Health

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.

Summary

Mr A's mother and partner complained about the care that Mr A received from the medical practice after he visited them with a number of different symptoms including tiredness, sweating and backache. Mr A was later diagnosed with testicular cancer and they felt that doctors has incorrectly attributed his symptoms to his existing long-term condition. They were concerned that there had been a failure to conduct appropriate investigations as a result and that an emergency hospital referral should have been made when Mr A's condition deteriorated.

After taking independent advice from a GP, we did not uphold these complaints. We received advice that there was no evidence that doctors had attributed Mr A's symptoms to his existing condition and we found that they had arranged appropriate investigations to determine the cause of his illness. The adviser also considered that the practice had made appropriate timely referrals for Mr A.

Summary

The mother and partner of Mr A complained about the care and treatment that he received from Dumfries and Galloway Royal Infirmary following a lung biopsy. The biopsy was carried out after a scan indicated the spread of cancer to the lungs and Mr A was later diagnosed with testicular cancer. Mr A's mother and partner were concerned that he did not receive timely treatment following the biopsy. They also felt that Mr A should have been admitted to hospital, rather than being discharged home to await the biopsy results.

After taking independent advice on this case from a consultant physician and a consultant urologist we upheld the complaint that Mr A had not received timely treatment. The advice we received was that the pathology team had not been provided with all the relevant clinical information to help them accurately report the primary site of Mr A's cancer. The advisers also both considered that there had been an unreasonable delay in arranging a specific blood test that can highlight testicular cancer. We considered that the delay in arranging this test was unreasonable as earlier scans had pointed towards testicular cancer and clinicians should have been aware of the potential for this diagnosis. The advice we received was also critical that there was not a more proactive approach to Mr A's care following a urology referral and that his case was not discussed with oncology when it became clear that there would be a delay in the biopsy result becoming available. We made a number of recommendations to address these findings.

We did not uphold the second complaint regarding the decision to discharge Mr A following his biopsy. The advice we received was that it was clinically safe to discharge Mr A and that the board should have been able to manage his care as an urgent patient without admission being necessary.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• take steps to ensure that all relevant clinical information is supplied to pathology to assist their analysis of biopsy samples;
• discuss this case at an appropriate clinical governance meeting and highlight the findings of this investigation to relevant staff for reflection; and
• take steps to ensure that referrals are acted on in an appropriate and timeous manner.

Summary

Mr C complained to us about the care and treatment provided to his mother (Mrs A) at Dumfries and Galloway Royal Infirmary before her death. Mrs A's GP had referred her to hospital. At that time, she had end stage kidney failure, but did not want dialysis (a form of treatment that replicates many of the kidney's functions) for this. Mrs A died four days later and the cause of death was recorded as pneumonia. It was also recorded at that time that Mrs A had deteriorated despite antibiotics and that her kidney function had worsened. Mr C had subsequently complained to the board about the care provided to Mrs A.

We took independent advice on Mr C's complaint from a medical adviser who is a consultant geriatrician. We found that although it would have been better to carry out an x-ray on Mrs A on the night she was admitted rather than waiting until the following morning, this delay did not alter her treatment. It would, however, have given the clinicians and Mrs A's family more information about her condition. We also found that Mrs A had been able to make her own decisions and had expressed strong wishes that she did not wish to be subjected to cardiopulmonary resuscitation in the event of a cardiac arrest. Although the form confirming that she should not be resuscitated had not been countersigned by a senior doctor as required, the senior doctors had recorded their agreement with the decision in the notes.

It is difficult balance between very active care to keep patients alive and then switching to palliative care once it is clear they are dying. We found that, overall, the care provided to Mrs A before her death had been reasonable. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the care and treatment she received from the board at University Hospital Crosshouse following her inner labial reduction surgery (reduction of the two flaps of skin on either side of the vaginal opening). Her concerns included that the board failed to provide her with a reasonable standard of care when she reported problems after the procedure and that the entire area of tissue from the inner labia had been removed during subsequent corrective surgery without reasonable discussion or explanation.

We obtained independent medical advice on the case from a consultant gynaecologist. They said that at the first sign of post-operative problems, Mrs C should have been seen as a matter of priority and the surgeon who carried out the operation should not have refused to see her. The adviser said that the surgeon suggesting that Mrs C's GP contact the plastic surgery service was not appropriate and caused further delay in Mrs C's treatment. We therefore upheld this part of the complaint. However, we noted that the adviser said that they did not feel that the outcome would have been materially different if the subsequent corrective surgery had taken place sooner. We also noted that the board had taken appropriate remedial action as a result of Mrs C's complaint.

In terms of the corrective surgery, the adviser said that almost the entire area of the inner labia was removed without consent or proper explanation. We therefore upheld this part of Mrs C's complaint. Although we noted that the board had taken reasonable remedial action in relation to their consent process, we made two recommendations.

Recommendations

We recommended that the board:

• feed back our decision on Mrs C's complaint to the staff involved; and
• provide Mrs C with a written apology for the failings identified.

