Health

Summary

Mrs C complained about a delay in diagnosing her late mother (Mrs A)'s brain tumour. Mrs A attended A&E on six separate occasions over a six month period (five attendances at Hairmyres Hospital and one at Wishaw General Hospital), with symptoms of dizziness, fainting and disorientation. Her third attendance resulted in a hospital admission, where abnormalities with her heart were identified and a pacemaker was fitted. When her symptoms continued and she attended A&E for a fourth time, she was referred to neurology for a routine out-patient appointment. She had two further A&E attendances while she waited for this, with the second resulting in a brain scan, which diagnosed a brain tumour. She was transferred to a hospital in another health board area for urgent surgery but unfortunately this was unsuccessful and she did not regain consciousness. She died ten months later.

Mrs C considered that a brain scan should have been carried out earlier. We took independent medical advice from a consultant in emergency medicine and a consultant physician. We were advised that it was reasonable for a cardiac cause of Mrs A's symptoms to have been pursued initially. However, it was noted that she had new symptoms when she attended A&E for the fourth time, having had her heart problem addressed. We concluded that a brain scan should have been considered at this point. We also identified that there was a further opportunity to diagnose the brain tumour earlier, at Mrs A's penultimate A&E attendance. On this occasion, A&E staff considered that admission was warranted, but the on-call physician decided to discharge her, pending pre-planned follow-up, without seeing her. We were critical of this. We upheld the complaint and made a number of recommendations, including one about record-keeping as the board could not locate the records from one of Mrs A's A&E attendances.

Recommendations

We recommended that the board:

• provide Mrs C with a written apology for the failings identified in this investigation;
• ensure that all relevant staff are made aware of the outcome of this investigation, including those no longer employed by the board;
• take steps to have this complaint included for discussion at the annual appraisals for all relevant staff, including those no longer employed by the board, to ensure learning opportunities are captured; and
• take steps to ensure that Hairmyres Hospital is complying with 'Records Management: NHS Code of Practice (Scotland)' following the missing A&E attendance records.

Summary

Mrs C complained to us about the board's assessment of the eligibility of her late mother (Mrs A) for NHS continuing health care (a package provided and solely funded by the NHS). During our investigation, the board told us that they had identified that they had incorrectly told Mrs C's family that they had previously exhausted the appeals process. They said that the family should have been informed that they could request a further appeal. The board apologised for this and said that they would be happy to consider a further appeal. We discussed this with Mrs C and she confirmed that the family wanted to submit a further appeal to the board. In view of this, it was agreed that we would close her complaint to this office.

Summary

Miss C complained to us about the failure of a GP at the out-of-hours service at Wishaw General Hospital to provide her with appropriate treatment when she attended with symptoms of severe abdominal pain. Miss C explained that she had told the GP that she had also fainted and that she had had a contraceptive coil removed five days previously. The GP felt that Miss C had either an ovarian cyst or menstrual pain and gave Miss C an anti-sickness injection and told Miss C to go home and see her own GP in the morning. Miss C's pain became unbearable and she re-attended the hospital and was admitted with a diagnosis of an ectopic pregnancy (when the egg implants itself outside the womb). Miss C believed that the GP was wrong to have discharged her home earlier.

We took independent advice from a GP adviser and concluded that although the GP had carried out an appropriate examination, they should have carried out a pregnancy test when Miss C first attended the hospital. We felt that it was unreasonable for the GP to have assumed that Miss C could not have been pregnant because she had only recently had the contraceptive coil removed. We noted that the GP had subsequently realised that they should have carried out a pregnancy test and that they would ensure that they would, in future, carry out a pregnancy test in women of child bearing age who presented with similar symptoms. We upheld Miss C's complaint. However, we did not make any recommendations as the board had already apologised for the failure to perform the pregnancy test and the GP had conducted a significant event analysis of this case.

Summary

Mrs C was recovering from breast cancer and had previously been diagnosed with truncal lymphedema (fluid affecting the trunk and/or breast following breast cancer treatment). Mrs C had therefore understood that she should be treated urgently if she became unwell. As she was experiencing pain between the shoulder blades, Mrs C was taken by ambulance to A&E at Monklands Hospital, where she was assessed by a registrar and a consultant, and then discharged with a prescription for pain medication.

