Health

Summary

Mr C, who works for an advice agency, complained to the medical practice on behalf of his client (Mr A) who suffered from lower back and leg pain. Mr A said that there had been a delay by the practice in referring him for a MRI scan (magnetic resonance imaging - a scan used to diagnose health conditions that affect organs, tissue and bone) and it did not appear that they had followed the correct referral process and that had contributed to the delay. It was only after an appointment with a private physiotherapist that a MRI scan was arranged.

We took independent advice from a GP adviser and concluded that the practice had made appropriate referrals for specialist opinions from physiotherapy and orthopaedics and that initially there were no indications that, from a clinical perspective, a MRI scan was appropriate. By the time Mr A had seen the private physiotherapist, the clinical situation had deteriorated and at that time it was then appropriate to make a referral for an MRI scan. We did not uphold the complaint.

Summary

Mrs C, who works for an advice agency, complained on behalf of the family of Mr A. She said they believed Mr A's nasogastric tube had been incorrectly inserted, which had caused a collapsed lung by puncturing the inside of his lung. They said that, following this, he had deteriorated and this had contributed to his death. Mr A's family believed that Mr A had been being prepared for discharge at the time of the insertion.

The board said that they did not believe it was possible that the nasogastric tube had led to Mr A's death. The tube had been inserted by an experienced nurse, and checked by x-ray. When it was found to be in the wrong place, it had been immediately removed. The board said that there had been no discharge plan in place for Mr A.

We received independent medical and nursing advice. The medical advice stated it was not medically possible for a nasogastric tube to puncture a lung. Mr A had suffered from serious lung disease and it was more likely that this had caused his collapsed lung. The nursing advice said the insertion of a nasogastric tube was routine, but that even if inserted correctly, it could subsequently move within a patient. It was appropriate for the board to have confirmed the position by x-ray and this was an example of good practice.

We found there was no evidence that Mr A had not received an appropriate level of care and treatment and did not uphold the complaint.

Summary

Ms C complained that the board failed to provide her with reasonable treatment for her thyroid problem. Ms C listed several issues regarding her care. She said that the consultant ear, nose and throat surgeon at the Southern General Hospital who dealt with her case underestimated the seriousness of the original scan and histology findings (report on the microscopic appearance of tissue). She complained that the surgeon unreasonably subjected her to repeat investigations and new referrals. She also complained that the surgeon ignored the final histology report which Ms C said confirmed she had cancer. Additionally, Ms C complained that the board did not respond reasonably to her complaint about her treatment.

We obtained independent advice on the complaint from a consultant surgeon specialising in ear, nose and throat, head and neck, and the thyroid gland. The adviser said that, given the length of time Ms C had had the nodule on her thyroid, the previous investigation of the nodule, and the fact there was no record of it having changed since it was first noted, the likelihood of malignancy (cancer) would have been low. The adviser explained that it was entirely reasonable for the consultant to undertake investigations before removing the nodule to check that there were no other medical issues which could cause problems with the anaesthetic and surgery.

The adviser did not consider that the consultant ignored the final histology report, just that they had not seen it. Ms C had moved house and was receiving treatment from another board by the time the consultant saw the report. However, the adviser said there was an unnecessary delay in the consultant noting and acting on the final histology report. This appeared to be caused by the process in the department for checking the results, and the board have indicated that action has been taken to improve this.

On balance, we considered that the board did not fail to provide Ms C with reasonable treatment. However, we also considered that the board did not respond reasonably to Ms C's complaint as there were inaccuracies in their response.

Recommendations

We recommended that the board:

• feed back our decision on Ms C's complaint about the treatment provided by the board to the staff involved; and
• provide Ms C with a written apology for the failings identified in both complaints.

Summary

Ms C complained that following an operation for pancreatic cancer she was discharged home from Aberdeen Royal Infirmary without being given medication (which was specifically for digestive problems involving the pancreas). As a result, Ms C's condition deteriorated and she developed symptoms of severe pain, sickness and diarrhoea. She had to be readmitted to hospital and the medication was re-started, and her symptoms began to improve.

We took independent advice from a medical adviser who noted that it was a discretionary decision for the consultant to make prior to Ms C's discharge from hospital and that this was a reasonable decision for them to take. Some clinicians would prescribe this specific medication on discharge whilst others would not. The fact that the medication was not prescribed was not, in itself, an indication of a failure in service.

We found that the decision to discharge Ms C without medication was appropriate in the circumstances but that it was unfortunate that her condition deteriorated and that she required a further admission to hospital. With hindsight, if Ms C had been given this medication, it may have prevented her deterioration but the consultant had to consider the available information at the time of discharge. We did not uphold the complaint but noted that the matter should have been discussed with Ms C prior to discharge.

