Health

Summary

Mr and Mrs C complained to us about the treatment they received at an out-of-hours centre where they took their baby on the advice of NHS 24 as he was not feeding well and was blue around his lips. There was a wait to see a GP and the baby went pale and struggled to breathe. The baby was seen urgently by a GP who examined him through his clothing and told Mr and Mrs C to take the baby to the A&E department at Crosshouse Hospital in their car. On arrival at the hospital, the baby stopped breathing and had to be resuscitated. The baby remained in hospital for three days. Mr and Mrs C felt that the GP should have given their baby oxygen and arranged for an ambulance transfer to hospital.

We took independent advice from an adviser in general practice medicine and concluded that the GP had carried out an inadequate examination of the baby as they did not remove the baby's clothing. In addition, we noted that the GP had maintained that they did not administer oxygen to the baby as it would have delayed the referral to hospital. We found that as oxygen was available at the out-of-hours centre, the GP should have administered it to the baby. We also found that it was inappropriate to have asked Mr and Mrs C to have transported their baby to hospital without clinical support. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings in care and treatment which have been identified during this investigation;
• ensure that the GP discusses this complaint with their GP appraiser as part of their yearly appraisal; and
• ensure that the GP considers whether there is additional learning in relation to the initial management of patients with unstable blood pressure. The GP may benefit from the clinical support group in this regard.

Summary

Mr C complained that he was not prescribed medication to treat high blood pressure and that during a home visit a GP did not diagnose a deep vein thrombosis (DVT) in his leg.

Mr C had a knee replacement operation in December 2014 and requested a home visit in January 2015 as he was suffering from pain and swelling in his leg. A GP attended and examined Mr C's leg but did not find any obvious signs of DVT. A week later, Mr C had a post-operative check on his leg and the DVT was discovered and he was admitted to hospital for treatment.

Our investigation included taking independent advice from a medical adviser who was of the view that the examination carried out by the GP was appropriate and that there were no recorded signs that would have suggested DVT. The adviser stated that DVTs can develop over time and that the signs are difficult to identify in the early stages. We did not uphold this aspect of the complaint.

Following his treatment for the DVT Mr C was referred to the anti-coagulation clinic to monitor his blood, and he was prescribed Warfarin (an anti-coagulation medication) to reduce the risk of further clots for six months. During this time Mr C stopped taking the medication to treat his high blood pressure. When he was advised by the clinic to stop taking the Warfarin, Mr C requested a prescription for his blood pressure medication from the GP which he stated was not provided for seven days. The records showed that the prescription was issued on the day it was requested and we did not uphold this aspect of the complaint.

Summary

Mr C complained that the board had failed to provide compression stockings for his varicose vein surgery at University Hospital Ayr. Mr C said he was unusually large and already received custom-made support stockings from the hospital. On the day of his surgery, however, the stockings he required needed to provide a greater degree of compression than his day-to-day pair. None had been ordered by Mr C's doctor and none of the standard sizes fitted him. As a result, Mr C's surgery was delayed. Mr C said he felt this was unacceptable and that staff had failed to recognise the serious inconvenience this had caused him.

We took independent advice from a consultant vascular surgeon and consultant physician. They found that it was unreasonable for the board to have not ensured the correct size of stocking was available. We therefore upheld this aspect of Mr C's complaint.

Mr C said that staff had made fun of his unusual size, which he considered unprofessional. We were unable to investigate this aspect of Mr C's complaint as it was not possible to confirm what had been said.

Mr C also complained that he had not been provided with an appropriate level of information about the planned surgical procedure and that he had subsequently found out there were possible serious side effects. Mr C said he would not have consented to the procedure had he been aware of these.

We found, however, that the decision not to proceed with surgery due to the correct size of stockings not being available was appropriate given Mr C's medical history.

With regard to the information provided to Mr C about his surgical options, the advisers found that this was adequate and set out clearly the possible risks of surgery. We therefore did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• remind the doctor concerned of the importance of confirming prior to surgery whether custom-made stockings are required and ensuring these are available on the day of surgery.

Summary

Mr C complained that he received poor wound care following surgery. He said this resulted in his wound splitting open at home and he had to be readmitted to Western Isles Hospital. Mr C experienced protracted pain and distress due to the condition of his wound.

We took independent advice from a nursing adviser and found that the risk of infection had been discussed with Mr C as part of the consent process before his surgery. We also found that the nursing records, including assessments and charts, were of a reasonable standard and demonstrated that Mr C's wound was appropriately monitored and treated before his initial discharge from hospital.