Mrs C complained there was a failure to carry out an adequate clinical assessment, a failure to provide adequate nursing care and an unreasonable delay in assessing and treating her. Mrs C was also unhappy about the attitude of staff towards her. The board said that Mrs C had behaved unreasonably towards members of A&E staff.

We took independent advice from a medical adviser and a nursing adviser. We found that while the majority of Mrs C's care and treatment was reasonable and she suffered no adverse outcome, the doctors who treated Mrs C should have sought information on truncal lymphedema, and there was no evidence they did so. In addition, the registrar had failed to record their consultation with Mrs C in her medical records. Therefore, we upheld Mrs C's complaint that there was a failure to carry out an adequate clinical assessment. However, we did not find evidence that there had been a failure to provide Mrs C with adequate nursing care or that there had been an unreasonable delay in assessing and treating her, and we did not uphold this part of Mrs C's complaint.

Mrs C attended the out-of-hours service at Monklands Hospital approximately two weeks later because she was concerned about having truncal lymphedema and that she possibly had shingles. Mrs C complained about the care and treatment she received and about staff attitude towards her. The advice we received from both advisers was that the care and treatment Mrs C received was appropriate, and we were unable to reach a conclusion on her complaint about staff attitude due to conflicting accounts. We did not uphold this part of Mrs C's complaint.

Recommendations

We recommended that the board:

• consider organising a consultation between A&E and the oncology department at Monklands Hospital and Mrs C's GP with a view to putting a care plan in place and to sharing the plan with her;
• remind relevant staff of the importance of ensuring that consultations and discussions with a patient are recorded in the patient's medical records; and
• provide evidence that nursing staff in A&E have been reminded of the need to routinely record a patient's pain score.

Summary

Miss C's mother (Mrs A) was diagnosed with diverticular disease (disease of the colon) a number of years ago, but did not experience any symptoms from this and was not on medication.

Mrs A was admitted to Monklands Hospital with symptoms of abdominal pain, vomiting and weight loss and was treated for a urinary tract infection. A possible diagnosis of diverticulitis (a condition related to diverticular disease, where the abnormalities in the large intestine become inflamed or infected) was made but she was discharged for follow-up as an out-patient.

Mrs A was then admitted to Hairmyres Hospital a few days later and diagnosed with diverticulitis. Staff had planned to treat her conservatively (without surgery) for a few days, but to consider surgery if she did not improve. Mrs A suffered a heart attack during this time, and the cardiac team advised that surgery should be avoided if possible. While Mrs A initially improved, her health then deteriorated and became critical due to septicaemia (blood poisoning). Emergency surgery was carried out, but Mrs A passed away a few hours after the surgery.

Miss C complained about Mrs A's discharge from Monklands Hospital and the delay in offering surgery. She also raised concerns about nursing care, including pain management. The board met with Miss C and her family and apologised for some aspects of Mrs A's care. They also conducted a Significant Adverse Event Review (SAER) which identified a number of failings in care, including pain management and record-keeping, as well as a delay in carrying out the emergency surgery. However, Miss C was not satisfied with this response and she brought her complaint to us.

After taking independent medical and nursing advice, we upheld most of Miss C's complaints. We found the discharge from Monklands Hospital was unreasonable in view of Mrs A's condition and, while it was appropriate not to offer Mrs A surgery until her condition deteriorated (in view of the risks), we found the delay in arranging emergency surgery at this point was not reasonable. We also found failings in communication and nursing care at Hairmyres Hospital, particularly in relation to pain management and appropriate use of the MEWS (Modified Early Warning System) - although we noted that the board had taken some action to address these issues as a result of the SAER.

Recommendations

We recommended that the board:

• feed back our findings about the inappropriate discharge of Mrs A from Monklands Hospital to the staff involved for reflection and learning;
• review their process for auditing that the MEWS is being used appropriately, including escalation where appropriate to a more senior practitioner when patients deteriorate;
• apologise to Miss C for the failings identified in our investigation; and
• feed back our findings to the medical and nursing staff involved at Hairmyres Hospital for reflection and learning.

