Health

Summary

Miss C complained to us following two admissions to University Hospital Crosshouse with severe abdominal pain and persistent vomiting. She was transferred between several different wards, and was due to have a scan of her abdomen. However, she discharged herself prior to this scan taking place. She was re-admitted five days later for an investigative procedure, but chose to be discharged the following day. She complained that the care and treatment was inadequate, and that she was not given the treatment she needed to resolve her symptoms. She also complained that there was a delay in giving her a scan and she was left in pain by poor practices in relation to the insertion of a cannula and a catheter. She said staff were dismissive of her pain and did not identify her as being at risk of falls. She also said hygiene standards were poor, and medical staff failed to diagnose and treat her appropriately.

We obtained independent nursing and gastroenterology advice. The nursing adviser noted concerns Miss C raised in relation to her care, and also the feedback from the board, which had acknowledged some failings. The adviser considered that it was reasonable that Miss C was not assessed for her falls risk, but noted that she should have been given access to a buzzer. The adviser also acknowledged apparent problems with Miss C's cannula site and catheter, though they did not find any evidence of problems in relation to hygiene.

The gastroenterology adviser did not identify any concerns with Miss C's treatment. The adviser noted that there was no evidence to indicate Miss C had Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system), as she thought she did.

We considered the evidence available, and were satisfied that there were failings in relation to Miss C's nursing care, but not in relation to her clinical treatment. We also considered the evidence in relation to her moves between wards, and were satisfied that in each case, these were made for appropriate clinical and nursing reasons.

Recommendations

We recommended that the board:

• remind staff of the importance of full documentation in relation to the insertion of catheters, to ensure their safe removal and for infection control.

Summary

Mr C was injured in an accident in the prison workshop. He cut his arm and suffered bruising to his elbow. This was treated in the prison health centre by a nurse, who cleaned and dressed the cut. Later that day Mr C raised concerns about his tetanus immunity and that evening he received a tetanus injection.

Mr C complained to us that he should have received testing and treatment for blood borne viruses and that the treatment he was given immediately after the accident was inadequate. He also complained about two separate incidents where he believed he had been given incorrect medication by nursing staff. Mr C also complained that the board had not handled his complaints reasonably.

After taking independent advice from a nurse and a GP on the care and treatment Mr C received following the accident, we did not uphold these aspects of his complaint. The advice we received was that Mr C's nursing care was reasonable and that he was appropriately tested for blood borne viruses. Although Mr C did receive a tetanus injection after raising concerns, we have made a recommendation that nursing staff be reminded to ask patients about their tetanus status when patients have suffered cuts.

After taking independent advice from a nursing adviser, we upheld Mr C's complaint about the administration of medication. We found that the board had acknowledged that Mr C was offered the wrong type of medicine on one occasion. The adviser considered this error to be unreasonable. The board advised Mr C they had taken steps to address this and we have made a recommendation in relation to this.

We found no evidence that the board acted unreasonably with regard to the complaints handling process, therefore we did not uphold Mr C's complaint in relation to this.

Recommendations

We recommended that the board:

• report to us on the steps that have been taken to prevent dispensing errors; and
• take steps to remind nursing staff to check the tetanus status of patients with cuts.

Summary

Ms C complained about the dental treatment she received on a tooth that was infected. The tooth had previously had root canal treatment and a crown. Ms C said the dentist had been clear that after two courses of antibiotics, they would take the tooth out and apply the antibiotic directly and replace the tooth temporarily to allow the infection to clear completely. Ms C understood that she would then be able to return in two months and that it would be refitted permanently. Ms C said that she was not made aware that the integrity of the tooth might be compromised or consented to the treatment that was carried out by the dentist. Subsequently, the dentist was unable to replace the root filling and later the tooth fell out.

We took independent advice from a dental adviser. We found that the evidence from Ms C's dental records showed significant failings around the consent process and shortcomings in relation to the prescription of antibiotics and taking of x-rays. We also found that the dentist failed to offer and discuss alternative treatments with Ms C and so opportunities to save the tooth were missed. In view of the poor outlook of the tooth, we recommended that the dentist refund the cost of treatment available on the NHS to remedy the situation (a bridge), as well as the costs of the treatments Ms C received during this period.

Recommendations

We recommended that the dentist:

• refund Ms C the cost of a bridge (in line with the statement of dental renumeration) on receipt of an appropriate invoice when treatment has been completed;
• refund Ms C the cost of treatments provided during the period in question;
• review their consent process, prescription of antibiotics and taking x-rays, in line with relevant guidance and standards; and
• apologise for the clinical failings this investigation identified.

Summary

Mrs C raised a number a number of concerns about the care and treatment given to her late mother (Mrs A) during an admission to Ninewells Hospital. Mrs C had complained to the board about the general clinical and nursing care that her mother had received. She had complained about the standard of communication and the delay in diagnosing and treating her mother, and she said that her mother had suffered unnecessary pain due to the non administration of medication. Mrs C was also unhappy with the board's handling of her complaint.