Summary

Mrs C complained to us about the care and treatment her late mother (Mrs A) had received in Ninewells Hospital before her death. In particular, she complained about the management of her mother's oxygen therapy immediately before her death. Mrs A had a number of health problems, including idiopathic pulmonary fibrosis (a lung condition that causes scarring of the lungs and where the cause is unclear). She was receiving oxygen therapy and a trial had indicated that she required a consistent high level of oxygen via a rebreathing mask (a mask that provides a high concentration and flow of oxygen and is used to provide patients with very specific oxygen needs).

However, a nurse had put in place a nasal cannula (two prongs that sit at the bottom of the nose and are more comfortable to wear, but which deliver a lower concentration of oxygen than a rebreathing mask), to allow Mrs A to eat her lunch and drink. A nurse had then observed Mrs A to be alert after lunch, but ten minutes later, Mrs A was found to be dead. She did not have the mask on at that time.

We took independent advice on Mrs C's complaint from a consultant in respiratory medicine. We found that, in general, the clinical treatment provided to Mrs A had been reasonable. However, the fact that her oxygen saturation had dropped to low levels when her oxygen had been disconnected several days earlier should have alerted medical staff to the fact that she needed oxygen via a rebreathing mask and not a nasal cannula. We found that her oxygen saturation levels should have been monitored during and after her lunch if the rebreathing mask was to be removed, although there was no clear evidence that Mrs A's death resulted from this. We upheld this aspect of Mrs C's complaint. We also upheld her complaint that the board did not respond reasonably to her enquiries and complaints in view of their delays in responding to her.

Recommendations

We recommended that the board:

• provide evidence that consideration has been given to establish how to prevent a repetition of this incident in the future;
• issue a written apology to Mrs C for the failings identified; and
• make complaints handling staff aware of our decision.

Summary

Ms C works for an advice and support agency. She brought the complaint on behalf of her client (Mr B). Mr B had concerns about the treatment his daughter (Miss A) received at Ninewells Hospital after she was referred by her GP with suspected appendicitis. Miss A was reviewed and appendicitis was considered to be unlikely. She was prescribed antibiotics for a urinary tract infection and was discharged home. Miss A did not improve and had to be taken back to the hospital two days later. Although initial assessment found appendicitis to be a possible cause of her symptoms, she was discharged after two days with a diagnosis of gastroenteritis (inflammation in the intestines caused by infection). Her condition did not improve and she had to be readmitted four days later. Miss A underwent surgery to investigate further. During this procedure her appendix was removed as it was found to be gangrenous. An abscess was also discovered. Miss A did not recover well and had to undergo more surgery as she had developed a deep pelvic abscess. In addition to his concerns about the treatment provided to his daughter, Mr B was dissatisfied with the time the board had taken to deal with his complaint.

After taking independent advice on this case from a consultant surgeon, we upheld the complaint about the treatment provided to Miss A. The adviser considered that Miss A's appendicitis could have been diagnosed and acted on at her second attendance at the hospital. We were advised that this would have lessened the risk of a pelvic abscess developing and the further problems that she experienced. The adviser also commented that the information about risks of the initial surgery had not been recorded comprehensively enough. As the board had introduced a new patient pathway document for children with suspected appendicitis following Mr A's complaint, the adviser was asked to review this. The adviser considered that it would benefit from further consideration by the board in light of our findings, and we made a recommendation about this.

We also upheld the complaints handling concerns that were raised. The board accepted that they had not responded within a reasonable timescale and had not met a reasonable standard as a result. They explained that their process had since been changed.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• take steps to ensure that all relevant paediatric and surgical staff are made aware of the findings of our investigation;
• consider the use of a clinical scoring tool for paediatric appendicitis;
• review the care pathway previously developed in light of the independent advice received in our investigation and provide us with a copy of this for review; and
• ensure that adequate details of the risks of surgery are explained and documented during the consent process.

Summary

Miss C complained about the clinical treatment provided to her late brother (Mr A). Mr A was admitted to Ninewells Hospital with chest pain. He was diagnosed with a chest infection and discharged the next day. Mr A died of a heart attack a few weeks later. Miss C was concerned that the hospital did not find a problem with Mr A's heart, particularly as he was admitted with chest pain and had a family history of cardiac (heart) problems.

In response to Miss C's complaint to them, the board said Mr A did not show signs of a heart attack during his admission and that they considered the care provided to have been reasonable. They noted that recovering from a chest infection can put an extra strain on the heart, which may have precipitated a heart attack, but that this could not have been predicted.

After taking independent medical advice, we upheld Miss C's complaint. While we were advised that the care provided was reasonable at first, it was not clearly recorded in the medical records that Mr A was properly reviewed before discharge and that he had no ongoing symptoms of concern.

However, we were not critical of the hospital not identifying a problem with Mr A's heart. The adviser explained that the investigations carried out were reasonable and supported the diagnosis of a chest infection. Based on the information available to the hospital at the time, the adviser considered it was reasonable that the doctors did not investigate a possible cardiac cause for Mr A's pain.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the lack of a detailed assessment on the day of discharge; and
• ensure the consultant reflects on our findings as part of their next annual appraisal.

