Health

Summary

Mr C complained that while his wife (Mrs C) was a patient in Murray Royal Hospital, she was assaulted by another patient and suffered a minor injury. The staff told him that Mrs C would be protected from the patient. Mrs C was then assaulted again by the patient and had to receive medical treatment for a severe injury to her eye. Mr C complained that the board staff had not taken appropriate action to prevent the second assault. The board maintained that the risk of the patient assaulting Mrs C on the second occasion was assessed as rare.

We obtained independent advice from two of our nursing advisers. They considered that there was no indication that the patient would assault Mrs C on the second occasion. We found that the board had taken appropriate action following both assaults, which would have greatly reduced the likelihood of a further assault.

Summary

Miss C complained that her mother-in-law (Mrs A) had not been properly assessed by a GP following episodes of dizziness and elevated heart rate and blood pressure. Mrs A had suffered a fatal heart attack three days after visiting the GP.

The GP said that Mrs A had suffered from a number of health problems. At the consultation in question she had been extremely anxious and had been prescribed medicine to counteract this. Her pulse and blood pressure had also been taken.

We took independent advice on the care and treatment provided. Our adviser said the medical records did not show that a comprehensive examination of Mrs A had been carried out. Our adviser noted that Mrs A suffered from diabetes and that the appropriate Scottish guidance for management of patients with this condition had not been followed, which was unreasonable. We found that the GP had not carried out an adequate examination of Mrs A. However, our adviser also said that Mrs A's death had been impossible to predict and that even had a more thorough examination been carried out, it would not have been possible to prevent her fatal heart attack.

Recommendations

We recommended that the practice:

• apologise to the family for the failings identified;
• provide evidence that the GP has familiarised themselves with the Diabetes SIGN (Scottish Intercollegiate Guidelines Network) guidance by including this as a learning need in their yearly appraisal;
• provide evidence that this case and our adviser's comments have been discussed between the GP and their appraiser; and
• carry out a Significant Event Review and discuss this with the GP and the local clinical director to ensure learning from the case is appropriately identified.

When it was originally published on 16 December 2015, this case referred to a Medical Practice in the Tayside NHS Board area. This was incorrect, and should have read a Medical Practice in the Fife NHS Board area. This was due to an administrative error which we have now corrected, and we apologise for any inconvenience that this has caused.

Summary

Mr C complained about the treatment his late wife (Mrs C) received from the practice. Mrs C suffered from chronic obstructive pulmonary disease (a collection of lung diseases) and died three days after she had attended the practice. It was also the day after Mr C had phoned the practice as he had concerns that the medication which Mrs C had been given was ineffective. He said that he had wanted to speak to a GP but was offered a phone consultation which was scheduled for later in the day that his wife died.

We took independent advice from one of our GP advisers, who said that she had concerns about the consultation Mrs C had attended. Our adviser was critical that the GP who saw Mrs C did not check Mrs C's oxygen saturation levels (pulse oximetry); did not ensure that Mrs C was able to use her inhaler appropriately; and failed to prescribe steroid medication. We found that the treatment which was provided to Mrs C was not of a reasonable standard.

We also considered whether Mr C's phone call to the practice was actioned appropriately. Mr C believed that he was contacting the practice to explain that Mrs C's medication was not working and that her condition was deteriorating. The receptionist at the practice had recorded the phone call as 'medication and issues' and had not contacted a GP for advice and had made arrangements for Mr C to have a phone consultation with a GP. We found that Mr C should have been given the opportunity to speak to a GP on the day of his phone call and that had they done so then the GP would have had the opportunity to make a clinical judgement as to whether a further consultation was required. The practice have accepted that the system which was in use for phone calls required updating. The system has now been updated and our adviser believes that the service has now been improved.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings identified;
• review chronic obstructive pulmonary disease management;
• ensure the GP in question discusses the case at their yearly appraisal;
• consider a peer reviewed Significant Event Analysis (provided by NHS Education Scotland) about the way the situation was managed; and
• apologise to Mr C for the failure to offer him the opportunity to speak to a GP when he phoned the practice.

Summary

Mrs C complained about the communication with her family during her late father (Mr A)'s admission to Cornhill Macmillan Centre for end of life care. She raised concerns that the family were excluded from most medical consultations and were not updated on changes to Mr A's condition or treatment. In particular, she complained that the family were not prepared for the fact that Mr A would not receive fluids once he was unable to take them orally. She said there was no continuity of care and there was no single member of staff who seemed to know Mr A well. She also complained that the visiting hours were overly strict, and that staff were defensive and did not support the family to make the most of Mr A's final weeks.

