Health

Summary

Mrs C, who is an advocacy worker, complained to us on behalf of her client (Mrs B) whose mother (Mrs A) had been a patient at Dr Gray's Hospital after being admitted with symptoms of abdominal pain, nausea, vomiting and with an infection. While in the hospital, Mrs B had concerns about her mother's clinical treatment and nursing care. These included a delay in diagnosing that Mrs A had fluid on her lungs and that the staff did not listen to the family's reported concerns about possible fluid build-up; that they did not provide Mrs A with assistance to mobilise; and that staff failed to communicate with them regarding Mrs A's condition and test results. Mrs B was also concerned that the board's formal response did not address all her concerns.

We took independent advice from a clinical adviser and a nursing adviser. We found that although the day-to-day clinical treatment which was provided was reasonable, there was a slow pace to the investigations and there was a clear lack of clinical direction. It was accepted that there were numerous medical specialties involved and that there was some uncertainty regarding a definitive diagnosis. However, there was a lack of any thoughtful or dynamic approach to Mrs A's care. We also found that the nursing care was appropriate but there were failings in communication by both nursing and clinical staff. We also found evidence of poor complaints handling as the board had not addressed all of Mrs C's concerns which were set out in the initial complaint letter to them. They had only generally referred to the communication issues and failed to address any of the concerns regarding the nursing care.

Recommendations

We recommended that the board:

• apologise to Mrs A for the way her clinical treatment was managed and for the subsequent delays to her treatment;
• share our findings with senior clinicians who were responsible for Mrs A's treatment in order that they can reflect on their actions;
• apologise to Mrs A for the failings in communication which we identified;
• share our findings with nursing and clinical staff in order that they can reflect on their actions;
• apologise to Mrs B for the inadequate response to her formal complaint; and
• remind all staff who are responsible for investigating complaints to ensure that all concerns are addressed in the final response.

Summary

Miss C complained regarding the care and treatment she received for a benign breast lump in 2011. In 2014, Miss C was diagnosed with breast cancer. The board said that the lump had been benign in 2011 and it was very unlikely that a benign lump becomes cancerous. Miss C said that she had not been provided with adequate follow-up or advice, and that the lump had become malignant. Miss C said the board should accept this was possible and that the lump should have been removed in 2011. Miss C also complained of an excessive delay in providing her with radiotherapy.

We took independent advice from one of our advisers, who is a consultant oncologist. Our adviser said there was no evidence to show benign lumps could become malignant. It was possible that despite the appropriate tests being carried out and the results from these showing no sign of cancer that it had in fact been malignant in 2011. Our adviser said that this did not constitute an unreasonable standard of care. However, the delay in the provision of radiotherapy was unreasonable, since it had breached Scottish Government targets and the board had been unable to provide evidence that they were taking steps to prevent a reoccurrence.

We found that the board had acted reasonably in 2011, both in terms of the tests carried out and the decision not to remove the lump from Miss C's breast at this time. When further tests in 2014 showed it to be malignant, the lump was appropriately removed, but the board unreasonably failed to provide radiotherapy within Scottish Government targets, so we made a recommendation about the delay.

Recommendations

We recommended that the board:

• provide evidence that the review being conducted into radiotherapy provision has addressed the delays experienced in this case.

Summary

Mrs C complained on behalf of her brother (Mr B) about the care and treatment his late partner (Ms A) received following a diagnosis of colorectal cancer.

Ms A's family said that had she received treatment sooner, the progression of the cancer could have been slowed. They also questioned whether shrinking her tumour with radiotherapy and concurrent chemotherapy was the best course of action, or whether the tumour should have been removed upon its discovery.

Ms A's family also complained there had been a failure to reasonably communicate her condition and prognosis throughout her care. In particular, they said that Ms A's consultant said she would be free of cancer by a certain date only later to be told her cancer had spread.

We took independent advice from a colorectal surgeon who said Ms A's treatment, based on her symptoms and condition at the time, was timely and had also been carried out within the appropriate national cancer treatment guidelines. The adviser also said the scans taken of Ms A were appropriate and the decision to use chemo-radiotherapy to shrink the tumour was the most reasonable treatment option and in line with the applicable guidance.

We accepted that Mr B and Ms A believed that when they met with the consultant they were told she would be free of the cancer by a certain date. The board, however, said that the consultant would not have given Ms A this information. We consider that it is essential that communication at an important consultation when there is discussion about a patient's prognosis is clear and the patient clearly understands what is being said. It was unsatisfactory this did not appear to have happened in this case. Given the different accounts and in the absence of further evidence, we were unable to conclude that the consultant miscommunicated Ms A's diagnosis during the consultation, but we made a recommendation about communication.

