Health

Summary

Mr C complained about the board after they shared a letter containing sensitive information about him with his school. He said that he had made it very clear that he was not comfortable with information being shared in this way and felt that his confidentiality had been breached.

Mr C then wrote to his doctor, outlining his concerns and explaining that these circumstances had caused him a great deal of distress and anxiety. His doctor responded, apologising if she had misunderstood but had thought that consent had been given by him for this to happen. Mr C remained dissatisfied with this response, as he did not feel that his complaint had been taken seriously.

We found that Mr C's complaint had not been formally investigated through the board's complaints procedure. His doctor had also noted in her records that she intended to seek consent from Mr C at their next appointment. However, the notes for the appointment in question did not contain clarification on whether or not consent had been asked for or given. We took independent advice from an adviser, who stated that they did not consider it to be reasonable to share sensitive information without consent being clearly given and recorded. We accepted this advice and, as such, upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C both for breaching his confidentiality and for the on-going distress and anxiety that this breach has caused him; and
• apologise to Mr C for not properly escalating his concerns and investigating them through their complaints procedure.

Summary

Mr C complained about the care and treatment provided by the practice. Mr C had attended the practice over the course of approximately three months with symptoms including weight loss, diarrhoea and vomiting. He was ultimately diagnosed at A&E with an intussusception of his small bowel (a condition in which a part of the intestine folds into another section of the intestine). Mr C raised concerns about the time taken to diagnose his condition, including whether appropriate investigations (including a CT scan, which uses x-rays and a computer to create detailed images of the inside of the body) were arranged. He also raised concerns that a GP had identified he had signs of an intussusception but did not appropriately treat this as an emergency.

The practice said Mr C's symptoms were fully and appropriately investigated. They observed that Mr C was referred for specialist investigation at an early stage which provided an alternative explanation for his symptoms. They also said intussusception is a very rare condition in adults. The practice said the medical records did not indicate the GP had diagnosed an intussusception.

After receiving independent advice from a GP, we did not uphold Mr C's complaint. The adviser agreed that there were complicating factors in the diagnosis. The adviser considered that the investigations arranged were appropriate in the circumstances, and found no evidence that a GP had diagnosed an intussusception prior to Mr C's admission to A&E. While we found Mr C's care and treatment was reasonable in the circumstances, we recommended that the practice use this case to consider and share any learning on the presentation and causes of intussusception in adults.

Recommendations

We recommended that the practice:

• use this case to consider and share any learning on the presentation and causes of intussusception in adults.

Summary

Mrs C complained on behalf of her son (Mr A) about the severe toe pain he suffered since undergoing a total nail avulsion (complete removal of the toenail) in 2013. Mr A had been seen by podiatry staff on a number of occasions following the surgery. As a result of the severe pain, Mrs C said that Mr A had lost his confidence and been unable to undertake his usual activities. Mrs C was concerned that a number of investigations, tests and referrals appeared to be undertaken only when she complained to the board two years after the initial surgery.

We took independent advice from a medical adviser. They said that the treatment decisions were reasonable in light of the main post-operative complications associated with a nail avulsion. However, while the initial referrals, tests and investigations appeared to be carried out within a reasonable time, repeating the surgical and other investigations when previous investigations had not provided a diagnosis to the problem delayed referral onto a specialist pain team. We found this to be unreasonable, so we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• review their processes to ensure referrals to specialised pain teams are made within a reasonable time;
• bring our decision including the adviser's comments to the attention of relevant staff; and
• apologise for the failures our investigation identified.

Summary

Ms C and her cousin (Mr A), complained about the care and treatment Mr A's late mother (Mrs A) received at Kincardine Community Hospital. Mrs A had dementia and had been admitted to Kincardine Community Hospital from Aberdeen Royal Infirmary for a period of rehabilitation following a fall at home. Ms C and Mr A also complained about the board's handling of their complaint.

Mr A said that he raised concerns with nursing staff about his mother's care while she was a patient in Kincardine Community Hospital, in particular, in relation to her developing pressure ulcers. Staff at the hospital and Mr A were also not told for several weeks that Mrs A had been diagnosed with a pelvic fracture while she was in Aberdeen Royal Infirmary. When Mrs A was discharged to a nursing home she was found to have a pressure ulcer on her sacral area (at the base of the spine) but Mr A had not been informed about this.

