Health

Summary

Miss C complained about treatment she received at the Glasgow Dental Hospital. She provided a copy of the board’s response to her complaint. Our initial view was that the actions the board said they took in response to her complaint were reasonable. These actions were, firstly, that a clinician would review Miss C’s case and bring to the attention of all staff the need for clear and open communication with all patients. Secondly, Miss C’s case would be used as a learning opportunity with staff.

We asked the board for evidence of the actions they took. We found that the review of Miss C’s case by the clinician was done as part of the board’s investigation into her complaint. The board should have told Miss C that the clinician had reviewed her case as part of their investigation, rather than promising future action which had, in fact, already happened for a different purpose. The board were unable to provide us with sufficient evidence that the other actions had been carried out. We upheld Miss C’s complaint, and recommended that the board take the actions they told her they would.

Recommendations

We recommended that the board:

• bring to the attention of all staff within the service the need for clear and open communication with all patients;
• ensure that Miss C's case is used as a learning tool with staff; and
• ensure that Miss C's case is discussed with the dentist involved.

Summary

Mr C complained that the board unreasonably failed to repair a hernia (where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) above his navel during surgery at Glasgow Royal Infirmary. He said that, after the operation, his hernia was still in place and the scar from the operation was located below his navel, rather than above it. Mr C was concerned that his hernia had not been operated on at all. He said that he repeatedly asked to speak to a member of the operating team about this but no one came to see him. Mr C also said that the board provided an inadequate response to his complaint.

We obtained independent medical advice from a consultant in general and colorectal surgery. The adviser said that the notes of Mr C’s original operation, together with the notes from the operation to finally repair the hernia the following year, indicated that the consultant did operate on the hernia above Mr C’s navel during the original operation. The adviser said that the location of Mr C’s surgical scar below his navel did not mean that his hernia was not operated on. The adviser explained that it was standard practice to make an incision in the natural skin crease just below the navel when repairing a hernia around the navel. However, the adviser said that Mr C’s hernia was inadequately fixed as it was present after his surgery.

We considered that the evidence in the nursing notes suggested that Mr C did ask to speak to a member of the surgical team after his operation. We accepted the adviser’s view that there was a failure by the board to communicate with Mr C at this time. We also found that the board did not appropriately investigate and address each element of Mr C’s complaint.

Recommendations

We recommended that the board:

• take steps to contact the consultant and feed back our decision on this case;
• feed back the failing identified in Mr C's complaint about complaints handling to the staff involved; and
• provide Mr C with a written apology for the failings identified in our investigation.

Summary

Mrs C complained that a trans-abdominal (TA) ultrasound scan (performed by passing the scanning device over the abdomen) she had received at Glasgow Royal Infirmary had not been properly carried out. As a result, she had been forced to seek private treatment. This had consisted of a gynaecological (relating to the female genital tract) examination and a trans-vaginal (TV) ultrasound scan (performed through the vagina, using a slim probe), as well as a TA scan. Three gynaecological problems were identified which Mrs C said the board would have identified if the scan had been done properly. Mrs C also complained that the board had failed to respond to her complaint properly.

We received independent advice from a consultant sonographer (a doctor who performs and analyses diagnostic ultrasound tests). The adviser said that the board's appointment times were too short to carry out the two separate types of scan needed in this case. The adviser noted, however, that of the problems identified during the private consultation, only one would have been apparent had Mrs C received both types of scan. We were advised that the outcome for Mrs C would not, therefore, have been different had she received both types of scan.

We found that, although there was no evidence the short appointment had caused Mrs C harm, she had not received the appropriate scans for her gynaecological condition. We found that the board had, however, responded appropriately to Mrs C's complaint.

Recommendations

We recommended that the board:

• review its standing operating procedures to ensure they provide greater clarity on when a trans-vaginal scan should be performed;
• review the time allocated for ultrasound appointments taking into account any relevant guidance; and
• apologise for the failings we identified.

