Health

Summary

Mrs C was referred to a specialist bone clinic in relation to ongoing pain symptoms, but the doctors were not able to find an explanation for this and told Mrs C she had chronic pain syndrome. Mrs C was concerned that the doctors did not undertake any tests or investigations before concluding this.

Mrs C asked for a second opinion from a specialist outside the board's area, and they arranged an out-of-area referral. However, the out-of-area specialist was not able to offer any further explanation for Mrs C's pain. Mrs C was concerned that this was because the referral letter to the specialist was factually inaccurate and did not explain why a second opinion was being sought. She did not consider this review constituted a second opinion.

Mrs C complained to the board with a number of questions about her treatment. The board responded to this, but Mrs C was not satisfied with the response and asked a number of additional questions. The board said they had already responded to the best of their ability, and suggested that instead of engaging in correspondence they could arrange a further out-of-area referral for Mrs C if she wished. Mrs C agreed to this and a referral was arranged, but this specialist declined to see Mrs C as she had already been reviewed by two experienced doctors.

After taking independent medical advice from a consultant physician and rheumatologist, we did not uphold Mrs C's complaints about care and treatment. We found that the relevant investigations had already been arranged when Mrs C was reviewed in the bone clinic and it was reasonable for them to rely on the results of these. We also found that the referral was reasonable and Mrs C had received a second opinion (although this did not find any explanation for her pain). While we found the board's reply to Mrs C's complaint was reasonable, we were critical of delays and several administrative failings in their handling of the complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the complaints handling failings we found; and
• review their processes for handling repeat complaints correspondence (to ensure a quick and accurate response is given when a person has already completed the complaints handling procedure).

Summary

Mr C complained about the care and treatment provided to his mother (Mrs A) during her admissions to Monklands Hospital and Coathill Hospital. Mrs A was suffering from dementia when she was admitted with a urinary tract infection. Mrs A deteriorated whilst in hospital and died just over two months after admission. Mr C said he had visited his mother every day and repeatedly asked to speak with the consultant responsible for her care. He was not given an appointment for over two months. Mr C said Mrs A's medical notes also showed that his mother had been designated as not fit for resuscitation on the day of her admission to Monklands Hospital. Mr C had not been informed of this for two months despite having welfare power of attorney for Mrs A, who had only a very limited ability to communicate. Mr C said Mrs A's ring had gone missing and that staff had failed to look for it. Mr C added that the board's complaints process had taken too long and been inadequate. Mr C also complained that an advocate was inappropriately involved by medical staff against Mrs A's wishes and that staff refused to explain why. Mr C also complained Mrs A had been forced to attend a Christmas party, which her family did not want her to do.

We took independent medical advice on the care and treatment provided. The advice said that Mrs A's designation as not for resuscitation was a medical decision and did not need the family's approval. It should, however, have been discussed with them as a matter of good practice. The advice noted the paperwork for the decision was not properly completed and this had not been reviewed at any point during Mrs A's admission. The advice concluded that the standard of communication with Mr C had fallen below a reasonable standard and that he should have had the opportunity to discuss Mrs A's care much earlier in her admission. The reason for involving an advocacy service should have been recorded and it was inappropriate for board staff to imply that it was required due to difficulties in communicating with Mr C without evidence to support this. The advice also said whilst taking Mrs A to a Christmas party on the ward was done with kind intentions, it should have been discussed with Mr C and the failure to do this had caused the family great distress.

We found communication with Mr C fell below a reasonable standard. Records for the decision to designate Mrs A as not for resuscitation and referral to an advocacy service were not completed properly. These decisions should have been discussed with Mr C, but were not. We also found that staff failed to communicate appropriately about the missing ring and that the evidence did not show any significant effort being made to locate it, despite promises being made to the family. We upheld the complaint.

