Health

Summary

Mr C said that his late father (Mr A) attended the GP practice on a number of occasions with symptoms indicating a serious condition. He said that the practice unreasonably failed to consider the possibility of bowel cancer and carry out appropriate tests, investigations and referrals. Mr A died a few months after several admissions to hospital where he was diagnosed with bowel cancer.

We took independent advice from a GP adviser. We found that the care and treatment provided by the practice was reasonable including that referrals and investigations were arranged within a reasonable time before Mr A's first admission to hospital. We also found no evidence suggesting that the practice failed to monitor Mr A appropriately when he was discharged from hospital.

Summary

Mrs C, who is an advocacy worker, complained on behalf of Mrs A about the care and treatment provided to her husband (Mr A). An abnormality was noted on a brain scan Mr A received and he was not informed of this until five years later, when he was told he had a tumour. A biopsy was then carried out but Mr A suffered a bleed in his brain as a result of the biopsy operation and was left significantly incapacitated and in need of residential care.

Mrs C complained that Mr and Mrs A were not informed about the existence of the brain tumour when it was first noted and that no follow-up action had been taken. The board noted that the abnormality was first thought to have been a stroke and it had not been confirmed as a tumour until more recently. We obtained independent medical advice from a consultant neurosurgeon and a general medical consultant. It was considered that the tumour could have been diagnosed much earlier had prompt follow-up been arranged. However, we were assured that treatment would only have been proposed if the tumour had grown in size or Mr A's condition deteriorated, meaning that this would have happened around the time treatment was ultimately considered anyway. We noted that Mr A was not informed of the findings of the initial scan and we concluded that this should have happened. We also concluded that these findings should have been followed up to allow a confirmed diagnosis to be made and communicated to Mr A. While we were satisfied that this delayed diagnosis did not significantly impact on his treatment, we upheld this complaint.

Mrs C also complained that the board had failed to explain to Mr A the risks attaching to the biopsy procedure. We observed that discussions surrounding the risks, including bleeding and brain damage, were documented in a clinic appointment note prior to the biopsy, and also on the consent form which Mr A had signed. We did not uphold this complaint.

Mrs C also complained about the board's handling of the complaint, including the timeliness and comprehensiveness of their response. We considered that the board's replies were unreasonably delayed and that they failed to adequately address all of the issues raised. We also noted that their complaint file did not appear to contain a full account of their investigation. We upheld this complaint.

Recommendations

We recommended that the board:

• ask the relevant clinicians to reflect on the findings of this investigation and ensure that appropriate action is taken in future to follow up on unexplained abnormalities, particularly when the clinical signs do not support the suspected diagnosis;
• ask the relevant clinicians to ensure that any unusual scan results are shared with the patient;
• apologise to Mr and Mrs A for the failure to share with them the findings of the initial scan, for the failure to follow this up, and for the consequent delay in confirming, and informing them of, Mr A's tumour diagnosis;
• ask complaints staff to reflect on the complaints handling failings this investigation has identified and take steps to ensure that their feedback and complaints handling procedures are fully adhered to;
• ask complaints staff to ensure that all correspondence relevant to their investigation of a complaint, including internal correspondence, is filed on their complaint file; and
• apologise to Mr and Mrs A for the failure to provide a clear, comprehensive and timely response to their complaint.

Summary

Mrs C, who works for an advice agency, complained on behalf of her client (Mrs B) who was concerned about the care and treatment given to her late mother (Mrs A) in Aberdeen Royal Infirmary. Mrs A had multiple sclerosis and was fed through a tube. Before her death in late 2014, she had been admitted to hospital on a number of occasions, mainly with breathing difficulties.

In mid-November 2014, Mrs A was admitted to hospital again, this time with diarrhoea and vomiting. Tests showed that her feeding tube was displaced and that she had colitis (inflammation of part of the large intestine) with a possible perforation (penetration of the organ wall). The situation was discussed with Mrs B and her mother and it was agreed that no surgery would be carried out. After being given antibiotics, Mrs A was noted to be improving although during her stay in hospital she also required treatment for a cyst.

Mrs A was discharged home in late November, but died later the same day. Mrs B believed that her mother had not been fit for discharge. She also complained that Mrs A had not been provided with appropriate care and treatment during her hospital admission and had not received a reasonable standard of nursing care.

