Health

Summary

Mr C contacted NHS24 to tell them that he had taken an overdose of paracetamol. He was advised to go to the local A&E department as soon as possible for blood tests and treatment. He agreed to do so. He called back some time later advising that he no longer intended to go to A&E. As a result, NHS24 asked a doctor from the board's GP out-of-hours service to call him. The doctor called and discussed the potential impact of the overdose and highlighted how important it was to attend A&E but Mr C still refused to attend. Following the call, the doctor discussed Mr C's call with the specialist mental health team and they suggested that the doctor call for an ambulance to attend Mr C's home.

Mr C complained to our office as he was unhappy that the doctor failed to take appropriate steps to ensure he was safe following the call.

We considered Mr C's concerns and reviewed the board's records. We also sought independent advice from an adviser who is a GP. Having done so, we were satisfied that the doctor did provide appropriate advice to Mr C and, by calling an ambulance, the doctor had taken appropriate steps to ensure his safety. As a result, we did not uphold the complaint.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter (Ms A) at Ayr Hospital. Ms A had a complex medical history and had required several operations over the course of her life.

Ms A suffered repeated urine infections and underwent an operation for this in the hospital. During the operation, Ms A breathed in fluid from her stomach. She was admitted into the intensive care unit (ICU) and placed on a ventilator. Ms A deteriorated over the weekend and did not recover, and she died shortly afterwards in the ICU.

Mr and Mrs C complained Ms A's care was inconsistent and that there was an inadequate level of medical staffing over the weekend. Mr and Mrs C said they had been given contradictory accounts of Ms A's condition and it had been a shock when they were informed treatment was to be withdrawn from her. They believed this should have been discussed with them and that the way the staff broke the news to them was inappropriate. They also complained that, after she died, Ms A was left connected to drips and monitors, which they felt was inappropriate.

The board met with Mr and Mrs C following their complaint. They did not discuss Ms A's care and treatment but they apologised if staff had increased the family's distress through their language or actions.

We took independent advice from a consultant in intensive care medicine and a senior nurse. The advice we received was that the care and treatment was reasonable. The medical records showed an appropriate level of medical review, along with the correct treatment for Ms A's condition. We found that communication with Mr and Mrs C was appropriate. It was, however, unreasonable for the family to have been left with Ms A after she died, without any attempts by staff to ascertain their wishes. We found this had added significantly to the family's distress. Although the care and treatment was reasonable, the board had accepted there were failings in communication with the family. We found they had apologised appropriately but that they needed to provide evidence of the actions taken to prevent a recurrence. We upheld this part of Mr and Mrs C's complaint and made recommendations to the board.

Recommendations

We recommended that the board:

• provide evidence that the actions identified in Mr and Mrs C's meeting with the board (following their complaint) have been carried out; and
• remind nursing staff of the importance of establishing family members' wishes should a patient die whilst in the ICU.

Summary

Mr C complained about his wife (Mrs A)'s neurological consultation which they both attended, the correspondence following this consultation, and the way the board handled his complaints. Mr C said that the way the consultation at Crosshouse Hospital had been conducted failed to meet Mrs A's specific needs and requirements arising from the fact that she was autistic and had dyslexia, Asperger's syndrome and anxiety. Mrs A was subsequently diagnosed with a disc protrusion (a common form of spinal disc deterioration that causes neck and back pain) by another consultant and Mr C said that the failure to meet Mrs A's needs meant that the first consultant missed the diagnosis.

We took independent advice from a medical adviser and an equalities adviser. We found that it was not reasonable to expect the first consultant to have diagnosed a disc protrusion and the findings from a later investigation were not evidence that the diagnostic process had been hindered. In relation to the equalities aspect of the complaint, however, it was not clear that the consultation booking process and the consultation procedure would meet the needs of people with disabilities generally. While we found that the consultant was aware Mrs A had specific needs and requirements and had made adjustments in line with their understanding of them, the current process (whereby information about the consultation was normally read by the consultant just before the patient was seen) did not enable the board to plan ahead and make reasonable adjustments once a patient's needs were known. It was also not clear if staff had received appropriate training about making reasonable adjustments. We therefore upheld the complaint in light of the evidence in relation to the equalities aspect of the consultation booking process and consultation procedure.

With regard to the other aspects of Mr C's complaint, we found that the subsequent correspondence about the consultation was reasonable and that the board handled Mr C's second complaint in a reasonable way. However, we were concerned about the way that the board had handled Mr C's first complaint in that there was an unreasonable delay and staff were not as proactive as they should have been in keeping Mr C informed about the delay and the reasons for it. Moreover, the complaint was only resolved when the board revisited it after their substantive response to the complaint and it was not clear why this did not happen when they first investigated it.

