Health

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A). Mrs C raised concerns that hospital staff at Dr Gray's Hospital unreasonably arranged to transfer Mrs A to Turner Memorial Hospital. Prior to the transfer, Mrs C had been treated in Dr Gray's Hospital for her existing chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). Mrs C said Mrs A had suffered diarrhoea on the day of the transfer and looked unwell.

The board said Mrs A's transfer had been reasonable. They said there was no evidence of diarrhoea prior to transfer, and Mrs A had been appropriately transferred.

After receiving independent advice from a geriatrician, we upheld Mrs C's complaints. We found that staff had unreasonably transferred Mrs A. In particular, we considered that Mrs A's condition was unstable, and her transfer was not subject to an appropriate level of consideration. We also considered that the board did not comply with the 'Can I help you?' guidance in answering Mrs C's complaint. We made a number of recommendations to address these concerns.

Recommendations

We recommended that the board:

• apologise to the family for the failings identified;
• confirm that the staff responsible will discuss this issue as part of their annual appraisal;
• remind staff of the importance of adequate record-keeping; and
• remind relevant staff of the complaints handling requirements under the 'Can I help you?' guidance.

Summary

Mrs C complained that the Royal Aberdeen Children's Hospital provided her son (Mr A) with inadequate care and treatment. In particular, Mrs C felt that there was not a proper care plan in place and that specific treatment should have been provided. Mrs C also raised concerns that a specialist nurse did not understand Mr A's health problems and acted inappropriately in making a referral to the Reporter to the Children's Hearing (an authority set up to safeguard children).

We took independent advice on this case from a medical adviser and a nursing adviser. We found evidence that the care provided by the hospital was appropriate. In particular, there was good interdepartmental communication between relevant specialities within the hospital and Mr A was reviewed regularly. A second specialist opinion was also appropriately requested from another hospital in England and followed up by the Royal Aberdeen Children's Hospital. Whilst we did not uphold the complaint, we found that the board had not provided Mrs C with a full response to her complaint. Therefore, we made a recommendation to address this.

We also considered that the specialist nurse acted in accordance with professional guidance in making the referral to the Reporter to the Children's Hearing given there was multi-agency concern about Mr A's health and wellbeing.

Recommendations

We recommended that the board:

• share with those staff dealing with complaints the importance of ensuring that full and comprehensive written responses are provided to complaints.

Summary

Mr C complained about the care and treatment his late wife (Mrs A) received at Aberdeen Royal Infirmary. Mr C accepted an apology and explanations from the board for a number of his concerns, but Mr C was not satisfied with the board's response to his concern relating to his wife's DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) status. Mr C was not satisfied that the hospital staff in the gastroenterology department had followed the DNACPR policy and disputed the accuracy of a record which stated that a doctor had discussed the decision with him and his wife. We took independent advice from a consultant physician who was critical of the failure to complete a DNACPR form and the low level of detail in the medical notes surrounding the decision. We upheld this part of Mr C's complaint.

Mr C also complained that the board had taken a number of months to provide him with a written response to his complaint and had exceeded their target response time. Mr C was also concerned that the board had not sufficiently investigated his complaint and he was not satisfied with the response that the board had given him. We acknowledged that, in investigating Mr C's complaint, the board had met with him on two occasions and that this had contributed to the delay in providing a response. However, we remained critical about the individual delays that contributed to the time it took the board to respond, and found that the board had failed to keep Mr C updated on the progress of their investigation into his complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to adhere to the DNACPR policy;
• provide evidence that staff in the gastroenterology department have been reminded of the importance of completing DNACPR forms where appropriate;
• provide evidence of any audit or quality improvement work which has monitored the completion of DNACPR forms in the gastroenterology department since staff were reminded to complete the forms;
• apologise for the failure to keep Mr C updated on the progress of their investigation into his complaint and failure to respond to his emails; and
• advise staff responsible for investigating complaints to update complainants in line with 'Can I Help You?' guidance.

Summary

Mr C complained about the dental care and treatment he received at the dental practice. Mr C attended the practice frequently over the course of a year, both for routine and emergency appointments. Mr C complained that at an appointment a dentist conducted an excessive investigation, causing two of his crowns to fall out during the following months. Mr C also raised broader concerns that failures in his care led his dental health to decline to a point where he required significant restorative work and multiple extractions.

