Health

Summary

Mrs C complained to us about the care and treatment provided to her late mother (Mrs A) in the Victoria Hospital. We took independent advice on Mrs C's complaints from a consultant geriatrician and a nursing adviser. Mrs C complained that the action taken in relation to the management of Mrs A's pain was unreasonable, particularly as Mrs A had dementia. We found that although there had been no clear cause of Mrs A's pain, medical staff had made reasonable attempts at diagnosing and managing the cause of her pain and it had been reasonably well controlled. There was also evidence in the nursing notes to indicate that nursing staff undertook very specific assessment and management of Mrs A's pain. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the action taken in relation to fluids and diet. We upheld this complaint, as we found that staff had not completed nutritional screening documentation when Mrs A was admitted and that she had repeatedly received the same types of meals. There was also no evidence that staff had taken action when Mrs A's dentures went missing. That said, we were satisfied that the board had apologised for these failings and had taken action to prevent similar problems occurring.

Mrs C also complained about the communication with the family. We found that this had been of an acceptable frequency and detail. We did not uphold this aspect of the complaint. In addition, we found that the end of life care provided to Mrs A had been reasonable and did not uphold Mrs C's complaint about this.

Summary

Mrs C complained that her late mother (Mrs A) did not receive appropriate care after she was admitted to Borders General Hospital. She also complained that the family were not informed in a timely manner when Mrs A's condition significantly deteriorated. In responding to the complaint, the board said that Mrs A's care was provided in a timely manner. However, they accepted and apologised that there was a failure by staff in informing the family about Mrs A's worsening condition when this was known.

We took independent advice from a consultant geriatrician. We identified evidence of poor record-keeping and that there was undue delay in identifying that Mrs A was significantly unwell. There was a delay of six hours in nursing staff checking Mrs A's blood pressure, which was contrary to national guidance. We also considered that blood tests could have been carried out sooner and that there was several hours' delay in staff taking the abnormal blood results into account after they were reported.

We noted there was a four-hour delay in the family being informed that Mrs A's condition had significantly worsened. Whilst the board apologised and had advised that they were taking action to address the matter, we asked for further evidence to demonstrate how this will prevent a similar delay occurring. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for not having identified Mrs A's deteriorating condition in a timely manner;
• share the findings about record-keeping, blood testing, and blood pressure monitoring with the medical and nursing staff who were involved with Mrs A's care in the medical assessment unit;
• conduct a review of care and treatment in the medical assessment unit to ensure timely care is provided to those patients at risk of rapid deterioration; and
• provide more detailed information on the pilot they carried out in relation to improving communication and on whether this has been implemented throughout the hospital.

Summary

Ms C complained about the care and treatment her late father (Mr A) received from the board's out-of-hours service shortly before his death. Mr A had been diagnosed with bladder cancer and was receiving palliative care. On the day Mr A died he was in severe pain in the early hours of the morning and Ms C's mother (Mrs A) contacted NHS 24. Mr A was seen by a doctor from the out-of-hours service and was given morphine for the pain. He remained in pain and another out-of-hours doctor was asked to attend but they felt they would not be able to attend before their shift ended, so asked that Mr A's GP attend instead. Mr A was told the GP would attend at 08:00 however the GP was not contacted until 08:05 and did not attend until 08:45. Mr A died in the early afternoon. Ms C complained that the actions of the out-of-hours doctors prolonged Mr A's severe pain during the final hours of his life.

We took independent advice on Ms C's complaint from a GP adviser. We found that the first out-of-hours doctor attended in good time but provided a dosage of morphine that was too low to improve Mr A's pain and did not take into account the medication he had already been taking which had little effect. We found there was a similar failure to look into Mr A's recent history by the second out-of-hours doctor as there was no evidence of this second doctor speaking to either Mr or Mrs A to assess Mr A's condition at that time nor of them making their decision with reference to the earlier out-of-hours attendance. We were critical that the decision to refer Mr A to his GP practice was taken without taking into account his needs. The second call to the out-of-hours doctor was given a one hour priority, but passing the call on to Mr A's GP practice (which had not yet opened at the time of the call being passed on) meant it was not possible for the one hour timescale to be met. We noted that the board's out-of-hours policy recognised situations like this and provided scope for the out-of-hours doctor to act if the presenting condition and treatment fell outwith the time-frame. In this case, however, this did not occur. At the time of the second call Mr A was in severe pain which had not improved following an earlier visit. We found that had the second out-of-hours doctor responded to the call and visited Mr A the pain, discomfort and distress he and his family endured may have been avoided.