Summary

Mrs C complained to us that her husband (Mr C) did not receive a reasonable standard of care from his GP practice. Mr C had been a patient at the practice for three months, having transferred from a different practice, when he suffered a heart attack and died.

Mrs C felt that the practice should have requested a chest x-ray and an echocardiogram (a test which records the rhythm and electrical activity of the heart). She said that there had been a sequence of failed attempts to diagnose and treat Mr C.

We took independent advice from a GP adviser. They found that Mr C had received reasonable care from the practice. The adviser noted that Mr C had been appropriately referred to the hospital respiratory medicine department and consequently considered that it was not unreasonable that Mr C was not referred for a chest x-ray or an echocardiogram. We accepted the adviser's comments and we did not uphold this complaint.

Summary

Ms C complained about the care and treatment she received during and after an operation to correct a squint at the Princess Alexandra Eye Pavilion. She raised concerns that she was not fully informed of what to expect, and that doctors performed additional procedures on her eyes that she had not consented to and which were not necessary. She also raised concerns about the use of experimental medications. Ms C attended the hospital for a follow-up consultation a month later, and was concerned about the attitude and thoroughness of the consultant during this consultation.

We sought independent advice from an ophthalmology adviser and an anaesthetic adviser. The ophthalmology adviser was satisfied that the surgery was of a reasonable standard, and there were no concerns raised about the surgical treatment Ms C received. However, they noted that significant elements of the consent process took place on the morning of surgery, and that this did not give Ms C the time she needed to assimilate the information. This was compounded by the stress she felt at being called in for the operation earlier than anticipated.

The anaesthetic adviser was satisfied that the care and treatment provided were appropriate, but noted that Ms C's recall of events may have been affected by the anaesthetic, and this, combined with confusion and potential delirium, could account for her concerns about what happened during and after surgery.

We were satisfied that the care and treatment Ms C received were reasonable, and we did not uphold this aspect of Ms C's complaint. However, we found that she was not given sufficient time to consider the information provided during the consent process. We were also critical of the poor level of record-keeping in relation to consent, which meant that the board could not verify what had been discussed and when. We upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• share the findings of this investigation with the appropriate ophthalmic surgical staff to ensure that patients give properly informed consent, and that discussions are appropriately documented;
• consider developing a leaflet informing patients of what is involved in squint surgery, including the risks or side effects and the likelihood of these; and
• apologise to Ms C for the failures identified and for the distress this caused her, and provide assurances that she still has full access to NHS ophthalmology services.

Summary

Mr C complained about the medical and dental care and treatment he received from the prison health centre. He suffered from severe pain, particularly head and face pain, due to historic injuries and he raised concerns that adequate pain relief was not provided to him and that nursing staff regularly refused his requests to see a doctor. He also complained about delays in getting dental appointments and about the standard of treatment received, including that the dentist favoured extraction of his teeth over treating them.

We took independent advice from a GP adviser, who advised that the prison health centre were using a recognised system whereby nursing staff triage patient requests before making appointments. The adviser did not consider that Mr C was unreasonably prevented from seeing a doctor and said that, overall, healthcare staff reacted to his requests and treated his symptoms appropriately. We did not uphold these aspects of his complaint. However, we identified that some of Mr C's records were missing and we made a recommendation relating to record-keeping.

We also took independent advice from a dental adviser, who identified that Mr C initially submitted a routine appointment request, which he subsequently re-submitted indicating that his need for treatment had become urgent. He was seen within 12 weeks of his initial request and within a week of his urgent request. When he later submitted a further urgent request, he was not seen for two months, and apparently only after he had complained. We were advised that patients in the community could expect to be seen within six to eight weeks for routine appointments and within 24 hours for urgent appointments. We concluded that Mr C's wait for treatment was unreasonable and we upheld this aspect of his complaint. We were advised that, when Mr C was seen by a dentist, he was given appropriate advice and treatment and we did not uphold this aspect of his complaint.

Mr C also raised concerns about the way in which his complaints were handled by the board. We reviewed the board's investigation processes and replies to Mr C and did not consider that his complaints were responded to in a timely, accurate and comprehensive manner. We, therefore, upheld this aspect of his complaint, however, we were satisfied that appropriate action had since been taken by the board to improve their complaints handling.

Recommendations

We recommended that the board:

• ask prison healthcare staff to reflect on the identified record-keeping failure and seek to ensure compliance with the relevant professional guidance at all times;
• apologise to Mr C for the identified delays in arranging dental appointments for him;
• review the process for prioritising dental appointments in the relevant prison and inform us of the steps they have taken to avoid similar future delays; and
• apologise to Mr C for the identified failings in the handling of his complaints.