Health

Summary

Mr C complained about his late father (Mr A)'s care and treatment in Wishaw General Hospital in the period before his death in June 2015.

Mr A had been diagnosed with terminal cancer in 2014 and in late May 2015 he was taken into hospital to have an oesophageal stent (a mesh tube in his throat) inserted. However, the procedure did not take place and only an endoscopy (a procedure where a tube-like instrument is put into the body to look inside) was performed. In June 2015, Mr A was admitted again and during his admission he suffered a number of falls. Mr C complained that Mr A was not provided with appropriate clinical or nursing care.

We took independent advice from a consultant geriatrician and from a nurse. We found that when Mr A was first admitted in May 2015, there were problems with the documentation available to the surgical team. It was brief and did not show that his condition had been considered in detail. Furthermore, we found that although a number of clinicians had been involved in his case, none of them had been involved with Mr A in any detailed or personal way and communication had been poor. On his second admission, our investigation showed that although it had been detailed in his notes, one-to-one care had not been provided to Mr A. Had it been, a third fall may have been avoided. For these reasons, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology for the failures identified;
• ensure that the clinicians involved in the case are aware of the adviser's comments and that they discuss them at their next formal appraisal;
• make a formal apology for the failure to provide one-to-one care observation; and
• review their processes for providing one-to-one care.

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was a patient in Wishaw General Hospital. Mr C had Parkinson's Disease and dementia and had been admitted to hospital for a period of assessment. Mrs C said that between his admission to hospital and his discharge to a care home (a period of several months), she was not properly consulted on his treatment plans, nor was she appropriately involved in multi-disciplinary meetings to discuss his care. She said that this was even although she had welfare power of attorney which allowed her to look after Mr C's interests (to consent to his treatment) as he no longer had capacity to do this.

While Mrs C had raised her concerns with the board, they had indicated to her that Mr C had been cared for appropriately but they apologised if she felt his nursing care had been poor.

We took independent advice from a senior mental health professional and we found that Mr C's care plan had been inadequate. There had been a particular omission with regard to his personal care. There was no evidence that in the absence of Mr C's participation and agreement that Mrs C as power of attorney had been involved. Similarly, Mrs C was not as involved as she should have been in decisions about her husband's care and treatment and her involvement in multi-disciplinary meetings was inconsistent and sporadic. For these reasons we upheld her complaint about this.

Although Mrs C had also complained that Mr C's medication regime was changed inappropriately, we found no evidence of this.

Recommendations

We recommended that the board:

• make a formal apology to recognise their failures with regard to care planning;
• ensure that all care plan templates are completed in full in relation to keyworker/patient/carer involvement and that they are appropriately signed and dated, and demonstrate to us that this has been done;
• make a formal apology to Mrs C for the fact that she was not involved in multi-disciplinary meetings as was appropriate; and
• ensure that staff involved in Mr C's care are reminded of the importance of ensuring that carers with power of attorney are fully and appropriately included in decision-making.

Summary

Mr and Mrs C made a complaint on behalf of their son (Mr A) who had been diagnosed with epilepsy some years ago. Mr A had been seizure free for a number of years but in July 2014 began to experience seizures again. He was admitted to Monklands Hospital on three occasions in November and December 2014 and Mr and Mrs C complained that he was not cared for or treated reasonably. They also said that communication with him was poor.

We took independent advice from consultants in emergency medicine and in neurology and we found that at each of Mr A's admissions, emergency clinicians treated him reasonably and appropriately. He was examined and assessed and appropriate tests were undertaken. He was released from hospital with advice to contact his GP and for psychiatric follow-up. The third time Mr A went to A&E, he was admitted for observation. He was exhibiting bizarre behaviour and suffering from depressive symptoms. However, it was established that although there was clearly documented evidence to confirm that Mr A was emotionally ill, it was accepted that he was suffering epileptic seizures and no definitive tests were requested to refute or deny this. Instead doctors concentrated on altering his medication. For this reason, Mr and Mrs C's complaints about Mr A's care and treatment were upheld. However, we did not find any evidence to suggest that communication with him had been poor.