Summary

Mr C suffered from cystic acne. He attended his GP practice on a number of occasions over several years and received treatment. Eventually he was referred to a skin specialist. The specialist prescribed Mr C medication that cleared his acne, but he was left with significant scarring on his face. He complained that, when he asked the board to provide treatment to remove the scarring, this was refused on the grounds that it was a cosmetic procedure and could not be funded by the NHS. Mr C felt that the NHS should provide the required treatment.

We found that the board had reached their decision with reference to national guidance on referrals for cosmetic procedures. Although acne was not specifically mentioned in the guidance, we were not critical of its use when considering Mr C's request for treatment. The guidance generally ruled out treatment unless there were special circumstances. We took independent advice from a consultant dermatologist (a specialist in diseases of the skin, hair and nails). The adviser said that the board had appropriately considered Mr C's request and, should he wish to pursue a referral on the grounds of special circumstances, he would have to do this through his GP. We were not critical of the board's handling of Mr C's case.

Summary

Mr C suffered from cystic acne. He attended the practice on several occasions over a number of years and received treatment. His GP referred him for treatment from a skin specialist. The specialist prescribed him medication which cleared his acne. However, he was left with significant scarring on his face which he was reportedly told may have been prevented if he had been referred sooner. Mr C complained that, had he been prescribed the medication sooner, he would not have been so badly scarred by his acne. He considered that the practice should have referred him to the specialist earlier, or that they should have prescribed him the medication directly.

We took independent advice from a consultant dermatologist (a specialist in diseases of the skin, hair and nails). The adviser said that GPs would never prescribe this medication directly and that the correct course of action is for the GP to refer the patient to a specialist for consideration of a prescription. We found that the practice had reviewed Mr C's acne on a number of occasions and had provided treatment according to his presenting condition. His treatment was appropriately altered as required and his acne was noted to have improved at various times. We concluded that he was appropriately referred to a specialist when his acne had recurred and showed signs of scarring, so we did not uphold the complaint.

Summary

Mr and Mrs C attended the Aberdeen Fertility Centre and were diagnosed with unexplained infertility. They underwent two in vitro fertilisation (IVF) cycles but neither cycle resulted in pregnancy. The board decided not to offer a further IVF cycle, saying that egg donation could be considered. Mr and Mrs C underwent assisted conception treatment privately. This found that Mrs C's ovarian reserve (the capacity of a woman's ovaries to produce healthy eggs) was higher than expected, and that Mr C's sperm had a significant number of antibodies which caused the sperm to stick together. Mrs C raised concerns about aspects of the assisted conception care and treatment provided by the Aberdeen Fertility Centre as well as the nursing care provided. She also raised concerns about the way the board handled their complaint.

We found that the board's actions were reasonable in relation to the provision of assisted conception. However, in light of the new information about the nature of the couple's infertility and Mrs C's ovarian reserve, we recommended that the board consider whether the couple met the board's eligibility criteria (as outlined in their policy) for a third round of IVF treatment. We also found communication and record-keeping failures by nursing staff, particularly around pain assessment and relief. In relation to the board's complaints handling, we found that the board should have told Mrs C about the delays in responding to her complaint, the reasons for the delays, and of her right to approach us in such circumstances.

Recommendations

We recommended that the board:

• consider whether Mr and Mrs C meet the eligibility criteria in the board's policy for a third cycle of assisted conception treatment in light of the new information about the nature of their infertility and Mrs C's ovarian reserve;
• bring the record-keeping and communication failures to the attention of relevant staff and review the process to ensure there is no recurrence;
• apologise for the failures identified in complaints handling and bring them to the attention of relevant staff; and
• apologise for the failures identified.

Summary

Mr A was admitted to Forth Valley Royal Hospital after taking an overdose of drugs. His sister (Ms C) said that it was considered that he had suffered an organically induced psychotic state and a few days later, after his blood pressure and temperature returned to normal, he was discharged. Ms C, however, remained concerned about Mr A's state of mind and wrote to his psychiatrist but her contact was rebuffed. Mr A took his life five months after the overdose. Ms C complained that the board had failed to contribute positively to Mr A's care and perhaps change his outcome. She also complained about the psychiatrist's attitude to the family and that he had focussed incorrectly on Mr A's physical, rather than his mental health.