We took independent advice from a nursing adviser who said there were serious failings in record-keeping and in compliance with guidance and best practice on the prevention and management of pressure ulcers. As a result, Mrs A's care was random and left to chance. Furthermore, although Mrs A was at high risk of developing pressure ulcers, there was a delay in managing her as high risk. We also found that the pelvic fracture incident had not been recorded as it should have been and there were failures in communicating with Mr A concerning aspects of Mrs A's care. Overall, the advice we received was that the standard of nursing care provided to Mrs A was very poor and we were critical of those failings.

In relation to the board's handling of Ms C and Mr A's complaint, although the board had apologised to them and had carried out a significant event analysis (SEA) we found that the board had not identified and acknowledged serious failings with Mrs A's nursing care and that, overall, the board's complaints handling was poor.

Recommendations

We recommended that the board:

• feed back the findings of the investigation to relevant staff, for reflection and learning;
• provide us with an action plan to address the failings identified in relation to record-keeping; skin and tissue viability care (to include a review of the education and training of nursing staff in skin and tissue viability care); and communication;
• apologise to Mr A and Ms C for the failure to provide reasonable care to Mrs A;
• feed back the findings of this investigation to the relevant staff who were involved in the SEA and complaints handling and reflect again on Mrs A's complaint by reviewing what went wrong with her care;
• consider a review of their SEA process and the training of staff who carry out such reviews, and give consideration to whether there should be an external independent review of how this is undertaken;
• provide evidence that the pelvic fracture incident has been reported and the date when it was recorded on the system;
• provide evidence of the review process concerning discharge documentation; and
• apologise to Mr A and Ms C for the failings to respond reasonably to their complaints.

Summary

Mr C complained that the board refused to fund his stay at a residential facility for patients receiving cancer treatment at Aberdeen hospitals. He attended Aberdeen Royal Infirmary for radiotherapy every weekday for around seven weeks but only received funding for the last two weeks of his stay. He complained that he was initially given the impression that his full stay would be funded and he said that he did not find out this was not the case until a few days into his stay.

The board confirmed that funding is available for patients from Orkney and Shetland, and also those with an IV postcode. As Mr C's postcode lay outwith these areas, he did not meet the main criteria for a fully-funded stay. The board advised that there is provision for funding patients from other postcodes where their physical condition makes it impossible for them to travel long distances. Mr C did not suffer from any of the listed qualifying conditions, except for radiotherapy-induced incontinence which automatically qualifies patients for funding for the last two weeks of their stay only. Mr C received this funding.

As it appeared that Mr C's funding application was appropriately assessed in line with the board's normal criteria, we focussed on whether the position was made clear to him in advance of his stay. We found no evidence of Mr C being incorrectly advised that he would receive funding for his entire stay. Therefore, we did not uphold the complaint. However, we noted that the board did not have a formal policy in place setting out their qualification criteria for funded places. We considered that such a policy would be helpful for staff and patients alike and we made a recommendation in this regard.

Recommendations

We recommended that the board:

• develop a formal policy, clearly setting out their criteria for funding accommodation at the residential facility involved in this complaint, and ensure this policy is communicated to relevant staff.

Summary

Mr C complained that the Golden Jubilee National Hospital did not carry out his knee surgery properly and that his aftercare was of a poor standard. He also had concerns about the consent he gave for the procedure as he was under the impression that his named consultant would mainly be performing it, but found out after the operation that another doctor had carried out the operation under the supervision of the consultant.

We took independent advice from a consultant orthopaedic surgeon. We considered that the need for Mr C to have revision surgery within a year was not acceptable and there were likely some failings in relation to the way in which the procedure was performed, so we upheld this part of his complaint.

We found that Mr C's consent to the procedure had been reasonably obtained by the other doctor the day before surgery, in that he had indicated that he would be involved with the procedure and had highlighted the risks. In addition, the consent form Mr C signed sets out that the procedure might not be performed by the clinician who had been treating him. In terms of Mr C's aftercare, we concluded that reasonable steps were taken in response to his ongoing symptoms of pain and difficulty walking. We did not consider that Mr C was intentionally misled in this respect and therefore we did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in relation to his surgery; and
• share the findings with the doctor for future learning.