Recommendations

We recommended that the board:

• carry out an equality impact assessment on the board's consultation booking process and consultation procedure;
• confirm the provision of training and guidance to ensure that clinical and booking staff make reasonable adjustments for patients with additional needs for consultations or, if this has already been delivered, provide us with evidence of the training and guidance;
• bring our decision, including the equalities adviser's comments, to the attention of relevant staff;
• bring our findings about complaints handling to the attention of relevant staff; and
• apologise for the failures this investigation identified.

Summary

Ms C complained that a member of staff at her GP practice had divulged confidential medical information about her to a mutual acquaintance and the practice did not thoroughly and appropriately investigate her complaint to them about this.

Our investigation found that the practice had taken reasonable and appropriate action to investigate the matter, including taking statements from Ms C's friend (who had overheard a conversation between the staff member and the mutual acquaintance), the mutual acquaintance and the staff member. Despite this, it was not possible to determine exactly what had been said. In these circumstances, we were unable to uphold the complaint.

Summary

Mrs C was removed from the treatment list of her GP practice following a difficult visit to the practice. Her husband (Mr C) complained about this and Mr and Mrs C were invited to a meeting to discuss the investigation. At the meeting they felt that no investigation had been undertaken and subsequently complained to us. The reasons the practice gave us for removing Mrs C from their treatment list did not meet the relevant criteria in legislation, policy or guidance for the immediate removal of a patient from a treatment list and we could see no other evidence that immediate removal was warranted. We saw no evidence that Mr C's complaints were dealt with in line with the NHS Scotland complaints procedure. As a result, we upheld both complaints.

Recommendations

We recommended that the practice:

• apologise to Mrs C for unreasonably removing her from their treatment list;
• review their policy for removal of patients to ensure it reflects the relevant regulations and General Medical Council guidance;
• ensure all staff are aware of the revised policy and are trained in managing difficult and challenging behaviour and in particular de-escalation techniques;
• apologise to Mrs and Mr C for not responding to the letter of complaint in line with the NHS Scotland complaints procedure; and
• ensure that staff with responsibility for responding to complaints are aware of the detail of the NHS Scotland complaints policy and related guidance.

Summary

Mrs C complained that the practice failed to take her late husband (Mr C)'s symptoms seriously between January and March 2014, in particular his weight loss. She also said that they were given inaccurate information about the length of time Mr C would be admitted to a hospice.

We took independent advice from a general practitioner and we found that Mr C had a history of back pain and diabetes, and in 2013 had been given advice about his diet. He lost weight as a consequence and, when he went to the GP a few months later suffering from leg pain, it was noted that he was still losing weight but this was considered to be because of his healthier diet. Nevertheless, Mr C's pain was investigated: blood tests were taken, he was referred for physiotherapy and an MRI (magnetic resonance imaging) scan of his back was carried out. Mr C's blood tests showed an abnormality, and he was, therefore, referred to hospital where he was later diagnosed with cancer. Mr C's pain was very difficult to control and he was admitted to a hospice on two occasions. On the second occasion, Mrs C felt that she had been misled as it was indicated his stay would only be short. However, because of the complexity of his needs, it took a considerable time to provide a solution to his pain.

We acknowledged that Mrs C had coped with a very stressful situation but we did not uphold her complaint. However, as we found that Mr C's referral to hospital should have been an urgent one (because of the presence of weight loss), we made a recommendation for the practice to familiarise themselves with appropriate guidance.

Recommendations

We recommended that the practice:

• ensure that GPs in the practice familiarise themselves with the appropriate guidance and discuss this as a learning point.

Summary

Mrs C complained about the care and treatment given to her late husband (Mr A) at Ninewells Hospital where he was a patient from March to September 2014, when he died. She said that there was a delay in making his diagnosis and that information was given to him in an uncaring and uncompassionate way. She also complained that there was often confusion about her husband's medication and that his pain was not properly managed.

We took independent advice from consultants in oncology and radiology and also from a senior nurse practitioner. We found that while Mr A's care and treatment had been appropriate and reasonable, his pain had been very difficult to control (due to his complex condition) and communication had not been as good as it could have been. He was given upsetting information at a time when support was not available to him, and was given his diagnosis over the phone. There was also confusion about his medication and treatment. In particular, there was confusion about Metformin (a drug Mr A was taking for diabetes) and whether he needed to stop taking it before his imaging test. When Mrs C later complained about these circumstances, the board delayed in providing her with a response. In view of this, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• send an appropriate letter of apology;
• ensure that the clinicians involved in this case are made aware of our findings, and that they are considered as part of the clinicians' next formal appraisal;
• review their policy on withholding Metformin;
• ensure that all patients receive suitable information prior to undergoing scans;
• provide a formal apology for the delay in responding to the complaint; and
• remind staff of the importance of replying to complaints in a timely manner.