Recommendations

We recommended that the board:

• apologise to Mr C's family for the poor standard of care and treatment that Mr A received;
• share our findings with the staff involved in Mr A's care and treatment with a view to identifying any areas where their clinical decision-making may be improved; and
• ensure clinicians have regard to the out-of-hours policy, in particular in relation to exceptional circumstances, when providing out-of-hours care and treatment.

Summary

Mrs C's GP referred her urgently to University Hospital Crosshouse in April 2014 as it was suspected that she had breast cancer. However, after examination and ultrasound, her tests were found to be normal. She was told that everything was satisfactory but, because of a family history of breast cancer, she would be referred to the genetics department for risk assessment. Mrs C said that she was never contacted by the genetics department and because of her results, she said she was unconcerned.

In November 2014, Mrs C was re-referred to hospital. She had a breast lump and breast cancer was confirmed. Mrs C complained that her illness should have been diagnosed earlier. She said that because it was not, her cancer had grown and she required to have a double mastectomy. She said that insufficient investigation was made in April 2014. She complained to the board who said that as no abnormality had been found initially, at either the scan or on examination, there had been no clinical indication to refer her for a mammogram and there was no abnormality to biopsy.

We took independent advice from a consultant breast surgeon and we found that, in view of her presenting symptoms, Mrs C had been treated reasonably and appropriately. She had been examined and assessed in terms of best clinical practice. Nevertheless, despite this, it was likely that her breast cancer had been missed the first time. There was nothing the board could have done to have prevented her delayed diagnosis. For this reason, the complaint was not upheld. However, it had been intended to see Mrs C in the genetics department for a risk assessment but it appeared that a letter inviting her to provide information about her family may not have been sent. Accordingly, the board were asked to apologise although, even if the letter had been sent, Mrs C's outcome would have been unchanged.

Recommendations

We recommended that the board:

• make an appropriate apology to Mrs C.

Summary

Mrs C complained about the care and treatment provided by the practice. Mrs C raised concerns that the practice did not provide a reasonable standard of care when she presented with symptoms of bowel discomfort and diarrhoea over a period of several months. In particular, she was concerned the practice failed to diagnose her colonic cancer at an early stage. Mrs C also raised concerns about timeliness of blood tests, the antibiotics prescribed, and her concerns that the practice was dismissive of her symptoms. She also complained the practice unreasonably failed to provide a letter of referral she asked for in order to arrange a private scan.

The practice said that Mrs C's treatment had been reasonable. In particular, they noted that Mrs C had attended a colonoscopy (an examination of the bowel with a camera on a flexible tube) two months prior to the period in question, which had shown no signs of cancer, but provided an alternative explanation, which was consistent with her symptoms. The practice said that the GP in question understood Mrs C had requested a scan, and had arranged appropriate investigations.

After receiving independent advice from a GP, we did not uphold Mrs C's complaint. We found that the practice had acted reasonably in the circumstances, based on the result of the colonoscopy, the alternative diagnosis, and the nature of the symptoms Mrs C experienced. We also considered that the practice provided appropriate care and treatment in relation to blood tests, prescription of antibiotics, and was responsive to her symptoms. We also considered the actions of the practice in relation to the scan were reasonable in the circumstances.

During the course of our investigation, we noted aspects of the practice's complaints procedure did not comply with the Scottish Government's 'Can I help you?' guidance, so although we did not uphold the complaint, we made a recommendation about this.

Recommendations

We recommended that the practice:

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

Summary

Ms C complained about the care and treatment she received from University Hospital Crosshouse for what she believed was suspected appendicitis. She said she made frequent visits to the A&E department at the hospital and was also admitted to the hospital, but her condition was not reasonably assessed and treated. She said her condition then deteriorated and spread to her bowel and she had to have part of her large and small bowel removed. Ms C also complained that her complaint about her treatment was not reasonably responded to by the board.

We took independent advice from two advisers, one a consultant in emergency medicine and the other a consultant colorectal surgeon (who specialises in conditions relating to or affecting the colon and rectum). The emergency medicine adviser said that the treatment Ms C received in the A&E department at the hospital was reasonable.