We took independent advice from consultants in obstetrics and gynaecology and in gastroenterology, and from a nurse practitioner. We found that all of Mrs A's clinical care had been reasonable and appropriate but that aspects of her nursing care (particularly concerning washing and showering which led to a doctor asking the family to wash Mrs A) had not been, so we upheld that aspect of the complaint. Nevertheless, we found that Mrs A had been fit to go home on the day of discharge. While her death was unexpected, because of the number of diseases and conditions from which she suffered, there was no action that could have been taken to have prevented this.

Recommendations

We recommended that the board:

• make Mrs B a formal apology for the shortcomings identified in Mrs A's nursing care;
• advise us of the actions taken to ensure that patients with mobility issues can access shower facilities; and
• bring this complaint to the attention of the doctor who approached family members to wash Mrs A in order for the doctor to reflect on it as part of their appraisal/training plan.

Summary

Mr C, an advice worker, complained about the treatment which his client (Mr A) received when he attended a consultation. Mr A had a previous medical history of facial and arm weakness and was thought to have long-standing hydrocephalus (build-up of fluid on the brain). He saw a GP as he wanted to have further investigations in order to reach a diagnosis. Mr A felt the GP had dismissed his symptoms. Mr A was admitted to hospital two days later with worsening neck and back pain, increasing confusion, poor mobility, right upper limb weakness and urinary incontinence. Over the next six months Mr A was found to have stable chronic hydrocephalus along with possible abscesses (painful swellings caused by a build-up of puss) of his neck and the area between the spine and spinal cord. It was subsequently discovered he had chronic discitis (infection of the vertebral disc space). Mr A believed that the GP had dismissed his symptoms and that his condition had deteriorated because of the delays which he had encountered.

We took independent medical advice from a GP and concluded that the GP had provided a reasonable level of care. When Mr A had attended the consultation the GP was aware of Mr A's medical history, including that he had attended hospital the previous day. He carried out an appropriate examination given the symptoms which were presented. There was no indication at that time for a hospital admission. It was clear from the records that Mr A's condition deteriorated two days after the GP consultation and it was only then that a hospital admission was appropriate. We did not uphold the complaint.

Summary

Miss C complained about the care and treatment received by her late father (Mr A). Mr A had an MRI (magnetic resonance imaging) scan at Forth Valley Royal Hospital to investigate leg weakness. The scan revealed an incidental finding of a six centimetre abdominal aortic aneurysm (AAA - a bulging of the aorta, one of the largest blood vessels in the body, which runs from the heart to the legs). This had not yet been shared with Mr A when he took unwell a few days later and, while being transported to hospital in an ambulance, he went into cardiac arrest and died. Miss C complained about the time taken to share and act upon the findings of the MRI scan.

The board informed Miss C that, in line with normal practice, the MRI was flagged for urgent reporting within two to three days. They explained that immediate intervention would only be arranged where there was evidence that the AAA had ruptured, which there was not in Mr A's case. They noted that the MRI was reported three days later and an urgent referral was made to the vascular team two days after that. This was the day of Mr A's death. The board noted that further tests would have been required and the national target for elective treatment of aneurysms is 42 days. They therefore considered that even if Mr A had been referred to the vascular team on the same day as the MRI scan, it would have been a few weeks before he received treatment.

We took independent medical advice from a consultant physician. They noted that, while they could not be certain of the cause of death, the risk of the AAA rupturing was low and that the board attributed Mr A's death to a heart attack. They noted that Mr A did not have any symptoms suggestive of a rupture at the time of his scan and they considered that the scan was reported and acted on within an appropriate timeframe. We accepted this advice and concluded that the outcome could not reasonably have been prevented.

Summary

Mrs C complained about the level of pain she experienced during a colonoscopy procedure (an examination of the bowel with a camera on a flexible tube) at Forth Valley Royal Hospital. Mrs C's pain was very bad and the procedure had to be stopped. Mrs C felt that the level of pain that she experienced was caused by failure to give her appropriate sedative and pain medication prior to the procedure. Mrs C highlighted that she had previously undergone the same procedure at another hospital with no ill effects.

After taking independent advice from a consultant colorectal surgeon, we did not uphold Mrs C's complaint. The adviser reviewed the medication that Mrs C received prior to the procedure and confirmed that this was appropriate. The adviser noted that Mrs C had previously had a similar procedure at another hospital and advised that whilst the reasons why this type of investigation can be successful for the same patient on one day but not another are not clear but that is sometimes the case. It was also noted that Mrs C had undergone major abdominal surgery in the past and the adviser explained that adhesions (scar tissue that can make tissues or organs inside the body stick together) can cause pain during colonoscopy procedures.

Although Mrs C's complaint was not upheld, the adviser pointed out that some of the patient information and other guidance did not appear to be current or was due for review, and also that the consent form for the procedure had not been countersigned. We made a number of recommendations to address these issues.