The board considered there was no evidence that an excessive investigation had caused the collapse of Mr C's crowns, which they linked with existing decay. More generally, the board said Mr C's care and treatment was appropriate.

After receiving independent advice from a dental practitioner, we did not uphold Mr C's complaint. We found there was no evidence that an excessive investigation occurred. We found the care and treatment Mr C received was reasonable.

Summary

About six weeks after the birth of her child, Mrs C attended her GP practice with bleeding and abdominal pain. She was treated with antibiotics. She was reviewed several times over the next few months, and a urine test and vaginal swab were carried out, with further antibiotics prescribed. Mrs C was then referred to gynaecology as a private patient, and subsequent investigations showed there were retained products of conception (pieces of placenta) left after the birth. Mrs C complained about the delay in referring her, and said she was only referred after telling the GPs she had private medical insurance.

The practice explained that the cause of Mrs C's bleeding had been unclear. Mrs C had had a CT scan (a scan which uses x-rays and a computer to create detailed images of the inside of the body) after the birth which had returned a normal result (suggesting there were no retained products of conception). In relation to the delay, the practice noted that on one occasion the GP asked Mrs C to come back in one to two weeks, but Mrs C did not return until six weeks later. Mrs C said this was the first available appointment, but the practice said there were a number of earlier appointments available with the same or different GPs. The practice gave us a copy of their audit records, which showed the appointment was booked only a few days before the date of the appointment.

After taking independent medical advice from a GP, we upheld Mrs C's complaint. The adviser said that the GPs should have arranged an ultrasound in view of Mrs C's symptoms of unexplained bleeding for six weeks after birth, and they should have referred Mrs C to gynaecology earlier. However, we agreed that part of the delay was caused by Mrs C returning in six weeks, rather than two (which may have been due to a misunderstanding or miscommunication).

Recommendations

We recommended that the GPs concerned:

• apologise to Mrs C for the failings our investigation found;
• familiarise themselves with postpartum complications and consider identifying this as a learning aim; and
• reflect on our findings as part of their next annual appraisals.

Summary

Mrs C complained about the management of her child's birth at Aberdeen Maternity Hospital. Mrs C's waters broke prior to labour, and although labour then commenced naturally, she made slow progress and developed a high temperature. In view of this, Mrs C was taken to the delivery theatre and, after a failed attempt with forceps, her baby was delivered via caesarean. Mrs C felt staff should have arranged a caesarean earlier and said she asked for this during her labour. She also raised concerns about the caesarean, in particular that there were retained products of conception (pieces of placenta left in the uterus) which caused ongoing complications and further surgery. Mrs C said the doctor was rude, did not adequately explain her treatment, and lied in their response to her complaint.

The board responded to several letters and met with Mrs C twice to discuss her concerns. They apologised that she felt the doctor had been rude to her, and the doctor attended the second meeting to offer their personal assurance that this was not their intention. The board considered Mrs C's medical treatment was appropriate (although they gave conflicting information about whether Mrs C had asked for a caesarean during her labour). They explained that Mrs C had a CT scan (which uses x-rays and a computer to create detailed images of the inside of the body) after the birth. They said that the CT scan was clear, so staff did not consider there were retained products of conception at that time (although they were sorry Mrs C experienced complications from this).

After taking independent medical advice from a consultant obstetrician and gynaecologist, we did not uphold Mrs C's complaints. We found staff had appropriately discussed Mrs C's treatment options, and there was no evidence that she asked for a caesarean during labour. The adviser said the retained products of conception were quite small, so it was not unreasonable that staff missed these (they also noted that cleaning the uterus too thoroughly can cause scarring and reduced fertility). We also found it was reasonable that staff did not identify Mrs C's retained products of conception during her admission, based on her CT scan and symptoms at the time.

Summary

Mrs C complained about the care she received prior to replacement pacemaker surgery at the Golden Jubilee National Hospital. She was concerned that her premedication had worn off before being taken to theatre and that the anaesthetist had missed the vein when cannulating her (inserting a thin tube into a vein). Mrs C was also in great pain when the anaesthetic drug was administered. When Mrs C came round from surgery, the cannula had been transferred to her other hand, and her hair was stained due to the solution used to cleanse the skin prior to the procedure and she had to have her hair cut. Mrs C also said that she had suffered from tinnitus since the procedure.