Recommendations

We recommended that the board:

• make Mr A a formal apology to recognise our findings about care and treatment;
• ensure that members of the neurology team involved in Mr A's care are familiar with the appropriate national guidance; and
• ensure that neurology staff involved in Mr A's case consider it at their next formal appraisal.

Summary

Mr C complained that his GP practice did not offer him an urgent appointment with a doctor after he attended the practice with chest pain. Mr C turned down the offer of an appointment with the nurse as he felt his symptoms were too severe. The duty doctor called him later that day and offered an appointment for the next working day (which was a Monday). Mr C chose instead to attend A&E where it was identified that he had a pneumothorax (collapsed lung). The practice accepted and apologised that Mr C should have been offered an urgent appointment to be seen the same day given his reported symptoms.

We took independent advice from a GP. We were concerned about the procedures in place at the practice for managing patient appointments. There was a lack of evidence to demonstrate that non-clinical staff were adequately trained and supervised in the procedures. We concluded that the care provided by the practice fell below a reasonable standard, and we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• work with Lanarkshire NHS Board to review their patient signposting procedures as a matter of urgency.

Summary

Mr C complained that a consultant nephrologist (a doctor who specialises in kidney care) provided inadequate medical care to him during a kidney biopsy. We looked at the board's complaint file and Mr C's medical records. We also took independent advice from a medical adviser. We found there were no failings in how the biopsy was explained to Mr C or in how it was carried out and the post-biopsy monitoring was appropriate. We also found that a rare but recognised complication was noticed in reasonable time and appropriate steps were taken to deal with the complication in reasonable time once it became apparent. We did not uphold Mr C's complaint.

Summary

Miss C complained to us that staff at Hairmyres Hospital and Monklands Hospital failed to provide her with appropriate and timely treatment, which resulted in the removal of her gallbladder. We took independent advice on this complaint from a medical adviser, who is a consultant general surgeon. We found that Miss C had been investigated and treated appropriately for her gallbladder disease within a reasonable time-frame. Whilst there was a short delay in referring her for a scan and in providing a prescription when she was discharged from hospital, these did not have an adverse impact on her care. In view of this, we did not uphold the complaint.

That said, Miss C's consultant had referred her to another consultant when she made a complaint about him. Miss C's care was not compromised by the change of consultant, but this was not in line with guidance from the General Medical Council (GMC), which states that a doctor should not end a professional relationship with a patient solely because of a complaint the patient has made about them.

Miss C also complained to us that staff in the hospitals had failed to communicate with her adequately throughout the treatment referral process. We found that there had been some failings in relation to communication. We upheld this aspect of Miss C's complaint, although we noted that the board had already apologised to her for these failings.

Recommendations

We recommended that the board:

• make the consultant aware of the adviser's comments about Miss C's transfer of care to a different consultant being contrary to guidance from the GMC; and
• provide evidence that the failings identified have been fed back to relevant staff.

Summary

Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take sufficient food by mouth). Mrs A had been admitted to the hospital with high output from her stoma (a stoma is a surgically made pouch on the outside of the body; when the output from a stoma is high, it means that you are losing more fluid and are at a greater risk of becoming dehydrated) and acute kidney injury.

We took independent advice on this case from a consultant general surgeon. We found that Mrs A had initially been treated appropriately. It was likely that the NJ feeding tube was exacerbating the high output stoma. It had been reasonable to allow Mrs A to remove the NJ tube under supervision, as this reduced her anxiety about having it removed. This did not cause an oesophageal perforation (a tear in the tube that takes food from the mouth to the stomach) that she subsequently experienced.

However, we found that Mrs A had been discharged from hospital without evidence that the measures taken in relation to her high output stoma were fully effective and would prevent a readmission with the same problem. During our investigation, the board told us that they were working on guidelines on high stoma output for staff, but these had yet to be finalised. We also found the records of communication with Mrs A and her family were inadequate. In view of these failings, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• provide evidence that guidelines for high output stomas have been developed and circulated to relevant staff; and
• feed back our findings to relevant staff.