The colorectal surgical adviser said they did not think that there was an unreasonable failure by the board to diagnose Ms C's appendicitis sooner, as the initial clinical signs would not have been very obvious for acute appendicitis. They also said there was a delayed diagnosis of acute appendicitis, but explained that the diagnosis of this is sometimes challenging even to an experienced surgeon and it would have been difficult to know and impossible to determine at what precise moment Ms C actually had acute appendicitis. We therefore did not uphold Ms C's complaint that her condition was not reasonably assessed and treated, but we did make a recommendation based on the advice we received about how the board should have shared the learning points from Ms C's complaints.

In terms of the complaints handling, Ms C indicated in her complaint to the board that she was concerned about the care and treatment she received from the board and her GP. The board did not appear to take any action to assist in progressing Ms C's complaint about her GP, either by contacting Ms C's GP practice or by advising Ms C to do so herself. We, therefore, considered that her complaint was not reasonably responded to by the board and we upheld this part of Ms C's complaint. We also found that at the time of Ms C's complaint, the board did not have a full written complaints procedure in place. They said that they were in the process of compiling a toolkit that would address this, so we made a recommendation about this too.

Recommendations

We recommended that the board:

• take steps to ensure that in future they keep documentary evidence of the remedial action taken as a result of patients' complaints;
• feed back our decision on their handling of Ms C's complaint to the staff involved;
• provide us with a copy of their comprehensive complaints tool kit and evidence that this has now been launched; and
• provide Ms C with a written apology for failing to respond reasonably to her complaint about her GP.

Summary

Mr C complained about the care and treatment that his late wife (Mrs A) had received at University Hospital Crosshouse across a number of admissions. Mr C was concerned that staff were overly focussed on Mrs A's existing conditions and did not pay enough attention to new symptoms that were unconnected to these. Mrs A passed away after she became very unwell with a bleeding duodenal ulcer (an ulcer in part of the bowel, just after the stomach) following a number of admissions to the hospital across four months.

After taking independent advice on this case from a consultant geriatrician, we upheld Mr C's complaint. We found that while many aspects of Mrs A's care had been good, there was a failure to carry out appropriate investigations to determine the cause of her anaemia after this was revealed by blood tests during one of her admissions. We received advice that this meant a potential opportunity to diagnose the ulcer earlier was missed and that this could have led to specific treatment to reduce the risk of this bleeding. We made a number of recommendations to address the issues we identified.

Recommendations

We recommended that the board:

• issue Mr C with a written apology for the failure to take further action to establish the cause of Mrs A's anaemia following a specific admission;
• ensure that this case is included for discussion at the appraisals of the relevant clinicians; and
• discuss this case at an appropriate clinical governance forum.

Summary

Mrs C complained about care and treatment provided to her late father at University Hospital Crosshouse, and about the board's handling of her complaint. During our investigation the board sent a letter to Mrs C that acknowledged and apologised for their failings, and set out an action plan to remedy the failings. We discussed the letter with Mrs C and, as she was satisfied that the board had resolved her complaints, we agreed to close the file on her complaint. In closing the file, we wrote to the board to express our concerns about the time they took to deal with Mrs C's complaint. While we did not make a formal recommendation, we asked them to provide us with evidence relating to their action plan, which they did.

Summary

Ms C complained about the treatment her father (Mr A) received from the practice over a five month period in 2013. Mr A had been diagnosed with bladder cancer in 2012 and attended the practice on a number of occasions complaining of back pain. Ms C did not feel that his condition was taken seriously or that adequate treatment was provided by the practice.

We sought independent medical advice on this case. Whilst we generally found that the practice provided good treatment in line with national guidance during the period in question, we found that the GPs could have been more proactive in arranging specialist investigations when Mr A's pain failed to reduce. Our investigation also highlighted significant concerns about the management of Mr A's pain some months later on the day he died. We were critical of the practice for failing to react to the urgency of the situation when family members contacted them, and for failing to have important palliative care drugs available to alleviate Mr A's pain.

Recommendations

We recommended that the practice:

• apologise to Ms C's family for the failings identified;
• discuss the adviser's concerns with the relevant staff members at their annual appraisals; and
• take steps to ensure that they have an adequate supply of ‘just in case’ drugs available to their palliative care patients.

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.