We took independent advice from an anaesthetist. We found that the medical records indicated a safe, uneventful anaesthetic procedure and that there were no failings. We were also satisfied that there was no evidence suggesting that failings by the anaesthetist led to Mrs C developing tinnitus.

Summary

Miss C raised her concern about the care she received from Forth Valley Royal Hospital during her pregnancy, labour and postnatal period.

During our investigation, we took independent advice from a consultant in reproductive medicine and surgery, a consultant obstetrician and a midwife. We also received advice on general nursing issues from a nursing adviser.

The board accepted that there had been errors in relation to the initial ultrasound scans Miss C received and, as a result, she had been incorrectly advised that she had suffered a miscarriage. The board had apologised for those errors and had taken action. The advice we received and accepted from the consultant in reproductive medicine and surgery was that it had been too early to diagnose a miscarriage and that there was no evidence consultant advice had been obtained. The adviser also said that there was a failure to record / obtain a complete menstrual history at the time of the scans.

The advice we received from the midwife was that carrying out an ultrasound scan before six weeks gestation would not normally happen. The midwifery adviser also said that it happened in this case in an attempt to meet Miss C's needs, given that she had recently undergone surgery. The adviser said that this was not clinically appropriate.

In the circumstances, we considered that the board had failed to provide Miss C with appropriate care and treatment and we upheld this aspect of the complaint.

We were satisfied that an appropriate assessment had been carried out when Miss C first attended the hospital when she believed her labour had started. However, while the advice we received and accepted from the consultant obstetrician and the midwife was that aspects of her care and treatment were reasonable when she returned to the hospital (in particular, that the obstetrician adviser did not consider that there was an unreasonable delay before the decision was taken to proceed with a caesarean section), we were concerned about a number of communication failings and a failure in record-keeping. We made recommendations to address these failings.

The board had apologised for Miss C's concerns in relation to her postnatal care and had taken action. The advice we received and accepted from the nursing adviser was that the action taken had been reasonable.

Recommendations

We recommended that the board:

• remind staff of the need to record/obtain a complete menstrual history at the time of ultrasound scans;
• bring to the attention of relevant staff the findings of this investigation, in particular the need for experienced medical involvement in a similar situation and the need for further scans;
• consider the suggestion received from the midwifery adviser that additional training in relation to dealing with bereavement surrounding early pregnancies should be provided for midwives who regularly work in this area; and
• remind midwifery staff of the need to maintain full and accurate nursing records in line with Nursing and Midwifery Council guidance.

Summary

Mr C, who works for an advice agency, complained on behalf of Mr A who was concerned about the care and treatment given to his late wife (Mrs A). In particular, he was concerned that there was an avoidable delay by staff at Forth Valley Royal Hospital in establishing that Mrs A was suffering from breast cancer. While the board accepted that there had been a delay and apologised, they said that Mrs A had suffered from a rare form of cancer which had been difficult to diagnose.

We took independent advice from a consultant breast surgeon. We found that while Mrs A's form of cancer was a very rare variant, opportunities had been missed to diagnose her sooner. There had also been an initial delay in Mrs A being seen and her cytology (examination of tissue samples under a microscope) results had been incorrectly reported. We therefore upheld the complaint and made recommendations.

Recommendations

We recommended that the board:

• make a formal apology recognising the shortcomings we identified; and
• check that the changes they outlined to Mr A are now in place and that all excision biopsies, as well as cytology aspirates and needle biopsies, are formally discussed at multi-disciplinary team meetings.

Summary

Mr C complained that a district nurse had wrongly carried out a procedure to reinsert a catheter at home. The district nurse failed to reinsert the catheter three times and he had to be taken to hospital for the catheter to be reinserted. At hospital it was established that a false passage had been created during the attempts at catheterisation. The hospital successfully reinserted the catheter. Mr C felt that the district nurse had not followed protocols when attempting to reinsert the catheter.

We obtained independent advice on the case from a nurse adviser. She said that there were problems when the district nurse tried unsuccessfully to reinsert the catheter and that contact was made with Mr C's GP for advice. It was decided to arrange a non emergency ambulance to take Mr C to hospital for the catheter to be reinserted. The adviser said that Mr C had suffered a relatively rare but recognised complication of catheterisation and that this did not necessarily mean that there had been a failure in carrying out the procedure. It was also noted that attempts at catheterisation were made in the hospital, and therefore we could not be certain exactly when the problem arose. We did not uphold the complaint.