Health

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.

Summary

Miss C's mother (Mrs A) was admitted to hospital at Mearnskirk House, following her discharge from the Prince and Princess of Wales Hospice where she received five weeks' care with advanced cancer. Miss C's sister (Mrs D) took their mother home from the hospital and Mrs A was officially discharged from the hospital into Mrs D's care three days later, following a meeting earlier that day at the hospital with medical staff and the family to discuss Mrs A's care.

Miss C complained about the board's decision to discharge her mother from the hospital and the way this decision was made. She listed a number of concerns, including that her mother was discharged without any input from her GP, with no care package in place and with no referral to a district or palliative care team.

We obtained independent medical advice on Miss C's complaint from a consultant physician in elderly care medicine. The adviser said this was an unusual case in that Mrs A had been taken home by Mrs D for a week's trial prior to her formal discharge. The board did not have time to plan Mrs A's discharge in the normal way. Mrs A and Mrs D were adamant that Mrs A should go home and the adviser said it would, therefore, be difficult to be critical of the board if their normal discharge procedure was not followed when they were trying to accommodate Mrs A and Mrs D's wishes. Therefore, we did not conclude that the board unreasonably discharged Mrs A from the hospital.

Summary

Mr C, who works for an advice agency, raised a complaint on behalf of his client (Ms B) about the care her mother (Mrs A) received while in Glasgow Royal Infirmary. In particular, Ms B was concerned that staff failed to take account of her advice about her mother's early onset of Parkinson's Disease and that they failed to deal appropriately with Mrs A's mobility issues and the risk of falling while in the hospital. She also complained that the communication between the hospital staff about Mrs A's care was inadequate and that the board's complaint response was inadequate.

During our investigation, we took independent advice from a mental health adviser and a nursing adviser. We were satisfied that Mrs A's risk of falling was reasonably assessed on admission and there were regular and focussed assessments of mobility with involvement from medical, nursing and physiotherapy staff. We also found that the nursing assessments, charts and notes were of a good standard and that Mrs A's medical records were clear about her level of mobility and the assistance required. However, we were concerned that, while the advice we received from the mental health adviser was that Mrs A may have been able to comprehend and recall instructions and that prior to a fall in the hospital she had been assessed as safe and independent with a walking frame, Mrs A's abbreviated mental test score was ineffectively recorded in the medical records. We found that there was a failure to re-assess Mrs A's cognitive state and keep this under review while in the hospital.

We were also concerned that, while the board apologised for the delay in replying to Ms B's complaint, there was a failure to provide updates or provide an explanation for the delay.

Recommendations

We recommended that the board:

• ensure that where a patient presents with confusion and memory impairment, their cognitive state is assessed on arrival to the ward and kept under review;
• ensure that cognitive testing results are effectively recorded in the medical records; and
• remind staff of the importance of adhering to the NHS Scotland complaints procedure.

Summary

Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and leg. Whilst Mrs A was in hospital, she suffered a series of falls, some of which resulted in further injury.

After taking independent advice from a nursing adviser, we did not uphold Mrs C's complaint that a fall Mrs A had while using the toilet at the Southern General Hospital was caused by unreasonable circumstances. The advice we received was that it was appropriate for Mrs A to have been allowed privacy to use the facilities after being assisted there by nursing staff. Although we did not uphold this aspect of the complaint, we did make a recommendation about this.

We also took independent advice from a consultant physician and geriatrician who considered whether it was reasonable that staff at the New Victoria Infirmary had not identified a hip fracture following a fall there. We did not uphold this complaint as the advice we received was that there was no indication that, following the fall, Mrs A had sustained a fracture. The adviser also said that an appropriate medical assessment had taken place. We also did not uphold Mrs C's complaint that Mrs A had to wait too long for surgery following admission to the Victoria Infirmary. We found that surgery had taken place within the recognised standard of 48 hours.

We did, however, uphold a complaint about Mrs A's premature discharge from the New Victoria Infirmary. We found that records, including National Early Warning Scores (NEWS), were unavailable and it was not clear whether there had been a failure to complete these or if they had been lost. These records, had they been available, would have enabled the adviser to confirm whether the decision to discharge was reasonable.

We also found that nursing staff caring for Mrs A should have requested a medical review before she was discharged due to her recent falls history and the level of pain she was experiencing.

Recommendations

We recommended that the board:

• ensure that the relevant staff are made aware of the nursing adviser's comments on toilet supervision requirements and facilities checks;
• issue an apology for the failing to request a medical review prior to discharge;
• make the relevant staff aware of the nursing adviser's comments on requesting a medical review; and
• take steps to ensure NEWS scores are appropriately taken and recorded on the ward and that medical records are appropriately stored.

Summary

Mr C saw a dentist at the practice. Arrangements were made for future treatment and Mr C attended a further appointment a few weeks later. In the interim, ownership of the practice had changed and Mr C was seen by a new dentist. He complained that the practice had not advised him of this change. The practice responded to Mr C's complaint and explained that they had been assured by the previous owner that all patients would be advised of the changes prior to the transfer. They also advised that no other patients had reported problems with this and that they were reassured that it had been an isolated incident.

After investigating Mr C's complaint, we accepted his position that he was not made aware of the upcoming changes at the practice. However, as the practice expected all patients to have been informed of this by the previous owner, we considered it was reasonable that they did not take steps to separately advise Mr C of the changes. Consequently, we did not uphold this complaint. We made a recommendation to the practice that they review their complaints handling procedure as, during our investigation, it was noted that some parts were not in line with Scottish Government guidance on NHS complaints.

Recommendations

We recommended that the practice:

• review their complaints procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.