Health

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.

Summary

Mrs C complained that the medical practice failed to identify that her father (Mr A) had cancer. Mr A had multiple health issues and regularly attended the practice but it was not until the family eventually took him to hospital that he was diagnosed with an aggressive tumour. He died nine days later. The practice noted that there had been no change to Mr A's longstanding symptoms other than some worsening in the weeks before he died, and they did not consider that his cancer could have been detected much earlier or would have responded to treatment.

We took independent medical advice from a GP who noted that the practice had arranged relevant investigations including chest x-rays, scans and blood tests. Although Mr A's liver function test results were noted to have been abnormal in the month prior to diagnosis, the practice had already arranged a colonoscopy and the adviser did not consider that further tests were indicated at that stage. When the tests were repeated two days prior to diagnosis, they showed a significant deterioration and the practice took appropriate steps to upgrade an existing ultrasound scan referral to urgent. The adviser noted that the hospital may have separately arranged investigations themselves around this time when Mr A self-presented with his family. However, we found that the practice had by then already taken reasonable and prompt action when they identified the deterioration in Mr A's liver function results. We therefore concluded that the practice did not unreasonably delay taking steps to have Mr A's cancer diagnosed and we did not uphold the complaint.

Summary

Mr C complained on behalf of his wife (Mrs A) about aspects of the care and treatment she received at Ninewells Hospital and Perth Royal Infirmary following an injury to her shoulder. He complained that surgery was not carried out when the injury was first diagnosed and that when surgery was carried out, Mrs A was given inaccurate information about the reduction in her pain. Mr C also complained that Mrs A was not warned that general anaesthetic could cause memory loss.

We took independent advice from a consultant orthopaedic surgeon and found that the decision to initially manage Mrs A conservatively (without surgery) was reasonable practice. There was evidence to show that Mrs A had consented to surgery after she was informed of the appropriate risks.

We also obtained independent advice from a consultant anaesthetist in relation to Mrs A's concerns about not being warned about the potential risk of memory loss following general anaesthetic. They noted that it is not standard practice to discuss this with patients prior to surgery because it is not considered to be the type of risk that falls into either of the two categories set out in the General Medical Council's guidance on consent. We therefore did not uphold Mr C's complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Miss A). Ms C complained about the failure of GPs to follow up Miss A's abnormal blood results when she registered with the practice. Miss A had abnormal blood results when tested at her previous GP practice and as a result, she was 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 when she moved into their area, the diagnosis of hepatitis C would have been made earlier and she would therefore not have suffered from other medical conditions.

The practice said that due to the passage of time, it was difficult to comment and that the GP who had seen Miss A had retired a number of years ago. The practice explained that there was a note that Miss A had had abnormal blood results at her previous practice but that the clinical picture was improving. However, they accepted that follow-up tests were not arranged. A GP had diagnosed that Miss A had Gilbert's syndrome (a genetic disorder where higher than normal levels of bilirubin, a substance found naturally in the blood, build up in the bloodstream causing jaundice).

We took independent advice and found that although there was an improvement in Miss A's condition initially, her blood results were still abnormal and that further tests should have been arranged by the practice. This had contributed to the delayed diagnosis of hepatitis C. We also found that although Miss A had abnormal blood results, her bilirubin level was not abnormal and as such the diagnosis of Gilbert's syndrome was not accurate.

Recommendations

We recommended that the practice:

• apologise to Miss A for the failings identified in this investigation.

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.