Health

Summary

Mr C complained that the board failed to take reasonable steps to diagnose and treat his elbow pain after he raised concern at Ayrshire Central Hospital in August 2013. He was unhappy with the time taken to carry out nerve conduction tests at the end of December 2013, which indicated that he had cubital tunnel syndrome (nerve compression). He was not given the results until six weeks later and was then referred for specialist surgical review. Mr C felt that, had his diagnosis been reached sooner and surgery carried out promptly, additional nerve damage would not have occurred.

We took independent advice from two advisers: a physiotherapist and an orthopaedic consultant (a specialist in conditions involving the musculoskeletal system). We noted that the board apologised to Mr C for a delay in Mr C receiving his results and they took reasonable action to carry out a review and make improvements in this respect. However, we identified that when Mr C first presented with his elbow pain, the physiotherapist did not take into account the possibility of nerve compression. In addition, whilst a different physiotherapist noted motor deficit two weeks later, they did not arrange immediate referral to a specialist in accordance with the board's musculoskeletal guidance. Instead, they raised concern in an email to an orthopaedic doctor but did not mention all the relevant symptoms. We also found records indicating that there had been earlier discussion about referring Mr C for nerve conduction tests at the beginning of September 2013 but this was not organised until four weeks later. Whilst we concluded that staff acted unreasonably in not referring Mr C for specialist review from the outset and arranging the tests sooner, there was insufficient evidence to demonstrate that he sustained additional nerve damage.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified;
• share the findings with the physiotherapy and orthopaedic staff involved in Mr C's care; and
• consider reviewing their musculoskeletal guidance to ensure that appropriate information is provided on cubital tunnel syndrome as a specific condition.

Summary

Mrs C complained about the gastroenterology care she received from the board. Mrs C was attending an out-patient clinic at University Hospital Ayr and had previously undergone surgery to remove her gallbladder. She continued to experience various problems with her digestion along with skin problems, particularly on her hands. Mrs C complained that there had been too many consultants involved in her care and that there had been a lack of continuity in her care. Mrs C also complained that the board had not coordinated her care appropriately and that they unreasonably failed to reach a diagnosis of her condition.

During our investigation, we took independent advice from a consultant gastroenterologist. We found that the board had acknowledged there were a number of gastroenterologists involved in Mrs C's care due to retirement and sick leave and they had apologised for this. However, the advice we received was that for patients with chronic conditions like Mrs C, the use of short term locum consultants should be avoided. We found that this had affected the continuity of Mrs C's care and resulted in a potentially avoidable referral to another NHS board. We upheld Mrs C's complaints regarding the number of consultants involved and the lack of continuity in her gastroenterology care.

The adviser considered that there was evidence of good coordination of Mrs C's care with referrals to other specialties being followed up promptly by a single consultant and consequently we did not uphold that element of her complaint. We also did not uphold Mrs C's complaint about a lack of definitive diagnosis. The advice we received was that the board had carried out numerous investigations to try to determine the cause of Mrs C's continuing symptoms and that reasonable steps were taken in attempts to reach a definitive diagnosis. The adviser highlighted two blood tests that could be carried out for completeness but overall, the board's action on diagnosis was considered to be reasonable.

Recommendations

We recommended that the board:

• ensure that all relevant staff are made aware of the adviser's comments on locum consultations for patients with chronic conditions; and
• ensure that Mrs C's consultant is made aware of the adviser's comments on additional blood tests that could be carried out for completeness.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during several admissions to Western Isles Hospital, following a fall. Mr C said they were initially told there were no breaks or fractures, but he found out over a week later that in fact Mrs C had several rib fractures. He then found out several weeks after this that Mrs C also had a fractured vertebra. Mr C complained about the delay in diagnosing the fractures, and raised concerns about the overall medical and nursing care. He also said staff told him he would be refunded for his expenses when he accompanied Mrs C to a hospital on the mainland, but the board later refused to reimburse him.

The board explained that Mrs C was very ill, with a severe chest infection and a number of medical conditions. They said the rib fractures appeared to be old, and would not have changed her treatment. They also said Mr C was not eligible to be reimbursed for his expenses under their travel policy (and they had updated their information leaflet to make this clearer). The board agreed that some aspects of Mrs C's care could have been better, in particular management of her diabetes, and they took actions to improve this.

