Health

Summary

Mrs C, who works for an advice agency, complained to us on behalf of Miss A. Miss A had attended her medical practice after falling over on her ankle. Her appointment was made by her pharmacist, who thought Miss A might have a deep vein thrombosis (DVT, a blood clot in the vein). Miss A was examined by a doctor, who diagnosed a calf strain. She was advised to take pain relief.

However, Miss A's pain continued and she attended A&E on a number of occasions, where she was diagnosed with a fractured ankle. Miss A continued to report problems and was subsequently referred to a vascular surgeon (a surgeon who treats disorders of the circulatory system). A DVT was found and Miss A was required to have her leg amputated below the knee.

Mrs C complained to us that the practice failed to appropriately diagnose and treat Miss A and about the way they dealt with Miss A's subsequent complaint.

We took independent advice from a GP. They found that Miss A's diagnosis had not been unreasonable, that she had been appropriately examined and that her circulation was reasonably assessed. They also found that Miss A's complaint received a reasonable reply. We therefore did not uphold Mrs C's complaints. However, the adviser noted that Miss A's GP had not been alert to Miss A's early signs of PVD (peripheral vascular disease, or peripheral arterial disease (PAD)) which should have been followed up. We therefore made recommendations to address this.

Recommendations

We recommended that the practice:

• ensure that the GP familiarises themselves with the diagnosis and management of patients presenting with early PVD and discusses this at their next yearly appraisal; and
• takes steps to ensure that they are familiar with the presenting signs of PAD and its management.

Summary

Mrs C complained to us about the care, treatment and support provided to her son (Mr A) by the board's mental health services before his death from an overdose. We took independent advice on Mrs C's complaint from a psychiatrist. We found that the clinical care provided to Mr A by the mental health services was reasonable and was consistent with current practice. We also found that there had been appropriate communication with other relevant parties. It had been reasonable to delay psychotherapy treatment for Mr A as the uncovering of previous trauma during therapy can sometimes lead to distress and increased suicidal ideation. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained to us that the board had failed to communicate with her adequately about the significant event review that was carried out after Mr A's death. We found that the conduct of the review had been consistent with good practice and was reasonable. However, the completion of the review was delayed and there were also errors in the draft report that was issued. In addition, Mrs C had not been signposted to support in relation to bereavement. We upheld this aspect of the complaint.

Finally, Mrs C complained that the board had failed to deal with her complaints about Mr A's care and treatment appropriately. Whilst we recognised that there had been a large number of complex issues to cover, we considered that the time taken by the board to respond had been unreasonable. We upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• provide evidence that they have considered how they communicate with relatives and other interested parties where an investigation becomes protracted and delayed and whether setting a standard for this would be beneficial; and
• provide evidence of the steps they have taken to avoid delays of this nature in the future.

Summary

Mrs C said that she attended Gartnavel General Hospital in 2012 because of a persistent chronic cough. She was told that there were a number of potential causes for this but that a high resolution computerised tomography (HRCT) scan and other tests had been ordered to exclude any structural lung disease, in particular bronchiectasis (a chronic lung condition). The required tests were carried out and reported at clinic in January 2013. At this stage, it appeared that there was no evidence of bronchiectasis.

Mrs C said that she remained unwell and a repeat HRCT was ordered. Following this, she was told in September 2014 that she had bronchiectasis. Mrs C complained to the board that they had failed to diagnose her in early 2013 and that as a consequence she did not receive the required treatment. The board, however, maintained that she had been treated appropriately and that changes occurred in the period after her first HRCT.

We took independent advice from a consultant in respiratory medicine and we found that HRCT scanning was the 'gold standard' to determine whether or not bronchiectasis was present. On the first such scan there was no such evidence of this but this was found to be the case in 2014. While the impact of the diagnosis for Mrs C has been great, we found no evidence to suggest that this was as a consequence of any shortcoming on the part of the board.

