Health

Summary

Mr C complained about the care and treatment provided to him at the diabetes clinic at the New Victoria Hospital. Mr C complained that when he was experiencing severe problems with his diabetes there were delays in him being given appointments, and that he was often given phone reviews instead of face-to-face appointments.

During our investigation we took independent advice from a diabetes nurse specialist. We found that Mr C had been reasonably assessed and offered appointments or phone reviews as appropriate. We found that over a period of six weeks he had eight phone reviews and two face-to-face appointments and we found that the advice and treatment given at each of these was reasonable. Therefore, we did not uphold these aspects of Mr C's complaint.

Mr C also complained about the phone service at the diabetes clinic. He said that often when he called he could not reach anybody to speak to and instead reached an answering service. We found that it was reasonable for the diabetes clinic to have an answering service as it was often the case that the nurses were unable to answer incoming calls as they were reviewing other patients. We did not uphold this aspect of Mr C's complaint.

Summary

Mr C was admitted to Queen Elizabeth University Hospital and diagnosed with atrial fibrillation (irregular and often rapid heartbeat). He was advised at this time that he would possibly need cardioversion (treatment to restore the normal heart rhythm) and that referrals would be made for him to have a scan of his heart and an out-patient appointment with a cardiologist. Mr C complained that it took eight months to receive treatment.

We took independent advice from a consultant cardiologist. We found that there were delays in Mr C receiving the scan, an out-patient appointment and treatment. We considered that the delays were unreasonable and failed to meet the Scottish Government's 18-week treatment time target.

Although we upheld Mr C's complaint, we did not consider that the delays would have affected Mr C's overall outcome. However, there would have been additional stress for Mr C in not knowing what was happening with his care.

Recommendations

We recommended that the board:

• apologise to Mr C for the delays that occurred in relation to his treatment plan after the diagnosis of atrial fibrillation; and
• take steps to ensure the problems which caused the delays do not recur and evidence the action they have taken to prevent them from recurring.

Summary

Mrs C complained about the care the board gave to her father (Mr A). Mr A had Parkinson's Disease and was admitted to Glasgow Royal Infirmary as he had fallen a few weeks before and had become confused and unable to cope at home. Mrs C said that shortly afterwards, he became constipated and was given an enema. She said that he was then left alone and when he attempted to go to the bathroom, he had fallen out of his bed which had the side rails raised. He broke his hip. Mrs C complained that if Mr A been properly assessed on arrival at hospital and properly supervised after the enema, he would not have broken his hip. She also complained that after the accident, he was not given appropriate physiotherapy treatment.

Mrs C complained to the board who agreed that there had been shortcomings with regard to Mr A's care. They said that a falls and bedrails assessment should have been carried out in a timely way and they should have ensured that Mr A understood the instructions he had been given about the enema. They apologised and put procedures in place to try to avoid the same thing happening in the future. However, with regard to physiotherapy, they said that as Mr A's condition had plateaued, it had come to an end.

We confirmed that there had been shortcomings in Mr A's assessments regarding falls, bedrails and cognitive condition. Although a comprehensive care plan was put in place, this should have been within 24 hours of Mr A's admission. Had this been the case, the risk of him falling may have been minimised or prevented. However, we further established that procedures with regard to the enema had been reasonable, as had Mr A's physiotherapy.

Recommendations

We recommended that the board:

• demonstrate to us the processes put in place as a result of Mrs C's complaint.

Summary

Mr C complained that his wife (Mrs A) underwent a number of surgical procedures for an anal fistula (an abnormal opening in the anus). He said that the procedures may have been unnecessary had staff at Inverclyde Royal Hospital identified that her high dose of Nicorandil (a medication used to treat angina) may have been the likely cause.

In responding to the complaint, the board acknowledged the possibility of a link between the Nicorandil and anal fistula, but said the only way to check was by stopping the medication to see if there were any improvements.

We took independent medical advice from a consultant colorectal surgeon. We found that although Nicorandil is known to cause mouth and rectal ulcerations when prescribed in higher doses, its association with anal fistula is much less clear. Therefore, given Mrs A did not present with ulceration, we considered it was reasonable that the surgeons involved in her care did not make the association between the anal fistula and Nicorandil. We concluded it was only with hindsight that the Nicorandil should have been stopped sooner.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter when she was delivered. At the time of, or shortly after, the delivery by forceps, she sustained a deep cut to her foot. The board were unable to provide an explanation for the cut. Mr and Mrs C complained that board staff failed to perform the forceps delivery in a reasonable manner, and that they subsequently failed to provide appropriate treatment for the injury.

