Health

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she attended her GP practice complaining of breathlessness and collapse. During this period, Mrs A also had three admissions to hospital. Shortly after her third admission to hospital, she suffered a heart attack and died. Mrs C said that the practice failed to take Mrs A's symptoms seriously and delayed in taking appropriate action. She also said that the practice should not have prescribed a certain medication in light of Mrs A's heart condition.

We took independent advice from an adviser who specialises in general practice. We found that while the standard of medical care in relation to Mrs A's symptoms was reasonable, there were shortcomings in relation to a referral to hospital and the prescription of medication. While these shortcomings did not contribute to Mrs A's death, we upheld the complaint because of the prescription of medication that should not be given to patients with heart conditions.

Recommendations

We recommended that the practice:

• ensure the relevant GP reviews the issues relating to the medication prescribed, including its contraindications;
• review their systems for sending urgent referrals to ensure there are no avoidable delays; and
• apologise for the failings this investigation identified.

Summary

Mrs C's father (Mr A) was treated with radiotherapy for cancer of the tongue. Following his treatment, Mr A was cared for in the community with regular reviews at a joint cancer clinic and input from dieticians 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 other 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 hospital (in another health board) 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 St John's Hospital (for intensive care and ear, nose and throat (ENT) investigations), and then to the Royal Infirmary of Edinburgh (for gastrointestinal investigations). Mr A suffered a major haemorrhage (bleeding) from the throat and died in hospital.

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 care and communication during the hospital admissions in June 2014.

After taking independent advice from an oncologist, a consultant in general medicine, an ENT surgeon and a SALT therapist, we upheld three of Mrs C's four complaints. We found that, although Mr A had regular reviews and involvement of appropriate clinicians in his care, there was a lack of integration and cohesion in the team's approach, which meant that Mr A's symptoms were not adequately addressed. We also found failings in relation to communication during Mr A's final admissions, although we found that the medical care during these admissions was reasonable.

Recommendations

We recommended that the board:

• feed back our findings to the staff involved for reflection and learning;
• use Mr A's experience as a learning tool to promote patient-centred care and provide us with evidence of this;
• review their processes for ensuring joined-up post-treatment care for patients with head and neck cancer;
• apologise to Mrs C and her family for the failings identified in our investigation;
• feed back our findings on communication to the nursing and medical staff involved for reflection and learning; and
• demonstrate that the incident of the missing Royal Infirmary of Edinburgh records has been investigated and reported, and provide details of any resulting action.

Summary

Mrs C complained about the care and treatment provided to her mother (Mrs A) when she was a patient at the Royal Infirmary of Edinburgh. Mrs A suffered from breathlessness and collapse and had three admissions to hospital.

During her first admission to hospital, tests showed that Mrs A had pulmonary oedema (fluid on the lungs that can indicate heart failure). After Mrs A's second admission to hospital several months later, she was followed up by the respiratory clinic and referred to the cardiology team after further tests showed a heart condition. Mrs A continued to suffer from breathlessness and episodes of collapse. Shortly after her third admission to hospital, Mrs A suffered a heart attack and died.

Mrs C said that staff unreasonably failed to notice the problems with Mrs A's heart and provide appropriate treatment within a reasonable time and that the failure to treat Mrs A led to her death.

We took independent advice from a specialist in cardiology. We found that the board missed an opportunity to diagnose the cause of pulmonary oedema, which had been identified during Mrs A's first admission to hospital, and that as a result Mrs A's heart condition was not diagnosed within a reasonable time. This in turn meant that there was an unreasonable delay in referring Mrs A to the cardiology team for further assessment and treatment. However, it was unclear whether an earlier diagnosis would have led to a different outcome, due to Mrs A's medical history. It was our view that a potential opportunity for further treatment was missed and we therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• provide a plan detailing the changes they have made to ensure that appropriate tests and referrals to cardiology are undertaken within a reasonable time;
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff; and
• apologise to Mrs C for the failures this investigation identified.

Summary

Mr C told us he waited too long to receive medication for a rash he developed and was unhappy that he had received tablets, rather than ointment or cream, and that this had been discussed with the nurse the previous day.

