Health

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.

Summary

Ms C complained to us about a dental practice's handling of her complaint about a dentist. We were satisfied that the practice's response had adequately addressed the issues raised by Ms C. The response was also issued in line with the timescales referred to in the practice's complaints policy. In view of this, we did not uphold Ms C's complaint.

Summary

Ms C complained to us that her dentist did not refer her to specialists in oral surgery to have her wisdom tooth extracted. She had attended a routine appointment with her dentist and explained that she had toothache in her bottom right wisdom tooth. An x-ray was taken but the dentist decided that, as there was no evidence of disease, the wisdom tooth did not need to be extracted. He therefore did not refer Ms C for dental surgery.

We took independent advice from a dental adviser. We found that the dentist had acted in line with the relevant guidelines, which state that impacted wisdom teeth that are free from disease should not be operated on. We did not uphold this aspect of her complaint.

Ms C also complained that the dentist did not tell her she would not be referred to have the wisdom tooth extracted. In response to our enquiries, the dentist told us that he had asked Ms C to wait in the waiting area for the results of the x-ray of her wisdom tooth. However, by the time he went to tell her the results, Ms C had already left the practice. The dentist left a note in her records that this was to be discussed with Ms C at her next visit. However, Ms C did not return to the dental practice.

We found that the dentist had acted reasonably in relation to this matter and we did not uphold the complaint.

Summary

Mr C complained to us about emergency treatment he received at the Royal Infirmary of Edinburgh after injuring his knee. He attended A&E at the hospital, where his injury was diagnosed as a soft tissue injury. Mr C was given advice on pain relief and told to see his GP if the pain persisted.

About a month later Mr C saw his GP, as the pain was continuing. An x-ray was taken of his leg and this showed a stress fracture.

The independent advice we received from a specialist in emergency medicine, which we accept, was that Mr C should have received an x-ray when he first attended A&E. As such, we upheld the complaint. However, we were advised that due to the nature of Mr C's injury it was unlikely this x-ray would have identified the fracture and it was therefore unlikely that this would have altered his treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to arrange an x-ray of his leg injury; and
• share the findings of this investigation with the staff in question and ask them to reflect on this for their future practice.

Summary

Ms C complained about the appropriateness of her late son (Mr A)'s discharge from a clinic at the Royal Edinburgh Hospital and also the adequacy of his follow-up care and treatment in the community. Mr A had a diagnosis of schizophrenia and also had alcohol and drug problems. He died of a drug overdose five weeks after discharge. Ms C complained in particular that community psychiatric nurses (CPNs) did not get help for Mr A, or alert her, when they visited him the day before his death and found him in an intoxicated state.

We took independent medical advice from a consultant psychiatrist and a mental health nurse. We were advised that Mr A was no longer suffering from the symptoms of his mental illness at the time of discharge. It was highlighted that his hospital detention could not have been prolonged solely on account of his drug taking behaviour. The advice we received indicated that the decision to discharge was reasonable and that it followed detailed risk assessment and appropriate multi-agency planning. We therefore did not uphold this complaint.

We were also advised that an intensive package of care was arranged, with multi-agency involvement, and we therefore did not uphold Ms C's complaint that adequate support was not in place for Mr A for his return to the community. However, we were advised that all relevant paperwork was not fully completed and distributed prior to discharge and so we made some recommendations to try to prevent a similar future omission.

In relation to the actions of the CPNs the day before Mr A's death, it was noted that it was not an unusual scenario for them to find him in an intoxicated state when they visited him. We were advised that there was no evidence to suggest that the level of risk was increased on this occasion or that it represented an emergency situation. As the CPNs did not perceive the circumstances to represent an emergency situation, they were required to respect Mr A's confidentiality. We therefore did not consider there to be an unreasonable failure to involve Ms C. We concluded that there was no unreasonable act or omission on the part of the CPNs that directly contributed to Mr A's death. However, with the benefit of hindsight, we noted that there were additional steps the CPNs might have considered taking and we made a recommendation about this.

Ms C also complained that mental health and addiction services staff did not work together to support Mr A the day before, and on the day of, his death. However, we were advised that addiction services had no acute role over these particular days and we did not uphold this complaint. In terms of their longer-term role, we were advised that they were appropriately involved in Mr A's care. However, as the addiction psychiatrist appeared not to have been invited to one particular meeting, we made a recommendation about this.

Finally, as we were unable to determine that the board's incident review report contained factual inaccuracies, we did not uphold Ms C's complaint in this regard. However, we considered that a report written by one of the CPNs could have been more clearly worded and we made a recommendation about this.

Recommendations

We recommended that the board:

• take steps to ensure that Care Programme Approach documentation is brought fully up to date prior to discharge and is circulated to all relevant parties;
• remind staff to ensure that standardised documentation, such as the Discharge Checklist, is completed fully and accurately;
• consider providing field management guidance to community staff who, in the course of their duties, are likely to encounter patients significantly under the influence of harmful drugs;
• remind staff to ensure that all relevant parties are invited to attend key multi-disciplinary meetings; and
• take steps to remind nursing staff that clinical reports should be factual and unambiguous in order to ensure that the meaning is clear and in line with Nursing and Midwifery Council record-keeping guidance.

