Health

Summary

Mrs C complained about the care of her daughter (Miss A) who committed suicide while she was an in-patient at Hairmyres Hospital. Mrs C raised concerns that staff did not appropriately supervise Miss A in view of her condition, and that the family were not told about a suicide attempt the day before Miss A’s death.

When we reviewed Mrs C’s complaint we found that the Crown Office and Procurator Fiscal Service was currently investigating the circumstances of Miss A’s death. Additionally, the Child Protection Committee was also conducting a significant case review in consultation with the Mental Welfare Commission. In view of these on-going investigations by other independent organisations, we decided not to investigate Mrs C’s complaints further at this stage. We invited Mrs C to contact us again if any issues raised in her complaint were not investigated as part of these processes.

Summary

Ms C was concerned about the care and treatment given to her late mother (Mrs A) at Wishaw Hospital. She felt that Mrs A's symptoms were initially not properly investigated and, had they been, her chances of survival may have been improved. She complained that, other than chemotherapy, Mrs A received little treatment. Ms C also said that the information provided to Mrs A was confusing.

The complaint was investigated and we took independent advice from a consultant general surgeon. We found that Mrs A had a type of stomach cancer that was very difficult to diagnose and was very aggressive. Because of this, there was only a very small chance of any treatment curing the cancer. Although Mrs A was given appropriate tests, the results were not regarded with enough suspicion and, despite not providing an explanation for Mrs A's symptoms, no further investigations were made. Mrs A was not diagnosed until a year later when the only treatment she could be offered was palliative chemotherapy. Mrs A died the following year. In light of our findings, this aspect of Ms C's complaint was upheld.

Mrs A initially responded well to treatment, which may have led her to question her diagnosis and the information she had been given. However, our investigation showed that discussions with Mrs A explaining her diagnosis and treatment had taken place. For this reason, we did not uphold this part of the complaint.

Recommendations

We recommended that the board:

• make a full, formal apology for their failure to diagnose Mrs A sooner; and
• bring the terms of this decision to the attention of the staff involved, including the endoscopist and the junior surgical doctor concerned, for them to reflect upon and discuss at their next formal appraisals.

Summary

Mr C complained about the treatment his father (Mr A) received from the board. Mr A had had a history of Parkinson’s disease, dementia and type 1 diabetes. However, Mr A controlled his diabetes well and lived independently before having a fall. He was admitted to Hairmyres Hospital with hip pain and reduced mobility. X-rays showed no sign of a fracture, but Mr A was kept in hospital due to his poor mobility. His pain and mobility worsened, and a second x-ray was taken around four weeks later. This showed a displaced fracture in his hip. Mr C complained that his father’s diabetes was poorly managed during his admission, causing increased confusion and unsafe blood sugar levels. He also complained about a delay to the second x-ray and the diagnosis of Mr A’s fracture.

We took independent advice from a nursing adviser, and found that the nursing staff failed to properly manage Mr A’s diabetes. The board had already identified failings in this respect and we were satisfied that they had learned lessons from Mr A’s experiences.

We also took independent advice regarding the diagnosis of Mr A’s hip fracture from a consultant in orthopaedic and trauma surgery and a consultant physiotherapist specialising in orthopaedics (relating to the musculoskeletal system). Whilst there was no visible sign of the fracture on the first x-rays, Mr A's pain and mobility did not improve. We concluded that, in line with national guidance, further x-rays or scans should have been ordered to rule out a fracture. There was a clear delay to this happening and, by the time of the second x-ray, the fracture had displaced. This required a more invasive operation than would have been needed had the fracture been diagnosed before it displaced. We were critical of the board for this delayed diagnosis.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's performance in terms of effectively managing diabetic patients' insulin regimes to gauge the effectiveness of action taken in response to Mr C's complaint;
• apologise to Mr A and his family for the delay in diagnosing his fractured hip;
• share our decision with their orthopaedic staff with a view to learning from Mr A's experiences; and
• consider whether orthopaedic staff would benefit from refresher training on the national guidance on treating hip fractures in elderly patients.

Summary

Mr C was diagnosed with attention deficit hyperactivity disorder. To help with his symptoms, he was started on a drug regime which was changed twice after his condition had been reviewed. However, Mr C said that he had not found any of the treatment he had been given particularly helpful, and he had continuing problems sleeping and concentrating. He questioned whether the care and treatment he received had been appropriate. He also complained that, since his diagnosis, the board had not taken reasonable steps to keep him informed. However, in responding to his complaint, the board said that he had been treated reasonably. While they acknowledged Mr C's concerns about communication, they said that his doctor always allowed 30 minutes for consultations to allow patients to raise questions.

We took independent advice from a consultant psychiatrist. We found that Mr C's care and treatment was all reasonable and in accordance with national guidance, as he was regularly reviewed and his medication was changed after reporting that his symptoms were not being helped. He had had the support of community psychiatric nurses and occupational therapists. Although Mr C considered that he had not been kept informed, there was evidence to show that his condition and drug therapy had been discussed with him. On this basis, his complaints were not upheld.