Recommendations

We recommended that the board:

• review their internal guidance and patient information leaflets in relation to colonoscopy procedures to ensure they are current;
• confirm the adviser's comments will be considered during the next review of the pre-procedure patient information leaflet and consent form; and
• take steps to ensure that all endoscopy consent forms are appropriately countersigned.

Summary

Mr C complained that the board had failed to carry out the hernia surgery at Forth Valley Royal Hospital that he had consented to and that they had failed to provide him with appropriate treatment following the surgery. Mr C said as consequence he suffered from regular and severe pain, which impacted on his quality of life and ability to work.

We found Mr C underwent surgery in the summer of 2012 without incident, although he did then attend the A&E department at the hospital complaining of pain at the wound site. He was examined and discharged as no cause for alarm could be identified. Mr C was reviewed in late 2012 and early 2013, and although a further review appointment was made, Mr C did not attend. In the absence of contact from Mr C, no further appointments were offered.

Mr C was re-referred by his GP and seen in 2015. He was reviewed in clinic by the surgeon who had performed the operation and provided with a scan of the area, which confirmed that the hernia had not reoccurred. Mr C was unhappy with the outcome of this review and a second opinion was arranged.

We took independent advice from a consultant colorectal surgeon, who said that the treatment Mr C had received was appropriate. The relevant consent documents had been filled in and signed and the operation had been performed in accordance with normal surgical procedure. There was no evidence that the operation performed was not the one Mr C consented to. The adviser also said the reviews of Mr C had been carried out appropriately post-surgery and it was reasonable to have referred him for a second opinion when the relationship with medical staff broke down.

We found there was no evidence Mr C had not consented to the operation performed on him, or that he had received inadequate care following the second surgery and did not uphold the complaint.

Summary

Ms C complained about the care and treatment she had received from her former GP practice. Ms C felt that doctors there had not managed an ongoing medical condition effectively and that there had been a delay in treating her acne. Ms C was also concerned by the practice's approach to her mental health.

After taking independent advice on this case from a GP, we did not uphold Ms C's complaint. The advice we received was that there were no failings in the care or treatment of Ms C's physical or mental health. The adviser reviewed Ms C's medical records and commented that her acne had been appropriately treated on the first occasion it was mentioned in her notes. They advised that responsibility for managing her ongoing condition lay with the local NHS board, rather than the practice, and that appropriate action had been taken in relation to Ms C's mental health.

Summary

Ms C raised her concern that there was an unreasonable delay by clinicians in diagnosing that she was suffering from ovarian cancer.

During our investigation, we took independent advice from a consultant gynaecologist. The advice we received and accepted was that while Ms C had been treated for possible precancer of the cervix from 2005 until 2011 this had no relation to her development of ovarian cancer and that there is no screening test for ovarian cancer. Even had Ms C's ovarian cancer been diagnosed earlier, in her circumstances, the treatment would have been the same - a total hysterectomy. We found no evidence that there had been an unreasonable delay by the clinicians in diagnosing that Ms C was suffering from ovarian cancer. However, we were concerned that while there had been discussions about Ms C's situation during the period she was being treated for possible precancer of the cervix, she was not made aware of these discussions, so we made a recommendation to the board about this.

Recommendations

We recommended that the board:

• report back on the action taken as a result of this case to improve communication with patients.

Summary

Mrs C complained that staff at the Victoria Hospital had failed to perform her hip surgery in an appropriate manner. We took independent advice on Mrs C's complaint from an adviser, who is a consultant trauma and orthopaedic surgeon. The adviser said that although the operation note in Mrs C's medical records indicated a completely satisfactory procedure, there were no images in the medical records to show the position of the implant in Mrs C's hip at the end of the operation. It was therefore impossible for the adviser to comment on the adequacy of the surgery carried out. However, they said that an image should have been taken to show the position at the end of the procedure and the fact that there was no such image in the records we received from the board amounted to a failure in record-keeping. We upheld this aspect of Mrs C's complaint for this specific reason and made the board aware of the adviser's comments.

Mrs C also complained that staff had failed to provide her with appropriate treatment following the hip surgery and this resulted in the amputation of her leg. It had been identified that Mrs C had sepsis (blood infection) at the time of her hip surgery. We found that the care and treatment she had received for this had been reasonable. The advice we received was clear that Mrs C's leg had been amputated due to a blocked artery and this had nothing to do with her previous hip surgery. Consequently, we did not uphold this aspect of Mrs C's complaint.