Recommendations

We recommended that the board:

• provide evidence that the actions identified in response to this complaint have been implemented;
• provide evidence of how they are monitoring the effectiveness of their new communication measures;
• review the process for discussing the decision to designate a patient as not for resuscitation with the patient or their carers, in light of the failure by medical staff to follow existing procedures in this case;
• remind ward staff of the need to ensure valuables are logged on admission, especially if the patient has a limited or impaired ability to communicate;
• provide evidence they have reviewed their procedures when items go missing so that staff are clear on the procedure to follow and information is shared appropriately between shifts; and
• review the process for referring patients to advocates to ensure that reasons for referral are clearly documented and discussed with the patient or their carers.

Summary

Miss C attended her GP after injuring her leg in a fall. Her pharmacist thought she might have a deep vein thrombosis (DVT) but after examination she was diagnosed as having a calf strain. However, her pain continued and the next day she attended Raigmore Hospital. She was diagnosed with a soft tissue injury to her lower leg. Over the next few days Miss C made three further visits to the A&E department and on her second visit she was seen by a nurse practitioner. A fracture was diagnosed and she was put in plaster. It was not until after another two visits that serious circulation problems were diagnosed but by this time, Miss C's leg was so affected that it required to be amputated below the knee.

We took independent advice from a consultant in emergency medicine. We found that the diagnosis of a soft tissue injury after the first visit to hospital had been a reasonable one. Miss C had been thoroughly and appropriately examined. The possibility of a DVT had been considered but there was no evidence of this. However, after her second unplanned visit to the emergency department, she should have been seen by a more senior doctor rather than a nurse practitioner. Her subsequent visits should also have been treated more seriously and a senior emergency doctor should have been involved. This did not happened and thus there was delay in diagnosing Miss C's condition. We upheld this aspect of the complaint.

Miss C also complained that the board failed to fully respond to points raised in her complaint and that they provided inaccurate information. The adviser said that he could see no evidence that the correspondence contained incorrect information and was satisfied with the action taken. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• apologise for the fact when Miss C made further unplanned visits to the emergency department, she was not seen by a more senior emergency doctor; and
• consider the root cause of the delay in diagnosis and the benefits of introducing a system where 'unplanned return' patients to the emergency department are seen by a senior emergency department doctor.

Summary

Mr C's late father (Mr A) was admitted to Lawson Memorial Hospital for several months for a period of rehabilitation following a stroke. He was then discharged to a care home but died two days later. The cause of death was established as methicillin-resistant staphylococcus aureus (MRSA), which came as a shock to Mr C and his family as it had not been communicated to them that Mr A had been diagnosed with this. Mr C complained about the lack of communication in this regard and also about a lack of treatment for MRSA.

We took independent medical advice from a hospital consultant who considered that the evidence available to demonstrate the clinical thinking behind Mr A's care was poor. They noted that Mr A's care was complex and that there would have been other factors for medical staff to consider. They said that more consideration should have been given to urine culture results and the potential for persistent infection. Consideration should also have been given to changing his catheter in line with NHS guidelines and the board's own policy on treating infections but there was no evidence that this happened. Neither was there any evidence of Mr A being informed of his diagnosis. The adviser said that this should have been communicated to Mr A and his permission sought to share this information with the family. We upheld this complaint.

Mr C also complained about the appropriateness of Mr A being discharged with MRSA. While Mr C considered that Mr A was still displaying symptoms of urine infection around the time of his discharge, we were advised that an appropriate medical review was carried out and no evidence was found to suggest that the discharge could not go ahead. We noted that the board's MRSA policy confirmed that a diagnosis of MRSA should not prevent discharge of a patient. We did not uphold this complaint.

Recommendations

We recommended that the board:

• feed the findings of this investigation back to relevant staff;
• arrange staff training on catheter related infections and MRSA;
• highlight to microbiology staff the importance of offering additional support to off-site wards in interpreting complex results;
• take steps to ensure future compliance with their MRSA policy, particularly in relation to the communication of a diagnosis to patients and carers;
• take steps to address the identified record-keeping failings and ensure future compliance with General Medical Council guidance in this regard; and
• apologise to Mr C for the failings this investigation has identified.