Summary

Mrs C complained to us about the nursing care that her father (Mr A) received at the Royal Alexandra Hospital. We took independent advice on this complaint from a nursing adviser. We found that there had been some problems on the ward in relation to communication and drug administration. However, we found that the nursing care provided to Mr A had been reasonable overall, as were the arrangements made for his discharge. We did not uphold this aspect of the complaint.

Mrs C also complained that the board had not appropriately assessed her father for NHS continuing care (a package of care provided and solely funded by the NHS) when he had been discharged from hospital. She also considered that they had not dealt appropriately with her request for a review of the decision that her father was not entitled to NHS continuing care. We took independent advice on this aspect of the complaint from a medical adviser who is a consultant in acute medicine for older people and general medicine. We found that the initial assessment of Mr A for NHS continuing care and the subsequent reviews were all appropriate. Although some incorrect dates were used in the board's correspondence, and some of the documentation was not fully completed, we also found that the communication with the family had been reasonable overall. In view of this, we did not uphold this aspect of the complaint.

Summary

Mr C complained about the treatment provided for a wrist injury that his client (Mr A) suffered while overseas.

Mr A attended hospital overseas where his wrist was put in a cast. He was told to attend hospital on his return home, which he did. The doctor arranged x-rays of the fracture and changed the cast. Mr A was reviewed a week later, and the cast was changed again. Mr A was reviewed four weeks later and told his wrist had healed (although the joint was tilted back slightly). He was discharged. However, Mr A continued to suffer symptoms of pain and loss of movement in his wrist, which he said were worse than his pre-existing symptoms from an old injury. He attended a private hospital, where he was told that his fracture had healed badly, and he had corrective surgery, which improved his symptoms. Mr A complained to the board about his initial care.

The board acknowledged that Mr A’s fracture had healed with the wrist tilted slightly, but said this was satisfactory. The board noted Mr A’s history of wrist pain going back to his old injury, and said that his pain was due to the new fracture exacerbating his osteoarthritis from the old injury.

After taking independent advice from a consultant orthopaedic (relating to the musculoskeletal system) surgeon, we upheld Mr C’s complaint. The adviser said the early x-rays clearly showed Mr A’s fracture was unstable and likely to heal badly, and the board should have offered Mr A the option of surgery at that stage (to prevent the fracture healing badly). The adviser also said that the badly healed fracture was the likely cause of Mr A’s additional pain and symptoms, and the board should not have discharged Mr A without offering him corrective surgery.

Recommendations

We recommended that the board:

• issue a written apology to Mr A, acknowledging that the treatment for his wrist fracture was unsatisfactory; and
• ensure this complaint is raised with the consultants involved as part of their annual appraisals, and that any training needs are addressed.

Summary

Mrs C had a hysterectomy (surgery to remove the uterus (womb)) at Aberdeen Royal Infirmary. She was later discharged and made an appointment with her local hospital (which is in another NHS board area) to have her wound clips removed. A short time after the removal of the clips, once Mrs C had returned home, her wound split open and she had to be admitted to hospital for emergency surgery. Mrs C complained to the board that it was unreasonable that her wound had reopened and that the discharge arrangements were not reasonable.

We took independent advice from a medical adviser, who is a consultant gynaecologist. We did not uphold Mrs C's complaint about her wound reopening. The adviser agreed with the board's own view that this is a recognised, but rare, complication of abdominal surgery. We upheld Mrs C's second complaint regarding discharge arrangements. The adviser considered that there was evidence of leakage from the wound prior to Mrs C's discharge which was not acted on appropriately. During their own investigation, the board had identified failings with the information provided to Mrs C when she was discharged from hospital. However, the advice we received found some remaining issues with the discharge advice and the checklist that the board introduced as a result. We made three recommendations in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C, acknowledging the failings our investigation has identified;
• ensure there is feedback to relevant staff on the findings of our investigation; and
• review their checklist and discharge advice for patients who have undergone hysterectomies, in view of the adviser’s comments.

