Health

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.

Summary

Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that the prison health centre had sent a referral to the plastic surgery clinic but it was subsequently decided that revision surgery was not appropriate, as Mr C was continuing to self-harm at the time. We were advised that the decision not to progress the referral in such circumstances was reasonable and in line with relevant guidelines. We accepted this advice and did not uphold this aspect of the complaint.

Mr C also complained about the way his complaints were handled by both the prison health centre and the board. He noted that he had asked specific questions in his complaints and that these had not been answered. We agreed that the prison health centre had only formally addressed one of the two points raised with them and the board's formal response omitted a reply to one of the four points raised with them. We, therefore, upheld this part of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for failing to fully respond to his feedback and complaint forms; and
• make the relevant complaints handling staff aware of our findings.

Summary

Mrs C brought a complaint to us on behalf of her late husband (Mr C), in relation to the care and treatment he received over a five week period shortly before his death. She was concerned that the medical practice had not acted with enough urgency when she felt Mr C's condition was deteriorating. He had three consultations with a GP over a four week period. At the final consultation the GP had concerns about his breathing and referred him for an x-ray, which took place the next day. The results of the x-ray indicated that Mr C had pleural effusion (a build-up of excess fluid around the lungs). The results arrived in the practice the following day, and the GP referred Mr C back to hospital when he viewed the results on his return to work the day after. Mr C was treated in hospital, and was discharged home, to await further treatment. He died before this further treatment could take place.

We sought independent advice from a GP adviser. The adviser reviewed all three consultations, and was satisfied that the GP had taken appropriate action, on the basis of the symptoms which Mr C presented with. They noted that there was no indication of pleural effusion until the third consultation.

The adviser also reviewed the practice's response to the x-ray results, and noted that the results did not indicate a need for urgent action. They considered the practice's response to the x-ray results to have been reasonable.

We noted concerns that Mrs C had raised which were beyond the scope of this investigation, in relation to conversations which could not be corroborated. We noted the adviser's comments in relation to the GP's actions, and we did not uphold Mrs C's complaint.

Summary

Mr C complained that a surgeon failed to properly carry out a laser prostatectomy (surgical removal or resection of the prostate gland) at the Queen Margaret Hospital causing him severe pain, blood loss and the need for further surgery two weeks later.

The board advised Mr C that the surgeon was assisted by a mentor experienced in this type of surgery, and no complications occurred during the procedure. However, they apologised that Mr C had experienced the recognised risk of post-operative bleeding. Mr C remained unhappy that there was a need for more surgery to address his pain and bleeding.

The laser surgery carried out is a relatively new technique which has not be universally adopted by urologists. We took independent advice from a consultant urological surgeon who has undertaken laser prostatectomy. We found evidence of poor record-keeping which fell below a reasonable standard in relation to Mr C being properly informed about all the risks associated with the laser surgery. We were also critical that there was no record of the surgeon's mentor having been present during the operation. Whilst we considered that there was no evidence of damage having been caused, the treatment was inadequate in removing tissue that was causing obstruction. We therefore upheld Mr C's complaint and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified;
• draw to the surgeon's attention the findings in relation to obtaining informed consent; and
• inform us of the outcome of their review and any action taken in relation to the surgical recording process.

Summary

Mr C attended the practice on three occasions between 2010 and 2013 for blood glucose tests (a standard test for blood sugar levels, used in diagnosing diabetes). Mr C was not diagnosed with diabetes until a fourth blood test later in 2013. He has complained that, based on these test results, the practice could have diagnosed his diabetes earlier than they did.

We took independent advice from a GP adviser. They noted national guidance and the protocols in place in the practice for diagnosing diabetes. They also reviewed the test results from Mr C's blood glucose tests. They identified that it was not clear whether the first test, in 2010, had been a 'fasted' blood sample (ie whether Mr C had been told to fast prior to the blood test). They noted that this would have had an impact on what further action was appropriate. Given that the GP involved at that point had since retired, and that the actions could have been reasonable, they were not critical. However, the second blood test results showed concerns and should have been immediately responded to. Instead, Mr C was advised to return for another test in six months. When he had another blood test 18 months later, the test results were conclusive of diabetes, and the adviser noted that the error in identifying this had already been picked up by the practice in their response to the complaint.

We concluded that the GP had not taken reasonable steps in their response to Mr C's second blood test, as further tests should have been taken at that time. We agreed with the practice's assessment of their response to Mr C's third blood test. We were also concerned that the local protocols in place for the assessment of blood glucose results did not fully reflect the national guidance.

Recommendations

We recommended that the practice:

• ask the GP involved to consider reviewing this case in conjunction with the World Health Organisation (WHO) Guidance on the diagnosis of diabetes and identifying any learning point at their next appraisal; and
• review their protocols for the management of abnormal diabetic blood results, to ensure they are in line with the WHO Guidance.