Summary

Miss C complained to us about the care and treatment provided to her partner (Mr A) at Hairmyres Hospital before his death. Mr A had been admitted to hospital because of increasing breathlessness. He was diagnosed with heart failure and subsequently discharged from hospital. However, he was readmitted to hospital two days later. It was initially thought that his heart failure had worsened, but when scans were carried out, it was identified that he had pulmonary fibrosis (a rare condition causing scarring of the lungs).

Miss C complained about the delay in diagnosing that Mr A had pulmonary fibrosis. We took independent advice on this aspect of Miss C's complaint from a medical adviser, who is a consultant in general medicine. We found that the findings from the scans and tests carried out when Mr A was initially admitted to hospital were not in keeping with a diagnosis of heart failure. We considered that Mr A should have remained in hospital and undergone further investigations to determine the cause of his symptoms and we upheld this aspect of Miss C's complaint.

Miss C complained that the board had failed to provide Mr A with appropriate medication when he was discharged from the hospital for a second time. We took independent advice on this complaint from a medical adviser, who is a consultant respiratory physician. We found that home oxygen therapy and other palliative options to alleviate Mr A's symptoms of breathlessness and lethargy should have been considered before he was discharged from hospital. We upheld this aspect of Miss C's complaint. That said, Mr A was suffering with severe pulmonary fibrosis, which was rapidly progressing when he was initially admitted to hospital and this would not have altered his prognosis. We also upheld Miss C's complaints that staff had failed to discuss the seriousness of Mr A's condition with him and his family and that he had been transferred between wards on an excessive number of occasions.

Recommendations

We recommended that the board:

• issue a written apology for the failings identified during our investigation;
• make the medical staff involved in Mr A's care and treatment aware of our decisions on Miss C's complaints; and
• remind the medical staff of the importance of communicating effectively in cases that involve severe life-threatening disease and of the importance of recording this communication in the medical records.

Summary

Miss C's young daughter (Miss A) has suffered gastrointestinal problems for most of her life and has had many hospital admissions. Miss C complained that she was treated unprofessionally and made to feel uncomfortable and inadequate by staff at Raigmore Hospital. She said that meetings were held behind her back and she was given very little notice about a multi-disciplinary meeting held to discuss her daughter's care. Miss C complained that the board failed to communicate with her appropriately about her daughter and that her daughter had not been provided with appropriate clinical treatment.

The board apologised if Miss C had been made to feel uncomfortable and said that this had not been their intention. They also said that meetings held to discuss Miss A had been routine and in her best interest; they said that she had been treated appropriately.

We took independent advice from a consultant paediatrician and we found that while Miss A's initial care was reasonable, given her longstanding problems, her admission to hospital to consider her symptoms should have taken place earlier than it did. Also, by the time a specialist dietician became involved in her care, Miss A had dietary deficiencies which had been likely to have been present for some time. We were also critical that some of the dietician notes were not available when we asked for Miss A's full medical record, so we made a recommendation to address this issue.

In relation to the way the board communicated with Miss C, the evidence showed that Miss C was given very little notice of a multi-disciplinary meeting held to discuss her daughter's care. There appeared to have been no effort to arrange a suitable date and time with her and she was put under unreasonable pressure to attend. We also found that she had not been given an explanation for meeting to discuss a child plan for her daughter. We therefore upheld Miss C's complaints.

Recommendations

We recommended that the board:

• make a formal apology to recognise the shortcomings in Miss A's care;
• ensure that the findings of this complaint are fed back to staff;
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)';
• make a formal apology for what happened in connection with the multi-disciplinary meeting, and also for failing to provide reasons why it was intended to hold a child plan meeting; and
• ensure that where discussions take place between professionals, an appropriate record is kept on file.

Summary

Ms C complained about the nursing and medical care received by her brother (Mr A) over two admissions to Belford Hospital. Mr A's first admission was due to severe abdominal pain and vomiting. He was treated and discharged the same evening. Mr A's second admission was two days later after he was found disorientated in his home. He was assessed and a request was made for an out-of-hours (OOH) scan of his brain. This was refused and the scan was not carried out until the following morning. The scan showed bleeding on Mr A's brain and he was transferred to another hospital for surgery. Ms C also complained that the board had failed to respond appropriately to their complaint.