We took independent advice from a consultant psychiatrist and we found that, initially, it had been reasonable to conclude that Mr A's behaviour was due to a transient illness caused by an organically induced psychotic state, and to treat him for this. However, Mr A's psychiatrist later declined important information from Ms C which should have been included in decision-making and clinical management (although it could not be concluded that this would have changed the outcome for Mr A). Subsequently, when Ms C complained, it took too long to provide her with an explanation. We upheld the complaint.

Recommendations

We recommended that the board:

• provide confirmation that the psychiatrist has completed a specialist training programme in communication style and technique;
• bring the General Medical Council document on confidentiality to the psychiatrist's attention and consider whether training on information governance is required; and
• remind all staff involved of their obligations in terms of their own complaints handling procedures. Furthermore, ensure that any changes anticipated to the complaints procedure are first discussed with the complainant and receive their prior permission.

Summary

Mr C complained that the board failed to provide him with the necessary preparation in advance of a procedure to examine his bowel (colonoscopy). The board acknowledged that Mr C was not given the necessary preparation, which he should have received three days in advance of the procedure, and they apologised to him. We took independent medical advice from a GP. They noted that the hospital had sent clear instructions to the prison health centre regarding the preparation for the procedure and the adviser therefore considered it unreasonable that this was not carried out.

The hospital subsequently recorded that Mr C had refused to attend his appointment and he complained about this as he did not consider that the fault for this lay with him. The board apologised to Mr C for inaccurately recording that he had refused to attend. The GP adviser considered that this incorrect recording was unreasonable as it could have resulted in Mr C not receiving a follow-up appointment when the investigation was important to rule out a potential underlying cancer diagnosis.

As it happened, the prison doctor re-referred Mr C for a colonoscopy but this was vetted by the hospital and the procedure was changed to an examination of only the lower part of his bowel (flexible sigmoidoscopy). Mr C complained that this change of procedure was not explained to him. We were advised that it would have been reasonable for the sigmoidoscopy procedure to be explained to Mr C on the day of the procedure and the records indicated that this happened. However, we could not see any evidence of the reasons for the change in procedure being explained to him.

Mr C also complained about the time the board took to respond to his complaint and for their failure to answer his questions. The board acknowledged that there were inconsistencies in their responses and that they had not answered all of Mr C's specific questions. They also acknowledged that they had taken too long to respond to Mr C's final letter. It had taken them six months to respond to this and we concluded that this was an unreasonable timescale.

We upheld all the complaints.

Recommendations

We recommended that the board:

• reflect on the process failings that have occurred in this case and inform us of the steps they have taken to ensure that similar future failings do not occur;
• remind staff to ensure that relevant information is shared with a patient when a procedure is changed and that this is documented;
• remind complaints handling staff of the importance of responding to complaints in a full, accurate and timely manner; and
• apologise to Mr C for the failings this investigation identified in their handling of his complaint.

Summary

Mrs C complained about the care her relative (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with severe abdominal pain but on her first night in hospital, she suffered a fall. An x-ray was taken but clinicians caring for Mrs A did not identify any fracture after reviewing the image. The x-ray was subsequently reviewed by a radiologist (a doctor specialising in medical imaging) who reported that there was a suspicion of fracture to the pelvis. This report was not acted on for over a week, during which time staff continued to try to mobilise Mrs A. A subsequent scan showed that Mrs A had sustained multiple fractures.

When Mrs C complained to the board, the first response she received included a number of factual inaccuracies including that Mrs A had been admitted to hospital following a fall at home. A later response apologised for these errors. Mrs C remained dissatisfied and asked that we consider her complaints that there was an unreasonable delay in identifying Mrs A's fracture and that she had been unreasonably mobilised.

After taking independent advice from a consultant geriatrician, we upheld Mrs C's complaints about the medical care Mrs A received. The adviser considered it unreasonable that the x-ray report indicating that there was a suspicion of fracture had not been acted on and said it appeared staff caring for Mrs A had wrongly assumed the initial opinion that there was no fracture was correct. We found no evidence that Mrs A had been inappropriately mobilised after her fractures were identified but, in light of the fact that attempts were made to do so prior to this, we upheld Mrs C's complaint on this issue. We also upheld Mrs C's concerns about complaints handling as it is vital that complaint responses are factually accurate. While the board have already apologised for this matter, we found that they had not referred to the delay in acting on the

x-ray report in their response, which we did not consider to be reasonable.

Recommendations

We recommended that the board:

• ensure that our findings are brought to the attention of the staff involved in Mrs A's care and treatment. This should include the adviser's comments on communication and the falls risk assessment;
• provide evidence that they have considered how to prevent the problem in relation to the result of the x-ray not being taken into account from recurring in the future; and
• provide a further apology to Mrs C for the complaints handling issue identified in this investigation.