Health

Summary

Mrs C complained that there was an unreasonable delay by the board in diagnosing her breast cancer.

We took independent advice from a consultant clinical oncologist, who said that there had been an unreasonable delay in diagnosing and treating Mrs C's breast cancer. We also found that it was not possible to know what the outcome would have been had Mrs C been diagnosed with earlier with breast cancer.

The board accepted that they had failed to meet the 12-week guarantee time for referrals and outlined the action they had taken to minimise delays to appointments and subsequent treatment, including managing out-patient referrals. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide an update on the review being carried out of the management of out-patient referrals.

Summary

Ms C, a GP, complained on behalf of her patient (Mrs B) about the care and treatment received by Mrs B's husband (Mr A) whilst he was in Queen Elizabeth University Hospital. Ms C complained that the board did not provide Mr A with a reasonable standard of medical treatment, that they did not provide a reasonable standard of nursing care, and that the board failed to communicate with Mr A's family about his condition and prognosis and provide a palliative care plan.

We took independent advice from a consultant physician and a nursing adviser. We found that whilst many aspects of Mr A's medical treatment had been reasonable, the palliative care team should have been involved in his care earlier, and that there was a lack of discharge planning. We upheld this aspect of Ms C's complaint.

We found that the nursing care provided to Mr A was of a reasonable standard and did not uphold this aspect of Ms C's complaint. However, in relation to the communication of Mr A's prognosis and condition, we found that the board did not check to ensure that Mr A's family understood his prognosis, and that a DNACPR form (do not attempt resuscitation form) and DS1500 form (an end of life benefits form) should have been completed as this may have helped the family have a better understanding of Mr A's condition. The board had accepted that the standard of communication with Mr A's family was not reasonable. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• report to us on the action taken to review discharge planning;
• take action to ensure that, in similar cases, the palliative care team are involved at the appropriate time; and
• feed back to staff the adviser's comments in relation to completion of a DNACPR form and DS1500 form.

Summary

Mr C complained on behalf of his constituent (Mr A) about cataract surgery he had undergone in 2014. During cataract surgery on his right eye, Mr A sustained a small corneal abrasion (a scratch on the clear, front part of the eye). He was not told of this at the time of the operation. Following the operation, Mr A suffered from discomfort in his eyes and further deteriorating vision. At an appointment with an ophthalmologist more than a year after the cataract surgery, he was told about the small corneal abrasion he had sustained but was reassured that this was not the cause of his ongoing issues. Mr A complained to the board as he believed his problems with his vision were due to the corneal abrasion sustained at the cataract surgery and that he should have been told of the injury at the time of it happening.

In our investigation we took independent advice from an ophthalmologist. We found that the corneal abrasion sustained to Mr A's right eye during cataract surgery would most likely have healed up within 48 hours. We considered the cataract surgery to have been performed to a reasonable standard. However, we found that Mr A should have been informed of the corneal abrasion at or near the time of surgery. We therefore recommended that the board apologise to Mr A and draw our comments to the attention of the surgeon who performed the cataract surgery.

Recommendations

We recommended that the board:

• apologise for the failure to advise Mr A of the corneal abrasion; and
• draw the comments of the adviser to the attention of the surgeon responsible for Mr A's cataract surgery.

Summary

Ms C had low abdominal and pelvic pain and was referred to a gynaecology clinic. She attended two appointments with the same clinician but complained that she was not treated or cared for appropriately and that she should have had a biopsy due to her family history. She also complained that the examining equipment at each appointment had not been fitted with a protective sleeve. She also complained that communication at the two appointments had been unreasonable.

We took independent advice from a consultant in obstetrics and gynaecology. We found that while an ultrasound scan at Ms C's first appointment had shown a small fibroid in the wall of her uterus, this was not cancerous and she was appropriately advised. She was given medication for her presenting symptoms and was to attend in two months' time. At her second appointment, we established that her treating clinician suggested a laparoscopy as her symptoms remained and while Ms C had not wanted this and wanted a biopsy, this would not have been the appropriate treatment. We found no evidence that a protective sleeve had not been used nor evidence of poor communication. We did not uphold Ms C's complaint.

Summary

Mr C complained on behalf of his constituent (Mrs B). Mrs B was concerned about the care her mother (Mrs A) received from her medical practice.

Mrs A was receiving palliative care in the home from Mrs B and the district nursing service. Mrs B was concerned that the GPs at the practice did not undertake home visits to provide medical and emotional palliative care support for her and her mother. In particular, Mrs B felt that a GP should have visited in the days prior to her mother's death. We took independent advice from a GP adviser. The adviser was satisfied that the GPs visited Mrs A on a reasonable number of occasions. Similarly, they did not find evidence that the GPs unreasonably failed to visit in the days before Mrs A's death and noted that the medical records did not indicate that an urgent home visit was clinically required at this time. Furthermore, the adviser did not consider that the practice had unreasonably failed to provide a reasonable level of support and guidance to Mrs B. We therefore did not uphold this aspect of Mr C's complaint.

