Health

Summary

Miss C complained about care her late mother (Mrs A) received from the medical practice. Mrs A had experienced chest pains and called an ambulance. Paramedics came to Mrs A's home and carried out an echocardiogram (a way of monitoring the heart). The paramedics did not believe Mrs A was suffering angina (chest pain caused by a problem in the blood supply to the heart) or a heart attack. They offered to take her to hospital. Mrs A, however, declined and said she would attend her GP the next morning.

Mrs A attended the practice the following morning, where she was seen by a GP. She was diagnosed with acid reflux and was prescribed medication for this. Mrs A passed away at home later that day.

We took independent advice from one our medical advisers who is a GP. They considered the evidence and found that the GP who treated Mrs A had made a reasonable diagnosis based on the symptoms at the time, and the previous advice of the paramedics. Therefore, we did not uphold the complaint.

Summary

Mr C complained that his uncle (Mr A) who suffered from dementia was not reasonably cared for after he was admitted to hospital and when a catheter was fitted. He said that Mr A was not discharged appropriately and that as his uncle's next of kin he was not always kept informed about what was happening about his care and about arrangements being made.

We took independent advice from a consultant urologist and from a senior nurse. We found that Mr A's clinical and nursing care were well within a standard that could be reasonably expected. However, there were occasions when Mr C was not kept informed and when he was given confusing information about out-patient appointments. He was also sent an appointment for Mr A which was for a location 50 miles away from his home. For these reasons, Mr C's complaints about poor communication were upheld.

Recommendations

We recommended that the board:

• make a formal apology for the communications shortcomings identified; and
• remind staff involved in this case of their professional responsibility to communicate with relatives, particularly next of kin, in a clear and timely manner.

Summary

Ms C complained about a delay in arranging surgery for her child (Miss A), who suffered from malocclusion (a misalignment of the teeth and jaws) and chronic facial pain. A treatment plan was agreed for Miss A's malocclusion, including a period of braces followed by maxillofacial surgery (surgery affecting the mouth, jaws, face or neck). After 18 months of braces, it was decided that Miss A was ready for surgery and she was placed on the waiting list of a surgeon at the Southern General Hospital. However, no surgery date was offered for about 16 months.

Ms C complained to the board about the delay during this time. They were unable to offer a date for surgery due to demand, and emphasised that the surgery was unlikely to help Miss A's pain. They suggested that Ms C discuss the possibility of an out-of-area referral with the surgeon. Ms C said she asked about this and was told to contact other hospitals herself. Although Ms C found a hospital willing to conduct the surgery, the time-frame for this was similar to the estimate given by the Southern General Hospital at that time, so Ms C decided not to take it. However, Ms C said the Southern General's estimate then shifted several months. Miss A ultimately received her surgery about 17 months after she was placed on the waiting list.

In response to our enquiries, the board said the national treatment time guarantee of 18 weeks referral to treatment did not apply to Miss A, as she was a returning patient. They said they had now engaged another consultant to improve their waiting times.

After taking independent medical advice, we upheld Ms C's complaint. Although we agreed that the national treatment time guarantee did not apply to Miss A, and it was unlikely that the surgery would improve Miss A's pain, we found that 17 months was an unreasonable delay for this kind of surgery. We were also critical of the board's communication, and we said they should have been more proactive about arranging an out-of-area referral for Miss A.

Recommendations

We recommended that the board:

• apologise to Ms C and Miss A for the delay and poor communication in relation to her surgery;
• review how they monitor waiting times for 'follow on' maxillofacial surgery, to ensure that any significant pressures are identified and addressed proactively; and
• review what processes they have in place to support patients with arrangements for out-of-area referrals (where this is due to the board's waiting times).

Summary

Mrs C's mother (Mrs A) received regular dialysis (a form of treatment that replicates many of the kidney's functions) at the Inverclyde Royal Hospital Renal Unit. During one session, Mrs A experienced some pain and bleeding and, shortly after this, nurses noticed a red scabbed area near the dialysis access. Two weeks later, Mrs A experienced a significant bleed from her dialysis access and required emergency surgery. Sadly, Mrs A suffered a heart attack shortly after the surgery and died.

Mrs C complained about the treatment provided by the dialysis unit, and in particular the decision not to refer Mrs A for medical review when the scab was noticed. The doctor Mrs C spoke to handled this as a concern, and arranged a meeting with relevant staff, with a written summary provided. Mrs C then wrote to the board to complain, and they investigated the issues. The board said the nurses did not consider Mrs A required medical review, and they were capable of making this decision. However, the board acknowledged that their documentation was poor and said they were making improvements to this. Mrs C was dissatisfied with this response, and complained to us about Mrs A's care and the board's handling of her complaint.

