Health

Summary

Mr C complained that there was an unreasonable delay in diagnosing his skull fracture, that there was a further delay in his being informed of the diagnosis and that there was an unreasonable delay in his being referred to an appropriate specialist.

Mr C declined to provide consent for his medical records to be accessed and his case was therefore discontinued.

Summary

Mrs C, an advocacy and advice worker, complained on behalf of Mr and Mrs A regarding a child protection referral which was raised by a children's physiotherapist in relation to their daughter (Miss B). The physiotherapist raised concerns in the referral that Mr and Mrs A were fabricating injury and illness in Miss B and were refusing to engage with physiotherapy. This was not taken forward by social services as Miss B was subsequently diagnosed with a genetic condition.

We took independent clinical advice from a senior nurse director, who noted that those raising child protection concerns have a duty to be as sure of their grounds for suspicion as is practicable. It was noted that Miss B had indeed sustained an injury but that there appeared to have been a misunderstanding as to the nature of this. It was also noted that while a formal diagnosis of Miss B's illness had not yet been received, there was evidence that she was undergoing genetic testing at the time. The adviser considered that, in both instances, the physiotherapist could reasonably have attempted to clarify matters by speaking to Mr and Mrs A and medical staff.

There were conflicting accounts as to whether Mr and Mrs A were refusing to engage with all physiotherapy, or just the physiotherapist in question. However, it was clear that relations between Mr and Mrs A and the physiotherapist were already difficult and the adviser considered that the board might reasonably have taken earlier steps to offer Miss B the opportunity to see a different therapist. The adviser also noted that the physiotherapist did not inform Mr and Mrs A about the referral, despite there being no record of any decision having been taken that this would not have been in Miss B's best interests. We therefore concluded that the physiotherapist did not act in line with the board's child protection procedures. We therefore upheld this complaint.

Mrs C also complained about a delay in providing Mr and Mrs A with copies of their children's medical records when they requested access to these. We noted that there had been a lengthy delay which the board had acknowledged and apologised for. However, while the board had undertaken to review their process to avoid a similar future delay, we noted that no action appeared to have been taken in this regard until after we sent an enquiry to them. We were critical that the board had not progressed action they had promised to take in response to a complaint. We therefore upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for the failings this investigation has identified;
• inform us of the steps they have taken to ensure that staff adhere to their child protection procedures, particularly in relation to the involvement of parents/carers;
• take steps to ensure that staff are aware of the importance of taking any action reasonably available to them to clarify the validity of any child protection concerns they have;
• apologise to Mr and Mrs A for the delay in taking forward the promised action to look at their process for responding to requests for access to medical records; and
• inform Mr and Mrs A of the outcome of their policy review and, particularly, any process changes that have been made to prevent a recurrence of the problems they experienced obtaining access to their children's medical records.

Summary

Mr C complained to us about the care and treatment provided to his wife (Mrs A) by the medical practice. He complained that the practice failed to provide Mrs A with appropriate treatment when she presented with lower back pain, and that they failed to appropriately examine her at her consultations. Mr C felt that the back pain was a symptom of the cancer Mrs A was later found to have and which led to her death. Mr C further complained that Mrs A had been provided with inappropriate inhalers for a number of years.

In investigating this complaint, we took independent advice from a GP adviser. We found that whilst Mrs A had presented with lower back pain for a number of months, there were no symptoms at that time which would have alerted her GP to the possibility of her having cancer. When Mrs A reported new symptoms, these were found to be due to abdominal cancer. We found that the management of Mrs A's original symptoms, which was primarily with painkillers, was reasonable. We also found that Mrs A was reasonably examined by GPs at the practice based on her reported symptoms. We therefore did not uphold this aspect of Mr C's complaint.

With regard to the inhalers Mrs A had been prescribed, we found that as Mrs A had never been formally diagnosed with an illness that would require regular use of inhalers, it was not reasonable that she had been prescribed these on a long-term basis. Whilst we did not find there to have been adverse effects as a result of this failing, we upheld Mr C's complaint. The practice acknowledged that the monitoring of Mrs A's inhaler use could have been better and told us they had undertaken a review of their system regarding this.

Recommendations

We recommended that the practice:

• apologise for the failings identified in this investigation;
• draw the comments of the adviser regarding prescription of inhalers to the attention of the relevant staff; and
• update this office on the action taken following the practice's review of their systems for recalling patients who are on regular inhalers.

Summary

Mrs C complained about several aspects of the nursing care that had been provided to her mother (Mrs A) at Western Isles Hospital and about the nursing staff's communication with the family.

We took independent nursing advice. We found that while some aspects of nursing care were reasonable, the board had already carried out their own review which had identified a number of failings with care and communication and apologised for these. We found that there had been poor practice in relation to the use of a hoist when lifting Mrs A. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide a further apology, for the inappropriate use of the hoist by staff on the ward; and
• provide Mrs C with a copy of the completed case review showing the action taken to address the concerns raised.

Summary

Mrs C, who had a history of osteoporosis, fell whilst in Ninewells Hospital. She complained that despite being in a great deal of pain, her back was not x-rayed.

On her discharge, Mrs C complained to the board but they advised that as she had been checked after her fall by increasingly senior doctors who found no bony tenderness, an x-ray had not been required and she had been discharged with appropriate advice. Mrs C learned from a subsequent x-ray that she had suffered a fracture to her spine.

We took independent advice from a consultant in acute medicine. We found that Mrs C had been appropriately assessed and examined after her fall. She had no bony tenderness which would have indicated that an x-ray was required. We also found that even if Mrs C had been x-rayed at the time and a fracture had been found, she would have been given no additional or different medication and her treatment would have remained the same. This was because she was already taking medication for a previous fracture.