Summary

Miss C complained about her son (Mr A)'s admission to the Langhill Clinic at Inverclyde Royal Hospital. Mr A was admitted with suicidal thoughts and diagnosed with personality disorder, but requested a second opinion. This was provided by a different psychiatrist about a week later, and supported the clinical team's view that Mr A did not suffer from a major psychiatric illness, with his presentation relating to personality traits and recent trauma and bereavement. The following day, Mr A was found to have taken illicit drugs while absent from the hospital on a day pass. In view of this and increasing incidents of aggression towards staff, the doctor decided to discharge Mr A the following morning. Mr A then became aggressive and staff called the police to escort him from the hospital. Miss C was concerned that Mr A was not appropriately assessed and felt he should not have been discharged so early. She also raised concerns about the board's handling of her complaint.

After taking independent psychiatric advice, we did not uphold Miss C's complaints. We found that Mr A received reasonable assessments which appropriately took into account his risk of self-harm. He was also given a second opinion when he requested this. We also found the discharge was reasonable and in line with the board's policy on the management of violence and aggression. In particular, we noted that Mr A's admission was intended to be short and there were numerous documented instances of aggressive behaviour not caused by a major psychotic illness. However, we found the board failed to handle Miss C's complaint in line with Scottish Government guidance as they did not accept her complaint at first because it was not in writing, there were significant delays in the investigation and there was no evidence that staff contacted Miss C to explain the delay.

Recommendations

We recommended that the board:

• apologise to Mrs C for failing to handle her complaint in a timely manner;
• feed back findings to the staff involved for reflection and learning;
• take action to ensure that all complaints to the clinic are appropriately recognised and acknowledged, including verbal complaints made to clinic staff; and
• put in place clear procedures to ensure that complaints are investigated within 20 days where possible, and that complainants are updated when the investigation is expected to exceed 20 days.

Summary

Mrs C's elderly mother (Mrs A), who suffered from dementia, was a patient in the Royal Alexandra Hospital. During her admission, members of Mrs C's family visited to find Mrs A naked and lying in a wet bed. Her pyjama top had been removed and her drip displaced, soaking the bed. The family complained and were advised that on two occasions in the hours before the incident, Mrs A was noted to be settled. They concluded that she had removed her top herself. Mrs C was unhappy with this as she believed that given her illness and debility, Mrs A could not have done this. She complained to us because she felt that the board had failed to investigate her concerns appropriately. She was also unhappy about the way they communicated with her.

We took independent nursing advice and we found that the board's investigations had been poor. There was no documentation in Mrs A's medical records to confirm that she had been settled, the incident had not been noted in the file and no statements had been taken from staff who were present on the ward at the time. While it was possible that Mrs A could have removed her top, the board made an assumption that she had done so. There was no mention of Mrs A wearing pyjama bottoms and this was both unacceptable and undignified. The board's complaint response, given the seriousness of Mrs C's complaint, was not a reasonable one. We upheld the complaints.

Recommendations

We recommended that the board:

• make a formal apology;
• emphasise to staff the importance of taking full and timely records;
• review their internal investigations process and consider whether this requires to be audited; and
• review the need for staff on the relevant ward to receive specific training and education regarding distressed behaviour in people with dementia.

Summary

Miss C's mother (Mrs A) was admitted to Glasgow Royal Infirmary with an exacerbation of her chronic obstructive pulmonary disease (COPD – a disease of the lungs in which the airways become narrowed). Miss C complained about the care and treatment her mother received from the board whilst in hospital and the arrangements for her subsequent transport home. She was concerned that her mother was weaned off oxygen too early. She was also concerned that the board should not have considered her mother for a normal flight home when she had been admitted to hospital with a severe COPD attack and chest infection. Miss C said that her mother should have been transported home by air ambulance.

We obtained independent advice on the case from a consultant respiratory and general physician. The adviser said there was no evidence to suggest that Mrs A was weaned off oxygen too early. They explained that Mrs A needed oxygen from day one to day five of her admission but that from day six to day eight her oxygen levels were stable and at a satisfactory level and no additional oxygen was required.

In terms of Mrs A's discharge and transport home, the adviser said that as Mrs A had been assessed appropriately by the board, her condition was deemed to be stable and she had recovered from her recent COPD exacerbation. We found that, on balance, it was reasonable for her to have been discharged and flown home on a short, low altitude, commercial flight without provision of additional oxygen.

Although we concluded that Mrs A received reasonable medical care during her in-patient stay and that her discharge arrangements were appropriate, we were concerned about the standard of the handwriting in Mrs A's medical records, the standard of the photocopy supplied to this office, the board's handling of Miss C's complaint and the board's late submission of their comments on this case to our office. We therefore made some recommendations to address these issues.