After taking independent medical and nursing advice, we upheld two of Mr C's complaints. We were not critical that staff did not identify Mrs C's fractures on the original x-rays, but we were concerned that there was a delay in the reporting of scans, which meant that staff were unaware of Mrs C's fractures for some time. We also found that staff failed to investigate a new symptom of pain when Mrs C returned to hospital a few days after her fall. Finally, we found there was evidence that nursing staff thought Mr C was eligible for reimbursement under the travel policy (so it was likely they gave him inaccurate information about this).

Recommendations

We recommended that the board:

• feedback our findings to the staff involved for reflection and learning;
• review their process for reporting on x-rays to ensure reports are completed within a reasonable timeframe;
• ensure relevant staff discuss the radiology adviser's comments on the scan at a discrepancy meeting;
• apologise to Mr C for the failings our investigation identified; and
• remind staff that the travel policy does not apply in relation to patients transferred by ambulance, or patients transferred between treatment centres.

Summary

A GP was called to Mrs A's home when she was experiencing breathing difficulties. The GP examined Mrs A and prescribed medication. Two days later Mrs A was admitted to hospital with respiratory failure. Mrs A subsequently complained to the practice about the care and treatment she received at the home visit. The practice explained the reasons why the GP had made his decisions and indicated that they considered that these had been reasonable. Mrs A remained dissatisfied and Mrs C, who works for an advice agency, complained to us on behalf of Mrs A. Specifically, Mrs A wanted to see if there was a preventable delay in her care.

We took independent advice from a GP adviser. The adviser reviewed the medical records for the home visit and considered that the symptoms and signs recorded were consistent with the diagnosis made, which was an acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD). The adviser told us that the GP had identified this appropriately and treated Mrs A in line with the National Institute for Health and Care Excellence (NICE) guidance relevant to COPD in Scotland.

Overall, the adviser was satisfied that the practice's care and treatment of Mrs A was reasonable. We agreed with this advice, and did not uphold the complaint.

Summary

Mr C complained about the care and treatment of his mother (Mrs A), who was admitted to Perth Royal Infirmary following some falls, and then transferred to Murray Royal Hospital for assessment. Mrs A remained in Murray Royal Hospital for about three months, although she was transferred back to Perth Royal Infirmary on several occasions.

During Mrs A's time at Murray Royal Hospital, Mr C made allegations of abuse by nursing staff, and he complained that the board did not investigate this properly. Mr C also raised concerns about Mrs A's nursing and medical care at Murray Royal Hospital. These included concerns about her falls and physical safety, the numerous transfers between hospitals, the delay in replacing Mrs A's dentures, Mrs A's medications, and the decisions to detain Mrs A under the Mental Health Act and to use covert medication. Mr C also said the board failed to reimburse him for items lost during Mrs A's admission.

The board apologised to Mr C for the time taken to replace Mrs A's dentures and for the lost items. They arranged several reviews of Mrs A's care in response to Mr C's complaint, but found her care was satisfactory.

After taking independent advice from a mental health adviser and an adviser who is a consultant in general medicine, we upheld two of Mr C's complaints. We found there had been some failings in nursing care, including inadequate care planning (particularly in relation to falls risk) and inadequate nutrition monitoring. We also found the board failed to agree a clear communication plan with Mr C. However, we found that Mrs A's medical care was reasonable, and the decisions to detain Mrs A and use covert medication were made appropriately and in line with relevant guidance. We also found that, although the board had not yet reimbursed Mr C for all the missing items, they had handled his claim reasonably.

Recommendations

We recommended that the board:

• apologise to Mr C for the overall failings our investigation found;
• feed back the findings of our investigation regarding falls prevention, care planning and nutrition monitoring to the staff involved for reflection and learning;
• take steps to ensure individualised care planning is used to proactively identify and address patients' comprehensive care needs;
• review the use of communication plans for relatives and carers at Murray Royal Hospital; and
• review staff training needs in relation to falls prevention planning and responding to a fall (particularly where there is a suspected fracture).

Summary

Mrs C's husband (Mr C) was admitted to Perth Royal Infirmary and treated for pneumonia. His condition did not improve whilst in hospital and he died seven days after being admitted.

Mrs C raised a number of specific complaints about the medical and nursing treatment her husband received at the hospital. In particular, she felt that his medication was not managed appropriately and that she was left to take care of many of his basic personal care needs.

We took independent advice from two advisers, one a consultant geriatrician and the other a nurse. Whilst we were critical of the board for failing to ensure Mr C's teeth were cleaned regularly and for initially denying Mrs C access to the ward outside of normal visiting times, we were generally satisfied that the medical and nursing care was of a good standard.

