Health

Summary

Mr C suffered from cystic acne. He attended the practice on several occasions over a number of years and received treatment. His GP referred him for treatment from a skin specialist. The specialist prescribed him medication which cleared his acne. However, he was left with significant scarring on his face which he was reportedly told may have been prevented if he had been referred sooner. Mr C complained that, had he been prescribed the medication sooner, he would not have been so badly scarred by his acne. He considered that the practice should have referred him to the specialist earlier, or that they should have prescribed him the medication directly.

We took independent advice from a consultant dermatologist (a specialist in diseases of the skin, hair and nails). The adviser said that GPs would never prescribe this medication directly and that the correct course of action is for the GP to refer the patient to a specialist for consideration of a prescription. We found that the practice had reviewed Mr C's acne on a number of occasions and had provided treatment according to his presenting condition. His treatment was appropriately altered as required and his acne was noted to have improved at various times. We concluded that he was appropriately referred to a specialist when his acne had recurred and showed signs of scarring, so we did not uphold the complaint.

Summary

Mr and Mrs C attended the Aberdeen Fertility Centre and were diagnosed with unexplained infertility. They underwent two in vitro fertilisation (IVF) cycles but neither cycle resulted in pregnancy. The board decided not to offer a further IVF cycle, saying that egg donation could be considered. Mr and Mrs C underwent assisted conception treatment privately. This found that Mrs C's ovarian reserve (the capacity of a woman's ovaries to produce healthy eggs) was higher than expected, and that Mr C's sperm had a significant number of antibodies which caused the sperm to stick together. Mrs C raised concerns about aspects of the assisted conception care and treatment provided by the Aberdeen Fertility Centre as well as the nursing care provided. She also raised concerns about the way the board handled their complaint.

We found that the board's actions were reasonable in relation to the provision of assisted conception. However, in light of the new information about the nature of the couple's infertility and Mrs C's ovarian reserve, we recommended that the board consider whether the couple met the board's eligibility criteria (as outlined in their policy) for a third round of IVF treatment. We also found communication and record-keeping failures by nursing staff, particularly around pain assessment and relief. In relation to the board's complaints handling, we found that the board should have told Mrs C about the delays in responding to her complaint, the reasons for the delays, and of her right to approach us in such circumstances.

Recommendations

We recommended that the board:

• consider whether Mr and Mrs C meet the eligibility criteria in the board's policy for a third cycle of assisted conception treatment in light of the new information about the nature of their infertility and Mrs C's ovarian reserve;
• bring the record-keeping and communication failures to the attention of relevant staff and review the process to ensure there is no recurrence;
• apologise for the failures identified in complaints handling and bring them to the attention of relevant staff; and
• apologise for the failures identified.

Summary

Mr A was admitted to Forth Valley Royal Hospital after taking an overdose of drugs. His sister (Ms C) said that it was considered that he had suffered an organically induced psychotic state and a few days later, after his blood pressure and temperature returned to normal, he was discharged. Ms C, however, remained concerned about Mr A's state of mind and wrote to his psychiatrist but her contact was rebuffed. Mr A took his life five months after the overdose. Ms C complained that the board had failed to contribute positively to Mr A's care and perhaps change his outcome. She also complained about the psychiatrist's attitude to the family and that he had focussed incorrectly on Mr A's physical, rather than his mental health.

We took independent advice from a consultant psychiatrist and we found that, initially, it had been reasonable to conclude that Mr A's behaviour was due to a transient illness caused by an organically induced psychotic state, and to treat him for this. However, Mr A's psychiatrist later declined important information from Ms C which should have been included in decision-making and clinical management (although it could not be concluded that this would have changed the outcome for Mr A). Subsequently, when Ms C complained, it took too long to provide her with an explanation. We upheld the complaint.

Recommendations

We recommended that the board:

• provide confirmation that the psychiatrist has completed a specialist training programme in communication style and technique;
• bring the General Medical Council document on confidentiality to the psychiatrist's attention and consider whether training on information governance is required; and
• remind all staff involved of their obligations in terms of their own complaints handling procedures. Furthermore, ensure that any changes anticipated to the complaints procedure are first discussed with the complainant and receive their prior permission.

Summary

Mr C complained that the board failed to provide him with the necessary preparation in advance of a procedure to examine his bowel (colonoscopy). The board acknowledged that Mr C was not given the necessary preparation, which he should have received three days in advance of the procedure, and they apologised to him. We took independent medical advice from a GP. They noted that the hospital had sent clear instructions to the prison health centre regarding the preparation for the procedure and the adviser therefore considered it unreasonable that this was not carried out.