Recommendations

We recommended that the board:

• feed back the failings identified in our decision on Miss C's complaint to the staff involved;
• ensure that in future readings are clearly recorded in patient records; and
• provide Miss C with a written apology for the failings identified.

Summary

Ms C said that a nurse injured her child's arm while removing a plaster cast. She complained to the board who made their own investigations but concluded that the cast had been removed in an appropriate way, and that neither the nurse or the doctor concerned had noted any injury.

We took independent nursing advice and we found that the records did not show any evidence of the child being distressed or injured. There was no evidence to show that the plaster cast had been removed in an inappropriate way. The complaint was not upheld.

Summary

Ms C, an advice worker, complained to the board about immunisations given to the child of her client (Ms A) by the community nursing team. The child had been given additional vaccinations on two occasions and the staff had failed to keep accurate records. Although the board upheld the complaints, Ms A felt they had not taken her concerns seriously.

We took independent nursing advice. The adviser found that vaccination errors had occurred but that the board had carried out a detailed investigation into the causes and that appropriate action had been taken to prevent a repeat occurrence. We upheld Ms C's complaints but made no additional recommendations.

Summary

Mrs C complained to us that the board had failed to provide reasonable care and treatment to her son (Mr A) when he attended the Royal Alexandra Hospital after taking an overdose of prescribed medication. Mr A was discharged from the hospital later the same day. Mr A had continuing symptoms of nausea and was given medication to prevent nausea and vomiting. He died two days later. This is thought to have been due to the effects of the overdose he took before attending hospital.

We took independent advice from a consultant in emergency medicine. They found that the level of medication taken by Mr A fell into the range that could cause death and required careful medical assessment and close observation. They noted that staff in the hospital ought to have contacted the National Poisons Information Service to discuss the matter, particularly as Mr A had taken a multi-drug overdose. We considered that the information service would have advised that Mr A should not be discharged until he was free of symptoms, as death can occur up to 54 hours after ingestion of the prescribed medication. Mr A was not free of symptoms as he required medication to control his vomiting.

Although we could not say whether Mr A would have survived had appropriate action had been taken, his symptoms could have been managed better had he remained in hospital. We therefore upheld Mrs C's complaint. However, we were satisfied that the board had learned lessons from the failures in Mr A's care and that the action they had taken in response to these failings was reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings in her son's care.

Summary

Miss C's mother (Mrs A) had cancer and was receiving care at home. During an admission to Glasgow Royal Infirmary for a review of her care, Mrs A suffered a fall. After her fall, Mrs A underwent a scan and was discharged two days later.

The scan report was issued six days after the scan took place and showed a fracture to Mrs A's L1 vertebra (a bone in the base of her spine). Miss C said that on Mrs A's discharge from hospital, Mrs A's family had been told that the scan was clear.

Mrs A's family continued to care for her at home but were concerned about her continuing back pain. They asked her GP to check the results of the scan with the hospital. Miss C said that the family was told that Mrs A had suffered a fracture to her L3 vertebra (a different bone in the base of the spine). Mrs A died the next day. Miss C was concerned that Mrs A had been cared for without her family being aware of her fracture.

Miss C complained to us that the family had not been reasonably informed about the results of the scan. We took independent advice from a consultant in general medicine and a radiologist. They noted that the fracture was clearly visible on the scan, but although the hospital's computerised audit trail showed staff had reviewed the scan, this was not documented in the medical records and there was no evidence that the results had been communicated to Mrs A or her family. While we did not find evidence that staff had given incorrect information to Mrs A or her GP, we were critical that staff did not identify the fracture and share this information. We therefore upheld this complaint.

Miss C also complained about the provision of Mrs A's pain relief during her admission. The advisers noted that staff had assessed and monitored Mrs A's pain appropriately and provided pain relief when required. We therefore did not uphold this aspect of Miss C's complaint.

Recommendations

We recommended that the board:

• apologise to Miss C's family for the failings found during our investigation;
• feed back our findings about the lack of documentation and communication of the scan results to the medical staff involved; and
• review and address any training needs for the staff involved, in relation to interpreting scans of this kind.