Health

Summary

Mr C complained that the board delayed in giving him his cardiac medication after he was admitted to prison. Mr C had a heart attack two days later and required surgical treatment. He was unhappy that the board withheld the medication he had in his possession at the time of admission to prison.

The board accepted that it had taken 24 hours longer than it should have done to verify and prescribe Mr C's medication. They apologised to Mr C and advised him of the steps they had taken as a result of the incident to reduce the likelihood of it recurring.

We took independent advice from one of our GP advisers and found that it was appropriate for the board to confirm Mr C's prescribed medication in line with General Medical Council guidance. However, we were critical that there was an unreasonable delay in this being done, although it was unlikely to have caused Mr C's heart attack.

Whilst we upheld the complaint, we made no recommendations as the board had taken reasonable action as a result of the incident to identify learning and improve their practice to ensure the matter would not recur.

Summary

Ms C's partner (Mr A) collapsed. He was treated by a paramedic and transported to hospital, where he later died. Ms C complained that Mr A's mobile phone went missing.

Our investigation focused on the actions taken by the Scottish Ambulance Service to locate the phone or to try to find out what happened to it. Although they did not find the phone, we were satisfied that reasonable efforts were made to investigate this matter.

Summary

Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have contacted either off-duty staff or trained responders to assist his wife, who was in pain.

We found that the ambulance service had acknowledged from the outset that there had been a delay in the ambulance being dispatched. We considered the ambulance service had acted in accordance with their call-out procedures in relation to off-duty staff and trained responders (including GPs) because there was no apparent threat to life.

The ambulance service provided information on the action they took as a result of the delay. They have reviewed their shift capacity and put further measures in place including the training of staff and new posts.

In terms of the ambulance service's handling of Mr C's complaint, we considered that there was an unreasonable delay of around six months in responding to additional questions Mr C had asked. The ambulance service accepted that there were failings in relation to the time they took to reply to Mr C. Therefore they introduced a pilot method to record contact from individuals as part of their complaints handling.

Recommendations

We recommended that the ambulance service:

• apologise to Mr and Mrs C for the delay in dispatching an ambulance and the delay in responding to the additional questions Mr C raised as part of his complaint; and
• provide documentary evidence on the outcome of the pilot they conducted in order to ensure appropriate steps have been taken to address the failings in relation to record-keeping and responding to complaints correspondence.

Summary

Mrs C said that her medical practice did not provide a reasonable response to phone calls she made when she became unwell. Specifically, she had to phone three times before her call was returned towards the end of the working day by a GP. We found the practice had no record of the first two phone calls Mrs C made, although they did not dispute she had made them.

We took independent advice from a GP adviser. We concluded that the response from the practice to Mrs C's calls was a reasonable one as she received a return call and telephone consultation the same day she requested it. Therefore we did not uphold Mrs C's complaint.

Mrs C also complained that the GP she spoke to on the phone failed to check her records for allergies. In doing so, the GP missed that a drug prescribed to Mrs C by an emergency out-of-hours GP was one that she had previously suffered an adverse reaction to. We therefore upheld this complaint. The GP practice apologised to Mrs C for the distress and discomfort she suffered.

Summary

Mrs C attended an out-of-hours GP service with sinus congestion and ear pain. Mrs C complained that medication was unreasonably prescribed without proper checks being carried out into allergies.

Mrs C was asked about known allergies by a nurse practitioner and declared the one she knew about. The nurse practitioner did not check her electronic care summary. Mrs C was then prescribed a drug she had previously suffered an adverse reaction to. The drug made her feel unwell. Mrs C only discovered she had a recorded allergy to the drug prescribed when she went to hospital for unrelated treatment.

We took independent medical advice. We found that the nurse practitioner should have checked the electronic care summary. We therefore upheld Mrs C's complaint. However, we were satisfied that the failure to check the electronic care summary was one of human error rather than evidence of a deficit in the training or clinical ability of the nurse practitioner. We found evidence that the practitioner and the out-of-hours service had reflected appropriately on the sequence of events and had apologised to Mrs C.

Summary

Mr C complained that the medical practice unreasonably failed to offer his son (Mr A) a referral for varicose vein surgery. Mr C was concerned that this was affecting Mr A's mental health. He was of the view that the practice were refusing to refer him for surgery because of Mr A's mental health problems.

We took independent clinical advice. We found that the practice had carried out a proper examination of Mr A and had noted that his varicose vein was not causing him discomfort. As a result of this, the practice were correct in following the board's guidance on the treatment of varicose veins which said that in instances such as this, varicose veins should be treated conservatively and surgical referrals should not be made. As a result, we did not uphold Mr C's complaint.

Summary

Mr C was referred by his GP for a possible hernia operation. Mr C complained to us that the board failed to arrange his operation within the 12-week treatment time guarantee under the Patients Rights (Scotland) Act and that they failed to advise him of his rights under that Act. He also complained that they failed to arrange his treatment at another health board.

We found that there was a delay in Mr C's case, though this was in arranging his out-patient appointment rather than the operation. We therefore did not uphold Mr C's complaint. However, the board failed to meet the 12-week waiting time target for out-patient appointments but apologised and explained this was because of staff shortages which had now been addressed.