Summary

Mr C's wife (Mrs C) had a complex medical history and had been diagnosed with asthma, bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened leading to a build-up of excess mucus) and frequent pneumonia. Mrs C struggled to recover between bouts of illness and she understood from healthcare professionals that she had emphysema (lung disease). In October 2013, Mrs C was told that investigations had shown mild abnormalities and that she did not have emphysema. Mr C said that his wife was very distressed at this.

Mrs C was admitted to Monklands Hospital two months later with respiratory problems. Her condition deteriorated significantly and she died several weeks after admission with sepsis (blood infection), heart failure and bronchiectasis. Mr C complained about the provision of medical and nursing care and treatment to Mrs C, and about the board's complaints handling.

We took independent advice from medical and nursing advisers. We found that the medical and nursing care and treatment provided to Mrs C was reasonable. However, at one of the out-patient appointments, the discussion about Mrs C's diagnosis was significant but there was no record of this and no comment on Mr C's understanding of the diagnosis and so, on balance, we upheld this complaint. In relation to record-keeping, we were satisfied that the board had responded to the complaint in a reasonable way.

Recommendations

We recommended that the board:

• bring the record-keeping failing and the medical adviser's comments to the attention of relevant staff; and
• apologise for the failings identified.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during her admission to Hairmyres Hospital. Staff suspected Mrs C had a rare endocrinology (related to hormones) disease, and arranged a number of tests to investigate this over the next two months. Mrs C developed sepsis (a blood infection) while in hospital and died.

Mr C raised concerns about Mrs C's overall treatment, including delays in investigations and treatment and failure to prevent infection. Mr C was also concerned that nurses did not understand Mrs C's condition (as she was nursed on a cardiology ward, rather than an endocrinology ward). The board met with Mr C's family twice and apologised for a number of aspects of care. They arranged a meeting to ensure nursing staff reflected on their practice, and developed an action plan for improvement, which they shared with the family. The endocrinologist involved in Mrs C's care also apologised that the investigations of Mrs C's condition did not move more quickly, and explained that they expected to have more time to treat Mrs C. Mr C was not satisfied with the board's response to some parts of his complaint, and brought these to us.

After taking independent medical and nursing advice, we upheld one of Mr C's five complaints. We found the medical and nursing care was reasonable in relation to most of the specific points Mr C raised, and that although there were some failings in nursing care, the board had already addressed these. However, we found that there was an unreasonable delay in sending laboratory samples to be tested.

The medical adviser also commented on Mrs C's overall care and said the board should have considered transferring her to a larger endocrine unit (which might have resulted in quicker treatment). We shared these comments with the board, but did not make any specific recommendations as the relevant guidelines do not require treatment in a particular setting and the endocrinologist involved had already apologised to the family and reflected on their practice.

Recommendations

We recommended that the board:

• review their processes for arranging external laboratory testing of samples, to ensure this is being completed in a reasonable timeframe.

Summary

Mrs C, who is an advice worker, complained to the practice about a lack of urgency in acting on Ms A's concerns about a problem with her young daughter's hip. She said that Ms A reported that her daughter's left leg was longer than her right leg and that one of the GPs failed to thoroughly examine her daughter. In addition, it was only after Ms A continued to report her concerns that her daughter was referred to hospital. However, one of the GPs marked the referral as non-urgent and Ms A had to ask the practice again to make an urgent referral. Her daughter was diagnosed as having a dislocated hip.

The practice apologised for the delay and said they had learned from the complaint. They were now aware that they can directly ask for an ultrasound scan of the hip in such circumstances. The GPs were more aware of the signs to look for and would mark any referrals as urgent. The practice apologised for the distress which was caused.

We took independent advice from a medical adviser who noted that the response from the practice to Ms A's complaint was thorough and explained the shortcomings which they had identified. The practice said that their GPs were now more aware of the referral options, the need for urgency and the later signs of congenital dislocation of the hip. However, we identified further failings by one of the GPs in regards to the inadequate examination and recording of findings related to Ms A's daughter and a failure to stress the urgency of the situation in the hospital referral letter, so we upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Ms A for the failings identified;
• discuss the complaint as part of the GP's annual appraisal; and
• explain their criteria for carrying out a significant event analysis and explain why one was not performed in this case.