Summary

Mr C complained about the physiotherapy and orthopaedic care he received from Forth Valley Royal Hospital after dislocating his knee-cap. He said that staff ignored his on-going symptoms and that he should have had a scan of his knee to identify what was causing him persistent pain. He was concerned that a locum orthopaedic specialist had wrongly diagnosed a meniscal tear (damage to cartilage in the knee) rather than a loose fragment under the knee-cap.

We took independent advice on this case from two of our advisers, one of whom is a physiotherapist and the other a consultant orthopaedic surgeon. We found that the physiotherapy management of Mr C's injury was in accordance with guidance on managing patients who have dislocated their knee-cap for the first time.

Whilst the board said that it would have been appropriate for Mr C to have had a scan prior to surgery, we did not consider that the diagnosis of a meniscal tear was unreasonable given that loose fragment can have similar symptoms. Furthermore, both meniscal tears and loose fragments can be treated by the surgery that Mr C underwent. We also considered that it was reasonable to proceed to surgery without a scan given that Mr C's symptoms were not resolving and were affecting his ability to work.

Summary

Mr C complained on behalf of his mother (Mrs A). He said Mrs A's GP practice had not diagnosed quickly enough that the symptoms she was suffering from were side effects of the medication she had been prescribed. Mr C said these side effects were well known. He did not believe the practice had been as aware as they should have been of these side effects, which had caused Mrs A unnecessary and prolonged suffering.

We took independent advice from a GP adviser on the care and treatment provided. The adviser said that the practice had reasonably considered Mrs A's ill health to be the result of a possible reoccurrence of breast cancer and had sought to rule this out. However, under national guidance for prescribing this medication, the practice should have been monitoring Mrs A's lung and liver function and they had failed to do so. The adviser noted the practice had subsequently taken all reasonable steps to address the failings in this case.

We found that the practice had not provided reasonable care and treatment, but they had taken the appropriate action to address this. We made no further recommendations.

Summary

Mr C complained about Victoria Hospital on behalf of his mother (Mrs A). He said that Mrs A had been prescribed a drug which had had serious side effects, causing liver damage and breathing difficulties. Mr C believed that these side effects were well known enough that they should have been considered sooner. Mrs A had been admitted to hospital by ambulance due to breathlessness, but was discharged with antibiotics. She was admitted again a few days later, but it took a further six days for the cause of her symptoms to be accurately identified.

We took independent advice from a specialist in emergency medicine, who said that Mrs A had been appropriately assessed on both admissions to hospital. The side effects she had were very rare, and it had been reasonable for medical staff to rule out more immediately dangerous and common causes for her breathlessness.

Summary

Ms C had gallbladder surgery at the Victoria Hospital. She was discharged without further follow-up but started to experience pain from a wound site. She was referred back to the board by her GP and had further surgery to address this. She was discharged the same day by nursing staff. Ms C complained that she had not been given a follow-up appointment following her initial surgery. She complained that her discharge at the second procedure was inappropriate as she was not reviewed by a member of the medical team. Ms C was also concerned that the board had failed to provide her with appropriate treatment following a further referral from her GP.

After taking independent advice from a nursing adviser and a consultant surgeon, we did not uphold Ms C's complaint about discharge. In relation to her concerns about the lack of follow-up after the first surgery, the surgical adviser confirmed that it is established practice not to offer a clinic appointment in such cases. Regarding the second procedure, we found that it is normal practice for patients to be discharged from day surgery cases without being seen by a doctor. The nursing adviser confirmed that appropriate checks had been carried out before Ms C's discharge. We noted that the board had taken learning from Ms C's complaint and were addressing her concerns about information that was provided to patients at discharge. Although we did not uphold this complaint, we made two recommendations to the board about the action they have taken.

We also did not uphold Ms C's complaint about the treatment she received following her GP referral. The surgical adviser considered that this had been appropriately managed.

Recommendations

We recommended that the board:

• provide evidence to confirm what action has been taken to improve the provision of information to patients on discharge; and
• advise us on the outcome of deliberations on offering patients the choice to see a doctor before discharge.