We obtained independent advice from a nursing adviser, who noted that aspects of Mr A's care appeared to be of a very good standard. The adviser said that a reasonable level of discussion with the family was documented, although she acknowledged that their needs did not appear to have been met in this regard. She considered that the family's concerns should have been picked up on early in Mr A's admission and support offered to them through a named individual. She noted that the board's assessment and decision-making in relation to fluid provision was well documented and appropriate to the circumstances. However, she considered that an early explanation to the family of the planned approach could have reduced their distress. The adviser also considered that the visiting policy was overly strict and outdated, when it should be flexible and adaptable to the individual needs of patients.

We were critical of the board that, after failing to resolve the concerns at the time, they did not use Mrs C's formal complaint to appreciate where things went wrong and identify specific learning opportunities. They developed an action plan in response to the complaint but we did not consider it to be robust enough. We felt that their response to the complaint was defensive and often missed the point of the issues being raised. We upheld the complaint.

Recommendations

We recommended that the board:

• further develop their action plan to take account of our findings and inform us of any learning and improvements that have taken place as a result of this complaint;
• consider providing training in early resolution skills, including difficult conversations, to staff involved in this episode of care;
• remind complaints handling staff of the importance of accurately assessing all issues raised, to ensure they are fully understood, and offering compassionate and understanding responses that clearly and specifically set out any learning that has taken place;
• review the visiting policy at Cornhill Macmillan Centre with a view to ensuring that it is person-centred and adaptable to the individual needs of patients and relatives; and
• apologise to Mrs C for the failings we identified.

Summary

Mr C, who is an advice worker, complained to us on behalf of Mr A. He said that Mr A has diabetes and had experienced a number of hypoglycaemic (low blood sugar) episodes. His colleagues had contacted the Scottish Ambulance Service (the service) to request an ambulance when he had another hypoglycaemic episode just before starting work. When the ambulance crew arrived, they carried out a blood glucose test, which showed that Mr A had hyperglycaemia (high blood sugar levels). Mr C complained that the ambulance crew had failed to take the blood glucose reading appropriately. He said that Mr A had spilled a sugary drink on his fingers. He stated that the ambulance crew had failed to clean Mr A's skin before carrying out the blood test and, because of this, the blood tests incorrectly showed that his blood sugar levels were very high.

We took independent advice on the complaint from an adviser in emergency medicine. We found that the ambulance crew should have cleaned Mr A's hands, using either soapy water or an alcohol wipe, before taking the blood glucose reading. This was to prevent getting a high reading in error, and also to reduce the chance of infection, which is a particularly high risk for diabetics. The evidence showed that the ambulance crew failed to clean Mr A's hands so we upheld this aspect of Mr C's complaint.

Mr C also complained that the ambulance crew then unreasonably took Mr A to the local hospital. However, ambulance crews are required to transport patients with hyperglycaemia to hospital. Although it was likely that the high blood sugar reading was due to the sugary drink on Mr A's skin, we found that the ambulance crew were required to take Mr A to hospital when the blood test showed that he had hyperglycaemia. We did not uphold this aspect of the complaint.

Recommendations

We recommended that the service:

• issue a written apology to Mr A for the failure to clean his skin appropriately before taking the blood glucose reading; and
• take steps to ensure that relevant staff are aware of the requirement to clean skin before taking a blood glucose reading.

Summary

Mrs C complained that the Scottish Ambulance Service (the service) did not have the appropriate equipment or vehicle to take her late husband (Mr C) to hospital for a scan. Mr C was terminally ill with cancer and had widespread pain which severely restricted his mobility. Mrs C was also dissatisfied that the service did not apologise or explain why they delayed in replying to her complaint about the matter.

We took independent advice on this case from one of our nursing advisers. We noted that the service had reviewed the way the situation was managed and took appropriate action to prevent a similar situation recurring. We found that there was confusion about what equipment was required to take Mr C downstairs to the vehicle. Whilst the ambulance staff did their best with the equipment and vehicle that was available, there was a lack of communication as to the type of vehicle needed to transport him. As Mr C could not sit for long periods due to his condition, we considered it unreasonable to transport him to hospital in a chair which would have caused him additional pain and distress.

We also found that it took the service over three months to respond to Mrs C's complaint, which was well beyond the 20 working day timescale. Additionally, the service did not provide Mrs C with regular updates about the progress of their investigation or the reasons for the delay.

Recommendations

We recommended that the service:

• apologise to Mrs C for the failure to appropriately transfer her husband and for the distress that this caused; and
• apologise to Mrs C for the failings in the handling of her complaint.