We found that Mr C had received his medication within roughly 30 hours of asking to see a nurse. He did not receive his medication the same day because, by the time the nurse had discussed his case with a doctor, the deadline for pharmacy orders that day had been missed. Mr C received his medication the following day.

We were satisfied that the treatment suggested, in tablet form, was reasonable. We therefore did not uphold Mr C's complaint.

Summary

Miss C, an advocacy and support worker, complained on behalf of her client (Miss A) that the board failed to provide Miss A with appropriate orthopaedic treatment based on the symptoms she presented with and that they inappropriately treated Miss A less favourably as Miss A has a disability.

Miss A suffered an injury to her shoulder. Miss C raised concerns about a decision by the board's orthopaedic surgeons not to operate on Miss A, including whether the surgeons took into account the views of Miss A's carers and managed her pain appropriately. Miss C also raised concerns about a second opinion provided by another orthopaedic surgeon, who also considered it would not be appropriate to treat the injury surgically.

The board said the care and treatment provided at Monklands Hospital and Hairmyres Hospital was based on the surgeons' assessment of the high risks of surgery and limited likely benefits. The board said this was based on the clinical situation at the time and that Miss A was not inappropriately treated less favourably by reason of disability.

After receiving independent advice from an orthopaedic surgeon, we did not uphold Miss C's complaint. We found it was reasonable of the board's surgeons to have considered there were high potential risks and a limited potential for improving the injury through surgery. We also found that the board appropriately involved Miss A's carers in the decision and managed Miss A's pain reasonably. We found that the board's surgeons were conscious of Miss A's disability in reaching their decision not to operate, but that this was appropriate given the significant impact potential complications would have on Miss A.

Summary

Mr C complained that there was an avoidable delay in a diagnosis of lung cancer after he was referred to Wishaw General Hospital.

We took independent advice from a consultant in general respiratory medicine. The advice we received was that there had been no avoidable delay in making a diagnosis of cancer. Mr C's initial CT scan was abnormal but did not show the typical appearances of lung cancer. The adviser found that the doctors took appropriate steps to ensure the possibility of cancer was not missed. We found that when a further CT scan showed clearer signs of cancer, appropriate management (surgery) was undertaken. We therefore did not uphold Mr C's complaint.

Summary

Ms C, an advocacy and support worker, complained on behalf of Mr A. Mr A was referred by his GP to orthopaedics for a knee problem from which he was suffering. He waited around 13 weeks to be seen and was told he required a replacement knee. Mr A also had an active skin condition which the orthopaedic consultant said would need to be controlled as it increased the risk of infection following surgery.

Mr A was not added to the surgery waiting list. His GP was asked to make a dermatology referral. After a further 12-week wait, Mr A saw a dermatologist and was referred on to a more local facility for phototherapy for his skin condition. The phototherapy was successful but the good effects were short-lasting. Mr A had still not been placed on the waiting list and had to undergo a further pre-assessment and round of dermatology treatment before his surgery took place, meaning that he had to wait 15 months from the time he was referred until he received treatment. We upheld Ms C's complaint.

We found that more could have been done in the chain of communication, and that a degree of difficulty in scheduling surgery around such a skin condition might have been predicted.

We also found a letter between two departments had not been sent to a named consultant and there was no evidence it had been actioned.

Recommendations

We recommended that the board:

• apologise to Mr A for the breakdowns in communication and lack of forward planning.

Summary

Mrs C, an advocacy and support worker, complained on behalf of Mrs A that the clinical treatment received by Mrs A at Raigmore Hospital had been of an inadequate standard.

Mrs A had suffered an injury to her calf while on holiday. She had received some treatment, including an MRI scan, but had been told that she did not have an Achilles injury. Mrs A had continued to experience significant pain and discomfort on her return home and attended A&E. Mrs A said she had been examined and told she must walk normally. Mrs A's symptoms did not improve and she attended A&E again on the advice of her physiotherapist. Mrs A was told that she had suffered a calf tear and she was discharged without further treatment.

