Health

Summary

Ms C was charged by her dental practice for a missed appointment. Ms C felt this was unreasonable in the circumstances and complained to the practice about this. She was dissatisfied with the practice's response and made further complaints. Following a subsequent visit to the practice she and her daughter were removed from the practice's treatment list. Ms C complained about this and was dissatisfied with the response she received. She complained further and also received a reminder for a check-up despite her having been removed from the practice's treatment list. Ms C complained about these matters but did not receive a response from the practice. She raised her complaints with this office.

We attempted to resolve the matter but this was unsuccessful. Following consideration we decided that the practice's actions in charging Ms C for the missed appointment, failing to send a reminder for an appointment and sending two copies of the letter advising Ms C that she had been removed from their treatment list were not unreasonable. We also found that there was insufficient evidence to determine whether the practice had refused to treat Ms C's daughter due to Ms C's outstanding debt. However, we did decide that the practice's actions in refusing Ms C's request for a meeting to discuss her complaints, the process by which they removed Ms C from their treatment list, their response to Ms C's complaints and their having sent her a reminder for a check-up after they had removed her from the treatment list were unreasonable and upheld these aspects of the complaint.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failures we identified; and
• undertake training with all practice staff in relation to the removal of patients from treatment lists and the practice's complaints procedure.

Summary

Mrs C complained about the care and treatment given to her late mother (Mrs A) during an admission to the Royal Alexandra Hospital. She said that staff at the hospital delayed in attending to Mrs A and in providing her with treatment, and that she was given too much fluid intravenously. Mrs C believed this all contributed to Mrs A's death. Mrs C also complained that there were delays in transferring Mrs A to a treatment ward which she said was also to her detriment.

We took independent advice from a consultant in emergency medicine and we found that while Mrs A had been assessed in the emergency department as an urgent case to be seen within an hour, she was not seen until after two hours of arrival on the ward. It also took 11 hours to transfer her to a ward for treatment which was far too long for someone who was sick, elderly and frail. Furthermore, Mrs A had been given a litre of saline solution which was too aggressive given that she was known to have pre-existing heart disease. For these reasons, we upheld the complaint. However, there was no evidence to suggest that the failures identified had contributed to Mrs A's death.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C recognising the shortcomings identified;
• satisfy themselves that such delays in the emergency department could not happen again and advise us of the processes since put in place to avoid this; and
• ensure that our findings are brought to the attention of the doctors and staff in the emergency department for them to consider further.

Summary

Mrs C had some metal work removed from her hip at the Southern General Hospital with the aid of an epidural anaesthetic. Afterwards, she said that she had not properly regained feeling in her right leg and that she had problems urinating. She said that she had been discharged from hospital too soon and that reasonable investigations had not been made into her symptoms.

She complained to the board but they were of the view that her discharge had been appropriate and that all reasonable investigations had been undertaken into her continuing problems. Mrs C was unhappy and complained to us.

We took independent advice from a consultant trauma and orthopaedic surgeon. We found that on the day of her discharge, Mrs C had been reviewed by a physiotherapist and assessed as safe to go home; her condition was improving and no further interventions were planned by medical staff. Thereafter, Mrs C's complaints about her leg and urination were extensively investigated with scans, nerve conduction studies, blood tests and a lumbar puncture being carried out. She had reported that her condition was improving. In the circumstances, we did not uphold Mrs C's complaint.

Summary

Mrs C complained that when she was admitted to the Western Infirmary with increasing shortness of breath and a productive cough (a cough that produces mucus and phlegm), she was assessed by a clinical nurse specialist (CNS) who said that she could be discharged home that day under the Early Supported Discharge (ESD) service. Mrs C had concerns that she was not fit for discharge and she remained in hospital until she was further assessed by a doctor as being fit for discharge. Mrs C was transferred to Gartnavel General Hospital prior to her discharge home. Mrs C complained that the CNS should not have assessed her as being fit for discharge and that when she arrived at Gartnavel Hospital her portable oxygen cylinder was found to be not working. She said that it must not have been checked at the Western Infirmary.