Ms C said Mr A was not properly assessed during his first admission. She said he should not have been discharged after receiving morphine and said Mr A had no memory of when he was discharged or how he got home.

Ms C said Mr A had been left in soiled clothing during his second admission, which had been distressing for his family. She said nursing staff had failed to provide personal care until the family had insisted. Ms C also said the failure to perform a brain scan sooner had put Mr A's life in danger. Ms C said the family had repeatedly told medical staff they believed Mr A was displaying symptoms of a brain injury.

We took independent medical advice from a consultant physician. The adviser said that Mr A's care and treatment during the first admission was adequate. However, the adviser said that Mr A was displaying sufficient symptoms of brain injury to justify OOH scanning earlier than he received the scan. This was unreasonable and should have been addressed in the board's complaint investigation.

We also took independent advice from a nursing adviser. They noted the records showed that staff had attempted to provide personal care to Mr A during his second admission, but that he had not been compliant.

We found the nursing care provided to Mr A was of a reasonable standard. However, we found that the medical care was not, since he should have had a brain scan sooner, although this delay did not impact on the outcome of his treatment. We also found the board's complaint response contained inaccuracies and Ms C's complaint was not investigated to a reasonable standard. We made recommendations to address the failings we identified in these different areas.

Recommendations

We recommended that the board:

• review their local protocol on the management of patients displaying abnormal brain function to ensure it is in accordance with Scottish Intercollegiate Guidance Network (SIGN) guidelines 107 and 108 which relate to the management of headache in adults and patients with strokes;
• draw the attention of the radiologist in this case to the requirement of SIGN guideline 108 for imaging for patients with suspected stroke;
• ensure the reasons for any delay in a complaint response are fully explained at the appropriate time;
• review this complaint to establish why the final response contained inaccuracies; and
• apologise in writing for the failings identified in this investigation.

Summary

Mr C, who works for an advice agency, complained to us on behalf of Mr A that the board had failed to diagnose what was causing his hypoglycaemia (low level of glucose in his blood). Mr A had been diagnosed with type 1 diabetes as a child. In his early twenties, he started to have hypoglycaemic episodes and was told to reduce his doses of insulin. He continued to have these episodes and was admitted to hospital on a number of occasions to be monitored.

We took independent advice on the complaint from a medical adviser, who is a consultant in medicine and endocrinology. We found that Mr A's recurrent hypoglycaemia had been promptly and appropriately investigated by the board and they had reasonably tried to manage this by giving him an insulin pump. We did not uphold this aspect of the complaint.

Mr C also complained that nursing staff had failed to provide reasonable treatment to Mr A when he was in Broadford Hospital. However, we found that the nursing staff had acted appropriately and we did not uphold this complaint.

Finally, Mr C complained about the board's handling of Mr A's complaint. We found that there had been an unreasonable delay by the board in responding to the complaint, although they had apologised for this delay in their response to Mr A. The board had also failed to respond to Mr A's complaint about nursing staff in Broadford Hospital. In view of these failings, we upheld this complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr A for failing to respond to all of the issues he had raised in his complaint; and
• make the staff involved in the handling of Mr A's complaint aware of our decision.

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Raigmore Hospital. In particular, Mrs A said that the hospital failed to communicate adequately with her and her family during her admission. She also said that the hospital failed to provide an appropriate standard of nursing care or appropriate medical treatment.

We took independent advice from a nursing adviser and a medical adviser who is a hospital consultant. We found that the level of communication with Mrs A and her family was reasonable, as was the level of communication between medical staff. However, our investigation showed that the board failed to provide Mrs A with an appropriate standard of nursing care. We were mindful that the board had accepted there were failures in relation to nursing care and had taken action to address these matters.

We found that the medical care and treatment Mrs A received in the hospital was reasonable.

Recommendations

We recommended that the board:

• consider the nursing adviser's comments about the overall standard of record-keeping and provide details about when the improvements to nursing documentation are to be implemented and evaluated;
• provide an action plan to address the failures in relation to nursing assessments and pain management identified in this case;
• consider the medical adviser's suggestion about the development of a care plan for Mrs A and report back to us on any action taken; and
• remind relevant staff of the need to label each page within medical records with the correct patient identification details.