Summary

Mrs C was referred to the Royal Infirmary of Edinburgh for a coronary angiogram and percutaneous coronary intervention (a procedure to examine the coronary arteries, and if narrowing or blockages are found, to stretch these to enable blood to flow properly). Following the procedure, Mrs C had a bleed from her femoral artery (a large artery in the thigh), and it was necessary to carry out emergency surgery to stop this.

Mrs C was concerned there was a lack of due care during the procedure, and said she had been traumatised by the procedure and suffered from flashbacks and memory loss. The board wrote to Mrs C to explain what had happened, and offered to meet with her, but she declined. The board said the bleed Mrs C experienced was a recognised complication of the procedure.

After taking independent medical advice, we did not uphold Mrs C's complaint. We found that staff carried out the procedure reasonably, and the bleed Mrs C suffered was a recognised complication of the procedure, with staff taking reasonable and appropriate action in response to this. However, the adviser noted that staff did not complete the board's pro formas for the procedure, and we were critical of this, so we made a recommendation to the board.

We also noted that the consent documentation showed Mrs C was not keen to read the information about the procedure, and there was no record that this information was given to her verbally or the key risks of the procedure discussed. While we acknowledged that Mrs C also had responsibility to ensure she understood the risks of the procedure before agreeing to it, we found that staff should have offered Mrs C the relevant information verbally (and documented this) before continuing with the procedure, so we also made a recommendation about this.

Recommendations

We recommended that the board:

• take steps to ensure the NHS Lothian pro formas for Diagnostic Cardiac Catheterisation and percutaneous coronary intervention are completed; and
• feed back our findings regarding informed consent to the staff involved.

Summary

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her late husband (Mr C) who died following an overdose. Mrs C said that her family had reported their concerns about Mr C's behaviour and that he should have been referred to the mental health services but the practice did not listen to their concerns.

The practice maintained that, on examination, there was no indication that Mr C suffered from mental health issues or that there was the possibility of a suicide risk.

We took independent advice from a GP. We concluded that as Mr C was showing signs of paranoid ideation (having beliefs that you are being harassed or persecuted, or beliefs involving general suspiciousness about others' motives or intent), verbal aggression, and transient confusion this would warrant a mental health assessment in the first instance with the possibility of referral for a specialist opinion. We also found that the practice should have taken action in view of the concerns voiced by the family. Although there was no evidence that the inactions of the practice directly led to Mr C taking an overdose, we upheld the complaint in light of the failings identified.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified in this report;
• make contact with the Health Board Clinical Support Group for guidance on training regarding patients with mental health problems; and
• ensure that the GP discusses this case as part of their annual appraisal.

Summary

Mrs C complained of continual abdominal pain and she had a scan. The scan showed a rotation in her gut and, as it was unclear whether or not this was the cause of her pain, it was agreed that she should have a diagnostic laparoscopy (a surgical procedure to access the inside of the stomach and pelvis through a small hole in the skin). This confirmed the mal-rotation but nothing to establish the pain Mrs C was experiencing.

However, Mrs C remained in severe pain after her operation and because of this and the diagnostic uncertainty, the procedure was carried out again but, once more, no new abnormalities were identified. It was concluded that further surgery would be unlikely to help Mrs C but because of her continuing pain she was admitted to a critical care bed for observation. Mrs C later complained that she had not been provided with appropriate medical treatment.

We obtained independent advice from a consultant general surgeon. We found that in view of Mrs C's chronic abdominal pain, all the investigations and procedures carried out were reasonable and that she had been provided with appropriate medical treatment. For this reason, the complaint was not upheld. However, our investigation also showed that there was no record of the reasoning for a second laparoscopy, discussions with Mrs C, or a copy of her consent. There was no evidence that Mrs C had been given an appropriate explanation for what had happened to her. As a consequence, we made recommendations to the board.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified;
• emphasise to the clinical staff concerned the necessity of following good practice by appropriately recording consent and completing records clearly, accurately and legibly; and
• remind clinical staff of the importance of good communication.

Summary

Mrs C complained after her mother (Mrs A) suffered a fall in Hairmyres Hospital. Mrs A suffered from dementia and was unsteady on her feet. Mrs C said the board had not done enough to prevent her mother's fall.

We took independent advice from a nursing adviser. The adviser found that the board had carried out appropriate assessments and were monitoring Mrs A's mobility. The adviser explained that staff had to balance trying to encourage Mrs A to be independent (with a view to getting her home) with the need to ensure her safety. The adviser was satisfied that the board had done all they reasonably could to mitigate the risk of Mrs A having a fall, recognising that they cannot eliminate the possibility altogether. For this reason, we did not uphold the complaint.