Summary

Mr C complained about the care and treatment given to his son (Mr A) in the month before he died. Mr A had two consultations at the practice during this period. During the consultations he expressed concern about his mental health. At his second appointment he saw a locum GP, who noted that his mood was lower. They discussed whether he should be off work, and he was prescribed anti-depressants. He also completed two questionnaires in a public place within the practice. He later reported to Mr C that he had found it difficult to complete these in such a public place. Nine days later Mr A took his own life. The GPs involved both met with Mr C and his family in the weeks after his death, and a significant event analysis (SEA) was conducted four months later.

Mr C complained that Mr A was not given enough support when he needed it, that he should have been signed off work, and that the locum GP should have had greater involvement in the SEA.

We sought independent advice from one of our GP advisers, who reviewed Mr A's notes. She said that, on the basis of these notes, the discussions at both appointments had been reasonable, that due consideration had been given to Mr A's symptoms, and that his subsequent death could not have been predicted. The adviser was also satisfied that the SEA was in line with NHS guidance.

We considered that, while Mr A's death was tragic and a sad loss for his family, the care and treatment he had from the practice was reasonable, and the GPs involved could not have predicted that his mental health would decline as it did. We were satisfied that the SEA had been conducted in a reasonable manner, and appropriately took into consideration a report provided by the locum GP.

Summary

Mrs C complained that GPs at the practice failed to provide her late husband (Mr C) with appropriate treatment over an eight month period. Mr C had reported symptoms of stomach pains and cramps and, despite changes to his diet and medication, the symptoms persisted. Eventually Mr C asked to be referred to a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) where it was diagnosed that he had a bowel blockage which turned out to be cancerous. The practice said that Mr C had shown signs of severe diverticulitis (a disease of the digestive system) for many years but had refused to give permission for investigations during that time. It was only recently that he had given permission for a referral to be made to hospital specialists who confirmed the diagnosis. Mrs C did not believe that the practice had sent reminder letters to Mr C and said that the practice should have followed this up.

We took independent advice from one of our GP advisers. We found that the practice had acted appropriately in that they had documented that they had advised Mr C of the risks should he fail to have further investigations carried out. They also explained what further investigations were required and that it was his decision whether or not to agree to the further investigations and that he should reconsider the options at regular intervals. The practice were not responsible for arranging the further investigations but would have referred Mr C to hospital specialists who would decide which further investigations were appropriate.

Summary

Ms C complained to the practice about treatment that her son (Mr A) had received. She was unhappy with the response that she received and information that was provided about the principal dentist at the practice.

After investigating, we upheld Ms C's complaint. We considered that although the response to her complaint about treatment addressed her concerns adequately, there were a number of other complaints handling failings. We found that the response letter did not refer Ms C to us if she remained dissatisfied with her complaint and that the practice's complaints handling procedure was not in line with the relevant Scottish Government guidance. We also found that there had been a failure to advise Ms C of changes to the staff structure at the practice in a timely fashion.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C, acknowledging the failings our investigation found;
• review staff training needs, to ensure complaints are appropriately coordinated and responded to; and
• review the complaints handling procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I help you?' guidance.

Summary

Mrs C complained to us about some dental treatment she had at the practice that she had been referred to. She had a wisdom tooth removed, and during the process, a filling came out of the adjacent tooth, and part of the tooth broke off. The dentist advised Mrs C to see her own dentist to have the damaged tooth seen to. Mrs C complained that the treatment on her wisdom tooth must have been done badly, otherwise the neighbouring tooth would not have been damaged.

We took independent dental advice in relation to Mrs C's dental treatment. Our adviser noted that both Mrs C's dentist and the dentist carrying out the extraction had told her that she had tooth decay. He said that this made her teeth more vulnerable to damage during a dental procedure. He also noted that Mrs C had been told that the procedure of removing her wisdom tooth involved some risk of damage to adjacent teeth. However, there was no evidence that the tooth adjacent to the wisdom tooth was known to be decayed, and there was no record of Mrs C being warned of the risk to this tooth in particular, given its proximity to the wisdom tooth.

We concluded that there was no evidence that the dental treatment had been carried out inappropriately, so we did not uphold the complaint. However, we were critical that the records indicated that the dentist had not been clear during the consenting process of the risks to the adjacent tooth, or noted specifically whether there was any decay in that tooth.

Recommendations

We recommended that the board:

• feed back the findings of this investigation to the staff involved, for reflection and learning, particularly in relation to ensuring patients are fully informed of the risks of a procedure, and that appropriate records are kept; and
• apologise to Mrs C that they failed to give clear information about the risks involved in the procedure when she was giving consent.