Health

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.

Summary

Ms C complained about the care and treatment provided to her father (Mr A) following two admissions to Glasgow Royal infirmary. Mr A, who resided in a nursing home, had vascular dementia and visual impairment. Ms C also complained about the time taken by the board to investigate and respond to her complaint.

During our investigation, we obtained independent medical and nursing advice.

Mr A was admitted to hospital after sustaining a fractured hip in a fall. He had surgery the following day and was discharged back to his nursing home several days later. The board accepted there were failings in Mr A's nursing care which had resulted in a failure to identify the infection(s) which Mr A was developing and had led to his premature discharge. The advice we received was that Mr A's surgical treatment was reasonable and he was not able to undertake rehabilitation due to his mental state.

However, we identified a number of failings in Mr A's medical care, nursing care, and in communication with his family. These included failure by staff to ensure they had the relevant information to make an informed decision about Mr A's discharge, as well as failures in record-keeping and nutritional care. We also found that during the assessment, planning and delivery of Mr A's care, there was a failure to fully comply with the Adults With Incapacity Act and the Standards of Care for Dementia in Scotland. We therefore upheld this aspect of Ms C's complaint. The board had apologised for the failings in communication during this admission and said they had introduced a new relatives communication sheet, in relation to which the nursing adviser said there were advantages and disadvantages.

Mr A was readmitted to hospital the following day. While Ms C considered the quality of care Mr A received was generally satisfactory and often good, she was critical of certain aspects of his care and about his subsequent transfer to Lightburn Hospital.

We did not find evidence that the medical treatment Mr A received during this admission was of an unreasonable standard and so did not uphold this aspect of Ms C's complaint. Although we considered that aspects of Mr A's nursing care were carried out to a reasonable standard, we found staff failed to ensure that it was appropriately person-centred. We found failures in complying with the Adults with Incapacity Act and the Standards of Care for Dementia in Scotland and also in the communication with Mr A's family. We therefore upheld Ms C's complaint in this regard.

The board also accepted that the time taken to investigate and respond to Ms C's complaint was unreasonable, and so we upheld this aspect of Ms C's complaint. We considered that the board had provided Ms C with an appropriate apology for this and taken steps to address what had occurred.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in Mr A's care and treatment;
• feed back the comments of the advisers and the findings of this complaint to the staff involved for reflection and learning;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Standards of Care for Dementia in Scotland, both in relation to patient care and treatment and in communication with relatives/carers;
• feed back to relevant staff the comments of the nursing adviser concerning the use of a relatives communication sheet;
• report to us on the steps taken to address the failings identified by this investigation in relation to complying with the Adults With Incapacity Act (2000), with particular regard to capacity to consent to treatment;
• carry out an audit of early readmissions following discharge from the ward concerned so as to identify any further avoidable failures; and
• provide evidence that the issues identified in relation to complaints handling have been fed back to their complaints lead and shared with complaints staff.

Summary

Mr C, who works for an advocacy service, complained on behalf of Mrs B. Mrs B's husband, Mr A, was a patient at the medical practice. He initially attended with left-sided chest pain that he reported had been present on and off for months. An x-ray was arranged but this was normal. He went on to report neck pain and urinary symptoms. Mr A was later diagnosed with lung cancer which had spread to the vertebrae in his neck. His urinary symptoms were found to be unconnected to this diagnosis.

Mrs B was concerned that the practice had not provided an appropriate level of care to Mr A. She said that his condition could have been diagnosed earlier and made particular reference to a scan which she felt should have been arranged.

After taking independent advice from a GP, we found that Mr A had not been provided with appropriate medical treatment. While we found that a scan could not have been arranged for Mr A by the practice, he should have been referred to the local NHS board's respiratory team after he reported chest pain being present on and off for months, even though the x-ray was normal. The adviser highlighted that this action was supported by the Scottish Referral Guidelines for Suspected Cancer. We found that the other aspects of Mr A's care were reasonable.

Recommendations

We recommended that the practice:

• apologise to Mrs B for the lack of respiratory referral;
• ensure that all relevant staff are familiar with the Scottish Referral Guidelines for Suspected Cancer; and
• ensure this case is discussed at the next appraisal of the doctor who saw Mr A at the relevant consultation.

