Health

Summary

Mrs C complained about her mother (Mrs A)'s discharge from Forth Valley Royal Hospital. Mrs A was 82 years old at the time and was admitted with chest pains, later diagnosed as a heart attack. Further to treatment, plans were made to discharge Mrs A but her family were concerned that she remained in poor health. Mrs C said they had alerted staff to Mrs A's breathing difficulties, shivering, leg swelling, lack of appetite and general weakness but were assured that she was fit to go home. Following discharge, Mrs A was readmitted in the early hours of the following morning. She was diagnosed with sepsis and did not recover. She passed away five days later.

Mrs C considered that the signs of sepsis were present prior to Mrs A's discharge and were not detected by staff. The board advised that the results of pre-discharge tests were not consistent with a diagnosis of sepsis. We took independent advice from a consultant in general and geriatric medicine. They noted that Mrs A's symptoms, observations and blood test results were considered prior to discharge and were relatively normal. In particular, they noted that her blood test results were sufficiently normal to allow discharge to proceed. They did not consider that there was any evidence Mrs A was suffering from sepsis at the time and, overall, they considered it reasonable for her to have been discharged. They noted that she was re-admitted a short time later and subsequently died but were not of the view that this could have been reasonably predicted at the time of discharge or that it was due to poor medical care during Mrs A's admission. We did not uphold Mrs C's complaint.

Summary

Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that the prison health centre had sent a referral to the plastic surgery clinic but it was subsequently decided that revision surgery was not appropriate, as Mr C was continuing to self-harm at the time. We were advised that the decision not to progress the referral in such circumstances was reasonable and in line with relevant guidelines. We accepted this advice and did not uphold this aspect of the complaint.

Mr C also complained about the way his complaints were handled by both the prison health centre and the board. He noted that he had asked specific questions in his complaints and that these had not been answered. We agreed that the prison health centre had only formally addressed one of the two points raised with them and the board's formal response omitted a reply to one of the four points raised with them. We, therefore, upheld this part of the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for failing to fully respond to his feedback and complaint forms; and
• make the relevant complaints handling staff aware of our findings.

Summary

Mrs C brought a complaint to us on behalf of her late husband (Mr C), in relation to the care and treatment he received over a five week period shortly before his death. She was concerned that the medical practice had not acted with enough urgency when she felt Mr C's condition was deteriorating. He had three consultations with a GP over a four week period. At the final consultation the GP had concerns about his breathing and referred him for an x-ray, which took place the next day. The results of the x-ray indicated that Mr C had pleural effusion (a build-up of excess fluid around the lungs). The results arrived in the practice the following day, and the GP referred Mr C back to hospital when he viewed the results on his return to work the day after. Mr C was treated in hospital, and was discharged home, to await further treatment. He died before this further treatment could take place.

We sought independent advice from a GP adviser. The adviser reviewed all three consultations, and was satisfied that the GP had taken appropriate action, on the basis of the symptoms which Mr C presented with. They noted that there was no indication of pleural effusion until the third consultation.

The adviser also reviewed the practice's response to the x-ray results, and noted that the results did not indicate a need for urgent action. They considered the practice's response to the x-ray results to have been reasonable.

We noted concerns that Mrs C had raised which were beyond the scope of this investigation, in relation to conversations which could not be corroborated. We noted the adviser's comments in relation to the GP's actions, and we did not uphold Mrs C's complaint.

Summary

Mr C complained that a surgeon failed to properly carry out a laser prostatectomy (surgical removal or resection of the prostate gland) at the Queen Margaret Hospital causing him severe pain, blood loss and the need for further surgery two weeks later.

The board advised Mr C that the surgeon was assisted by a mentor experienced in this type of surgery, and no complications occurred during the procedure. However, they apologised that Mr C had experienced the recognised risk of post-operative bleeding. Mr C remained unhappy that there was a need for more surgery to address his pain and bleeding.

The laser surgery carried out is a relatively new technique which has not be universally adopted by urologists. We took independent advice from a consultant urological surgeon who has undertaken laser prostatectomy. We found evidence of poor record-keeping which fell below a reasonable standard in relation to Mr C being properly informed about all the risks associated with the laser surgery. We were also critical that there was no record of the surgeon's mentor having been present during the operation. Whilst we considered that there was no evidence of damage having been caused, the treatment was inadequate in removing tissue that was causing obstruction. We therefore upheld Mr C's complaint and made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified;
• draw to the surgeon's attention the findings in relation to obtaining informed consent; and
• inform us of the outcome of their review and any action taken in relation to the surgical recording process.

Summary

Mr C attended the practice on three occasions between 2010 and 2013 for blood glucose tests (a standard test for blood sugar levels, used in diagnosing diabetes). Mr C was not diagnosed with diabetes until a fourth blood test later in 2013. He has complained that, based on these test results, the practice could have diagnosed his diabetes earlier than they did.

We took independent advice from a GP adviser. They noted national guidance and the protocols in place in the practice for diagnosing diabetes. They also reviewed the test results from Mr C's blood glucose tests. They identified that it was not clear whether the first test, in 2010, had been a 'fasted' blood sample (ie whether Mr C had been told to fast prior to the blood test). They noted that this would have had an impact on what further action was appropriate. Given that the GP involved at that point had since retired, and that the actions could have been reasonable, they were not critical. However, the second blood test results showed concerns and should have been immediately responded to. Instead, Mr C was advised to return for another test in six months. When he had another blood test 18 months later, the test results were conclusive of diabetes, and the adviser noted that the error in identifying this had already been picked up by the practice in their response to the complaint.

We concluded that the GP had not taken reasonable steps in their response to Mr C's second blood test, as further tests should have been taken at that time. We agreed with the practice's assessment of their response to Mr C's third blood test. We were also concerned that the local protocols in place for the assessment of blood glucose results did not fully reflect the national guidance.

Recommendations

We recommended that the practice:

• ask the GP involved to consider reviewing this case in conjunction with the World Health Organisation (WHO) Guidance on the diagnosis of diabetes and identifying any learning point at their next appraisal; and
• review their protocols for the management of abnormal diabetic blood results, to ensure they are in line with the WHO Guidance.

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.