Health

Summary

Mrs C complained about the care that her late husband (Mr A) received at Monklands Hospital after attending the emergency department. Mr A was to be admitted to a private room but none was available. He remained in A&E until a suitable room was found. Mr A was later moved to a different area in the hospital, where he fell while in the toilet.

Mrs C complained that Mr A waited in A&E for too long. She was also concerned that the toilet where he fell was not properly equipped and that staff had not taken reasonable steps to help him afterwards. Mrs C also considered that his risk of falls had not been assessed and that the recording and investigation of the incident had not been carried out properly. Finally, Mrs C complained that Mr A's bed was not adjusted for his height quickly enough.

After taking independent advice from a consultant in emergency care, we upheld the complaint about Mr A's wait in A&E. We found that he had waited longer than was reasonable in the circumstances and that the board had already apologised for this. We recommended a review of their policy for escalating cases like Mr A's.

We took independent advice from a registered nurse in relation to Mrs C's other concerns. We did not uphold the complaint regarding a falls assessment as the advice we received was that this had been carried out in A&E with no risk identified. We also did not uphold Mrs C's concerns about the toilet facilities as we received advice that these were reasonable. We found that there were two different accounts of events around Mr A's fall and we were unable to determine exactly what had happened within the scope of our investigation, therefore we did not uphold this element of the complaint. We did, however, uphold the complaint about the initial investigation of the fall. The advice we received was that although it was appropriately recorded, there were missed opportunities to resolve Mrs C's concerns locally. We made two recommendations to address this.

Finally, we upheld Mrs C's complaint about the failure to adjust Mr A's bed. The advice we received was that this was unreasonable in the circumstances and the adjustment can be made easily. We made two recommendations to the board in light of this.

Recommendations

We recommended that the board:

• review the escalation procedure for individual patients awaiting specific beds, taking into account the adviser's comments;
• review the training they have in place for early resolution of concerns and complaints;
• ensure mechanisms are in place for staff to access support from more senior colleagues in the ongoing resolution of complaints;
• apologise for the failure to take the falls assessment into account and adjust the bed in a timely manner; and
• ensure staff are aware of the appropriate considerations when making adjustments to beds.

Summary

Ms C, an advice and support worker, complained on behalf of Ms A. Ms A had developed mobility problems and, after an episode of severe dizziness, was admitted to Hairmyres Hospital and discharged a week later. She then attended the movement disorder clinic for further tests and investigations.

Two months later, Ms A was readmitted to Hairmyres Hospital before being discharged the following week. She was referred to community physiotherapy and visited by them on a number of occasions. She was then referred to out-patient physiotherapy.

Ms C said that had Ms A been allowed to stay as an in-patient for longer and been provided with sufficient support and treatment (as both an in-patient and out-patient), she would have recovered her ability to walk.

We took independent advice from specialists in physiotherapy and in care of the elderly. We found that the standard of physiotherapy provided during both Ms A's admissions to hospital was reasonable, and that the follow-up care was reasonably provided for the second admission. However, there was an unreasonable failure to refer her for appropriate physiotherapy services when she was first discharged from hospital. We found that while the decision to discharge her was reasonable, there were failings in the discharge planning in relation to the provision of physiotherapy in the community. We also were satisfied that the decision to discharge Ms A from her second admission to hospital was reasonable.

Recommendations

We recommended that the board:

• take steps to ensure that all in-patients receiving physiotherapy are appropriately reviewed by the service and, where appropriate, referred for community physiotherapy prior to discharge home;
• bring the failings identified to the attention of the relevant physiotherapy and medical staff involved; and
• apologise for the failings identified.

Summary

Mrs C complained that her dentist had failed to provide her with appropriate treatment for an infection in her gum. Mrs C said that this had caused her stress and anxiety as she felt she had not been diagnosed correctly.

We took independent dental advice and found that both the examination and the treatment Mrs C received were reasonable and appropriate. We did not uphold the complaint.

Summary

Mrs C complained that her dentist had failed to provide her with appropriate treatment for an infection in her gum. Mrs C said that this had caused her stress and anxiety as she felt she had not been diagnosed correctly.

We took independent dental advice and found that both the examination and the treatment Mrs C received were reasonable and appropriate. We did not uphold the complaint.

Summary

Mrs C complained that her dentist had failed to provide her with appropriate treatment for an infection in her gum. Mrs C said that this had caused her stress and anxiety as she felt she had not been diagnosed correctly.

We took independent dental advice and found that both the examination and the treatment Mrs C received were reasonable and appropriate. We did not uphold the complaint.

Summary

Mrs C, who works for an advice and support agency, complained on behalf of her client (Ms A) that her medical practice had failed to investigate, diagnose and treat her symptoms. We took independent medical advice and found that Ms A had previously been referred to a number of specialists. She had no new symptoms that warranted further investigation and it was reasonable not to refer her back to the specialists. We found that the care provided by the practice had been of a reasonable standard and we did not uphold this aspect of Mrs C's complaint.

Ms A considered that she was suffering from Jarisch Herxheimer's reaction (a physical reaction within the body during antibiotic treatment). Mrs C complained that the practice had unreasonably stated that this was not the cause of Ms A's symptoms. We found that this had already been investigated in hospital and there was no evidence that this was the diagnosis. We considered that the practice's comments in relation to this matter had been reasonable and we did not uphold the complaint.

