Health

Summary

Miss C complained to us that staff at Hairmyres Hospital and Monklands Hospital failed to provide her with appropriate and timely treatment, which resulted in the removal of her gallbladder. We took independent advice on this complaint from a medical adviser, who is a consultant general surgeon. We found that Miss C had been investigated and treated appropriately for her gallbladder disease within a reasonable time-frame. Whilst there was a short delay in referring her for a scan and in providing a prescription when she was discharged from hospital, these did not have an adverse impact on her care. In view of this, we did not uphold the complaint.

That said, Miss C's consultant had referred her to another consultant when she made a complaint about him. Miss C's care was not compromised by the change of consultant, but this was not in line with guidance from the General Medical Council (GMC), which states that a doctor should not end a professional relationship with a patient solely because of a complaint the patient has made about them.

Miss C also complained to us that staff in the hospitals had failed to communicate with her adequately throughout the treatment referral process. We found that there had been some failings in relation to communication. We upheld this aspect of Miss C's complaint, although we noted that the board had already apologised to her for these failings.

Recommendations

We recommended that the board:

• make the consultant aware of the adviser's comments about Miss C's transfer of care to a different consultant being contrary to guidance from the GMC; and
• provide evidence that the failings identified have been fed back to relevant staff.

Summary

Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take sufficient food by mouth). Mrs A had been admitted to the hospital with high output from her stoma (a stoma is a surgically made pouch on the outside of the body; when the output from a stoma is high, it means that you are losing more fluid and are at a greater risk of becoming dehydrated) and acute kidney injury.

We took independent advice on this case from a consultant general surgeon. We found that Mrs A had initially been treated appropriately. It was likely that the NJ feeding tube was exacerbating the high output stoma. It had been reasonable to allow Mrs A to remove the NJ tube under supervision, as this reduced her anxiety about having it removed. This did not cause an oesophageal perforation (a tear in the tube that takes food from the mouth to the stomach) that she subsequently experienced.

However, we found that Mrs A had been discharged from hospital without evidence that the measures taken in relation to her high output stoma were fully effective and would prevent a readmission with the same problem. During our investigation, the board told us that they were working on guidelines on high stoma output for staff, but these had yet to be finalised. We also found the records of communication with Mrs A and her family were inadequate. In view of these failings, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings identified;
• provide evidence that guidelines for high output stomas have been developed and circulated to relevant staff; and
• feed back our findings to relevant staff.

Summary

Mr C's wife (Mrs C) had a complex medical history and had been diagnosed with asthma, bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened leading to a build-up of excess mucus) and frequent pneumonia. Mrs C struggled to recover between bouts of illness and she understood from healthcare professionals that she had emphysema (lung disease). In October 2013, Mrs C was told that investigations had shown mild abnormalities and that she did not have emphysema. Mr C said that his wife was very distressed at this.

Mrs C was admitted to Monklands Hospital two months later with respiratory problems. Her condition deteriorated significantly and she died several weeks after admission with sepsis (blood infection), heart failure and bronchiectasis. Mr C complained about the provision of medical and nursing care and treatment to Mrs C, and about the board's complaints handling.

We took independent advice from medical and nursing advisers. We found that the medical and nursing care and treatment provided to Mrs C was reasonable. However, at one of the out-patient appointments, the discussion about Mrs C's diagnosis was significant but there was no record of this and no comment on Mr C's understanding of the diagnosis and so, on balance, we upheld this complaint. In relation to record-keeping, we were satisfied that the board had responded to the complaint in a reasonable way.

Recommendations

We recommended that the board:

• bring the record-keeping failing and the medical adviser's comments to the attention of relevant staff; and
• apologise for the failings identified.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during her admission to Hairmyres Hospital. Staff suspected Mrs C had a rare endocrinology (related to hormones) disease, and arranged a number of tests to investigate this over the next two months. Mrs C developed sepsis (a blood infection) while in hospital and died.