After taking independent advice from a specialist renal nurse, we upheld Mrs C's complaint. We found that nursing staff should have taken further action in response to Mrs A's condition, including monitoring the scabbed area and documenting this, and referring Mrs A for access review. However, during our investigation the board gave us information on additional action they had taken to improve their dialysis service after Mrs A's experience and a similar incident, and we considered that the board had now taken appropriate steps to address the failings in care. We also found Mrs C's complaint should have been investigated as a complaint as soon as she had raised it, rather than being handled as a concern.

Recommendations

We recommended that the board:

• feed back our findings to the staff involved for reflection;
• feed back our findings on complaints handling to the doctor involved for reflection; and
• apologise to Mrs A's family for the failures identified.

Summary

Miss C attended the practice on a number of occasions for acute stomach pain, and was treated with omeprazole (medication for an acid-related stomach disorder or ulcer). Miss C then visited a private GP, who suggested she try esomeprazole (another stomach medication). Miss C told the practice this gave her some relief from her symptoms, and they gave her a repeat prescription. The practice also referred Miss C to a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) when she requested this (about six weeks after she first reported symptoms). Miss C later arranged a private endoscopy overseas, which showed that she had probably had a stomach ulcer which had now healed.

Miss C complained that the practice failed to diagnose a stomach ulcer and delayed in referring her to gastroenterology. She was also unhappy that the practice did not prescribe esomeprazole until she had received this from a private GP, and she raised concerns that her ulcer could have been caused by the practice prescribing ibuprofen in the past.

After taking independent advice from a GP, we did not uphold Miss C's complaints. We found that the practice's treatment was reasonable, and in line with national guidance on dyspepsia (indigestion) at the time. The adviser explained that Miss C did not have any 'alarm features' to warrant referral to gastroenterology, and omeprazole was an appropriate medication to treat both ulcers and gastritis (inflammation of the stomach). The adviser said Miss C did not take this medication for a long enough period to know whether or not it was effective (before switching to esomeprazole). The adviser also considered that it was reasonable that the practice previously prescribed ibuprofen (while this can cause either ulcers or gastritis, this is rare in patients under 60).

Summary

Miss C suffered from stomach pain and was given medication by her GP practice for an acid-related stomach disorder or an ulcer. She attended the out-of-hours clinic a few days later and was given antibiotics for a urinary tract infection. Miss C continued to suffer symptoms and she was referred for an appointment with a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). However, the appointment was delayed and when she was seen about three months later she had few symptoms. The board said Miss C told the gastroenterologist she had stopped taking her stomach medication before the appointment, but Miss C said the gastroenterologist told her during the appointment to stop taking her stomach medication.

The gastroenterologist told Miss C that, if her symptoms returned, her GP could call his secretary to arrange an endoscopy (where a tube-like instrument is put into the body to look inside). Miss C's symptoms returned over the next week and she asked her GP to do this, but her GP had not yet received the clinic letter with these instructions. Miss C then arranged a private endoscopy overseas, which showed she had probably had a stomach ulcer which had now healed.

Miss C complained that the out-of-hours doctor did not diagnose or treat her stomach ulcer, and the gastroenterologist did not arrange an endoscopy. She also raised concerns about the delay in the clinic letter.

After taking independent advice from a GP and a gastroenterologist, we did not uphold Miss C's complaints. We found that the out-of-hours treatment was reasonable, and it was appropriate for them to refer Miss C back to her own GP for management of ongoing symptoms. We also found the gastroenterology care was reasonable, as there was no clinical need for an endoscopy. While there appeared to have been a misunderstanding about the medication, there was no evidence that this was due to a failing by the gastroenterologist. Although the two-week delay in sending the clinic letter was not ideal, we found this was reasonable in the context of Miss C's clinical condition.

Summary

Ms C complained about the care and treatment she received from the Early Pregnancy Assessment Service (EPAS) at the former Southern General Hospital in Glasgow following a positive pregnancy test. Ms C had been referred to the EPAS by her GP practice as she was in the early stages of pregnancy and had a three-week history of constipation, vaginal bleeding and abdominal pain. When Ms C called the EPAS, a midwife advised her that she may be having a miscarriage and she was given an appointment for the following week to have a scan.

The following evening, Ms C called the EPAS again as she was in pain but as the service was closed her call was passed to a midwife at the maternity assessment unit. Ms C said she was offered no new advice as it was too early in her pregnancy. When Ms C attended her appointment at the EPAS, the scan revealed she had an ectopic pregnancy. As a result, Ms C required emergency surgery. Ms C felt the midwives at the EPAS should have acted sooner.

We took independent advice from a midwife adviser. We found that the midwives involved in Ms C's care and treatment appeared to have followed the relevant guidance which included the health board's Early Pregnancy Assessment (EPA) guidance for dealing with phone calls, and that their actions were reasonable. We also found that there did not appear to have been any unreasonable delay before the scan was carried out as the guidance suggested that women presenting with symptoms like those Ms C presented with are given a non-urgent appointment. We did not identify any failings in Ms C's care and treatment and, therefore, we did not uphold Ms C's complaint. However, we did find some issues with record-keeping and the EPA guidance, and we made recommendations to reflect these findings.