During our investigation, we took independent advice from a consultant geriatrician and a nursing adviser.

When responding to Mrs C's complaints the board accepted that there had been a number of failings and had taken action to address these. This included putting in place an improvement plan. However, notwithstanding the failings identified by the board, the advice we received and accepted from the geriatrician adviser was that there were failings in relation to the clinical treatment provided to Mrs A. These related to failings in communication within and between departments. We also found that the consent process for a procedure to fit a stent had not followed the relevant guidance.

While the board had already accepted failings in relation to the nursing care provided to Mrs A, the advice we received from the nursing adviser was that there had been other failings by nursing staff. We found that there were gaps in nursing care, particularly around the use of the malnutrition universal screening tool (MUST - a way to screen patients to identify and treat adults at risk of malnutrition), and checking Mrs A's food, fluid and nutritional care.

In relation to complaints handling, the board accepted that they had failed to deal with Mrs C's complaints in a timely and reasonable manner, so we upheld all aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• provide an update on the improvement plan put in place as a result of this case;
• investigate further the actions taken in relation to the stent procedure and provide details of the reasons for the delay, including the provision of anaesthetic staff for this process, to ensure lessons are learned;
• bring to the attention of the relevant staff the consultant geriatrician's comments, that a number of doctors were involved in Mrs A's care but there was no clear indication of who was in charge overall;
• bring the geriatrician adviser's comments in relation to the management of Mrs A's medication and an error which occurred in relation to her medication to the attention of relevant staff;
• ensure that relevant staff are able to complete the MUST and carry out actions as appropriate and report back to us on this;
• formally apologise to Mrs C for the additional failings identified by this investigation and for the handling of her complaint; and
• provide an update on the review being carried out on their complaints process.

Summary

Miss C complained that the dental care and treatment she received in relation to the removal of a wisdom tooth was unreasonable. We took independent advice from a dental surgeon. The advice we received was that the procedure was carried out appropriately and in line with relevant guidelines, and that the treatment provided to Miss C was reasonable and appropriate. However, we were concerned that there was no evidence in Miss C's dental records to confirm that she was given sufficient information prior to the extraction to allow her to give informed consent. Although we did not uphold Miss C's complaint, we did make a recommendation to the board with regard to the consent process and providing information to patients prior to surgery.

Recommendations

We recommended that the board:

• introduce a process for written consent for this type of procedure to be obtained evidencing the discussion of risks; and
• consider producing an appropriate local patient information leaflet for this type of procedure.

Summary

Miss C complained about the care and treatment provided to her late father (Mr A). Mr A became unwell and an ambulance was called. The ambulance crew examined him and suspected a heart attack. They contacted the coronary care unit at the Royal Infirmary of Edinburgh and it was agreed that Mr A should be brought there. However, Mr A went into cardiac arrest on the way and, despite the ambulance diverting to the nearest hospital at that time, he could not be resuscitated and he died. Miss C complained about the time taken for the ambulance to set off for hospital and also about the decision to take Mr A to Edinburgh rather than his local hospital.

The ambulance service noted that the ambulance was present at Mr A's home for a total of 33 minutes. They advised that this included all the patient assessment process, liaison with the Royal Infirmary of Edinburgh, and transferring Mr A to the ambulance. They indicated that the only issue that may have created a slight delay was difficulty in establishing intravenous access (where a thin tube is placed inside a vein to administer or withdraw fluids).

We took independent clinical advice from a paramedic. They considered that the ambulance crew had provided appropriate clinical treatment and acted within Mr A's best interests. While they noted that the ambulance was at Mr A's home for 13 minutes more than the optimum recommended time for a coronary case, they considered that the delay was not unreasonable in the circumstances. They advised that it was the correct decision to transfer Mr A to Edinburgh for specialist treatment, right up to the point that he went into cardiac arrest. They informed us that it was accepted practice to bypass nearer hospitals to take patients to the best possible place of treatment and they said it was not certain that Mr A would have survived the cardiac arrest had he been in hospital when it occurred. We accepted this advice and did not uphold the complaint.

Summary

After suffering recurrent ear infections, a child had surgery to insert grommets in his ears (a small tube inserted into the ear to help drain away fluid in the middle ear and maintain air pressure) at a private hospital in 2013. He then attended the Royal Hospital for Sick Children from early in 2014 as he had been experiencing nose bleeds. The child had a number of procedures carried out in May of that year but soon afterwards experienced another ear infection. He was seen in hospital again and a further set of grommets were inserted in August. He was reviewed in November and it was planned to see him in six months but his appointment was brought forward as he had been suffering constant infections and pain.