Mr C raised concerns about Mrs C's overall treatment, including delays in investigations and treatment and failure to prevent infection. Mr C was also concerned that nurses did not understand Mrs C's condition (as she was nursed on a cardiology ward, rather than an endocrinology ward). The board met with Mr C's family twice and apologised for a number of aspects of care. They arranged a meeting to ensure nursing staff reflected on their practice, and developed an action plan for improvement, which they shared with the family. The endocrinologist involved in Mrs C's care also apologised that the investigations of Mrs C's condition did not move more quickly, and explained that they expected to have more time to treat Mrs C. Mr C was not satisfied with the board's response to some parts of his complaint, and brought these to us.

After taking independent medical and nursing advice, we upheld one of Mr C's five complaints. We found the medical and nursing care was reasonable in relation to most of the specific points Mr C raised, and that although there were some failings in nursing care, the board had already addressed these. However, we found that there was an unreasonable delay in sending laboratory samples to be tested.

The medical adviser also commented on Mrs C's overall care and said the board should have considered transferring her to a larger endocrine unit (which might have resulted in quicker treatment). We shared these comments with the board, but did not make any specific recommendations as the relevant guidelines do not require treatment in a particular setting and the endocrinologist involved had already apologised to the family and reflected on their practice.

Recommendations

We recommended that the board:

• review their processes for arranging external laboratory testing of samples, to ensure this is being completed in a reasonable timeframe.

Summary

Mrs C, who is an advice worker, complained to the practice about a lack of urgency in acting on Ms A's concerns about a problem with her young daughter's hip. She said that Ms A reported that her daughter's left leg was longer than her right leg and that one of the GPs failed to thoroughly examine her daughter. In addition, it was only after Ms A continued to report her concerns that her daughter was referred to hospital. However, one of the GPs marked the referral as non-urgent and Ms A had to ask the practice again to make an urgent referral. Her daughter was diagnosed as having a dislocated hip.

The practice apologised for the delay and said they had learned from the complaint. They were now aware that they can directly ask for an ultrasound scan of the hip in such circumstances. The GPs were more aware of the signs to look for and would mark any referrals as urgent. The practice apologised for the distress which was caused.

We took independent advice from a medical adviser who noted that the response from the practice to Ms A's complaint was thorough and explained the shortcomings which they had identified. The practice said that their GPs were now more aware of the referral options, the need for urgency and the later signs of congenital dislocation of the hip. However, we identified further failings by one of the GPs in regards to the inadequate examination and recording of findings related to Ms A's daughter and a failure to stress the urgency of the situation in the hospital referral letter, so we upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Ms A for the failings identified;
• discuss the complaint as part of the GP's annual appraisal; and
• explain their criteria for carrying out a significant event analysis and explain why one was not performed in this case.

Summary

Mrs C complained that the practice cancelled an important appointment with the practice nurse without giving her notice. Mrs C moved to a different practice, and she complained there was delay in sending her medical records to the new practice.

We found that the practice could have told Mrs C sooner that the appointment had been cancelled, and there was no record that they had tried to contact her before she arrived for the appointment. We also found that the practice should have tried to re-arrange the appointment for Mrs C, or arrange an alternative appointment nearby. In addition, we found that there was an unexplained delay of several weeks in the practice sending Mrs C's medical records to her new practice. We upheld Mrs C's complaints.

Shortly after Mrs C complained to the practice, it changed management from GPs to the local health board, as the GPs had left the area. Given these specific circumstances, we did not make recommendations to the health board, as they were not responsible for running the practice at the time of the events complained about. However, we asked the board to confirm whether any relevant staff currently working at the practice were there at the time of the events complained about and, if so, to share our findings with them so they could learn lessons from what happened, to try to ensure that similar problems do not arise again.

Summary

Mr and Mrs C complained to us that the board had failed to inform Mrs C of a diagnosis of diverticulitis (a common disease of the digestive system) that was reached when she had a colonoscopy (examination of the bowel with a camera on a flexible tube) under the Scottish bowel screening programme. Mrs C had undergone the colonoscopy following the detection of blood in samples she submitted under the bowel screening programme. During the colonoscopy, a minor non-cancerous growth had been removed and it was assumed that this had been the cause of the blood. The unit who carried out the colonoscopy wrote to Mrs C's GP practice to inform them of this. However, in the cover letter sent to the GP practice, they did not refer to a diagnosis of diverticulitis that had also been made during the colonoscopy. They also failed to inform Mrs C that she had also been diagnosed with diverticulitis at that time.