Summary

Ms C complained on behalf of Miss A who said she suffered from Jarisch Herxheimer's reaction (a severe but treatable reaction to antibiotics). Miss A said doctors at Raigmore Hospital had failed to treat her properly by refusing to accept that she suffered from this condition and refusing to admit her to hospital for a week-long course of supervised antibiotics that would have demonstrated that her condition was genuine.

We took advice from a consultant in infectious disease medicine. The advice said the condition was normally found in patients being treated with antibiotics for a specific type of bacterial infection, such as syphilis or Lyme disease. Miss A had been tested for these and been found to be clear of infection. She had also been tested for latent tuberculosis. The advice said Miss A's doctors had eliminated any possible infections that might cause the condition when treated with antibiotics. It would not be appropriate to provide antibiotic treatment to a patient without an identified infection. This could lead to an increase in antibiotic resistance both in Miss A and the general population, reducing the effectiveness of future treatments. It would also put Miss A at risk of side effects including possible significant bowel disease.

We found that Miss A had been provided with a reasonable standard of care and treatment. While it was acknowledged that Miss A had suffered a very distressing experience, there was no medical evidence to show she suffered from Jarisch Herxheimer's reaction and we did not uphold the complaint.

Summary

Mrs C, who works for an advice agency, complained to us on behalf of Miss A. Miss A had attended her medical practice after falling over on her ankle. Her appointment was made by her pharmacist, who thought Miss A might have a deep vein thrombosis (DVT, a blood clot in the vein). Miss A was examined by a doctor, who diagnosed a calf strain. She was advised to take pain relief.

However, Miss A's pain continued and she attended A&E on a number of occasions, where she was diagnosed with a fractured ankle. Miss A continued to report problems and was subsequently referred to a vascular surgeon (a surgeon who treats disorders of the circulatory system). A DVT was found and Miss A was required to have her leg amputated below the knee.

Mrs C complained to us that the practice failed to appropriately diagnose and treat Miss A and about the way they dealt with Miss A's subsequent complaint.

We took independent advice from a GP. They found that Miss A's diagnosis had not been unreasonable, that she had been appropriately examined and that her circulation was reasonably assessed. They also found that Miss A's complaint received a reasonable reply. We therefore did not uphold Mrs C's complaints. However, the adviser noted that Miss A's GP had not been alert to Miss A's early signs of PVD (peripheral vascular disease, or peripheral arterial disease (PAD)) which should have been followed up. We therefore made recommendations to address this.

Recommendations

We recommended that the practice:

• ensure that the GP familiarises themselves with the diagnosis and management of patients presenting with early PVD and discusses this at their next yearly appraisal; and
• takes steps to ensure that they are familiar with the presenting signs of PAD and its management.

Summary

Mrs C complained to us about the care, treatment and support provided to her son (Mr A) by the board's mental health services before his death from an overdose. We took independent advice on Mrs C's complaint from a psychiatrist. We found that the clinical care provided to Mr A by the mental health services was reasonable and was consistent with current practice. We also found that there had been appropriate communication with other relevant parties. It had been reasonable to delay psychotherapy treatment for Mr A as the uncovering of previous trauma during therapy can sometimes lead to distress and increased suicidal ideation. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained to us that the board had failed to communicate with her adequately about the significant event review that was carried out after Mr A's death. We found that the conduct of the review had been consistent with good practice and was reasonable. However, the completion of the review was delayed and there were also errors in the draft report that was issued. In addition, Mrs C had not been signposted to support in relation to bereavement. We upheld this aspect of the complaint.

Finally, Mrs C complained that the board had failed to deal with her complaints about Mr A's care and treatment appropriately. Whilst we recognised that there had been a large number of complex issues to cover, we considered that the time taken by the board to respond had been unreasonable. We upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• provide evidence that they have considered how they communicate with relatives and other interested parties where an investigation becomes protracted and delayed and whether setting a standard for this would be beneficial; and
• provide evidence of the steps they have taken to avoid delays of this nature in the future.

Summary

Mrs C said that she attended Gartnavel General Hospital in 2012 because of a persistent chronic cough. She was told that there were a number of potential causes for this but that a high resolution computerised tomography (HRCT) scan and other tests had been ordered to exclude any structural lung disease, in particular bronchiectasis (a chronic lung condition). The required tests were carried out and reported at clinic in January 2013. At this stage, it appeared that there was no evidence of bronchiectasis.

