Health

Summary

Miss C suffered burns to her legs and attended A&E at Glasgow Royal Infirmary. She complained that she had received an inadequate standard of treatment and that she had been inappropriately discharged. She said that she had been discharged the same day, despite being unsteady on her feet, and that she was asked to attend a burns clinic the following day. Miss C said that on attendance at the burns clinic, she was admitted to the hospital and spent two weeks as an in-patient.

We took independent medical advice from a consultant in emergency medicine. The adviser said that Miss C had been appropriately assessed at the hospital and that it was reasonable for her to have been discharged once her pain had been brought under control. They noted that Miss C had been accompanied and that her discharge had been in line with standard practice. The adviser also noted that there was no defined standard for admission with the type of burn Miss C had sustained and that her medical records supported the decision not to admit her. Miss C's subsequent admission had been prolonged due to an infection in her wound, which had not been present at the time of her first attendance. Miss C's length of stay was therefore not due only to the severity of her burns.

We found that the board acted reasonably both in terms of the care and treatment provided to Miss C and in terms of the decision to discharge her. We therefore did not uphold Miss C's complaint.

Summary

Ms C complained about the treatment she received after fracturing her ankle and that she had attended unnecessary out-patient appointments.

Ms C underwent surgery on her ankle at Western Infirmary. As she continued to suffer constant pain in the ankle and restricted mobility, she was referred to orthopaedic appointments at Glasgow Royal Infirmary and she received different opinions on treatment options. Ms C was dissatisfied with the explanations she was given about her ankle and the treatment options.

We took independent advice from a consultant trauma and orthopaedic surgeon. They noted that the orthopaedic care and treatment received by Ms C had been appropriate and was within the range of standard medical practice. Although Ms C had seen several doctors, their opinions fell within the range of accepted treatments. Therefore we did not uphold this aspect of Ms C's complaint.

We accepted that it must have been both inconvenient and frustrating for Ms C to have attended unnecessary out-patient appointments. The board had apologised to Ms C for this and acknowledged that on one occasion the correct patient hospital appointments process was not followed by staff and that they had taken action to address this. While we considered the board's action to have been reasonable, we made a recommendation relating to this.

Recommendations

We recommended that the board:

• provide evidence of the action taken on staff feedback and training with regard to issuing patients with hospital appointments.

Summary

Mrs C complained to us about the treatment her mother (Mrs A) received from her medical practice. In particular, she was unhappy with the treatment Mrs A received for pain in her left arm and in relation to choking episodes. She also made a number of complaints about the medication prescribed to Mrs A.

We took independent advice from a GP adviser. We found that, in general, the treatment provided to Mrs A by the practice had been of a reasonable standard. However, although Mrs A had angina, she had been prescribed an anti-inflammatory medication by a GP that is contraindicated in (should not be given to) patients with angina. In addition, Mrs A had incorrectly been prescribed a double prescription of heart medication and iron tablets. Although there was no evidence that Mrs A suffered harm as a result of these prescribing errors, in view of these failings we upheld the complaint. The practice had already apologised for this.

Mrs C also complained that a GP had told Mrs A that she had cancer when she attended a consultation at the practice on her own. We found that the specialist clinician who had previously arranged tests for Mrs A should have previously informed her of the diagnosis. It was reasonable for the GP to assume that Mrs A had already been informed of her diagnosis. We did not uphold this aspect of Mrs C's complaint.

Finally, Mrs C complained about the practice's handling of her complaint. We upheld this, as we found that the practice had delayed in responding and had not advised Mrs C that she could contact SPSO.

Recommendations

We recommended that the practice:

• ensure that all GPs are aware of the contraindications for the anti-inflammatory medication prescribed; and
• take steps to ensure that responses to complaints are issued within a reasonable timeframe and include signposting to SPSO.

