Health

Summary

Mr C complained about the care and treatment provided to him by the prison health centre. He said that he was not being provided with appropriate pain relief for a number of complex medical problems and his complaints about these issues had not been properly investigated. Mr C said that the GP he saw in prison changed his prescription from that provided to him in the community. Mr C said his mobility and balance had been severely affected.

We took independent medical advice on Mr C's prescriptions. The adviser said that Mr C was properly reviewed and the changes to his prescriptions were in line with national guidance on the management of chronic pain and the prescribing of pain relief within a prison setting. Mr C had been reviewed and his medication discussed with him. The adviser did not find evidence that Mr C had been significantly affected in the ways he described by the changes to his medication.

Our investigation found that Mr C's complaints were responded to promptly and addressed the issues he raised. There was no evidence that complaint procedures were not properly followed.

Summary

Mr C complained about the way the board dealt with his review application for NHS continuing healthcare for his late mother (Mrs A), who was resident in a care home. He also complained about how the board handled his subsequent complaint.

Mr C's application was rejected by the board on the basis that Mrs A did not meet the criteria as set out in the Scottish Government Guidance Circular CEL 6 (2008), the relevant guidance at the time. By the time the board had referred the application to two clinicians for assessment, Mrs A had died. Their assessments were paper based.

We took independent advice from a consultant in medicine for the elderly. They said it could reasonably be interpreted from the wording of the CEL 6 (2008) guidance that a paper based assessment constituted a clinical opinion. The adviser agreed with the findings of the clinicians that Mrs A had not satisfied the criteria for NHS continuing healthcare. The adviser also said that Mrs A's deteriorating health, her admissions to hospital, and the fact that her care home was unable to meet her care needs did not mean that she met the criteria. We accepted that advice.

However, we found that that there were unacceptable and lengthy delays by the board in reaching a decision on Mr C's application, that their review process was slow and disorganised, and that they had not appeared to have taken Mr C's review application and concerns seriously. We also found that there was a failure to communicate effectively with Mr C during the review process. For this reason, we upheld the complaint.

The board had accepted there had been unacceptable delay in responding to Mr C's complaint, for which they had apologised. However, we considered the board's actions were then aggravated by their failure to obtain a suitable person to carry out an independent review of their decision, having said to Mr C that they would do so, which resulted in yet further unreasonable delay.

Recommendations

We recommended that the board:

• issue Mr C with a formal apology for the failings in relation to delay and their communication with him during the review process;
• issue Mr C with a formal apology for their failure to carry out an appropriate independent review and to handle his complaint in a timely manner;
• provide evidence of the review carried out of their patient experience processes in relation to complaints handling; and
• reflect on the comments of the adviser in relation to the need to identify an independent reviewer.

Summary

Mrs C complained that GPs at the medical practice failed to diagnose cholesteatoma (an uncommon abnormal collection of skin cells inside the ear). Mrs C felt the practice had failed to do this over a number of years.

We took independent advice from a GP adviser. We found there was no evidence that Mrs C's consultations with GPs several years ago were linked to her recent consultations in terms of cholesteatoma diagnosis. We also found that the practice's management of Mrs C's case was reasonable during all consultations, and when they noted that her symptoms were not settling they arranged an urgent review with a hospital specialist. There was no evidence of a delay in the referral and we concluded that the care provided to Mrs C was to a reasonable standard given the circumstances at the time. Therefore we did not uphold Mrs C's complaint.

Summary

Mr C complained about the care and treatment he received during a number of admissions to Borders General Hospital.

Mr C was concerned that given previous surgery, he should not have been offered endoscopic retrograde cholangiopancreatography (ERCP, a procedure where a flexible tube is passed into the small intestine). Mr C also complained that the ERCP was not carried out in an appropriate manner and led to the need for further surgery and treatment, which were also not carried out in an reasonable manner.

We took independent advice from a consultant general surgeon. The advice we received was that the care and treatment provided to Mr C was appropriate and reasonable. Mr C suffered a number of recognised complications following what the adviser considered was a reasonable decision to offer him ERCP. The advice we received was that the clinical management decisions made in Mr C's care and treatment were in accordance with accepted good practice. We therefore did not uphold these aspects of Mr C's complaint.