Mrs C said that she remained unwell and a repeat HRCT was ordered. Following this, she was told in September 2014 that she had bronchiectasis. Mrs C complained to the board that they had failed to diagnose her in early 2013 and that as a consequence she did not receive the required treatment. The board, however, maintained that she had been treated appropriately and that changes occurred in the period after her first HRCT.

We took independent advice from a consultant in respiratory medicine and we found that HRCT scanning was the 'gold standard' to determine whether or not bronchiectasis was present. On the first such scan there was no such evidence of this but this was found to be the case in 2014. While the impact of the diagnosis for Mrs C has been great, we found no evidence to suggest that this was as a consequence of any shortcoming on the part of the board.

Summary

Miss C complained about her son (Mr A)'s admission to the Langhill Clinic at Inverclyde Royal Hospital. Mr A was admitted with suicidal thoughts and diagnosed with personality disorder, but requested a second opinion. This was provided by a different psychiatrist about a week later, and supported the clinical team's view that Mr A did not suffer from a major psychiatric illness, with his presentation relating to personality traits and recent trauma and bereavement. The following day, Mr A was found to have taken illicit drugs while absent from the hospital on a day pass. In view of this and increasing incidents of aggression towards staff, the doctor decided to discharge Mr A the following morning. Mr A then became aggressive and staff called the police to escort him from the hospital. Miss C was concerned that Mr A was not appropriately assessed and felt he should not have been discharged so early. She also raised concerns about the board's handling of her complaint.

After taking independent psychiatric advice, we did not uphold Miss C's complaints. We found that Mr A received reasonable assessments which appropriately took into account his risk of self-harm. He was also given a second opinion when he requested this. We also found the discharge was reasonable and in line with the board's policy on the management of violence and aggression. In particular, we noted that Mr A's admission was intended to be short and there were numerous documented instances of aggressive behaviour not caused by a major psychotic illness. However, we found the board failed to handle Miss C's complaint in line with Scottish Government guidance as they did not accept her complaint at first because it was not in writing, there were significant delays in the investigation and there was no evidence that staff contacted Miss C to explain the delay.

Recommendations

We recommended that the board:

• apologise to Mrs C for failing to handle her complaint in a timely manner;
• feed back findings to the staff involved for reflection and learning;
• take action to ensure that all complaints to the clinic are appropriately recognised and acknowledged, including verbal complaints made to clinic staff; and
• put in place clear procedures to ensure that complaints are investigated within 20 days where possible, and that complainants are updated when the investigation is expected to exceed 20 days.

Summary

Mrs C's elderly mother (Mrs A), who suffered from dementia, was a patient in the Royal Alexandra Hospital. During her admission, members of Mrs C's family visited to find Mrs A naked and lying in a wet bed. Her pyjama top had been removed and her drip displaced, soaking the bed. The family complained and were advised that on two occasions in the hours before the incident, Mrs A was noted to be settled. They concluded that she had removed her top herself. Mrs C was unhappy with this as she believed that given her illness and debility, Mrs A could not have done this. She complained to us because she felt that the board had failed to investigate her concerns appropriately. She was also unhappy about the way they communicated with her.

We took independent nursing advice and we found that the board's investigations had been poor. There was no documentation in Mrs A's medical records to confirm that she had been settled, the incident had not been noted in the file and no statements had been taken from staff who were present on the ward at the time. While it was possible that Mrs A could have removed her top, the board made an assumption that she had done so. There was no mention of Mrs A wearing pyjama bottoms and this was both unacceptable and undignified. The board's complaint response, given the seriousness of Mrs C's complaint, was not a reasonable one. We upheld the complaints.

Recommendations

We recommended that the board:

• make a formal apology;
• emphasise to staff the importance of taking full and timely records;
• review their internal investigations process and consider whether this requires to be audited; and
• review the need for staff on the relevant ward to receive specific training and education regarding distressed behaviour in people with dementia.