medical staff failed to investigate fully Mr A's kidney injury. We therefore upheld this aspect of Miss C's complaint. However, due to Mr A's limited life expectancy as a result of his cancer, we could not say what the outcome would have been had Mr A had been investigated in a reasonable manner and treated with antibiotics earlier. However, the failings identified meant that it was possible that an opportunity to extend Mr A's life had been missed.

Miss C also complained that the board failed to respond to her complaint within a reasonable timeframe. The board acknowledged this and apologised to Miss C. We therefore upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• take action to ensure the failings in aftercare and support are addressed to ensure no recurrence;
• provide us with an action plan to address the failings highlighted in this investigation and ensure no recurrence; and
• apologise for the failings identified during this investigation.

Summary

Miss C complained about the care and treatment provided to her father (Mr A) when he attended his medical practice with urinary problems. Tests and investigations indicated prostate cancer that had spread to Mr A's bones and he was admitted to hospital shortly after. Mr A's condition deteriorated significantly due to sepsis (a bacterial infection of the blood) and he died a few days later. Miss C complained that the practice failed to properly investigate Mr A's symptoms, that the treatment decisions were unreasonable and that the family's concerns were not taken seriously.

We took independent advice from a specialist in general practice. We found the standard of care and treatment provided was reasonable, including the investigations carried out and Mr A's referral to hospital. We did not find that the practice failed to take seriously the concerns of Mr A's family. We therefore did not uphold Miss C's complaint.