Mrs B also expressed concern that the practice had not responded to her complaint in a compassionate manner. We found that the practice had not followed their own complaints procedure in this instance in that they had not adopted as conciliatory and sympathetic a tone as possible when responding to the complaint. We further considered that the practice had failed to respond to the complaint in a person-centred way as required by the Scottish Government's 'Can I help you?' guidance for handling healthcare complaints. For these reasons, we upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the practice:

• apologise for failing to respond reasonably to Mrs B's complaint; and
• feed back the findings of this investigation to staff in the practice responsible for responding to complaints.

Summary

Mrs C complained that a blood test that can detect heart damage was not carried out on her son (Mr A) when he attended A&E at Glasgow Royal Infirmary. Mrs C said she made the ambulance crew aware of an extensive family history of heart trouble and that they indicated that, in the circumstances, the blood test would be carried out. However, Mr A was discharged later the same day without the test having been carried out. He died just over three weeks later as a result of a problem with his heart.

The board noted that the ambulance record described Mr A's presenting complaint as non-traumatic back pain. They found no evidence that Mr A had not received appropriate treatment in light of his presenting symptoms.

We took independent medical advice from an emergency medicine consultant, who noted from the records that hospital staff requested and recorded appropriate information. The adviser considered that reasonable action was taken in response to this and that sufficient symptoms, or other factors, did not exist to prompt the blood test to be carried out. It was noted that the ambulance record did not document a family history of heart trouble and, when Mr A was asked about this, an extensive history was not given. We therefore did not conclude that the blood test was unreasonably omitted and did not uphold Mrs C's complaint.

Summary

Mr C complained that he received inadequate care for problems with his testicles. He also said his complaints about this matter had not been responded to reasonably. The board said they had provided Mr C with a reasonable standard of care and treatment and responded to his complaints appropriately.

We took independent medical advice. We found that Mr C had been examined on a number of occasions by doctors at the prison health centre. The medical records showed that at each review, the appropriate action was taken in response to the doctors' findings. When a problem was identified with Mr C's testicles, he was referred for specialist review immediately.

We found there was no evidence that Mr C's care and treatment was not of a reasonable standard. We also found no evidence Mr C's complaints had not been responded to appropriately.

Summary

Mrs C complained about various aspects of the nursing care she received during an admission to the Royal Alexandra Hospital. This included her concerns about the assistance she received with her personal care, the attitude of staff and the management of her pain.

We took independent nursing advice. The adviser found no evidence to support Mrs C's concerns and considered that the overall nursing care she received appeared reasonable. Therefore we did not uphold Mrs C's complaint.

However, while reasonable efforts appeared to have been made to manage Mrs C's pain, it was noted that she had been refusing pain medication and the nursing adviser considered that staff might have done more to explore the reasons for this with Mrs C. In addition, we considered that some of the language used in the nursing records could be viewed as lacking compassion. We made a recommendation in this regard.

Mrs C also complained about her medical care as she considered that she received inadequate sedation before an attempt to carry out a lumbar puncture (a procedure where a needle is inserted into the lower part of the spine). This initial attempt was abandoned due to Mrs C's distress and the procedure was carried out successfully the following day. We took independent advice from a consultant physician, who considered that the procedure was carried out appropriately and that reasonable steps were taken to try to control Mrs C's pain. They advised that it would be unusual and not in line with routine practice to offer sedation to patients for such a procedure. We did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that the staff involved are made aware of, and reflect on, the nursing adviser's comments.

Summary

Miss C complained about the care and treatment provided to her mother (Mrs A) at Glasgow Royal Infirmary. Mrs A had a complex medical history and was admitted to hospital for a blood transfusion. Her condition deteriorated and she remained in hospital, where she died six weeks later.

Miss C believed there was an unreasonable delay in establishing the source of an infection contracted by Mrs A and in the treatment of it, and that the cause of death was related to the infection and not to diabetes or heart disease.

We took independent advice from a specialist in kidney diseases. We found that appropriate investigations were carried out within a reasonable time and treatment decisions (particularly in relation to the prescription of antibiotics) were reasonable, including a decision not to resuscitate. We noted that Mrs A was very unwell on admission and the subsequent infection at the site of an intravenous cannula (a tube inserted into a vein, often to deliver medication) was in addition to a background of significant chronic medical conditions. We found that medical staff failed to communicate this and its implications in a reasonable way to Mrs A's family and made a recommendation to address this. We found no failings in the medical treatment provided to Mrs A and therefore did not uphold Miss C's complaint. However, while the infection at the site of the cannula was a recognised complication of the procedure Mrs A underwent, we made a recommendation in relation to policy regarding the insertion and care of intravenous cannulas.

Recommendations

We recommended that the board:

• provide us with an action plan to address the failings in communication highlighted in this investigation and ensure no recurrence;
• provide evidence that appropriate governance arrangements are in place to minimise the risks of an infection at the site of intravenous cannulas; and
• apologise for the failures this investigation identified.

Summary

Mr C complained that he was not provided with reasonable psychiatric treatment during his time in prison. In particular, he complained that he was not seen by a psychiatrist when he asked to be and that he was not given appropriate medication.

We took independent psychiatric advice. We found that during the time period Mr C was complaining about, he was seen by a mental health nurse on 17 occasions and by two different psychiatrists on 13 occasions. We considered the assessments and examinations carried out to have been reasonable and noted that Mr C's medication was prescribed reasonably and appropriately monitored. We therefore did not uphold Mr C's complaint.