Summary

Miss C raised a number a number of concerns about the care and treatment her daughter (child A) received when she attended Raigmore Hospital. In particular, she complained that staff failed to listen to her and this had an adverse effect on her daughter. Miss C also complained that there was an unreasonable delay in obtaining a jejunal feeding tube (a small tube that is passed through the nose or mouth and into the small intestine).

We took independent advice from a consultant general paediatrician. The advice we received and accepted was that, overall, the care and treatment child A received was reasonable. However, we were concerned about the delay in obtaining the jejunal feeding tube. The adviser also said that there was no evidence in the medical records of an overarching plan for child A's care and that, overall, the communication with Miss C was not adequate for her needs. We upheld Miss C's complaint. During our investigation the board met with Miss C and agreed to discuss ways in which they could improve communication with her around medical issues whilst her daughter was in hospital.

Recommendations

We recommended that the board:

• consider how staff might escalate matters when there appears to be unnecessary delays in obtaining specialist items, such as jejunal tubes, which are not kept in hospital and which result in delays in treatment;
• provide an update on the improvements implemented in relation to the communication with Miss C around medical issues whilst her daughter is in hospital; and
• consider the adviser's comments, particularly in relation to the need for an overarching care plan agreed with Miss C, in future admissions to hospital.

Summary

Mrs C raised a number of concerns about the care and treatment provided to her late mother (Mrs A). She said that the board had failed to appropriately investigate her mother's symptoms and that this led to a delayed diagnosis of a brain tumour.

Mrs A was admitted to Raigmore Hospital following a seizure. She was evaluated by the Stroke Team and various procedures were carried out including a CT scan (a scan that uses a computer to produce an image of the body) and an electroencephalogram (EEG - a test that measures and records the electrical activity of the brain). The results were reported as normal and Mrs A was discharged a few days later.

Around five months later, Mrs A was readmitted to Raigmore after suffering a further seizure. She was admitted to Nairn Hospital soon after this with a history of a loss of consciousness and episodes of twitching and seizures. There were further episodes in hospital. It was thought that these were likely epileptic seizures and an antiepileptic drug was prescribed. Mrs A was again discharged. Around seven months later, Mrs A attended a follow-up appointment at Raigmore Hospital, and the following day was admitted to A&E at Perth Royal Infirmary where Mrs C was advised that Mrs A had a brain tumour.

During our investigation, we took independent advice from a consultant neurologist. We found that, while some aspects of Mrs A's care and treatment were reasonable, there was an unreasonable delay in performing an MRI (magnetic resonance imaging - a scan used to diagnose health conditions that affect organs, tissue and bone) of her brain. This should have been arranged within four weeks of Mrs A's admission after the loss of consciousness and seizures.

We found that it was appropriate that the board started Mrs A on antiepileptic medication but that the subsequent monitoring of the medication and her condition were not reasonable. We found that there was a delay in Mrs A receiving a follow-up appointment at the neurology clinic, as best practice would have been to arrange out-patient review within a few weeks of discharge. It would also have been good practice to have involved an epilepsy specialist nurse in Mrs A's care. We also found that the management of Mrs A at the follow-up appointment fell short of best practice.

Recommendations

We recommended that the board:

• apologise to Mrs C for their handling of this matter;
• ensure that the relevant clinical teams are aware of the latest Scottish Intercollegiate Guidance Network and National Institute for Health and Care Excellence guidelines on the management of strokes, transient ischemic attacks (or 'mini' strokes) and epilepsy, and the requirements for prompt neuroimaging;
• ensure that the consultant neurologists are aware of the limitations of EEG in the diagnosis of epilepsy and that they reflect on the adviser's comments at their next appraisal; and
• consider the adviser's comments that it would be good practice to provide epilepsy specialist nurse care to patients with epilepsy.

Summary

Ms C was pregnant with twins when she was taken to Raigmore Maternity Unit by paramedics. She was found to be in premature labour and despite attempts to stop her contractions, her twins were delivered prematurely with very low birth weights. Ms C was 20 weeks pregnant at the time of the delivery and her twins did not survive. Ms C complained about the care and treatment that was provided to her and the twins. She also complained about the information and advice provided by the board on taking the babies away from the hospital. Ms C was concerned about the board's final response to her complaints as she felt this took a long time to be issued and contained a lot of mistakes.

After taking independent advice on this case from a midwife, an obstetrician, a neonatologist and a consultant physician, we did not uphold Ms C's complaints about the care and treatment. The advice we received was that the care was appropriate and no failings were identified in this regard. We also did not uphold her complaint about the information or advice that was given on taking the babies away from the hospital as this was considered to be reasonable in the circumstances. We did, however, make recommendations in this respect.

We upheld Ms C's complaint about the board's final response to her concerns. We found that while the response was issued within a reasonable timescale, there were a number of factual errors with details such as dates.

Recommendations

We recommended that the board:

• consider the introduction of a booklet for bereaved parents to assist staff in providing information;
• provide a specific apology for the error in the times of death noted on the removal forms;
• apologise for the issues identified with their final response; and
• review their process for fact-checking decisions before issue.