Summary

Miss C's baby was not lying properly, but was in the breech position (legs downward). After unsuccessful attempts to turn the baby, she was booked in for a caesarean section (an operation to deliver a baby which involves cutting the front of the abdomen and womb). However, several days before the planned caesarean, Miss C began experiencing labour pains and called Ayrshire Maternity Unit. She was asked to come in and was reviewed, then sent back home. Two days later she called again and was asked to come in. Miss C was then admitted and monitored on the ward. She was reviewed by a doctor on several occasions, but told she was not in active labour and a caesarean was planned for the following morning. However, Miss C continued to experience symptoms and a consultant reviewed her and found she was in active labour. Miss C was sent immediately to the labour suite, where her baby was born a few minutes later. Miss C complained about the advice she was given on the phone and the management of the birth, in particular that staff did not recognise that she was in labour and arrange an emergency caesarean.

Staff from the board met with Miss C to discuss her complaint. They explained that when she was examined by the first doctor her cervix was closed, which meant that she was not in active labour. They also explained that, because Miss C's baby was under 39 weeks, the doctor wanted to prescribe steroids and allow time for these to work before conducting a caesarean (to decrease the risk of breathing problems for the baby).

After taking independent obstetric and midwifery advice, we did not uphold Miss C's complaint. We found that Miss C experienced rapid labour, which could not have been predicted by staff, and the care and treatment was reasonable in light of the circumstances known to staff at the time.

Summary

Mr C was admitted to University Hospital Crosshouse with a suspected infection following shoulder surgery a few days earlier. He complained that he received poor care in relation to the infection that developed in his wound, which required treatment under three separate general anaesthetics. Mr C was dissatisfied with the nursing care in terms of the lack of access to a bathroom and a shower, as well as the way in which his medicines were administered. He also complained about the board's delay in responding to his complaint.

We took independent advice from medical and nursing advisers on the care and treatment Mr C received. We were critical of a lack of evidence showing that Mr C's wound had been examined by three different doctors who had reviewed him on the day of admission to hospital. We made a recommendation to address this failing. However, we considered the assessments and treatment carried out thereafter were reasonable. In terms of the nursing care, we found that there was good reason (because of infection control and the facilities in the high dependency unit) for Mr C not having specific access to a bathroom and shower.

We did not uphold Mr C's complaints about his medical and nursing care, although we did identify shortcomings in the prescribing of his medication and made two recommendations to the board about this. There was also an unreasonable delay of four months in the board responding to his complaint and we made a further recommendation to address the matter.

Recommendations

We recommended that the board:

• review their medicines reconciliation process to ensure that medication is prescribed and checked in a systematic manner;
• draw to the attention of the medical staff involved in Mr C's care the failure to review his heart rhythm to check whether he required to continue with the existing treatment or have any additional medication prescribed;
• review their handling of Mr C's complaint in order to identify ways in which they can ensure regular updates are given and keep any delays to a minimum; and
• share the adviser's comments with the three doctors involved in Mr C's care.

Summary

Ms C raised concerns that the there was a failure to reasonably inform her of her treatment options prior to having a laparotomy (a surgical procedure that involves an incision being made into the abdominal wall) at Western Isles Hospital. Two ultrasound scans of Ms C's pelvis, carried out six weeks apart, showed she had a cyst on her right ovary. Ms C said she initially understood that she was to have a laparoscopy (a surgical procedure to access the abdomen and pelvis) to treat the cyst and only learned at a pre-operative appointment that she was to have a laparotomy. The board accepted that more explanatory detail could have been provided to Ms C.

We took independent advice from a medical adviser who said that the entries in Ms C's medical records indicated that she was always to have a laparotomy, and as she thought she was having a laparoscopy, she evidently had not been given enough information to make an informed choice about her treatment options. Also, it was unclear if the risks of surgery had been explained to Ms C. Therefore, we upheld this part of the complaint.

Ms C also complained she had not been provided with reasonable care and treatment. When Ms C had the laparotomy, no cyst was found on her right ovary and she questioned this. The adviser agreed with the board that the most likely explanation was the cyst had ruptured before surgery. The adviser also said that overall, the care and treatment Ms C received was reasonable. We agreed with this and did not uphold this part of the complaint.

Ms C further complained that she was not provided with reasonable post-operative care. She said that following the laparotomy she suffered continuing abdominal pain and tenderness. The advice we received was that the symptoms Ms C was experiencing post-operatively were not unusual and would be expected. There was also no evidence she had a post-operative infection. While we did not identify any failings in Ms C's clinical care we considered there were failings in communication with Ms C and for this reason we upheld this part of the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failure to ensure that she understood the surgical procedure she was to undergo;
• provide evidence that clinicians have been advised to confirm with patients that they understand the procedure they are to undergo and that this information and any comments made by the patient will be recorded in the patient's case records;
• ensure that where the risks of surgery are explained to a patient, this information is clearly recorded in the patient's medical records;
• provide an update on the review and development of their obstetric and gynaecological protocols;
• consider investing in appropriate training to improve the communication skills of their medical staff; and
• feed back the outcome of this investigation to the relevant clinicians.