Summary

Miss C said that she had attended the Early Pregnancy Clinic at Raigmore Hospital as she was considering having a medical termination of her pregnancy. She had experienced bleeding and was concerned that she was going to miscarry. She was unhappy that the consultant had told her to take the contraceptive pill, and that she had to return the following day for a medical termination of her pregnancy. Miss C continued to suffer from pain. She attended her GP, who told her not to take the contraceptive pill and that she would probably miscarry without medical intervention. Miss C did not return to the clinic but subsequently attended her GP. The GP arranged for a pregnancy test which proved to be negative. Miss C felt that it was inappropriate for the consultant to have ordered her to take the contraceptive pill.

We took independent advice from a nursing adviser. The adviser said that the medical record of Miss C's attendance at the clinic was detailed. It contained information regarding the plans for a medical termination of her pregnancy, and confirmed that Miss C was advised to seek medical advice if she should have additional bleeding or pain. The adviser felt that in such situations it would also be appropriate for a consultant to discuss family planning matters such as contraception. We did not uphold the complaint.

Summary

Mr C had a longstanding spinal problem and the board had been providing treatment to him for many years. When Mr C's condition deteriorated to the point that he could no longer walk 100 yards without pain, his regular consultant at Raigmore Hospital referred him to a specialist colleague. Mr C said he heard nothing and after 12 weeks he phoned the board. He was told they did not know when he would be offered an appointment. He phoned again two weeks later and was told the same thing. After 18 weeks Mr C complained. He said there had been an unreasonable delay and no communication from the hospital.

We upheld both of Mr C's complaints. We found that the time taken to give Mr C an out-patient appointment (30 weeks) was too long. We found the board had not been proactive in communicating with Mr C, which they should have been, given the known pressure the service was under at the time.

Recommendations

We recommended that the board:

• review the process for managing the orthopaedics waiting list to ensure that people receive clear and accurate information about waiting times.

Summary

Mrs C said that she had moved to a new GP surgery, where her symptoms had been quickly diagnosed as due to hyperthyroidism (excess thyroid hormone). Mrs C then complained to her former GP practice that she had reported the same symptoms to them for the past two years but they had failed to reach the true diagnosis. She complained that she may have been prescribed inappropriate medication.

The practice maintained that they had provided appropriate treatment based on the symptoms reported at the time. They apologised for the failure to order a set of blood tests on one occasion and said this was caused by an administrative failure. They said that it was not possible to say that hyperthyroidism was present at that time.

We sought independent advice from a GP adviser. The adviser considered that, other than the failure to carry out specific blood tests on one occasion, the practice had performed appropriate investigations in an effort to reach a diagnosis. The symptoms which Mrs C had shown during the period were not classically suggestive of hyperthyroidism. The adviser did not think it was a failure that the GPs at the practice were not alerted to a possible alternative diagnosis. We did not uphold the complaint.

Summary

Mr C complained that the treatment provided to him for his shoulder injury was unreasonable. In particular, he said the health centre had only prescribed him pain relief, and had not arranged for him to have a scan or referred him for physiotherapy.

We found that Mr C had been assessed by a doctor several times due to his shoulder pain, and that medication for his pain had been prescribed. We took independent advice from a GP adviser on whether the treatment provided to Mr C was reasonable. The adviser noted that Mr C had indicated he had muscle pain but there were no concerns about swelling, bruising or restricted movement. The adviser explained that symptoms like these would have indicated trauma or a fracture. As Mr C did not have those symptoms, the adviser considered it was reasonable for the doctor to treat Mr C's shoulder pain with painkillers. The adviser also said that referral to a physiotherapist was not necessary because Mr C had a full range of movement in his shoulder joint. The adviser also said a scan was not necessary because Mr C did not have symptoms to suggest he had a fracture.

In light of the evidence available, we did not uphold Mr C's complaint.

Summary

Mr C visited the practice about his cough. He was referred for an x-ray, which took place the following day. Mr C contacted the practice three times for the results and was told that they had not arrived. Mr C's symptoms worsened and he was admitted to hospital with pneumonia and heart failure. Mr C complained that the practice did not have adequate procedures in place to identify that his x-ray report was missing.

Normally, a paper copy of the x-ray report would be sent to the practice and uploaded to the practice's information management system. In this case, for reasons we were unable to establish, the report was not uploaded. This suggests the report may not have been received. The GP at the practice was able to access the report through the hospital's computer system when they realised that the report had not been received. However, the GP was only prompted to do this after receiving notification of Mr C's hospitalisation.

The practice apologised to Mr C and explained that there was a gap in their protocols for occasions when information was not received in the normal way. They explained that they had updated their protocols for dealing with patient phone calls regarding x-ray results. The new protocol meant that, if a patient contacted the practice three weeks or more after an x-ray for which no report had been received, reception staff would advise the GP who requested the x-ray. The GP would then check for the report on the hospital's computer system. The practice were also piloting a new process to keep copies of x-ray requests with the aim of ensuring the practice followed up on any results not received after four weeks.

We took independent advice from a GP adviser. We found that the practice did not have adequate procedures in place to identify that Mr C's x-ray report was missing and so we upheld his complaint. We recognised that the practice had apologised and made changes to their protocols to prevent a recurrence, and we felt that there were no further actions required.

Summary

Mrs C complained on behalf of her sister (Miss A) about care received from her GP practice on two occasions. Mrs C complained that the practice did not thoroughly investigate Miss A's symptoms and did not provide reasonable treatment.

We took independent advice from a medical adviser. The adviser said that, based on the consultation notes, the care Miss A received was of a reasonable standard, and we did not uphold the complaint.