However, taking account of the evidence overall, on balance we did not find there was a failure by the board to reasonably communicate Ms A's condition and prognosis throughout her care, so we did not uphold Mrs C and Mr B's complaints.

Recommendations

We recommended that the board:

• ensure this case is discussed with the consultant as a learning point and consideration is given by them to undertaking communication training as part of their continuing professional development.

Summary

Ms C attended her GP with swelling and hardening tissues between her vagina and rectum. The GP prescribed antibiotics to be taken for seven days. She was told to return in one week, or sooner if her symptoms became worse. Three days later, she returned to the practice and saw a different GP as the pain was worse. The medical notes also state that she was experiencing diarrhoea and vomiting. She was examined and the medical records indicate that her vaginal symptoms were no worse, and that the GP considered the diarrhoea and vomiting to be side effects of the antibiotics. On Ms C's request the GP prescribed anti-sickness medication. The GP told her to take the antibiotics for only five days, recorded that there was no sign of infection and gave her a one-week sick note. Six days later, Ms C attended the first GP again, who diagnosed a perianal (situated in or affecting the area around the anus) abscess. Ms C was admitted to hospital. Ms C complained that, at her second appointment, the GP had failed to provide adequate medical advice, care and treatment.

We obtained independent advice from one of our GP advisers. We concluded that, while the care and treatment provided to Ms C was reasonable, it was unreasonable that Ms C was not given any specific instructions by the GP at the second appointment about what to do if her vaginal symptoms did not improve or got worse. As this particular failure was significant, we upheld Ms C's complaint. During our investigation, the practice apologised to Ms C and the GP reflected on her practice. The GP explained that, in future, she would try to give more specific instructions for patients so they are sure they can come back if they need to. Therefore, we did not consider that we needed to make any specific recommendations.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs C) by her GP practice in relation to her stomach problems. The practice investigated her stomach problems by carrying out blood tests and arranging for further investigations in hospital. When she was admitted to hospital, it was subsequently established that she had a mass on her liver, and it was confirmed that she had secondary cancer of the liver. Mr C complained of a lack of treatment and investigations into Mrs C's symptoms by the practice, and said that if they had taken her abdominal problems more seriously, then the cancer would have been diagnosed sooner.

We took independent advice from one of our medical advisers, who specialises in general practice. We found that the practice properly investigated Mrs C's symptoms, including making referrals to secondary care within a reasonable time, and that, overall, the treatment provided was reasonable.

Summary

Mr C complained about the care and treatment provided to his daughter (Miss A) at Forth Valley Royal Hospital. He was dissatisfied that she was not reviewed by a cardiologist (doctor specialising in disorders of the heart) when she reached the age of two, despite concerns about her heart when she was born. He complained that he was not informed about the change of plan about reviewing her. Mr C was also unhappy that the board's complaints team had access to Miss A's clinical records without his consent, that they took an unreasonable length of time to respond to his complaint, and that they did not respond reasonably to his questions.

We took independent advice on this case from one of our medical advisers who is a consultant paediatric cardiologist. We did not identify clear evidence that Mr C had been told Miss A would be reviewed at the age of two. We considered that the care given to Miss A was in accordance with established good practice, and there was no evidence of a heart defect requiring further review. It would have been difficult for the board's complaints team to respond fully to Mr C's concerns without access to Miss A's clinical records. However, there was no evidence that Mr C was clearly informed of the possibility that relevant health records would be handled by a member of the complaints team (in accordance with national complaints handling guidance and the board's procedures). Therefore, we upheld this part of the complaint.

We considered, on balance, that the board's responses were reasonable and were issued to Mr C without undue delay.

Recommendations

We recommended that the board:

• draw to relevant staff's attention the failings identified.

Summary

Miss C complained on behalf of her late mother (Mrs A). Miss C complained that Mrs A's dressings were not changed regularly enough, that the board failed to communicate with her regarding how ill her mother was and, in particular, that Mrs A had signed a do not attempt cardiopulmonary resuscitation (DNACPR) order. Miss C also complained that after her mother's death, she had asked nursing staff to re-dress her mother and this request had not been carried out. Miss C said the board took an unreasonable amount of time to respond to her complaint.

We took independent advice from one of our nursing advisers. The adviser said Mrs A's dressings should have been more closely monitored, so we upheld this complaint. However, as the board had already acknowledged this and taken appropriate action, we did not make a recommendation.

Our adviser noted that Mrs A was competent and able to make decisions about her own care. The DNACPR order had been properly communicated and administered by staff. It was for Mrs A to decide if she wanted to discuss this with anyone else. We did not uphold this complaint.