The hospital subsequently recorded that Mr C had refused to attend his appointment and he complained about this as he did not consider that the fault for this lay with him. The board apologised to Mr C for inaccurately recording that he had refused to attend. The GP adviser considered that this incorrect recording was unreasonable as it could have resulted in Mr C not receiving a follow-up appointment when the investigation was important to rule out a potential underlying cancer diagnosis.

As it happened, the prison doctor re-referred Mr C for a colonoscopy but this was vetted by the hospital and the procedure was changed to an examination of only the lower part of his bowel (flexible sigmoidoscopy). Mr C complained that this change of procedure was not explained to him. We were advised that it would have been reasonable for the sigmoidoscopy procedure to be explained to Mr C on the day of the procedure and the records indicated that this happened. However, we could not see any evidence of the reasons for the change in procedure being explained to him.

Mr C also complained about the time the board took to respond to his complaint and for their failure to answer his questions. The board acknowledged that there were inconsistencies in their responses and that they had not answered all of Mr C's specific questions. They also acknowledged that they had taken too long to respond to Mr C's final letter. It had taken them six months to respond to this and we concluded that this was an unreasonable timescale.

We upheld all the complaints.

Recommendations

We recommended that the board:

• reflect on the process failings that have occurred in this case and inform us of the steps they have taken to ensure that similar future failings do not occur;
• remind staff to ensure that relevant information is shared with a patient when a procedure is changed and that this is documented;
• remind complaints handling staff of the importance of responding to complaints in a full, accurate and timely manner; and
• apologise to Mr C for the failings this investigation identified in their handling of his complaint.

Summary

Mrs C complained about the care her relative (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with severe abdominal pain but on her first night in hospital, she suffered a fall. An x-ray was taken but clinicians caring for Mrs A did not identify any fracture after reviewing the image. The x-ray was subsequently reviewed by a radiologist (a doctor specialising in medical imaging) who reported that there was a suspicion of fracture to the pelvis. This report was not acted on for over a week, during which time staff continued to try to mobilise Mrs A. A subsequent scan showed that Mrs A had sustained multiple fractures.

When Mrs C complained to the board, the first response she received included a number of factual inaccuracies including that Mrs A had been admitted to hospital following a fall at home. A later response apologised for these errors. Mrs C remained dissatisfied and asked that we consider her complaints that there was an unreasonable delay in identifying Mrs A's fracture and that she had been unreasonably mobilised.

After taking independent advice from a consultant geriatrician, we upheld Mrs C's complaints about the medical care Mrs A received. The adviser considered it unreasonable that the x-ray report indicating that there was a suspicion of fracture had not been acted on and said it appeared staff caring for Mrs A had wrongly assumed the initial opinion that there was no fracture was correct. We found no evidence that Mrs A had been inappropriately mobilised after her fractures were identified but, in light of the fact that attempts were made to do so prior to this, we upheld Mrs C's complaint on this issue. We also upheld Mrs C's concerns about complaints handling as it is vital that complaint responses are factually accurate. While the board have already apologised for this matter, we found that they had not referred to the delay in acting on the

x-ray report in their response, which we did not consider to be reasonable.

Recommendations

We recommended that the board:

• ensure that our findings are brought to the attention of the staff involved in Mrs A's care and treatment. This should include the adviser's comments on communication and the falls risk assessment;
• provide evidence that they have considered how to prevent the problem in relation to the result of the x-ray not being taken into account from recurring in the future; and
• provide a further apology to Mrs C for the complaints handling issue identified in this investigation.

Summary

Ms C complained to us about the system that the medical practice used for reporting on warfarin (a drug used to prevent blood clots) blood tests. Her mother (Mrs A) had been discharged from hospital and a blood test was taken on a Friday. Ms C was told to phone the practice later that day for the result. Ms C did so and was told by a receptionist that the results would not be ready until Monday and that her mother should continue on the same dosage of medication (one tablet daily) in the meantime. On the Monday, the practice phoned Ms C and advised her that her mother's medication should be reduced to one tablet every other day. In the meantime, Mrs A had developed speech problems and had difficulties swallowing, eating and drinking. Ms C felt that the dosage of medication that her mother was taking over the weekend had caused Mrs A's deterioration.

