Health

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Miss A). Ms C said that Miss A's medical practice failed to follow up her abnormal blood results, and that as a result she was subsequently diagnosed with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood) a number of years later. Miss A believed that had the practice kept the blood results under review, the diagnosis of hepatitis C would have been made earlier and that she would therefore not have suffered from other medical conditions.

We took independent medical advice and found that although there was an improvement in Miss A's condition initially, her blood results were still abnormal and further tests should have been arranged. As a result, this had contributed to the delayed diagnosis of hepatitis C. We therefore upheld Ms C's complaint. We also found that the practice procedure for the reporting of blood results had subsequently been updated and that the current process is appropriate and would highlight that action is required when abnormal results are identified.

Recommendations

We recommended that the practice:

• apologise to Miss A for the failure to arrange follow-up blood tests.

Summary

Mr C complained that the board failed to provide the results of a scan that he underwent at the Western General Hospital. He said that his GP had not been given the results of the scan, and that when he called the board he was given results over the phone by a secretary who had not been able to explain the results in full. He also complained about the board's handling of his complaint.

We took independent advice from a hospital consultant. We found that it was the responsibility of the consultant who ordered the scan to report the results back to Mr C, and that this was not done. Whilst there was some limited evidence that the consultant had notified the GP of the results, there was no evidence of what form this notification took. We found that when the results were viewed by the requesting consultant, a letter should have been sent to both Mr C and his GP. We therefore upheld this aspect of Mr C's complaint.

In addition, we found that the board's response to Mr C's complaint contained several inaccuracies and upheld Mr C's complaint in this regard.

Recommendations

We recommended that the board:

• ensure that this case is brought to the consultant's attention at their next annual appraisal for them to reflect on;
• reflect on this case and consider whether this was an isolated error or whether steps should be taken to ensure scan results are being communicated to patients in a timely manner;
• bring the findings of this investigation regarding the communication of test results to the relevant secretarial staff's attention;
• apologise for the failings identified with regards to their complaints response; and
• remind complaints handling staff of the necessity of providing factually accurate and non-contradictory responses.

Summary

Mr C complained that he was not warned about the possible specific side effect of developing cataracts (a clouding of the lens of the eye leading to a reduction in vision) when taking steroid drugs via an inhaler.

Mr C had been treated by his GPs and specialists for a number of years for respiratory conditions. He was prescribed inhalers and nasal drops, some of which were steroids. Mr C was diagnosed with cataracts on both eyes while on holiday overseas and had surgery there to remove the cataract from one eye. He was told by his surgeon that the cataracts had been caused by his steroid inhaler.

We took independent medical advice and found that although recognised as a possible side effect, cataracts were such a rare occurrence that it was reasonable that this would not have been specifically discussed with Mr C. Information was available about this in the patient information leaflet supplied with each new batch of the drug. Our view, therefore, was that the actions of the practice were reasonable and in line with relevant General Medical Council guidance to GPs.

Summary

Mrs C complained about the care and treatment she received at the Royal Infirmary of Edinburgh when she has a hysterectomy (surgical removal of the womb). Mrs C was concerned that the surgery should not have gone ahead given that she had been suffering from a cold and cough a couple of weeks earlier. Mrs C became significantly unwell after surgery and further tests identified that she had internal bleeding and a blood clot. Emergency surgery was carried out and she also developed a chest infection.

We took independent medical advice and found that there was evidence to show that Mrs C was fit for surgery with no evidence of active infection or respiratory problems. We considered that the hysterectomy was performed appropriately and that the problems she experienced after surgery were recognised complications of the surgery, rather than failings in care. Whilst we did not uphold the complaint, we were critical that there was a lack of clear documentation to demonstrate that Mrs C was fully appraised of all the relevant risks and complications associated with hysterectomy. Therefore, we made two recommendations to the board in order to address the matter.

Recommendations

We recommended that the board:

• ensure that the staff involved in Mrs C's consent process reflect on these findings to ensure that all recognised risks of hysterectomy are fully discussed with patients and documented on the consent form prior to surgery; and
• consider providing patients with written information where appropriate in relation to hysterectomy.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs A) when she was admitted to the Western General Hospital for radiotherapy to treat a spinal condition. Mr C said that nursing staff failed to provide reasonable care in relation to the taking of blood samples, pressure ulcers and use of a pressure-relieving mattress, and said that the failings caused Mrs A pain and distress.

We took independent advice from a nursing adviser. We found that the standard of nursing care in relation to blood sampling and pressure ulcer care was reasonable, but that there were shortcomings in relation to record-keeping and the explanation about the mattress and we made recommendations in relation to this. However, on balance we were satisfied that the standard of nursing care and treatment on the whole was reasonable and we did not uphold Mrs C's complaint.

Recommendations

We recommended that the board:

• take steps to ensure the record-keeping shortcomings are addressed including that they are raised with relevant staff; and
• inform this office of the safeguards in place to ensure that mattresses requiring inflation do not deflate inadvertently.