We found delays in the handling of Mr C's complaints to the board and we therefore upheld this aspect of his complaint. The board apologised to Mr C and said they are taking steps to address future delays.

Summary

Miss C complained that her dentist failed to provide her with appropriate dental treatment. Miss C was advised by her dentist that she needed a crown on one of her teeth. She subsequently suffered problems with her tooth and had to receive further treatment. She questioned the advice to place the crown. Miss C also complained about subsequent treatment and the management of her pain during this time as well as the dentist's handling of her complaint.

After receiving independent advice from a dentist, we upheld Miss C's complaints. We found that the dentist failed to provide Miss C with appropriate options, including risks and benefits, and therefore failed to get informed consent. We also found that placing the crown was not the best option, given Miss C's periodontal (gum) disease. Finally, we found that the dentist failed to respond to Miss C's formal complaint in line with the NHS complaints procedure.

Recommendations

We recommended that the dentist:

• review their consent process regarding treatment options, risks and benefits in line with General Dental Council (GDC) standards;
• apologise for the clinical failings identified by this investigation;
• refund the cost of either root canal treatment and a new crown or, if necessary, replacement by means of a denture or bridge on receipt of an appropriate invoice when treatment has been completed;
• refund Miss C the cost of treatments for the crown and x-rays;
• review the complaints handling requirements under the Scottish Government's 'Can I Help You?' guidance; and
• apologise for the failings in complaints handling identified by this investigation.

Summary

Ms C complained to us about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with significant pelvic girdle pain (a collection of uncomfortable symptoms that can cause severe pain due to a misalignment or stiffness of the pelvic joints at either the back or front of the pelvis) in the late stages of pregnancy. She also complained that the board did not reasonably respond to her complaints.

We took independent midwifery advice. We found that the care and treatment provided to Ms C in relation to pelvic girdle pain and pitting oedema (a build-up of fluid under the skin that holds the imprint of a finger when pressed) had been appropriate. We also considered that the pain relief provided to her was appropriate, although we acknowledged that pelvic girdle pain is difficult to manage in severe cases. Ms C's pressure areas had been frequently checked in the hospital and the steps taken once the sore skin on her inner thighs had been noted was appropriate and timely.

However, we found that the board had not followed the guidance from NICE (National Institute for Health and Care Excellence) on caesarean sections as they had not provided her with information in order for her to make an informed choice on her mode of delivery given her concerns and anxiety about childbirth at that time. The delivery plan should have been reassessed when Ms C was admitted to hospital with excessive pain and mental health concerns. There was also a delay in providing her with a swivel turntable and other disabled-friendly equipment and the nursing records indicated delays in emptying her catheter. In addition, Ms C should have had an occupational health review prior to discharge to ensure she was safe to manage and care for her baby at home and had the assistance she required. We therefore upheld her complaint.

We found that there was a delay in the board responding to Ms C's complaint. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that relevant staff in the maternity unit are aware of our decision on the complaint;
• take steps to ensure that the staff are aware of and understand the NICE guidance in relation to requesting a caesarean section;
• provide evidence that steps have been taken to ensure that moving and handling equipment is easily accessible for staff;
• review the maternity ward to ensure that there is suitable disabled access;
• review the discharge arrangements for women with pelvic girdle pain;
• issue a written apology to Ms C for the failings identified; and
• make the staff involved in the handling of Ms C's complaint aware of our decision.

Summary

Mr C complained to us about the care and treatment his wife (Mrs A) had received from the board. Mrs A had been diagnosed with functional disease (where the functioning of the body is disturbed in the absence of any disease). Her condition deteriorated significantly and she died. A post mortem was carried out and it was found that she had motor neurone disease (a rare condition that progressively damages parts of the nervous system). Mr C complained to us about the care and treatment provided to Mrs A and about the failure to diagnose motor neurone disease.

We took independent advice from a consultant neurologist and a general medical adviser. We found that the initial diagnosis of functional disease had been reasonable and the care and treatment Mrs A had received in relation to this had been excellent. However, when Mrs A then displayed other symptoms that were not typical of functional weakness, staff failed to reasonably investigate these symptoms. It was likely the further tests would have led to a diagnosis of motor neurone disease, although this could not be proved. In view of this, we upheld Mr C's complaints that the board did not provide reasonable care and treatment to his wife and that they failed to diagnose motor neurone disease.

Mr C also complained that the board failed to arrange a package of home care for Mrs A. We found that the actions of staff had been reasonable given Mrs A's initial diagnosis. The correspondence from the board had set out the type of support she would require in the future. We could not say definitively that a diagnosis of motor neurone disease would have been made had the relevant tests been carried out. On balance we did not uphold this aspect of the complaint.

Finally, Mr C complained about the board's handling of his complaint. We did not find failings by the board in relation to the issues Mr C had raised and we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• ensure that relevant staff are aware of the latest National Institute for Health and Care Excellence guidance, 'Motor neurone disease: assessment and management', which was published in 2016; and
• ensure that relevant staff are aware of the motor neurone disease red flag diagnosis tool.