Mrs A subsequently arranged for her MRI scan to be reviewed privately. This found a tear of her Achilles tendon. When Mrs A returned again to A&E, she was supplied with a protective boot. Mrs A was subsequently seen by an orthopaedic specialist and a complete tear of the Achilles tendon was diagnosed. Her leg was placed in a plaster cast. Mrs C said Mrs A believed that she should have been diagnosed much sooner, that staff had failed to appropriately review the MRI scan results and that they had been unsympathetic to her condition.

The board said they did not believe staff had acted inappropriately towards Mrs A. They said that she had been examined using the standard techniques and that these had not indicated damage to the the Achilles tendon. The board provided information on the reliability of the test, accepting that it was not infallible. They noted the information Mrs A provided about the MRI scan results suggested that she did not have an Achilles tendon injury, which appeared to have been confirmed by her physical examination. The board said that they did not agree with Mrs A's recollections of the attitude of staff towards her.

We took independent advice from a consultant in emergency medicine. The advice we received said there was no clinical reason for staff to question Mrs A's description of the findings from the MRI scan, as this was consistent with the findings from her physical examination. They said that it would not be appropriate for A&E staff to attempt to interpret MRI images as this is a specialist skill. Although the diagnosis had not been accurate, Mrs A's care and treatment had been reasonable.

On the basis of the advice received, we found there were no grounds for upholding Mrs C's complaint. Although the board had failed to identify Mrs A's injury, this was not due to failings on the part of their staff, rather a combination of the original inaccurate interpretation of Mrs A's MRI scan and Mrs A's atypical presentation at the physical examination.

When it was originally published on 15 February 2017, this case referred to a medical practice in the Highland NHS Board area. This was incorrect, and should have read a medical practice in the Grampian 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.

We have put measures in place to help avoid recurrence of this issue.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) by the practice. She said that the care had been poorly organised and gave specific examples of what she believed was a substandard examination of Mr A by a GP and a failure to follow up on blood test results. Mrs C also said the practice had insisted on some care being provided by the practice nurse, whom she said was not competent. Mrs C felt the practice's response to her complaint had also been inaccurate. Mrs C believed that had the care Mr A received been of a higher standard, he may have been able to undergo treatment before his cancer became terminal.

We took independent medical advice. We found that Mr A's examination had failed to identify a condition which merited urgent referral. We therefore upheld this aspect of Mrs C's complaint. This failure had not, however, had any impact on Mr A's prognosis as the condition was unrelated to Mr A's cancer. The other aspects of Mr A's care were, however, reasonable.

We also took independent nursing advice. The adviser said that the actions of the practice nurse were adequately documented and there was no evidence of incompetency.

We found that while Mr A did not receive a reasonable standard of examination from the practice on one occasion, in other respects his care, including his nursing care, was reasonable. The practice's complaint response was detailed and provided a full explanation of Mr A's care and showed the practice had reflected carefully on the actions they had taken. We therefore did not uphold these aspects of Mrs C's complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified during this investigation.

Summary

Mrs C complained about a delay by clinicians at the Victoria Infirmary in diagnosing that her husband (Mr A) had a cancerous tumour at the site of a previous operation.

Mr A was under two-yearly surveillance following his original surgery. Several years after his original surgery, Mr A reported new symptoms to clinicians and his GP. However, it took six months for a diagnosis of a colonic tumour to be made. Mrs C felt that the diagnosis should have been reached at an earlier stage.

We obtained independent medical advice. We found that Mr A should have been on yearly rather than two-yearly surveillance, in accordance with British Society of Gastroenterology guidelines. Arrangements were made for a procedure to be performed five months after Mr A began to report symptoms, but in the meantime he reported further symptoms. An appointment with a consultant was cancelled due to a change in the consultant's work patterns and this led to Mr A having to attend A&E with deteriorating symptoms.

We found that the clinicians should have arranged further investigations into the cause of Mr A's reported symptoms at an earlier stage. We therefore upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with relevant staff and ask them to reflect on their actions; and
• apologise to Mr A and Mrs C for the delay in arranging a medical review for Mr A.