Health

Summary

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.

Recommendations

We recommended that the board:

• feed back the comments of the advisers to medical and nursing staff in the acute medical unit;
• issue a written apology to Mr A's family for the failings in nursing and medical care identified by the advisers;
• provide evidence that the learning from this complaint has been implemented;
• issue a written apology to Mr A's family for failing to respond reasonably to the concerns that were raised;
• issue a written apology to Miss C for the complaints handling failings identified in this investigation;
• feed back to staff the importance of interviewing staff within good time of events, of concluding a complaint investigation with a written report and of updating complainants with the progress of the investigation where delays occur;
• provide Miss C with a copy of the substance misuse leaflet and details of the steps taken to improve communication;
• feed back the comments of the adviser to the member of staff who wrote the discharge letter;
• make an addendum to the records, which notes that the statement about the family in the letter was not reflected in the clinical notes, and send a copy of this addendum to Practitioner Services to be filed with Mr A's GP records; and
• issue a written apology to Mr A's family for the inaccurate statement in the records.

Summary

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.

Recommendations

We recommended that the board:

• make a formal apology for the shortcomings identified;
• ensure that staff are made aware of the findings of this investigation so that they may consider these further with a view to preventing similar occurences;
• make a formal apology referencing the identified failures in dealing with Mr A's care and treatment;
• advise us of the action taken and confirm that this would prevent a similar occurrence; and
• carry out an internal review of this case which should be presented and discussed at a morbidity and mortality meeting with peer review.

Summary

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.

Summary

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.

Recommendations

We recommended that the board:

• apologise for the failure to report and act on the abnormality shown in
• x-rays of Mrs C's ankle and for the prolonged waiting time between being referred to orthopaedic services and receiving an orthopaedic appointment;
• consider the adviser's comments on the failure to observe the radiological abnormalities in this case and identify any action which could be taken to minimise the occurrence of such errors;
• ensure patients are advised in a timely manner that they may not be seen within waiting-time targets; and
• provide us with evidence that the action taken to reduce waiting times is having the desired effect.

Summary

Mr C was receiving his medication and an officer observing suspected that Mr C had attempted to conceal his medication. After consultation with the prison doctor, Mr C's medication was discontinued and he was offered an alternative medication.

Mr C complained about the decision to discontinue his medication. He said he had not attempted to conceal the medication and felt his recent dental surgery had affected his ability to take the medication appropriately. We found that the prison health centre had acted appropriately, in line with their protocol, and offered Mr C a reasonable alternative. We did not uphold Mr C's complaint.

Summary

Ms C, an advocacy and support worker, complained to the board on behalf of her client (Mrs A) who was admitted to Glasgow Royal Infirmary with a urinary tract infection and was prescribed an antibiotic to take at home. Mrs A was readmitted to hospital some months later with a kidney injury, as a result of sepsis and dehydration. On her initial admission to the hospital, Mrs A was already on medication for high blood pressure and she felt the antibiotic should not have been prescribed.

We took independent medical advice. We found that it was not unreasonable to have prescribed the antibiotic in view of Mrs A's previous medical history. We also found that clinical staff had given advice that Mrs A should seek a further clinical opinion should her symptoms worsen. We therefore did not uphold Ms C's complaint.

Summary

Mr C complained about a lack of treatment during an admission to the Royal Alexandra Hospital. He had been admitted following fracture of his hip and femur. Mr C said that he vomited throughout one night and now suffers from throat discomfort. He said that although staff changed his basin on occasions he now feels that the lack of treatment for his vomiting caused this.

We took independent medical advice. We found that nursing staff reported the vomiting. The adviser noted that Mr C was stable and that anti-sickness medication was prescribed and that an appropriate treatment plan was put in place. We therefore did not uphold Mr C's complaint.

Summary

Miss C complained that her medical practice unreasonably removed her from the practice patient list because of comments which had been made on her social media site. The practice said that they would not tolerate such comments and that there had been a breakdown in the doctor/patient relationship which meant that it was not possible for them to treat Miss C. They considered the tone of the comments to be both threatening and bereft of any respect for the practice.

We took independent advice from an adviser in general practice and concluded that the comments which were made could be reasonably interpreted as threatening to the practice and as such it was not unreasonable that Miss C was removed without a preceding warning. We found the practice had adhered to their contractual specifications in this regard and their actions were reasonable. We did not uphold Miss C's complaint.

Summary

Mr C asked the prison health centre to prescribe him a medicine used in the treatment of opiate addiction. The prison health centre refused and explained to Mr C that he did not meet the relevant criteria.

We took independent medical advice. We found that the decision to refuse to prescribe Mr C the medicine he requested was taken following a thorough clinical assessment and that the care and treatment given to him was reasonable. We therefore did not uphold Mr C's complaint.

Summary

Mr C complained that the prison health centre unreasonably reduced his medication for nerve pain. He said the decision had affected his wellbeing and he wanted to have the dose increased.

The information available confirmed Mr C was reviewed and assessed by a number of clinicians and they did not feel there was any clinical need to increase his medication. We took independent medical advice. The adviser found that the health centre's decision appeared to be reasonable and in line with appropriate guidance. We therefore did not uphold Mr C's complaint.