Summary

Mr C, who suffers from chronic back pain, raised a number of concerns about surgery performed on his spine at Aberdeen Royal Infirmary. Mr C complained that he suffered significant blood loss during the operation and that the surgeon failed to record on the operation note that he required blood transfusion. Mr C also complained that the surgeon operated on him using old scan images and that the operation caused nerve damage.

We took independent advice from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). They did not find evidence that the surgeon unreasonably failed to record a blood transfusion on the operation note and noted that it was only after the conclusion of the operation that the requirement for transfusion became apparent. The adviser was satisfied that it was reasonable for the surgeon to operate on Mr C using an old scan, and considered that there was no evidence that the operation caused nerve damage. Although we did not uphold this complaint, the adviser was critical about the level of detail in the medical records and we made a recommendation to address this.

Mr C also underwent operations to replace his hips. He complained that the board unreasonably failed to diagnose his hip condition for five years. The adviser noted the extended process involved in diagnosing the cause of Mr C's pain but found that it was reasonable of the board to have focused their investigations on his back given that he had a known back condition. The adviser did not consider that successive consultant neurosurgeons failed to diagnose Mr C's hip condition and said that it was the responsibility of a patient's GP to first investigate the potential of a hip pathology. We did not uphold this complaint.

Mr C also complained about the way the board communicated with him during their investigation into his chronic pain. Mr C felt that a consultant neurophysiologist (a doctor specialising in disorders of the central and peripheral nervous systems) failed to inform him that he had nerve damage following a consultation. The adviser reviewed the findings of the neurophysiologist and concluded that the clinical significance of the findings was questionable and did not necessarily indicate nerve damage. The adviser was therefore satisfied that it was not unreasonable that the neurophysiologist failed to discuss the abnormality in the findings with Mr C. We did not find evidence that the board's communication was unreasonable and we did not uphold this complaint.

Mr C also raised concerns about the way the board handled his complaint. We found that the board had commissioned an independent clinical review into Mr C's concerns about his treatment but we noted that this investigation was not undertaken in accordance with the complaints procedure. We found evidence of a number of instances where the board did not treat Mr C's concerns as complaints, and we considered that this unnecessarily prolonged the board's handling of Mr C's concerns. We found evidence that only one of Mr C's concerns had been handled through the board's complaints handling procedure, although the board noted that there was a delay in responding to Mr C. The board confirmed to us that the Feedback Team (the department that handles complaints) has since introduced a process to prevent such delays. We upheld this complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• feed back the adviser's comments about the level of recording in the clinical notes in this case to clinical staff in the neurosurgery department;
• issue Mr C with a written apology for the complaints handling failures identified in this investigation;
• ensure that the clinical staff involved in this case receive appropriate support and training in handling complaints in line with the board's complaints handling procedure; and
• provide us with details of the Feedback Team's change in process.

Summary

A firm of solicitors (company C) complained that their client (Mr A) did not receive a reasonable standard of care and treatment from the board for his mental health while in prison. Their concerns included that the board failed to provide Mr A with one-to-one appointments with a psychiatrist when this had been provided for him in a previous prison. They were also concerned that the board incorrectly suggested that Mr A failed to attend appointments, when his disengagement was as a direct consequence of him being unable to participate properly. Mr A died during our investigation of the complaint and his mother (Ms B) gave us her consent to continue the investigation.

We obtained independent medical advice from a consultant psychiatrist. The evidence showed that Mr A attended joint assessment appointments with a psychiatrist and a mental health nurse on two occasions. At the first appointment, Mr A voiced his concerns about joint assessment. However, after explanation from the psychiatrist, he appeared to accept this approach and the board then arranged a further joint assessment. The adviser said that when Mr A expressed further concern at the second assessment, it was not reasonable for the board to have attempted to continue joint assessment that day. The evidence also showed that for the period under consideration in this complaint, Mr A only failed to attend one appointment (for a self-referral clinic) and that the board's statement about his attendance was, therefore, incorrect.