We took independent advice on Mrs C's complaint from a medical adviser who is a GP and from another medical adviser who is a consultant physician. Mrs C clearly should have been informed of the diagnosis of diverticulitis and we found that the unit who had carried out the colonoscopy should have made her aware of this. We considered that this problem originated from the lack of clarity in the board's procedures in relation to the Scottish bowel screening programme regarding sharing information with patients. We upheld the complaint, although we found that the board had already apologised to Mrs C for this.

Mr and Mrs C also complained that the board had failed to provide Mrs C with treatment for diverticulitis within a reasonable timescale. We found that it was unlikely that she required any treatment for this, although she should have been told to increase the fibre in her diet. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the board:

• consider adding further guidance about sharing information with the patient when they review their procedures in relation to the Scottish bowel screening programme.

Summary

Mr C complained to us about how the board had handled his enquiries about NHS continuing health care. His mother had been assessed as needing continuing care, but was in hospital in another health board's area. Mr C had written to the board to ask for further information about this. The board did not respond and he had to contact them again. Despite this, he still did not receive a response and in view of this, we upheld this aspect of Mr C's complaint.

Mr C also complained that the board had failed to handle his complaint about this matter in accordance with their complaints procedure. We found that the board had adequately responded to the points Mr C had raised in his complaint. We also found that it had been reasonable for the board to contact his mother's power of attorney to obtain consent to share the details of the investigation with him. However, we found that there had been a delay in responding to Mr C's complaint and we also upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in responding to his complaint; and
• make relevant staff aware of our findings on his complaints.

Summary

Mr C complained about the medical and nursing care and treatment he received in Raigmore, Broadford and Ross Memorial hospitals between June and December 2012. Mr C had a complex medical history and began to experience chronic back pain at the end of June 2012. This proved to be a lumbar disc infection and he was treated conservatively. Mr C complained about various aspects of his care and treatment during his various admissions to the hospitals including the frequency and standard of consultant review, treatment decisions, diagnosis, pain management, communication and the decisions to discharge him home or to other hospitals.

We took independent advice from a nursing adviser and two medical advisers, one in emergency medicine and the other in orthopaedics (conditions involving the musculoskeletal system). We found that the standard of medical care and treatment provided by Raigmore Hospital was reasonable and that the nursing treatment was also reasonable with the exception of the use of a commode for showering purposes. We made a recommendation to address this.

We also found that the standard of medical and nursing care and treatment provided by Broadford Hospital was reasonable. However, in relation to the standard of medical care and treatment at Ross Memorial Hospital, while we found no failings in relation to nursing care, we found that there was a missed opportunity to potentially manage Mr C's pain more effectively and that a planned discharge home was unreasonable. We made a number of recommendations to address these failings.

Recommendations

We recommended that the board:

• bring the shortcoming in nursing care to the attention of relevant staff;
• bring the failings to the attention of relevant staff;
• clarify referral procedures to the chronic pain team and ensure staff are aware of the procedure; and
• apologise for the failures we identified.

Summary

Mr C complained about how his new dentist communicated with him after taking over his care. He was also concerned that the dentist had failed to provide appropriate dental treatment to him over a number of appointments. The new dentist took over Mr C's care after his dental practice was sold to a new owner. Mr C advised he had not been told about the changes and felt uncomfortable.

After taking independent advice on this case from a dental adviser, we upheld Mr C's complaint regarding communication. The adviser explained that in order to obtain valid consent, patients must be given all options including the risks and benefits of each. We found that there was insufficient evidence that this had been done, particularly with regard to the option of extracting the tooth in question. The adviser also considered that there was a lack of evidence that the changes to staff providing Mr C's care had been properly explained to him, particularly after his treatment became problematic and required referral to a more experienced dentist at the practice. We made two recommendations to address the issues highlighted during the investigation. The adviser found no issues with the actual treatment that had been provided to Mr C by the dentist and so we did not uphold this element of his complaint.

Recommendations

We recommended that the dentist:

• review the process followed for obtaining patient consent and ensure this is in line with the General Dental Council Standards; and
• issue an apology for the standard of communication with Mr C.