We took independent advice from our nursing adviser and found that the CNS was an appropriate health professional who was qualified to assess Mrs C and that her decision that Mrs C was fit for discharge, further to medical review, was appropriate. We made no finding on the complaint as to whether the oxygen cylinder was working on discharge from the Western Infirmary as there was no substantive evidence to establish when the oxygen cylinder stopped working. This may have occurred at the time Mrs C was being taken from the Western General or in transit during the hospital transfer.

Summary

Miss C said she attended the practice for a check-up with the dentist and he removed a tooth which had been causing her pain for some time. She said she suffered extreme pain after the extraction and attended the practice again for an emergency appointment with the dentist. Miss C complained that the dentist unreasonably dismissed the pain she was feeling in her gum and unreasonably failed to notice and treat a hole in her gum. She also complained that the practice manager unreasonably failed to answer her questions about her treatment by the dentist in the practice's written response to her complaint.

We obtained independent dental advice on Miss C's complaint from a senior dental practitioner. Our adviser said Miss C's dentist reasonably diagnosed that Miss C had a dry socket (a well-recognised complication of tooth extraction, characterised by increasingly severe pain in and around the extraction site, usually starting 24 to 48 hours post-operatively) and treated it in line with the guidelines and established good practice – suggesting that the pain in her gum was not dismissed.

As we were not present at Miss C's appointment, it was not possible for us to say if there was a hole in her gum which the dentist then failed to treat. Given this and our adviser's view that the dentist's treatment of Miss C's condition was reasonable, we did not conclude that the dentist unreasonably failed to notice or treat a hole in Miss C's gum.

However, in terms of the complaints handling, we considered that on balance the practice manager's response did not address all the points Miss C made and was not a full response to her complaint. We were also concerned that the practice manager deemed Miss C's letter of complaint to be for information only and initially failed to issue a response, when the letter's contents indicated that a written response was required.

Recommendations

We recommended that the dentist:

• feed back our decision on Miss C's complaint to the staff involved; and
• provide Miss C with a written apology for failing to provide a full response to her letter of complaint.

Summary

Mr C complained to us that staff had failed to carry out an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) when he attended Glasgow Royal Infirmary after injuring his back at work. Although a junior doctor who examined Mr C had recorded that an x-ray and MRI scan should be considered, Mr C was then reviewed by a consultant orthopaedic surgeon, who decided that they were not required. Mr C continued to suffer from back problems and considered that he would have received treatment for this earlier if an MRI scan had been carried out on the day he injured his back.

We took independent advice on Mr C's complaint from a medical adviser who is an experienced consultant in trauma and orthopaedic surgery, with a specialist interest in lumbar spine problems. We found that an MRI should be carried out on patients where surgery is being considered because of escalating pain and/or neurological deficit or those in whom the pain has persisted for several weeks (this is usually a minimum of six weeks with no improvement). We found that it was reasonable that an MRI scan was not carried out when Mr C attended hospital on the day he injured his back. It was also appropriate not to carry out an x-ray at that time. We therefore did not uphold Mr C's complaint.

Summary

Mr C, who is an advice worker, complained to the board about the care and treatment Ms A received from Stobhill Hospital in relation to the fitting of a mirena coil (a contraceptive device inserted into the womb which can treat heavy bleeding). Six years later, there were difficulties in removing the device. It was found to be embedded in her womb and had to be removed under general anaesthetic. Ms A believed that she may not have been suitable for a mirena coil because of having a retroverted (backward-tilting) womb. She felt that this should have been taken into account before the device was implanted, and was concerned about not being properly informed of the risks.