Summary

Mr C saw a podiatrist because of the deteriorating condition of his foot due to an ulcer. He then had several admissions to Ninewells Hospital as well as being seen as an out-patient. He underwent an artery bypass (a procedure to improve blood flow) from just below the knee to the foot with amputation of several toes and a skin graft. The bypass and the skin graft failed and Mr C may need further surgery in the future.

We took independent advice from a podiatrist and a vascular surgeon. In relation to the podiatry treatment provided, we found that there were clear indications that Mr C had progressive foot disease when he saw the podiatrist on three occasions which the podiatrist failed to act on including referring Mr C to secondary care within a reasonable time. Clinical notes of Mr C's assessments were also inadequate. We found that the relevant guidelines (Scottish Intercollegiate Guidelines Network, SIGN) were not followed. We upheld this aspect of Mr C's complaint. With regard to the surgical care that Mr C received during his two admissions to hospital, we found that on the whole the board provided a reasonable standard of care and treatment but that there was an unreasonable delay in treating the foot initially when clinicians became aware that it was infected. We upheld this aspect of Mr C's complaint. In relation to Mr C's out-patient appointments following discharge from hospital, we were satisfied that there was evidence showing that assessment for each out-patient appointment was reasonable as was communication in relation to the management plan. We did not uphold this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• review the podiatry service to ensure complex foot problems are appropriately managed in the community in line with relevant SIGN guidelines including access to multi-disciplinary teams;
• bring our decision including the medical advisers' comments to the attention of the podiatrist and ensure it is reflected upon and addressed at their annual appraisal;
• address the shortcomings in record-keeping with the podiatrist;
• bring our decision including the medical advisers' comments to the attention of the relevant vascular healthcare professionals and ensure it is reflected upon and addressed at their annual appraisal; and
• apologise for the failings identified.

Summary

Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy was not viable and a medical miscarriage was performed. Mrs C was discharged after this without an x-ray to locate the missing IUS. Her GP arranged an x-ray, which showed the IUS was in her abdomen, and she was referred to gynaecology for surgery to locate and remove it. Mrs C raised concerns about the failure to x-ray her after the medical miscarriage, and about her surgery (which was more complex than expected). Mrs C said she was told an x-ray would be taken before the surgery to confirm the exact location of the IUS, and she queried why this did not happen. Mrs C also complained about delays in her gynaecology appointment and in the board's response to her complaint.

The board agreed Mrs C should have been x-rayed after her medical miscarriage and they apologised for this. They said the delay in gynaecology appointments was due to increased demand, and they were taking action to improve this. However, they considered the surgery was carried out appropriately.

After taking independent medical advice, we upheld Mrs C's complaints. We agreed the board should have x-rayed Mrs C earlier, and we found unreasonable delays in arranging the gynaecology appointment. However, we found that the surgery was carried out reasonably. The adviser explained that x-rays are not normally used to confirm the location of an IUS before surgery, as an x-ray cannot show the exact location (in three dimensions) and the position of the IUS can also change during the surgery as the patient is moved. We found the delay in responding to Mrs C's complaint was unreasonable, as the bulk of the delay (over five weeks) was caused by a delay in the draft response being signed off, rather than the investigation itself.

Recommendations

We recommended that the board:

• demonstrate to us the steps being taken to ensure the national standards for waiting times for gynaecology can be met;
• apologise to Mrs C for the failings we found; and
• review their processes for clearing draft complaint letters, to ensure this does not cause undue delay.

Summary

Mrs C raised a number of issues about the care and treatment her late husband (Mr C) received during admissions to Ninewells Hospital and Royal Victoria Hospital.

During our investigation, we took independent advice from a consultant geriatrician and a nursing adviser. We found no evidence that the clinical and nursing care was unreasonable. In particular, the consultant geriatrician noted that Mr C had been suffering from several conditions and had required significant medication to try and control his symptoms, and we found that there had been a number of discussions with Mrs C about her husband's condition. The consultant geriatrician was satisfied that the medication given to Mr C was always appropriately considered, prescribed and administered. While some of the medication caused side effects, the consultant geriatrician was satisfied that the board tried to avoid this medication as much as possible and that the side effects were unavoidable.

The nursing adviser was satisfied that Mr C had been regularly assessed and care was planned for his mobility problems. We were satisfied that the care planning and assessment charts and nursing notes confirmed that Mr C's needs were fully assessed and managed. We did not uphold Mrs C's complaints.