Mrs C also complained that it was unreasonable for the practice to suggest in their diagnosis that that there were psychological or psychiatric factors which were worsening Ms A's physical symptoms. We found that the practice's clinical assessment and opinion on this matter had been reasonable and we did not uphold this aspect of the complaint.

Summary

Mrs C complained about the care and treatment provided to her by her medical practice in relation to her ongoing ankle pain.

During our investigation we took independent advice from a GP adviser. The advice we received was that the care and treatment provided by the practice in relation to the ongoing management of Mrs C's ankle injury was of a reasonable standard and no failings were identified. We did not uphold the complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of Mrs B about the care and treatment given to Mrs B's husband (Mr A) after he had two wisdom teeth extracted under general anaesthetic at Raigmore Hospital. Ms C said that on his return home after discharge, Mr A became very unwell. Mrs B twice phoned the hospital for advice but it was only after her second call that he was asked to return. When Mr A returned to the hospital, no record was found of the calls made.

After examination and a scan, Mr A was diagnosed with sepsis and was admitted to intensive care where he stayed for about a week. Ms C said that information about Mr A's discharge failed to reach his GP and dentist in a timely way. Mrs B made a formal complaint to the board about these matters. Ms C complained that they failed to properly address Mrs B's concerns.

The board were of the view that they had treated Mr A reasonably although they recognised a number of shortcomings (namely that records of phone calls to the hospital were not properly recorded and that letters and discharge information were delayed).

We took independent advice from a consultant in oral and maxillofacial surgery and found that there was no record of phone conversations prior to Mr A's admission. However, after his re-admission Mr A's care had been reasonable. We also found that there had been delays in issuing discharge letters and that addresses had been omitted. Furthermore, Mrs B's complaint had not been properly addressed in that although these shortcomings had already been identified by the board, they had put no plan in place to prevent the same thing happening again. We therefore upheld Ms C's complaint.

Recommendations

We recommended that the board:

• advise of the action taken in the interim to prevent the same thing happening again (in relation to information not being recorded in the clinical notes) and if no action has been taken, they should advise of their proposals;
• advise what they have done to address communications concerns since they were brought to their attention and failing any action, they should undertake an audit of the clinics and ward concerned to establish the extent of any continuing problem and provide their solution should problems remain; and
• make a formal apology for their oversights to Mr A and Mrs B.

Summary

Mr C complained to us on behalf of his daughter (Mrs A). Mrs A experienced complications following hysterectomy surgery at Glasgow Royal Infirmary, including an injury to her bladder. Her right ovary and fallopian tube were also removed. Mrs A subsequently developed a vesico-vaginal fistula (an abnormal tract between the bladder and vagina). Mr C complained that the hysterectomy surgery had not been performed appropriately.

We took independent advice on the complaint from a consultant gynaecologist. We found that the hysterectomy surgery provided to Mrs A had been reasonable. The adviser said that whilst the development of a vesico-vaginal fistula was likely to be due to the hysterectomy surgery, there was nothing that suggested the surgery had not be performed to a reasonable standard. Additionally, the adviser considered it reasonable that Mrs A's right ovary and fallopian tube were removed as it had been deemed necessary during the surgery. However, in our investigation we identified some areas of the consent process which did not meet national guidelines. We made a recommendation to the board on this basis.

We also determined that in response to Mr C's complaint, the board had failed to respond to all the issues raised. We therefore recommended that the board take steps to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failure to notify her of all the risks involved in hysterectomy surgery;
• apologise to Mr C for the failure to adequately respond to his complaint;
• feed back the findings of this investigation to the relevant staff and ensure that they review their process for taking consent for hysterectomy surgery to ensure it is in line with national guidance; and
• take steps to ensure that complaint responses address all issues raised by complainants.

Summary

Mrs C complained on behalf of her son (Mr A), who was admitted to the Royal Alexandra Hospital with kidney failure and physical collapse. He was transferred to the Western Infirmary and was diagnosed with neuroleptic malignant syndrome (NMS), a rare condition caused by some medications (particularly antipsychotics). Mrs C was concerned that Mr A's overall treatment pathway for the previous ten years led to his collapse. In particular, Mrs C felt that the clinicians treating Mr A had inappropriately used strong antipsychotic drugs and had not taken into account Mr A's particular risk factors in relation to his medication. Mrs C also felt the board had ignored alternative treatment options for Mr A, including an alternative diagnosis of an anxiety disorder. Mrs C also complained about the board's handling of her complaint to them.

The board met with Mrs C and wrote several letters in response to her complaint and further queries. While the board acknowledged the severe impact of NMS on Mr A, they said that NMS is a rare and unpredictable event, and they considered Mr A's treatment was appropriate in view of his chronic psychotic illness. The board noted that Mrs C disagreed with clinicians about Mr A's diagnosis.

After taking independent psychiatric advice, we did not uphold Mrs C's complaints. While we found that Mr A's NMS was caused by his medications, the adviser explained that the risk of NMS was very small and the decisions made about Mr A's medication during this period were in line with the relevant guidance and standard practice. We found no evidence that the board had failed to consider Mr A's particular risk factors or the alternative diagnosis suggested by some clinicians. While we acknowledged that Mrs C was not satisfied with the board's response to her complaint, we did not find any failings in their complaint investigation or replies.