Regarding Miss C's request for her mother to be re-dressed, we noted that the nurse Miss C spoke to had assured her this would be done by mortuary staff. When the mortuary were contacted, however, they did not believe it would be appropriate for them to carry out this request and passed it on to the undertaker. We were critical that the board had assured Miss C that this request would be carried out. However, the adviser's view was that the decision taken by the mortuary staff was reasonable and was taken to ensure Mrs A's dignity. We did not uphold this complaint.

The board had explained that the reason for the delay in responding to Miss C was caused when staff continued to request information from a doctor who no longer worked for the board. For that reason, we upheld the complaint and made one recommendation.

Recommendations

We recommended that the board:

• reflect on why staff were not alerted to the fact that the doctor had left the board, and how this might be avoided in future.

Summary

Ms C complained about the care and treatment she received from her GP practice. She had an operation to fit a catheter, during which she sustained an injury to her bowel. This injury was not identified at the time and she subsequently experienced a lot of pain. She consulted the practice and a number of tests were carried out but the damage to her bowel was not diagnosed. It was not detected until she was admitted to hospital two months after her initial surgery. Further surgery was carried out to correct the damage. Ms C complained about the practice's failure to diagnose the bowel injury. She also complained that the practice refused to prescribe two drugs that had been recommended by hospital specialists; that they failed to appropriately treat her urine infections and that they failed to provide the hospital with details of her medical condition prior to an emergency attendance.

We took independent advice from one of our GP advisers. Our adviser considered that the tests the practice carried out were reasonable and that the damage to Ms C's bowel would have been difficult to diagnose. However, as Ms C's pain was not resolving and no cause for this pain was identified, the adviser considered that further assessment should have been arranged. She stressed the importance of keeping a wide differential diagnosis in mind when investigating unexplained symptoms in patients (a systematic method of diagnosing a disorder that lacks unique symptoms or signs). We accepted the advice we received and upheld this complaint. We recommended that this should be fed back to the doctor concerned.

We did not uphold Ms C's other complaints. Our adviser noted that the practice had not prescribed the two drugs recommended by specialists as they were concerned about potential interactions with other drugs Ms C was taking. Our adviser considered that this was reasonable and in line with safe clinical practice. She also noted that the urine tests in question had produced no evidence of infection and that no treatment was, therefore, required. Finally, she noted that the practice spoke with the hospital and faxed details to them prior to Ms C's emergency attendance. We therefore concluded that the actions of the practice were reasonable in this regard.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C, acknowledging the failings identified; and
• confirm that the doctor in question will discuss our findings as part of their yearly appraisal and ensure that they reflect on the importance of keeping a wide differential diagnosis in mind when investigating unexplained symptoms in patients.

Summary

Mrs C complained about the way the medical practice handled two phone calls when she became ill while on holiday. During the first call, which was made by her son, Mrs C felt that the receptionist concentrated too much on the fact that she was currently outside the practice area and that she should seek an appointment with a local GP practice. Mrs C did so and the GP diagnosed quinsy on her tonsil (a complication of tonsillitis where an abscess forms between a tonsil and the throat). Mrs C phoned the practice the following day to arrange an appointment for when she returned home. She was informed that there were no pre-bookable appointments available for the next two days. Mrs C felt that the reception staff should have sought advice from a doctor rather than make decisions about whether her medical condition could wait until an appointment was available.

We sought independent clinical advice from a GP adviser who felt that the practice had handled both calls appropriately. During the first call, her son was advised that Mrs C should seek a medical opinion from a local GP in order that her condition could be assessed. During the second call we found that the receptionist had accurately explained the process for making appointments. We did not uphold the complaint.

Summary

Mr C complained about the treatment provided to his late father (Mr A) when he was admitted to Biggart Hospital for a mental health assessment. While in hospital, Mr A's condition deteriorated and he stopped eating and drinking. His medication was amended but Mr A subsequently died of an infection. Mr C felt that Mr A's deterioration was due to the medication prescribed for his mental health problems. He also said that, despite repeatedly reporting his concerns to staff, they did not take his views into account.

The board said that Mr A had been prescribed appropriate medication for his mental health issues, that his medications were continually monitored, and that they were amended in view of the changes to Mr A's clinical condition. They also explained that there was evidence of regular communication with Mr C.

After taking independent advice from a medical adviser who is a consultant in old age psychiatry, we did not uphold Mr C's complaint. We found that the doctors involved in Mr A's care provided appropriate treatment for his physical and mental health symptoms. The medications prescribed were appropriate, and were closely monitored and amended when required. We also found that the staff were fully aware of Mr C's concerns about his father's treatment, and that they took these concerns into account when setting up the treatment plan.