During our investigation, we took independent advice from an obstetrician and a paediatrician. We found that the forceps delivery was not the cause of the cut and that the cut was most likely to have been sustained after the delivery. We did not uphold this aspect of Mr and Mrs C's complaint. Additionally, we found that the treatment given was timely and reasonable and, therefore, did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained about how the board handled their complaint. They said that the board had taken a long time to respond to their complaint and that they had not made efforts to contact all of the staff involved in the delivery. The board said they had initially not thought that the complaint was to be treated as such, and that they had confirmed this with Mr and Mrs C. However, they could not provide evidence of this being confirmed with Mr and Mrs C. We found this to be unreasonable. In addition, we found that the board could have made further efforts to contact staff involved in order to give a fuller explanation of events surrounding the cut. We also found that in recording the incident, the board had not made efforts to contact midwifery staff and we did not find this to be reasonable. Therefore, we upheld this aspect of Mr and Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the complaints handling failures identified by this investigation;
• feed back the findings of this investigation to the relevant complaints handling staff; and
• feed back the comments of the obstetrician adviser to the relevant staff.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Mrs B) about the care and treatment her father (Mr A) had received at the Queen Elizabeth University Hospital before his death. We took independent advice on the complaint from a consultant in acute medicine. Mr A had been diagnosed with cancer and Ms C complained that he had been discharged from the hospital on two occasions, despite the fact that he was still very ill. Ms C also said that there had been a delay in carrying out a biopsy. We found that it had been reasonable to discharge Mr A on the first occasion and that there had not been an unreasonable delay in carrying out the biopsy. However, it had been unreasonable to discharge Mr A on the second occasion, as he had not been medically reviewed for at least two days at that point, despite concerns being raised about his fitness for discharge.

We also found that medical staff should have been clearer about Mr A's poor prognosis and likelihood of death. Some of the communication with his family had not been reasonable and as a result, they not been prepared for his death. The board had already apologised to the family for this. There should also have been better communication between the oncology and respiratory teams and a more realistic assessment of Mr A's fitness for chemotherapy. In view of these failings, we upheld this aspect of Ms C's complaint.

Ms C also complained about the nursing care Mr A had received. We took independent advice on this complaint from a nursing adviser. Although there were problems with replacing Mr A's water, we found that the nutritional care and personal care provided to Mr A had been reasonable. Whilst a nurse had incorrectly told Mrs B that her father was nil by mouth, the nurse had then phoned her back to apologise for this. We also found that the pain relief provided to Mr A had been reasonable and we did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mrs B for the failings in relation Mr A's discharge from hospital on the second occasion; and
• provide evidence that the failings identified in this investigation have been fed back to the staff involved in Mr A's medical care.

Summary

Mrs C complained about the treatment provided to her by the board at two appointments regarding her breast implants at Cannisburn Plastic Surgery Unit at Victoria Infirmary. Mrs C complained that at the first appointment she had not been offered a chaperone and had not been introduced to the trainee doctor who was present during her appointment. She also complained that at the second appointment the doctor had examined her without discussing her problems first. Mrs C said that she had not been offered appropriate medical treatment for the problems she had been having with her breast implants and she further complained about the way the board handled her complaint.

During our investigation we took independent medical advice from a consultant plastic surgeon. We found that, while Mrs C and the consultant's accounts of the first appointment differed, it was not recorded whether any discussion regarding a chaperone took place. This was contrary to national guidance issued by the General Medical Council in relation to intimate examinations. We therefore upheld this aspect of Mrs C's complaint. During our investigation, the board had implemented local guidance regarding these issues which we considered reasonable, but we also recommended an apology be given to Mrs C.

With regards to Mrs C's second appointment, we did not identify evidence to suggest that the appointment was not carried out in a reasonable manner. We found that Mrs C had been offered appropriate clinical care for the issues she was having with her breast implants. We also found that the board had made efforts to deal with her complaint in a timely manner. Therefore we did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation.