Recommendations

We recommended that the board:

• feed back to relevant staff that advice given to patients should be clearly documented in the patient's medical records and patients are given as much information as possible about what they might expect, especially while they wait for a scan; and
• consider our findings in relation to providing a clear definition in the EPA guidance for specific stages of pregnancy with combinations of symptoms; and 'non urgent' appointments and the women who fall into this category.

Summary

Ms C attended an appointment at her GP practice with a three-week history of constipation, vaginal bleeding and abdominal pain. Ms C was asked by her GP if she could be pregnant and Ms C said she was not. Ms C carried out a pregnancy test that same evening, and it showed that she was in the early stages of pregnancy.

Ms C subsequently had three phone consultations with the practice over the following days. Ms C was advised to contact the Early Pregnancy Assessment Service who informed her that, given her symptoms, she may be having a miscarriage. An appointment was made for her to have a scan the following week. When Ms C attended her appointment, the scan revealed she had an ectopic pregnancy and required emergency surgery.

Ms C was unhappy with the care and treatment she received at the practice. She complained about the attitude of one of the doctors who she felt did not listen to her and treat her with sensitivity. Ms C also said that she was not prescribed antibiotics for a urinary tract infection until she insisted and she was not offered an examination even though she was pregnant.

We took independent advice from a GP. They considered that the care and treatment provided to Ms C at her appointment and during the first phone consultation was appropriate and reasonable. In relation to the second phone consultation which involved the doctor Ms C was unhappy with, there were different versions of what had occurred which we were unable to reconcile. The advice we received was that based on the information provided in the medical records, the doctor's actions in relation to Ms C's clinical treatment were reasonable. However, it appeared that the doctor had not meaningfully engaged with Ms C. We also found that during the third phone consultation with another doctor, that doctor had failed to take into account the relevant guidance on the management of bacterial urinary tract infections in pregnant women and had failed to follow appropriate prescribing guidance. We upheld Ms C's complaint.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failings identified;
• feed back our findings to relevant staff for reflection and learning; conduct a significant event meeting to discuss all aspects of this case; and submit a further significant event analysis for review to this office to include their reflection on communication and prescribing; ensures that the first doctor reflects on his consultation skills and discuss this complaint and, in particular his communication skills, as part of his annual appraisal; and
• ensures that the second doctor reviews the relevant prescribing guidance for the management of urinary tract infection in pregnancy and identifies this as a learning need as part of his annual appraisal.

Summary

Miss C decided to proceed with a surgical procedure (to divert the normal flow of urine from the kidneys and ureters into a specially created stoma) to address urine incontinence when other procedures had failed. As a result of the operation, which was performed at the Southern General Hospital, Miss C said she suffered from urinary infections and altered acid-based metabolism (tendency for the blood to become more acidic than normal that required medication) and that she had not been informed of any possible side effects or complications of the procedure beforehand.

We took independent advice from a medical adviser who specialises in urological surgery. We found that while it was documented that medical staff had several discussions with Miss C about the procedure, they failed to document the details of the consent discussions and it was not possible to determine if the risks were discussed with Miss C and understood by her before the operation. Therefore, we were not satisfied that Miss C was fully informed of the risks and in a position to give informed consent.

Recommendations

We recommended that the board:

• review the consent form to ensure that discussions between patients and clinicians about possible risks and complications are clearly recorded;
• bring the failings in record-keeping to the attention of relevant staff;
• consider the adviser's comments in relation to the use of information leaflets; and
• apologise for the failings this investigation identified.

Summary

Mrs C complained that there was a four-month delay in the board carrying out her six-month follow-up scan at Gartnavel General Hospital to monitor her condition. When Mrs C had the scan done, it showed secondary cancer which she felt could have been avoided had her care plan been properly followed. In responding to the complaint, the board accepted that there had been an administrative error and apologised to Mrs C. They said that the scan would likely have gone ahead had a return clinic appointment been made then and took steps to remind administrative staff of their responsibilities. However, Mrs C remained concerned that the board were unable to explain why the error had occurred and if adequate steps had been taken to avoid the matter recurring.

We took independent advice from a consultant urological surgeon and found that the delay was unreasonable and not in line with local guidance. However, we considered that Mrs C's prognosis would not have been significantly affected had the scan and treatment been done sooner. We concluded that there was a lack of evidence to demonstrate whether or not the form requesting the scan was mislaid by either clinical or administrative staff or whether the urology doctor had in fact completed it in the first instance. Whilst an electronic system is now in place which will assist in reducing the likelihood of paper forms going missing, we made a recommendation to address the matter and we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• demonstrate what systems are in place to ensure that scan results are reviewed by the clinician responsible for the patient's care and that further monitoring takes place where appropriate; and
• draw these findings to the attention of the clinical team responsible for Mrs C's care.