We took independent advice from a GP adviser and concluded that whilst the dosage of medication taken over the weekend had not harmed Mrs A (and was not the cause of her deterioration), the system of reporting warfarin blood test results was not entirely in accordance with local guidelines and that it was not clear whether the receptionist had spoken to Ms C on the instructions of a clinician. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs A for the delay in informing her of the warfarin blood test result;
• review their warfarin blood test results procedure for Fridays to ensure that it is in accordance with board guidelines; and
• ensure that where medical information is being communicated to a patient by a receptionist that it is on the instructions of a clinician.

Summary

Mr A, who had a history of type 1 diabetes, chronic kidney disease and who had had a leg amputated, was admitted to Dumfries and Galloway Royal Infirmary in November 2013. He was complaining of chest pain, a shortage of breath and had an ulcerated toe. After admission, Mr A continued to be unwell and a week later, he had a cardiac arrest and died. His sister (Mrs C) complained that board staff failed to do enough for him or to recognise that he was a very sick patient. She also complained about the way in which her formal complaint was subsequently handled.

We took independent advice from a consultant geriatrician with an accreditation in general medicine and from a senior nurse. We found that Mr A's condition was a complex one and that doctors had treated him reasonably in terms of his symptoms and there were no reasonable precautions that could have been taken which could have prevented his death with certainty. We also found that the nursing care given to Mr A had been reasonable, although we identified some failure and shortcomings in record-keeping. We did not uphold Mrs C's complaints about care and treatment. However, we found that Mrs C's complaint had been dealt with badly. It did not initially progress through the complaints process and was beset by delay and confusion. Even when the board identified that this had happened, Mrs C was sent an inadequate reply. For these reasons, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• remind the nursing staff involved in Mr A's care of their responsibility to keep appropriately detailed records;
• make a full apology for the delay and confusion in dealing with Mrs C's complaint; and
• ensure that they provide complaint responses that are thorough and appropriate.

Summary

Mrs C complained about the board's handling of a surgical procedure that was recommended by a surgeon at Borders General Hospital. Mrs C was dissatisfied with delays in the surgery going ahead because she had been in pain for a long time and had difficulty walking.

We took independent advice from an adviser who is a specialist surgeon. We found that there were appropriate medical reasons initially why Mrs C's surgical procedure could not go ahead. The board had acknowledged and apologised to Mrs C that the 12 week treatment time guarantee had not been met. However, we found that it was an unusual procedure where there were exceptional circumstances for this. It had come to the board's attention that the risks, complications and outcomes of the procedure to treat a nerve related condition had not been properly reviewed. Therefore, we concluded that there was good reason on patient safety grounds for a comprehensive review to be carried out and formally reported on before offering the surgical procedure to Mrs C.

Summary

Mr and Mrs C complained that a consultant obstetrician and gynaecologist at Borders General Hospital unreasonably decided that Mrs C should undergo a caesarean section. Mrs C had previously given birth to two children by caesarean section, but was keen to have her third child by vaginal birth. When her waters broke, she was told that medical staff would allow 48 hours for the labour to progress before carrying out a caesarean section. However, she then saw the consultant who said that there would be high risks in waiting for another 48 hours and that a vaginal birth was unlikely anyway. He said that Mrs C should have the caesarean section as soon as possible.

We took independent advice on Mr and Mrs C's complaints from a medical adviser who is also a consultant obstetrician and gynaecologist. We found that it had been reasonable for her consultant to hold the view that Mrs C should undergo a caesarean section at that time, even if this conflicted with advice she had received from other medical staff who had been prepared to allow her to wait slightly longer. We did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained that the consultant had not communicated with them in a reasonable manner. We found that there was evidence, including a statement from a midwife, that the consultant's communication with the couple had not been reasonable and had lacked empathy. The consultant had also failed to acknowledge where his advice differed from others and the reasons for this. Whilst we upheld the complaint, we were satisfied that the board had apologised to Mr and Mrs C. They had also stated that this had been raised with the consultant and that the complaint would be included in his annual appraisal.

Summary

Mr C complained about the care and treatment he received at Ayr Hospital's A&E department after injuring his foot several years ago. Mr C said that no fracture was detected at the time, however, when he was reviewed a short time later a fracture was found. Mr C sustained a similar injury a year later and said that a doctor had told him he would not have needed surgery had his foot been put in plaster at the time of the original injury.

We were unable to complete our investigation into Mr C's complaint and reach a decision because he did not respond to our efforts to contact him.