Health

Summary

Mr C complained that a hospital unreasonably delayed communicating an abnormal microbiology report to the relevant consultant.

We were satisfied that Mr C had a more appropriate remedy for his complaint and we considered that it would be reasonable for Mr C to use this remedy rather than SPSO. We decided to discontinue our investigation into Mr C's complaint.

Summary

Mr C complained about a change that prison healthcare staff made to his medication dosage. He also complained that he had not been included in the investigation into his complaint.

We took independent advice from a medical adviser. Their view, which we accepted, was that Mr C's medication had been appropriately prescribed and so we did not uphold this complaint.

We also found that Mr C had been consulted during the investigation, and so we did not uphold this complaint either.

Summary

Mrs C raised concerns about the care and treatment she received at Aberdeen Royal Infirmary. She complained that she was provided with inappropriate gynaecological treatment for her reported symptoms, that her operation was cancelled on the day of the proposed surgery, and that she was discharged despite having received pre-medication. She complained that there was poor communication about her medication and about the rescheduled operation. She also complained that the length of time she would have to wait for the rescheduled operation was unreasonable.

We took independent advice from a consultant gynaecologist and a consultant physician. We were advised that both the treatment suggested and the management of Mrs C's medication were reasonable. We were also advised that the date given for the rescheduled operation meant that the board had failed to meet the target guarantee time in line with The Patient Rights (Scotland) Act 2011 and that, as such, the delay was unreasonable. However, the medical records demonstrated that alternative options had been discussed with Mrs C's GP. We were advised that Mrs C's operation would not be classed as medically urgent.

We were concerned that the board was unable to provide copies of Mrs C's medical records from her admission to Aberdeen Royal Infirmary and that therefore the adviser was unable to comment on the care and treatment provided after Mrs C was admitted to hospital, including her discharge and the level of communication.

While the medical records demonstrated there was some communication with Mrs C and her GP following the cancellation of the operation, we were not satisfied that this was adequate.

Recommendations

We recommended that the board:

• provide a plan detailing the changes which have been made to prevent a recurrence in relation to the failure to store medical records securely;
• apologise to Mrs C for the failings identified in this investigation; and
• remind relevant staff involved in this case of the importance of maintaining comprehensive records in line with General Medical Council guidance.

Summary

Mr C complained to us about the care and treatment he had received from the maxillofacial (the speciality concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) unit at Aberdeen Royal Infirmary. Mr C had been referred to the unit because of a lesion (an area of abnormal tissue) on his palate.

A biopsy (tissue sample) was taken out but two weeks later he suffered a bleed from the site of the biopsy and had to re-attend the hospital. The following morning, Mr C experienced another bleed and was again advised to attend the hospital. After experiencing a further bleed on the next day, he contacted the hospital and was given the option of readmission for the bleeding to be monitored. Mr C refused this as he was due to go into a private hospital the next day for prostate surgery.

Mr C was admitted to the private hospital for the prostate surgery. However, he suffered a serious bleed from the site of the biopsy and it was decided the surgery could not go ahead. Instead a maxillofacial consultant was called and they took action to stop the bleeding from Mr C's palate, in theatre under general anaesthetic. Mr C had to pay for this procedure. He subsequently complained about the care and treatment he had received from the board's maxillofacial unit.

We took independent advice on Mrs C's complaint from a specialist in oral and maxillofacial surgery. We found that the biopsy had been carried out in a reasonable manner. We also found that the treatment provided by the maxillofacial unit in response to Mr C's bleeding had been reasonable and appropriate. We did not uphold the complaint.

Summary

Mr C complained about his treatment at Victoria Hospital. Mr C had injured his shoulder and felt the care and treatment provided by A&E was not reasonable. Mr C said his examination had been inadequate and inappropriately carried out and that he had been referred first for physiotherapy, rather than orthopaedic examination.

Mr C's physiotherapist diagnosed a serious injury and Mr C was referred to an orthopaedic specialist. He underwent a scan and was told he was not suitable for surgery as he was too old and the joint had suffered too much wear and tear. Mr C received a further examination as part of a second opinion offered by the board. This examination found Mr C to be a suitable candidate for surgery and he underwent a successful operation.

Mr C complained that the delay in diagnosing his shoulder injury had affected his treatment and chances of making a full recovery. We took independent advice from a consultant in emergency medicine and from a consultant orthopaedic surgeon. We were advised that Mr C had been treated appropriately in A&E and that it was normal practice to refer patients for physiotherapy in such cases. However, we were advised that Mr C's orthopaedic treatment had fallen below a reasonable standard as Mr C was within an appropriate age range for treatment. We therefore found that Mr C's orthopaedic treatment had been unreasonable.

Mr C also complained that the board had not responded reasonably to his complaints. Although the board's responses had on occasion been delayed, we found that their responses to Mr C's complaints were reasonable and so we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• provide evidence that the orthopaedic specialist has reflected on the case and in particular the assessment of the adviser on Mr C's suitability for surgery; and
• apologise to Mr C for the failings identified in this report.

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.