Summary

Ms C complained that a GP failed to carry out a reasonable assessment when she attended the board's out-of-hours service. The GP carried out an assessment and discharged her, stating that she probably had a non-specific viral illness. Ms C was admitted to hospital approximately 24 hours later and was subsequently diagnosed with a different condition.

We took independent advice from a medical adviser. We found that the assessment carried out by the GP had been appropriate for the symptoms described by Ms C. We also found that it had been reasonable for the GP to consider that Ms C had a non-specific viral illness. Although Ms C said that she had not been asked about her medical history, the GP said that they had asked Ms C about this but had not recorded her response. We found that if the response was negative and not relevant, it would have been reasonable for the GP not to have recorded it. It had also been reasonable not to refer Ms C to hospital and there was no evidence that the delay in diagnosis of Ms C's condition was a result of unreasonable practice by the GP. We did not identify failings by the out-of-hours service and we considered that the care provided by the GP was of a reasonable standard. We therefore did not uphold Ms C's complaint.

Summary

Mr C complained about the board's management of healthcare appointments for his child, who suffers from allergies and diabetes. In particular, Mr C was concerned that the board cancelled an out-of-area appointment for a joint allergy and gastroenterology clinic, on the basis that equivalent local services were available. However, the board did not provide a gastroenterology appointment until about six months later.

The board acknowledged that some of the appointments were outwith the

12-week waiting time target for new out-patient appointments, including a clinical genetics appointment (delayed due to a missed referral), an allergy appointment (provided out-of-area as the child's GP had requested this), and a gastroenterology appointment (which took longer to arrange as it was a joint appointment with gastroenterology and the head of the local allergy service, and was further delayed by a consultant gastroenterologist leaving the board).

After taking independent medical advice, we found that it was reasonable for the board to take the position that an out-of-area referral for allergy and gastroenterology was not required, as there were equivalent services available within Scotland. We found that the delay in the clinical genetics appointment was unreasonable, and while the board had already acknowledged this and addressed the problem, we considered they should also apologise to Mr C. However, we were not critical of the timeframes for the gastroenterology and allergy appointments. While we acknowledged these were outwith the 12-week target, we noted that the target is for 95 percent of cases to meet these timeframes, and in this case we considered the timeframes were reasonable in view of the specific circumstances.

Mr C also said the board gave inaccurate information in their complaint response about what kind of support it was agreed at a clinical meeting the health visitor should provide. We found there were conflicting accounts about exactly what was said at the meeting, but the board's description of this was consistent with the health visitor's role and in keeping with the support actually provided, and we therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to meet the waiting time target for his child's clinical genetics appointment.

Summary

Mrs C complained about the care and treatment she received in relation to her labour at Forth Valley Royal Hospital. Mrs C had a long and difficult labour, and her baby was born with the use of forceps. An episiotomy (a surgical cut of the area between the vagina and anus) was performed and Mrs C suffered a fourth degree tear (a severe tear in the vaginal tissue), which was repaired that day. A few months later, Mrs C was diagnosed with a recto-vaginal fistula (an abnormal connection between the rectum and the vagina) and disrupted anal sphincter (muscle that surrounds the anus), for which she underwent several unsuccessful operations. Nine months later, Mrs C was referred to a specialist at Glasgow Royal Infirmary, who decided that a colostomy bag (a pouch placed over one end of an intestine) was required to allow healing before further procedures to repair the fistula.

We took independent obstetrics and gynaecology advice and surgical advice. In relation to Mrs C's complaint about the standard of obstetric care and treatment provided, we found that the fourth degree tear was properly identified and repaired within a reasonable time, but that the board failed unreasonably to arrange an obstetric review before discharge from Mrs C's first admission to hospital (which also had an adverse effect on communication) and that there was confusion about postnatal appointments and delays.

Regarding the standard of surgical care and treatment provided, while we were satisfied that medical staff managed the fistula in a reasonable way, we found that they failed unreasonably to obtain consent for one of Mrs C's operations. Finally, we were critical that the board failed to respond formally to the surgical aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• ensure that consent is obtained and documented in line with the relevant guidelines;
• raise the failings this investigation identified with the relevant staff;
• inform us of the actions taken to address the complaints handling failings this investigation identified; and
• apologise for the failings this investigation identified.