We did not uphold the complaint.

Summary

Mrs C suffered hearing loss following minor oral surgery at Perth Royal Infirmary. She complained that the board failed to provide appropriate treatment and failed to adequately explain the risks of the procedure she received.

The board said Mrs C received appropriate treatment. They said the procedure was performed correctly and they considered hearing loss was not a recognised complication, and was unpredictable. They said Mrs C was seen by various specialists, who investigated the complication. The board also considered the risks of the procedure were adequately explained, as the risks Mrs C complained about were unknown and diminishingly rare.

After receiving independent advice from an oral and maxillofacial surgeon, we did not uphold Mrs C's complaint. We found the care provided was appropriate, taking into account the complication could not reasonably have been predicted by the clinicians. We found the board acted appropriately in investigating the complication. We also considered the board did not fail to adequately explain the risks of the procedure, as the risks in question were exceedingly small. We did not uphold Mrs C's complaint.

Summary

Mrs C's husband (Mr A) suffered a suspected stroke at work. An ambulance was called. Mrs C complained that there was an unreasonable delay in an ambulance attending. She was also unhappy that the caller was not properly informed that there were no ambulances currently available and, later, that there was going to be a delay in the ambulance attending.

We took independent advice from a specialist in emergency medicine. The adviser found that the categorisation of the call was reasonable and that, while there was a delay in attending, there are times when demand will exceed capacity and that at these times, it will not be possible to provide a response within an ideal timescale. Therefore, while we accepted that there was a delay, we did not consider that the delay was unreasonable. We also accepted the adviser's view that it was reasonable that initially the caller was told that the ambulance would be there as soon as possible and, in relation to the further call, that it took four minutes before the ambulance arrived, so giving further detail to the caller was not necessary. We therefore did not uphold Mrs C's complaint.

Summary

Mr and Mrs C complained on behalf of their daughter (Miss A) regarding the dental care and treatment she received from the board. Mr and Mrs C complained that Miss A's anxiety was not taken into account whilst the board were attempting to remove two of her teeth over several dental appointments, and that it was decided that the dental treatment was not necessary.

We took independent dental advice and found that the care and treatment provided to Miss A had been reasonable and the board had made many attempts to acclimatise Miss A to receiving dental care. In addition, we found that whilst it had been reasonable for the board to pursue treatment over several months, it was reasonable that they eventually decided not to carry out the treatment as the benefits of treatment no longer outweighed the risks of Miss A's anxiety becoming worse. Therefore, we did not uphold this complaint.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) in Western General Hospital and St John's Hospital.

We took independent advice from a consultant physician and a nurse. Though we found Mr A's medical treatment reasonable, we identified a number of other concerns. In particular, we found that communication of Mr A's prognosis was not carried out reasonably with Mr A or his family. We also had concerns about the adequacy of record-keeping by nursing staff in relation to Mr A's stay in St John's Hospital. We were also concerned that no arrangements had been put in place for a member of Mr A's family to travel with him in the ambulance when he was transferred from St John's Hospital to hospice care.

Recommendations

We recommended that the board:

• apologise for the failure to properly communicate with Mr A and his family with regards to his prognosis and who his consultant was;
• take steps to ensure communication between staff and families is properly documented;
• ensure that relevant staff are made aware of our comments in relation to communication of prognosis;
• take steps to ensure complete daily nursing records are properly kept at all times;
• apologise for the failure to properly document nursing care provided to Mr A; and
• consider putting in place specific guidelines for allowing family members to travel alongside patients in ambulances.

Summary

Ms C complained about the care and treatment given to her father (Mr A) at the Western General Hospital. Mr A, who had cirrhosis (scarring of the liver as a result of continual, long-term damage), deteriorating liver function and liver cancer, was admitted to the hospital for a head scan to investigate possible brain metastasis (a cancer that has spread from its primary site).

Ms C considered that staff gave Mr A inappropriate sedation, which rendered him unconscious, and failed to provide him with appropriate medication for alcohol withdrawal. Ms C believed this led to a sudden deterioration in Mr A's condition and his subsequent death in the hospital.

We took independent advice from a consultant physician experienced in the management of liver disease and cancer of the bile ducts. We found that parts of Mr A's care and treatment were reasonable, in particular that there was no undue delay in carrying out Mr A's head scan and that the palliative care given to Mr A was appropriate.

However, the adviser identified failings in relation to the sedation and medication given to Mr A, in the assessment of his alcohol dependency, and in treating his ongoing constipation. The adviser also considered there were shortcomings in parts of the board's alcohol withdrawal plan (AWP). However, the adviser concluded that despite the failings identified in Mr A's care and treatment, his death was not caused or hastened by these failings. We accepted this advice. Given that our investigation found failings in Mr A's care and treatment, we considered this to be unreasonable and upheld Ms C's complaint.

In the course of our investigation, the board told us they accepted there had been a lack of documentation relating to the sedation administered to Mr A, for which they had apologised.

Recommendations

We recommended that the board:

• apologise to Ms C and her family for the failings in Mr A's care and treatment;
• urgently review and update the AWP, taking account of the comments of the adviser and the relevant National Institute for Health and Care Excellence Guidelines, in relation to the sedation and medication given to patients and the use of validated scores for the assessment of alcohol dependency;
• ensure the comments of the adviser are shared with the relevant staff and acted upon; and
• provide evidence of the action taken to prevent a recurrence of the lack of documentation relating to the sedation administered to Mr A.