We took independent advice from one of our medical advisers who is a consultant gynaecologist. We found that there were no clear records of a verbal discussion taking place with Ms A about the possible risks associated with the procedure. However, there were clear records showing that the doctor had given her a patient advice leaflet, which provided enough information for Ms A to make an informed decision. We also found that, before fitting the coil, the doctor had carried out a pelvic examination to check the positioning of Ms A's womb. This was in accordance with national guidelines and done to ensure that the mirena coil was appropriately positioned. It can be difficult to clearly identify the positioning of a woman's womb, and although it was likely in retrospect that the womb was retroverted, we did not consider this an unreasonable failing at the time.

Summary

Mrs C complained about the care and treatment she received at Glasgow Royal Infirmary in relation to breast reconstruction following a bilateral mastectomy (surgical removal of both breasts). Mrs C was concerned that her choice of reconstruction was interfered with by the specialist breast reconstruction nurse, that the medical choice of expander breast implants was inappropriate, and that the nurse who had inflated the implants had overfilled them, which led to additional treatment and surgery to address the problems.

During the board's investigation of the complaint, they identified the need to implement a protocol for the inflation process. However, they did not clearly acknowledge to Mrs C that the nurse had overfilled the implants well above the manufacturer's recommended guidelines.

We took independent advice on this case from two of our advisers, one of whom is a specialist surgeon in breast reconstruction and the other a specialist nurse. We did not find evidence to clearly show that Mrs C's decision about reconstruction options was unduly influenced by either the surgeon who was responsible for her care or the specialist breast reconstruction nurse. Whilst we considered that to proceed with implants was not unreasonable, we were critical of the size of expander implants used at her second operation. We were also critical that the higher risk of the implant failing was not discussed with Mrs C. We found that the nurse had overfilled the implants above the manufacturer's guidelines and had not sought permission from the surgeon as she should have done. The surgeon also failed to give clear instructions about the total volume of saline to be put into the implants, and the speed at which the filling was to be done. This was particularly important given Mrs C's previous radiotherapy, which makes the breast skin more vulnerable.

Recommendations

We recommended that the board:

• contact the surgeon to share these findings about the failure to discuss and document the higher risk of implant loss when increasing Mrs C's breast size;
• apologise to Mrs C for failing to inform her of the additional risks associated with a larger implant;
• apologise to Mrs C for overfilling her implants and for not including this information in their complaint response to her; and
• ensure the findings are shared with the nurse and the surgeon and that any training needs are appropriately dealt with.

Summary

Mrs C complained to us about the Glasgow Dental Hospital's decision to give her son (Mr A) colchicine (a medication normally used to treat gout) to treat his mouth ulcers. Mr A had mental health problems and subsequently died from an overdose of the medication. Mrs C said that the medication was not listed as a treatment for mouth ulcers. She also considered that the doctor who had recommended the prescription of the medication had failed to adequately assess the risks of giving this to Mr A, in view of his mental health problems and previous suicide attempts by overdosing.

We took independent advice on Mrs C's complaint from an adviser who is a consultant in oral medicine. We found that colchicine is an appropriate choice of drug for mouth ulcers. It had been reasonable to give this to Mr A because the ulcers extended into his throat and other treatments had not been successful. The doctor had been aware of Mr A's mental health problems and of his suicide attempts by overdosing. The doctor considered that the risks of this happening again were mitigated as Mr A received his medication on a daily basis to reduce the chance of overdosing. We considered that, based on the evidence available at the time, it had been reasonable for the doctor to decide that Mr A should be given colchicine. We did not uphold the complaint.

Summary

Mrs C, who is an advocacy worker, complained on behalf of her client (Mrs A). She said that Mrs A had complex medical conditions and that she began to suffer from seizures after the practice had prescribed indapamide (medication for high blood pressure). The practice said that Mrs A's blood pressure had risen due to her other medication and that they prescribed indapamide in order to control her blood pressure. They said they monitored her condition and also sought medical advice from a hospital specialist.

We took independent advice from one of our GP advisers. Our adviser was satisfied that the practice had prescribed the medication appropriately, and that they had sought specialist advice and monitored the situation. We did not uphold the complaint.