Health

Summary

Mr C had surgery on his prostate at Forth Valley Royal Hospital and he subsequently experienced a common complication of the procedure. He complained that he was not told in advance that this complication would be permanent and he considered that the information he was provided suggested it would only be temporary. He said he would not have gone ahead with the procedure if he had realised that the complication was irreversible.

The board noted that the potential risks were explained to Mr C before the procedure and were listed on the consent form which he signed. They also noted that he was given a patient information leaflet, which stated that three out of four men would experience the complication in question. However, Mr C stated that the leaflet said the complication would only last a few weeks.

We obtained advice from a consultant urologist, who was not critical of the consenting process and considered that Mr C was in a position to provide informed consent. They noted that the leaflet did not state that the complication would only last a few weeks. They considered that it was implicit in the leaflet that the complication could be permanent, however, they said it could benefit from being changed so that this is stated explicitly. We agreed that the leaflet did not state that the complication was temporary. However, we noted that it did refer to some other side effects as being temporary. Given that there is a 75 per cent chance of the complication in question occurring following surgery, and as it is often permanent, we considered that this position should be made clearer in the board's information leaflet. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to make it clear in the information leaflet the likelihood of the complication of his surgery being permanent; and
• clarify in the information leaflet the likelihood of the complication being permanent.

Summary

Mr C complained that a GP practice did not properly maintain the medical records of his wife (Mrs A) and as a consequence, when she was admitted to hospital she was given medication which led to serious side effects. He further complained that a member of staff spoke to him inappropriately and told him that by stopping his wife's medication he could cause Mrs A's death.

We took independent general practice advice and noted that while Mrs A's medical records showed that a conversation with Mr C had taken place where he said that he was stopping her medication due to his belief that it caused side effects, they did not record a change to her medication. This was because Mrs A had the capacity to make decisions about her treatment and any changes could only be made after discussion with her. Whilst the records noted a terse conversation with Mr C about his wife's medication, there was no evidence that he had been spoken to inappropriately. It was clear that the repercussions of Mrs A stopping taking her medication had been clearly explained to Mr C. We did not uphold the complaint.

Summary

Mr C complained about the length of time his wife (Mrs A) spent in Dumfries and Galloway Royal Infirmary. He also complained that before giving medication to Mrs A, staff had not asked him which medication Mrs A was taking prior to her admission.

Mr C also said that the medication prescribed to Mrs A had a detrimental effect on her, physically and mentally, and that the tests she underwent after her admission were unnecessary.

We took independent advice from a consultant geriatrician. The adviser noted that because Mrs A was able to tell staff about her medication, there was no requirement for staff to discuss it further with Mr C. The adviser also found that the admission and the tests subsequently undertaken were appropriate and reasonable. We therefore did not uphold Mr C's complaints.

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.