Summary

Mr C complained that the staff at Glasgow Royal Infirmary failed to appropriately assess and treat his mother (Mrs A) when she was referred there by her GP. His concerns included that the consultant in acute medicine who treated Mrs A made a diagnosis of temporal arteritis (where the temporal arteries, which supply blood to the head and brain, become inflamed or damaged), despite there being no supporting evidence from investigations or tests. Mrs A was discharged home that day. Mr C also complained that the staff at the hospital failed to appropriately monitor and manage Mrs A's blood pressure readings when she was admitted the following day.

We obtained independent medical advice from a consultant physician in acute and internal medicine. The adviser explained that Mrs A was referred to the hospital by her GP as they felt she might have temporal arteritis and it would, therefore, have been reasonable for the consultant to have considered this condition as part of the list of possible diagnoses. The adviser explained that after examination and consideration of Mrs A's history and blood test results, the consultant, correctly, did not consider Mrs A to be suffering from temporal arteritis. However, the adviser said that Mrs A should have been admitted to the hospital and treated for her high blood pressure and failure to do so sat outside the scope of standard practice. Mrs A was subsequently admitted to the hospital the following day as a medical emergency. We upheld this part of Mr C's complaint.

The adviser said the board did not unreasonably fail to take into consideration the effect of the reintroduction of Mrs A's existing high blood pressure medications when assessing her fall in blood pressure, and that it would have been reasonable to start Mrs A on her blood pressure medication in the circumstances. Therefore, we did not uphold this part of Mr C's complaint.

Recommendations

We recommended that the board:

• provide Mr C and Mrs A with a written apology for failing to admit Mrs A to hospital for treatment of her high blood pressure; and
• feed back the failings identified to the doctor involved for reflection for future practice.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Miss A that a locum GP working at her GP practice inappropriately prescribed her antibiotic medication which she was allergic to. Miss A suffered a severe allergic reaction to the medication, resulting in an emergency hospital attendance that evening. Ms C also complained that, when Miss A returned to the practice the following day, the GP failed to appropriately examine her allergy rash.

We took independent medical advice and found that the medical records noted that Miss A had previously had a reaction to the medication. As it should not, therefore, have been prescribed, we upheld the complaint. However, it was noted that the GP had already acknowledged and apologised for the prescribing error, which we were assured was down to human error and not systemic in nature. We did not, therefore, make any recommendations in this regard.

In relation to the subsequent attendance, the adviser noted that Miss A had already been examined and treated at the hospital the previous night and that a detailed examination was not required. We did not uphold this aspect of the complaint.

Ms C also complained that the practice had not responded appropriately to the complaint. We noted that the practice passed the correspondence to the GP (who was by then working at another practice) to respond to directly. This resulted in delays. We concluded that the practice should have retained ownership of the complaint and managed it in line with their complaints process. We upheld this aspect of the complaint.

Recommendations

We recommended that the practice:

• write to Ms A and apologise for their failure to properly handle her complaint.

Summary

Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission.

We obtained independent advice from a nurse and a consultant in the care of the elderly. The nursing adviser identified failings in relation to the planning, monitoring and recording of Mr A's nutritional care and hydration and his personal care. They also identified that documentation had not been adequately completed. Mr A appeared to have suffered four falls during his admission. We found it was of concern that Mr A's falls risk appeared to have been ineffectively assessed and there was an unreasonable delay in making a referral to a falls prevention specialist. We also considered that communication with Mr A's family was unreasonable.

While we were unable to conclude that any of these failings were significant contributing factors in Mr A's death, we were satisfied that Mr A's nursing care and treatment fell below a reasonable standard and upheld this aspect of Mr C's complaint.

The medical adviser said Mr A was frail, had a history of heart disease and that there was evidence he had chronic kidney disease. While the advice we received was that a number of aspects of Mr A's medical care and treatment were reasonable, the medical adviser identified issues concerning Mr A's medications. The medical adviser also commented that there was a failure to contact Mr A's family when there was a serious deterioration in his condition. We upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's nursing care and treatment and communication this investigation has identified;
• feed back the comments of the nursing adviser and the findings of this complaint to the nursing staff involved for reflection and learning;
• issue a full written apology to Mr C and Mr A's family for the failings in Mr A's medical care and treatment and communication this investigation has identified; and
• feed back the comments of the medical adviser and the findings of our investigation to the medical staff involved for reflection and learning.