Mr C also complained that he was not given appropriate information about what might happen should the drain fail. We found that the medical records did not detail any discussion held with Mr C about alternatives to ERCP and failed to detail what advice was given to Mr C. We therefore upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• consider reviewing their procedure-specific consent form for ERCP to include a section to record any alternatives to the procedure;
• consider the adviser's comments on the importance of including in the medical records detail of discussions held with patients with regard to treatment options and their potential outcomes and report back to this office on any action taken;
• remind staff of the importance of recording key information given to patients; and
• consider the adviser's comments on the use of a leaflet for patients with information on how to manage surgical drains, including information on what to do if a drain appears blocked and report back to this office on any action taken.

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. In the 18 months following his treatment, Mr A received ongoing support from community dieticians and speech and language therapy (SALT), and regular reviews at a joint cancer clinic. During this period, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. In June 2014 Mr A was referred back to hospital with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to a different hospital. Mr A passed away about ten days later.

Mrs C complained about the care provided by the practice during this period. She said Mr A's family constantly raised concerns about his weight loss, increasing pain and frailty, but these were not listened to. She said the practice often phoned Mr A (instead of arranging face-to-face appointments) and did not adequately monitor his weight loss and malnutrition. Mrs C was also concerned that the practice did not provide adequate care for Mr A's emotional wellbeing or diagnose him with depression. In addition, Mrs C said the practice refused to refer Mr A back to hospital in late May 2014, and the admission was only arranged when her sister called the specialist nurse directly a few days later.

After taking independent advice from a GP, we did not uphold Mrs C's complaints. We found that the practice provided reasonable care during this period, including responding to Mr A's symptoms (and the adviser noted that many of Mr A's symptoms related to his recent cancer treatment, for which he was receiving specialist care). In relation to emotional support, the adviser said the records did not show any symptoms that should have prompted a diagnosis of clinical depression, and they explained that information on support for cancer patients is normally provided by the hospital (so this is not a specific role for the GP). In relation to Mr A's final hospital admission, we found the practice had arranged appropriate assessments for Mr A and had already begun making arrangements for admission before his daughter called the specialist nurse about this.

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A received ongoing support from the board's community dieticians and regular reviews at a joint cancer clinic in another health board. He also received speech and language therapy (SALT) as part of the cancer clinic for about six months, and was then referred back to the board for ongoing SALT care.

In the 18 months following his treatment, Mr A had increasing difficulty swallowing and suffered from recurrent mouth ulcers and pain. He also had several short hospital admissions with bleeding from the mouth. He was subsequently admitted to Borders General Hospital in June 2014 with weight loss, decreased ability to swallow and stridor (noisy breathing caused by a narrowed or obstructed airway). He underwent endo-tracheal intubation (insertion of a tube to maintain an open airway to the lungs) and was transferred to a different hospital. Mr A passed away about ten days later.

Mrs C complained about Mr A's care during this period, and raised concerns that clinicians failed to adequately respond to Mr A's mouth pain, malnutrition and weight loss, as well as infections in his mouth. Mrs C also raised concerns about communication during two hospital admissions, including that Mr A was incorrectly told that his cancer had returned in May 2014.

After taking independent advice from a consultant in general medicine, a SALT therapist and a dietician, we upheld two of Mrs C's complaints. We found that when Mr A's SALT care was referred back to the board, the referral was not actioned properly, which meant that Mr A did not receive any SALT support for about a year (until shortly before his final admission). We also found there were failings in communication during Mr A's final hospital admission (although we noted that the board had acknowledged and apologised for this). However, we found no evidence that Mr A was given incorrect information during his May 2014 admission.

Recommendations

We recommended that the board:

• apologise to Mrs C's family for the failings our investigation has found;
• demonstrate to us what action has been taken to ensure SALT referrals are properly actioned in future;
• review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer; and
• demonstrate to us what steps are being taken to improve communication with patients and their families (and documentation of this) at Borders General Hospital.

When it was originally published on 15 February 2017, this case referred to a dentist in the Ayrshire and Arran NHS Board area. This was incorrect, and should have read a dentist in the Greater Glasgow and Clyde NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

Ms C complained about the dental care and treatment she received during a course of treatment for a root canal. She complained that at one appointment, the local anaesthetic injection had resulted in her lower lip becoming tingly for several months, and that it then went completely numb. She also complained that she had not been told of the potential risks of local anaesthetic injections.

During our investigation, we took independent advice from a dental practitioner. We found that whilst altered sensation is a rare complication of a local anaesthetic injection, it does not suggest any failing on the part of the dentist. We also found that there is no requirement for dental practitioners to discuss potential risks of local anaesthetic injections with patients. Therefore, we did not uphold Ms C's complaints.