Summary

Mrs C complained about a number of issues regarding her care and treatment at the Golden Jubilee National Hospital. She was also unhappy about the way in which her complaint was handled.

Mrs C was concerned about the lack of action by a doctor between November 2012 and September 2013 which she felt impacted on a decision taken in August 2014 that she required further heart surgery. Mrs C also complained about the actions of a second doctor in dealing with her care given that he was aware of her dissatisfaction with the first doctor.

We took independent advice from a cardiologist. We found that the first doctor unreasonably delayed in discussing Mrs C's case at multi-disciplinary team meeting and in reviewing Mrs C, which meant that her symptoms would have persisted unnecessarily causing her distress. We made a recommendation about this.

However, we did not consider that these delays would have impacted on Mrs C's need to undergo further surgery. We considered that the second doctor's actions were reasonable and noted that Mrs C had been given an apology about the delays in the management of her earlier care.

We concluded that the handling of Mrs C's complaint fell below a reasonable standard because the hospital initially dealt with it outwith their complaints procedure and because of the time they took to complete their investigation. We made a recommendation to address this.

Recommendations

We recommended that the board:

• share these findings with relevant staff involved in Mrs C's care to ensure timely case discussions and follow-up reviews are carried out;
• share these findings with relevant staff in order to ensure that staff dealing with complaints inform people of their right of appeal to us on complaints which have been time barred; and
• ensure that relevant staff provide timely responses in terms of their complaints procedure and apologise to Mrs C for failing to handle her complaint within a reasonable timescale.

Summary

Mr C complained to the board about the treatment they offered him for an injury he suffered to his knee. He had originally attended a GP at the prison health centre and received an x-ray which showed no problems. It was therefore decided that he should attempt physiotherapy and return if the pain persisted. However, when he requested a further appointment to see the GP because he felt he should have a scan, his request was triaged by a nurse who advised that as his x-ray had been normal, he did not need an appointment or a scan.

We took independent advice from two advisers, one a GP and one a nurse. We found that Mr C's records showed that after the x-ray, his GP mentioned that a scan may be required if problems persisted. The advisers confirmed that the nurse in question should have consulted a GP and that, in line with national guidelines for the management of knee pain, further investigation would have been appropriate in the circumstances. As such, we upheld the complaint.

Recommendations

We recommended that the board:

• bring the failings to the attention of relevant staff;
• review their clinical decision-making in light of the relevant guideline;
• review the triage system to ensure that decision-making is made appropriately within the clinician's scope of expertise;
• apologise to Mr C for the failings identified; and
• arrange for a further GP assessment of Mr C's knee, if this has not happened already.

Summary

Ms C made a complaint about health care she received whilst in prison. During our investigation, Ms C was released. We made attempts to trace Ms C but were unable to establish contact with her. As such, we did not issue a decision on Ms C's case.

Summary

Mrs C complained about her mother (Mrs A)'s discharge from Forth Valley Royal Hospital. Mrs A was 82 years old at the time and was admitted with chest pains, later diagnosed as a heart attack. Further to treatment, plans were made to discharge Mrs A but her family were concerned that she remained in poor health. Mrs C said they had alerted staff to Mrs A's breathing difficulties, shivering, leg swelling, lack of appetite and general weakness but were assured that she was fit to go home. Following discharge, Mrs A was readmitted in the early hours of the following morning. She was diagnosed with sepsis and did not recover. She passed away five days later.

Mrs C considered that the signs of sepsis were present prior to Mrs A's discharge and were not detected by staff. The board advised that the results of pre-discharge tests were not consistent with a diagnosis of sepsis. We took independent advice from a consultant in general and geriatric medicine. They noted that Mrs A's symptoms, observations and blood test results were considered prior to discharge and were relatively normal. In particular, they noted that her blood test results were sufficiently normal to allow discharge to proceed. They did not consider that there was any evidence Mrs A was suffering from sepsis at the time and, overall, they considered it reasonable for her to have been discharged. They noted that she was re-admitted a short time later and subsequently died but were not of the view that this could have been reasonably predicted at the time of discharge or that it was due to poor medical care during Mrs A's admission. We did not uphold Mrs C's complaint.