Whilst noting that it was not reasonable for the board to attempt to continue with the second joint assessment after Mr A had expressed further concern, the adviser said that overall, Mr A received a reasonable standard of care and treatment from the board for his mental health. We therefore did not uphold company C's complaint. However, we made recommendations to address aspects of the board's complaints handling.

Recommendations

We recommended that the board:

• feed back our decision on this complaint to the health and complaints staff involved;
• ensure that, in future, complaints are forwarded to the complaints team in a timely fashion and are acknowledged in accordance with the board's complaints procedure; and
• apologise to company C and Ms B for the failings identified.

Summary

Mr C complained that the board had acted unreasonably by not offering him surgery to address his back, leg and foot pain.

We took independent advice from an orthopaedic surgeon. They noted that at the time of the board's decision, surgery was not appropriate for Mr C. We therefore did not uphold Mr C's complaint.

Summary

Mr C complained about the medical and nursing care and treatment provided to his wife (Mrs A) at Victoria Hospital from when she was diagnosed with advanced lung cancer until her death four months later. During this period, Mrs A had three admissions to Victoria Hospital. During her second admission, she was found to have spinal-cord compression and was admitted to the Western General Hospital for five days.

Mr C was concerned about a wide range of medical and nursing issues, including treatment and medication decisions; communication; whether appropriate investigations and tests were carried out within a reasonable time; the decision to transfer Mrs A to a hospice near the end of her life; record-keeping failings; nutrition; and monitoring. Mr C was also concerned that Mrs A had contracted diabetes and pneumonia, which he believed were hospital-acquired infections. He said that the board's failings hastened Mrs A's death. Finally, Mr C complained about the way the board handled his complaint.

We took independent advice from four advisers, who specialise in oncology, respiratory care, palliative care and nursing. In relation to the standard of medical care and treatment provided, we found that this was reasonable.

We were also satisfied that while Mrs A contracted diabetes and a chest infection, these were an accepted complication of the medication prescribed and/or prolonged hospital stay and low immunity, and that there was no evidence any hospital failings led to Mrs A's death.

With regard to the standard of nursing care and treatment provided, we found that while this was reasonable in a number of aspects, there were failings around record-keeping and in relation to completing assessment and monitoring for nutrition, wound management and blood glucose. We therefore upheld this part of Mr C's complaint. We also found failings in the way the board dealt with Mr C's complaint in that there were unreasonable delays.

Recommendations

We recommended that the board:

• inform us of the action taken to ensure compliance and better completion of documentation by nursing staff including action taken to ensure adequate training in light of the nursing adviser's comments; and
• provide a further apology for the failings identified.

Summary

Mrs C complained that she was unreasonably asked by her medical practice to pay for a travel assessment before she could access typhoid vaccinations for her family. Mrs C said her family travelled regularly and that she kept an accurate record of her family's vaccination history. Mrs C said the practice's assessment had merely confirmed that typhoid vaccinations were required.

The practice said they had been advised by the British Medical Association that such a travel assessment was acceptable. They believed they were acting in line with the charging structure set out in their contract with the board and that this allowed them to charge for the assessment carried out before the vaccinations were given. The practice said it was appropriate to insist that a clinician determine which travel vaccinations the patient required and that whilst different practices had different approaches to charging, theirs remained appropriate.

We took independent advice from a GP adviser. They noted that the provision of travel vaccines fell under the 'additional services' section of the General Medical Services (GMS) contract. We found that the practice had acted inappropriately in charging a fee. As the service was funded, the practice could not charge for access. We therefore upheld Mrs C's complaint.

The board said that they were unaware of the practice's charging structure. They considered the practice's interpretation of what they could charge for to be inaccurate and said they had contacted the practice and asked them to review their charging procedures. They said that the practice had agreed to make necessary arrangements to comply with the statement of financial entitlement (SFE) relating to travel vaccination under the GP contract.