In April 2015 after attending at hospital, a decision was taken to allow a three month period of 'watchful waiting' before taking a decision to insert grommets again. The child's mother (Miss C) was unhappy with this and arranged for him to be treated privately. She complained that the board had not treated her son appropriately.

We took independent advice from a consultant ear, nose and throat surgeon and we found that the child had been treated in accordance with established guidance. This was because the type of problem from which he suffered could often resolve spontaneously, and it was usual to recommend a period of 'watchful waiting' before taking a decision to proceed with surgery. For this reason we did not uphold Miss C's complaint.

Summary

Mr C complained about a delay in being referred for psychology treatment. He was referred to the community mental health team and was seen initially by a consultant psychiatrist and a community psychiatric nurse (CPN). He continued to see the CPN over the following months but it was deemed that no psychiatric follow-up was necessary. However, the CPN subsequently discussed Mr C with the psychiatrist when the Mr C had reported experiencing vivid dreams, and the psychiatrist recommended a referral to psychology. Mr C raised concerns that he was not seen by a psychologist until several months later, when he considered that he should have been referred directly after his initial appointment.

We obtained independent advice from a senior mental health nurse, who did not consider that there was any indication for a psychology referral initially and deemed it reasonable for this to have been proposed when it was. However, the adviser noted that the CPN did not make the referral until almost three months later, despite having indicated that she would progress this. While Mr C was seen by a psychologist within the national 18 week waiting target from referral to treatment, the adviser considered that the delay in making the referral was unreasonable. We were critical that the board did not identify the delay when investigating this complaint and their response inaccurately indicated that the referral had been made around the time it was first proposed. We upheld this complaint.

Mr C also raised concerns about the contribution of a medical secretary at a meeting he attended with the psychiatrist and clinical director to discuss his complaint. He complained that the secretary inappropriately intervened to speak on the psychiatrist's behalf. The minutes of the meeting and the board's response to the complaint confirmed that this happened, although not to the extent described by Mr C. Nonetheless, the adviser considered that the secretary's documented input was inappropriate, noting that she was at the meeting solely as minute taker and should have left any explanations and/or apologies about care and treatment to the professional clinicians in attendance. We also upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in referring him to psychology;
• ask the staff involved in Mr C's care to reflect on the findings of this investigation and take steps to ensure that psychology referrals, once deemed appropriate, are progressed without any avoidable delay;
• highlight to complaints handling staff the importance of establishing the facts and accurately reflecting them in complaint responses;
• apologise to Mr C for the psychiatry secretary's inappropriate contributions at his complaint review meeting; and
• ensure clear directions are given to administrative staff taking on the role of minute takers at meetings, setting out the limitations of their role in this regard.

Summary

Mr C complained about the care and treatment he received from the medical practice. In particular, he raised concerns about a specific consultation where he felt that he should have been referred to a psychiatrist due to him suffering from severe depression. He was not referred to psychiatry until around a year later and he considered this to have been to the detriment of his mental health in the interim period. He also complained that the practice had increased his dosage of antidepressant medication to what he considered to be an unsafe level.

We obtained independent medical advice from a GP. They noted that details of the consultation in question had not been recorded and they were, therefore, unable to assess whether a referral to psychiatry was indicated at that time. While they did not consider that there was any indication for a referral at subsequent consultations six and eight months later, due to the fluctuating nature of Mr C's mental health difficulties we could not conclude that the same applied at the time of the relevant consultation. With regard to Mr C's medication, the adviser noted that it was prescribed at dosages within recommended levels and they could find no evidence of unsafe prescribing.

In light of the identified record-keeping failure, we were unable to evidence that Mr C had been appropriately assessed and, in turn, whether the decision not to refer him to psychiatry was reasonable. Therefore, on balance, we upheld the complaint and made some recommendations to the practice relating to record-keeping.

Recommendations

We recommended that the practice:

• apologise to Mr C for the identified record-keeping failure; and
• reflect on the identified record-keeping failure and seek to ensure compliance with the relevant General Medical Council guidance at all times.

Summary

Mr C was experiencing pain in his left knee and was referred to Raigmore Hospital by his GP. Mr C was seen by specialists at a number of appointments over the following two years as his symptoms worsened and began to affect other areas including his back. Mr C complained that the staff caring for him at the board had failed to pick up on his spinal problems or investigate appropriately.

After taking independent advice on this case from a consultant orthopaedic surgeon, we did not uphold Mr C's complaint. The advice we received was that Mr C had appropriate treatment for his symptoms and that thorough clinical investigations had been carried out.

However, we found that after one of his appointments, no clinic letter had been issued (a letter that would be sent from a hospital specialist to the patient's GP). The adviser did not consider that this had any impact on the care provided in Mr C's case, but as this could potentially be significant in other cases, we did make a recommendation to the board about this.

Recommendations

We recommended that the board:

• take steps to ensure that clinic letters are appropriately issued following out-patient appointments.