Health

Summary

Mr C attended both his medical practice and A&E on several occasions with back, leg, neck and arm pain. After a visit to A&E, a scan was arranged and Mr C was referred to neurosurgery. He underwent surgery to improve his pain, although Mr C was advised that he will never be pain-free.

Mr C complained that the practice failed to take his condition seriously and contributed to a delay in his treatment. He also complained that the practice did not arrange a new prescription for painkillers in time for his discharge from hospital after surgery, despite him giving them notice of this. Mr C raised concerns that although he has been sober for several years, the practice was treating him differently due to his history of alcohol addiction.

We took independent advice from a GP. We found the practice made several referrals to neurosurgery and that Mr C did not attend the first appointment, although it is unclear whether Mr C received the letters. The hospital declined further referrals as a scan showed surgery was not appropriate for Mr C at that time. The adviser said there was no indication that Mr C's condition had changed until he attended A&E, when an urgent scan was arranged. The practice then made a further urgent referral to neurosurgery, which was accepted.

We also found it was reasonable for the practice not to have issued a repeat prescription for Mr C's medications until they had received the hospital discharge letter and Mr C had been reviewed by a GP. The adviser explained that this would be the same for all patients in this situation and that there was no evidence the practice had treated Mr C differently in view of his past history of alcohol addiction. We did not uphold Mr C's complaints.

Summary

Mrs C complained about the practice's handling of her cervical screening (commonly known as a smear test), and also about their response to her complaint.

Mrs C received a positive result from her smear test, and over the following year underwent investigations for suspected cancer. No cancer was detected and in looking into the matter, the board decided to look again at the original smear test result.

The board convened a Problem Assessment Group (PAG) with input from a public health specialist and investigated the circumstances. As part of the investigation they tested the DNA on the original smear test and identified two sets of DNA, Mrs C's and another, unidentified sample. The PAG was unable to say definitively how or when the test was contaminated with another DNA sample. The laboratory that tested the sample was confident contamination could not have occurred there.

The PAG concluded that the correct procedure in handling and processing smear tests had not been followed. All tests should be sent to the laboratory on the day taken or the next working day if done in the afternoon. The practice instead was sending batches of tests over a number of days or weeks. Women who had had smears around the same time as Mrs C were re-tested and none were found to have cancer.

We were not able to establish for certain how the DNA and that of another person ended up in the same sample. Clearly, an error had occurred, and the independent advice we took from a nursing adviser confirmed that the nurse who took the smear test had not followed best practice guidance. The adviser also noted that Mrs C's appointment was not recorded in her medical records; only the date the test was sent was noted, which had led to confusion about the date of Mrs C's test. We made a recommendation to address this.

We confirmed with the board that the nurse in question had discussed the incident at the time with senior staff at the practice and was now processing smear tests in the correct manner. We also noted that the practice had updated its cervical screening protocol in light of the incident. We therefore had no further recommendations to make.

While we noted that Mrs C had found the practice's approach to her complaint to be lacking in empathy, we did not find evidence to support this and so did not uphold this aspect of her complaint.

Recommendations

We recommended that the practice:

• provide reassurance that action has been taken to ensure that both the date of the appointment for the smear test and the date the test is sent to the laboratory are noted.

Summary

Mrs C complained about the care and treatment received by her husband (Mr A) during an admission to Cameron Hospital for rehabilitation following a spinal injury. She complained about various aspects of nursing care, particularly surrounding the fitting of, and monitoring of time Mr A spent in, his back brace. We took independent advice from a nurse. The adviser considered that this challenging aspect of care was appropriately considered across the multi-disciplinary team and that reasonable action was taken to achieve a suitable balance and ensure Mr A's comfort and dignity were maintained. Overall, the adviser considered that the standard of nursing care provided to Mr A was reasonable and we did not uphold this complaint.

Mrs C also complained about the standard of physiotherapy and occupational therapy care provided to her husband. She felt that Mr A only received a token programme of rehabilitation and also raised concerns about the occupational therapist's input during an assessment of their home prior to discharge. We were advised that the care provided to Mr A during his admission was reasonable. The adviser also noted that Mr A's discharge was complex to coordinate but considered there to be evidence of detailed planning by the multi-disciplinary team, overseen by the occupational therapist, in order to meet the family's needs in this regard. Overall, we concluded that the standard of physiotherapy and occupational therapy care provided to Mr A was reasonable and we did not uphold this complaint.

Finally, Mrs C complained about the communication between staff, and with her and her family. In particular, she complained that the nursing staff responded negatively to her raising concerns about Mr A's treatment. She said that the way she was spoken to by a nurse left her feeling unable to return to the ward to visit her husband. She did not consider that the board had sufficiently addressed her concerns in this regard. While the adviser found that the records demonstrated a reasonable standard of communication, it was recognised that there were significant difficulties in communication between healthcare staff and Mrs C's family, which led to a breakdown in relations. We were satisfied, however, that the board made reasonable efforts to resolve these difficulties and we did not uphold this complaint.

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.