Recommendations

We recommended that the practice:

• provide evidence they have ceased charging for all pre-vaccination forms and that their arrangements now comply with the SFE;
• reimburse the fee paid;
• notify their respective GP appraisers of this complaint and provide evidence the GPs have familiarised themselves with the correct contractual procedure;
• ensure the practice manager has received additional training on travel vaccinations and interpretation of GMS regulations; and
• apologise to Mrs C for the failings identified in this investigation.

Summary

Mrs C complained about the care and treatment she received when she gave birth at Dumfries and Galloway Royal Infirmary. In particular, she said that a pessary used to induce labour was left in too long, she was unable to use the birthing pool and a tear she suffered was not effectively repaired.

We took independent midwifery advice and found that overall, Mrs C's labour and birth had been conducted reasonably. The pessary had been used appropriately and was removed as labour progressed. Stitching of the tear she sustained was completed quickly and though it was recognised that sutures could become loose, Mrs C was referred to an obstetrician as required.

However, it was noted that Mrs C either did not receive or did not understand information given about anaesthetic and how its use had repercussions with regard to the use of the birthing pool. Furthermore the clinical records, which were not of the standard required by current guidance, lacked information. For these reasons, we upheld Mrs C's complaint.

Mrs C also complained about her aftercare. However, we found no evidence to show that this had not been reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failures identified in this investigation; and
• ensure that relevant nursing staff are reminded of their obligations with regard to guidance on record-keeping.

Summary

Mr C complained on behalf of his late father (Mr A). He raised concerns that staff at Dumfries and Galloway Royal Infirmary failed to provide Mr A with appropriate medical treatment and about the board's handling of his complaint.

Mr A attended the hospital for a hernia operation. The operation was performed and Mr A was discharged. However, Mr A became unwell and was readmitted to hospital the same day. Mr A's condition continued to deteriorate and he died some months after the operation. The board conducted a significant adverse event review (SAER) and complaints investigation. These processes identified a number of failings, including an error in the prescription of bisoprolol (a beta-blocker, used to treat high blood pressure) and a failure to review blood tests.

Mr C questioned whether the board had appropriately identified all the issues in Mr A's care and whether they had appropriately taken action to address these failings. In addition to the issues with the medication and the review of blood tests, Mr C raised concerns about monitoring Mr C's fluid levels, attending to his catheter and the actions of the consultant surgeon and anaesthetist prior to and after Mr A's admission, including whether staff should have undertaken the operation. Mr C also raised concerns about the way the board's investigations had been conducted, including the interaction between the two processes and delays in responding to his correspondence.

After receiving independent advice from a consultant in general medicine and a nurse, we upheld Mr C's complaints. We found that the prescription of bisoprolol was unreasonable. We also found the board failed to review Mr C's blood tests. We found the board had subsequently taken appropriate action in relation to these issues. However, we also found there was a lack of specific medical review prior to Mr A's discharge and we were critical of this aspect of Mr A's care. We also found failings in respect of monitoring Mr A and in attending to his catheter. In relation to the decision to proceed with Mr A's operation, we found that Mr A had given his informed consent to the procedure, and as Mr A had capacity to make this decision, it was appropriate to proceed with the operation.

We also found that the board's handling of Mr C's complaint was unreasonable. In particular, we found there was confusion about the interaction between the SAER and the complaints process, which lengthened the process and resulted in significant errors in communication with Mr C.

Recommendations

We recommended that the board:

• take steps to ensure the clinician responsible for the error in giving Mr A his heart medication is made aware of the findings of this investigation for reflection and learning;
• confirm that the consultant surgeon will discuss this case in their appraisal;
• provide this office with a progress report on the actions taken to address the issues in the case, including catheter care;
• apologise for the clinical failings identified in this investigation;
• take steps to ensure that staff explain to complainants how the SAER and complaints handling processes are being taken forward in each case;
• feed back the findings of the investigation to the relevant staff for reflection and learning; and
• apologise to Mr C for the failures in complaints handling.