Summary

Ms C was admitted to the Royal Edinburgh Hospital. She complained that her care and treatment during her two-day admission was not reasonable. She also complained about record-keeping.

Ms C said that during her admission, an earlier misdiagnosis of personality disorder was relied upon and a more recent diagnosis of post partum psychosis (the onset of psychotic symptoms following childbirth) was ignored. Ms C also said that her medical records did not reasonably portray where she wished to go after her discharge.

During our investigation we took independent advice from a consultant psychiatrist. We found no evidence that the board had relied upon the diagnosis of personality disorder that had been previously made, nor that they had ignored the more recent diagnosis of post partum psychosis. We also found that the care and treatment provided to Ms C during her admission was reasonable. Finally, we found that medical records relating to where Ms C wished to go after her discharge were reasonable. We therefore did not uphold Ms C's complaints.

Summary

Miss C complained about the dental care and treatment received by her son (Mr A). Mr A had a tooth extracted by the board's dental service and several days later was experiencing severe pain from a hard swelling on the floor of his mouth. Mr A was admitted into hospital for emergency surgery to drain what was found to be an infected oral haematoma (a solid swelling of clotted blood). Miss C complained that the extraction of Mr A's tooth had resulted in him having to undergo emergency surgery.

During this investigation, we took independent advice from a dental practitioner. We found that a haematoma is a rare but known complication of extraction, and is not due to anything being done incorrectly. We therefore did not uphold this complaint.

Miss C also complained that the board's response to her complaint contained several inaccuracies. We found that the board's response had been based on the dental records which were available to them, and therefore we did not find their complaints response to be unreasonable.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) by his medical practice. She said that despite his serious symptoms, the practice failed to ensure that appropriate tests were carried out. In particular, he was not referred for a scan. She maintained that he was misdiagnosed and not properly treated as a consequence.

We took independent medical advice which confirmed that the practice had provided a reasonable standard of care. We found that doctors in general practice were unable to request scans and that once a referral had been made to hospital (as happened in Mr A's case), his treatment was determined by clinicians there. We did not uphold Mrs C's complaint.

Summary

Mrs C complained about the care and treatment provided by the board to her husband (Mr A). In particular, she said that there was an unreasonable delay in diagnosing him with non-Hodgkin lymphoma (a cancer that develops in the lymphatic system) and that a procedure involving a drain to his lungs was not carried out to a reasonable standard.

We took independent advice from consultants in nephrology (the study of the kidney) and haematology (the study of the blood) and we found that on his admission to hospital, Mr A was seriously ill and suffering from numerous illnesses including heart and lung disease and diabetes. He was admitted to investigate anaemia (a deficiency of red cells in the blood) but on examination was found to have a liver dysfunction and an enlarged liver and spleen. Appropriate tests were made at Monklands Hospital and Mr A was treated for his presenting symptoms. However, his condition continued to worsen and a scan followed with various biopsies being undertaken. These confirmed that Mr A had lymphoma. While Mr A's diagnosis was delayed, this was not unreasonable as priority had been given to his presenting symptoms and existing illnesses. Tests were difficult because of these.

Mr A's treatment options were limited because of his many illnesses and his cancer did not respond to chemotherapy. His declining condition led to further complications including a collapsed lung and Mr A later died. We found that Mr A's symptoms had been treated reasonably and therefore we did not uphold Mrs C's complaint.

Summary

Mr C complained about the time taken to diagnose the cause of his ongoing pain following a bone marrow biopsy at Hairmyres Hospital. About 12 months after the biopsy, Mr C was referred to orthopaedics at a different hospital and it was found that the pain was likely caused by damage to his sacroiliac joint (a joint in the pelvis). Mr C queried why he was not referred to orthopaedics or given an MRI scan sooner, and why he was not warned about the risk of ongoing pain before the biopsy.

The board considered staff took appropriate action to investigate Mr C's pain. They explained that they do not routinely warn patients of the risk of persistent pain from bone marrow biopsies as this is extremely rare, but they proposed to update their patient information leaflet in light of Mr C's experience.

After taking independent haematology (study of the blood) and radiology advice, we did not uphold Mr C's complaints. We found staff had taken reasonable action following the biopsy to investigate the cause for Mr C's pain, including a scan and treatment for signs of infection. When the pain persisted, staff treated this appropriately with medication and a referral to the pain clinic. While we acknowledged that an earlier scan would have been helpful to diagnose the cause of Mr C's pain, given that Mr C was undergoing chemotherapy and radiotherapy during this time which could have contributed to the pain, we considered it was reasonable for staff to wait until Mr C's cancer treatment was finished before referring him for further investigations.

We also found that, while persistent pain has been recognised as a complication from bone marrow biopsy, this is extremely rare. In view of this, we did not consider it unreasonable that staff did not warn Mr C about this risk.