Summary

Mr C complained to us that his GP had not provided him with appropriate medication in view of his symptoms and medical history. Mr C had on-going high blood pressure and this was complicated by low sodium levels. He felt that the medications his GP had prescribed him were the cause of him being hospitalised due to low sodium and dehydration.

We took independent medical advice and found that whilst it had been difficult to balance Mr C's blood pressure and sodium levels, his GP had prescribed him appropriate mediation. We found that when he was hospitalised, he was suffering from a very rare side effect of one of his medications. The adviser said that they would not have expected Mr C's GP to have been alert to the possibility of this side effect. We found that there was one occasion on which Mr C's GP could have given Mr C a blood test and failed to. However, we noted that the practice had already apologised for this. Therefore, we did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment given to her husband (Mr A), who suffered from dementia and was wheelchair-bound. Mr A was admitted to University Hospital Ayr with a urinary tract infection, was kept in hospital for about a week, then discharged on a Friday. Mrs C required a lot of assistance to manage Mr A over the weekend, and following a GP visit the following Monday, he was readmitted to hospital. It was agreed that Mr A would be transferred to a nursing home for his future care. However, while in hospital he suffered ischaemia (lack of blood supply) to his left leg and died. Mrs C complained about a number of aspects of care, including that nursing staff did not seem to have a good understanding of dementia and did not understand Mr A's needs.

The board met with Mrs C and apologised for some aspects of care. They developed an improvement plan in response to Mrs C's complaint, which included changes to improve continuity of care and staff communication with families. The board also introduced a 'dementia champion' on the ward to raise awareness of dementia. However, they did not tell Mrs C about the action that had been taken in response to her complaint until prompted by this investigation.

After taking independent medical and nursing advice, we upheld Mrs C's complaints about the first discharge and about nursing care. While we found most aspects of nursing care were reasonable, we were critical that the board used a standard chart for monitoring Mr A's pain, whereas they should have used a chart designed for people with cognitive impairment (such as dementia), who are not always able to express their pain verbally. We did not uphold Mrs C's complaint about communication, as we found there was evidence that staff had regular conversations with Mr A's family about his condition. While Mrs C said she always had to initiate conversations, it was not possible to tell this from the clinical records, and we found no evidence that staff did not communicate reasonably. However, we found that some conversations between staff discussing Mr A's care were not recorded, and we made a recommendation regarding this.

Recommendations

We recommended that the board:

• feed back the findings of this investigation relating to Mr C's discharge to the doctor involved for reflection and learning;
• review the discharge planning process on the ward to ensure there is adequate planning, including assessment of ongoing care needs where appropriate;
• remind relevant medical staff of the importance of recording multi-disciplinary team discussions about patients' care (including 'whiteboard meetings');
• introduce a tailored pain assessment tool for use with people with dementia;
• provide us with information on steps taken (or an action plan) to indicate how dementia awareness is being carried out, in line with the national Promoting Excellence framework; and
• apologise to Mrs C for the failings found during this investigation.

Summary

Miss C complained about the care and treatment received by her partner (Mr A) at University Hospital Ayr. Mr A attended the hospital for a urology review as he had been experiencing problems involving his testicles, perineum and groin area. Miss C complained that no cause could be found for his pain and that although he had previously undergone a procedure involving his scrotum, this would not cause the sharp pain about which he was complaining. Mr A was subsequently admitted to hospital as an emergency. A scan showed that there was no blood flow to his left testicle, and it had to be removed.

Miss C complained that Mr A had been discharged too soon and without being seen by the consultant. She also said that the consultant concerned had refused to do further tests to establish the cause of Mr A's problems.

We took independent advice from consultants in emergency medicine and urology. We found that Mr A's treatment in A&E was of a reasonable standard and in line with his presenting symptoms, and that he was admitted and referred to the appropriate specialist in a timely way. We also found that the surgery Mr A had was reasonable. However, the level of documentation justifying the consultant urologist's decision-making and the information given to Mr A to allow him to make informed consent was not in accordance with General Medical Council (GMC) guidance. Furthermore, Mr A received little in the way of explanatory information and he was not examined when he attended for review. We upheld this aspect of Miss C's complaint.

In response to Miss C's complaint to the board, Mr A was referred to a urologist in another area, which we found to be good practice. However, Miss C's complaint to the board was not handled within the relevant timeframe and we upheld this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise formally for identified failings;
• ensure that the consultant urologist involved is made aware of the findings of this investigation and remind them of their obligations regarding note-taking and consent as per GMC guidance; and
• remind staff involved of their responsibilities in relation to the complaints process, and the importance of addressing complaints within the relevant time frame.