Health

Summary

Ms C complained to us about the system that the medical practice used for reporting on warfarin (a drug used to prevent blood clots) blood tests. Her mother (Mrs A) had been discharged from hospital and a blood test was taken on a Friday. Ms C was told to phone the practice later that day for the result. Ms C did so and was told by a receptionist that the results would not be ready until Monday and that her mother should continue on the same dosage of medication (one tablet daily) in the meantime. On the Monday, the practice phoned Ms C and advised her that her mother's medication should be reduced to one tablet every other day. In the meantime, Mrs A had developed speech problems and had difficulties swallowing, eating and drinking. Ms C felt that the dosage of medication that her mother was taking over the weekend had caused Mrs A's deterioration.

We took independent advice from a GP adviser and concluded that whilst the dosage of medication taken over the weekend had not harmed Mrs A (and was not the cause of her deterioration), the system of reporting warfarin blood test results was not entirely in accordance with local guidelines and that it was not clear whether the receptionist had spoken to Ms C on the instructions of a clinician. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mrs A for the delay in informing her of the warfarin blood test result;
• review their warfarin blood test results procedure for Fridays to ensure that it is in accordance with board guidelines; and
• ensure that where medical information is being communicated to a patient by a receptionist that it is on the instructions of a clinician.

Summary

Mr A, who had a history of type 1 diabetes, chronic kidney disease and who had had a leg amputated, was admitted to Dumfries and Galloway Royal Infirmary in November 2013. He was complaining of chest pain, a shortage of breath and had an ulcerated toe. After admission, Mr A continued to be unwell and a week later, he had a cardiac arrest and died. His sister (Mrs C) complained that board staff failed to do enough for him or to recognise that he was a very sick patient. She also complained about the way in which her formal complaint was subsequently handled.

We took independent advice from a consultant geriatrician with an accreditation in general medicine and from a senior nurse. We found that Mr A's condition was a complex one and that doctors had treated him reasonably in terms of his symptoms and there were no reasonable precautions that could have been taken which could have prevented his death with certainty. We also found that the nursing care given to Mr A had been reasonable, although we identified some failure and shortcomings in record-keeping. We did not uphold Mrs C's complaints about care and treatment. However, we found that Mrs C's complaint had been dealt with badly. It did not initially progress through the complaints process and was beset by delay and confusion. Even when the board identified that this had happened, Mrs C was sent an inadequate reply. For these reasons, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• remind the nursing staff involved in Mr A's care of their responsibility to keep appropriately detailed records;
• make a full apology for the delay and confusion in dealing with Mrs C's complaint; and
• ensure that they provide complaint responses that are thorough and appropriate.

Summary

Mrs C complained about the board's handling of a surgical procedure that was recommended by a surgeon at Borders General Hospital. Mrs C was dissatisfied with delays in the surgery going ahead because she had been in pain for a long time and had difficulty walking.

We took independent advice from an adviser who is a specialist surgeon. We found that there were appropriate medical reasons initially why Mrs C's surgical procedure could not go ahead. The board had acknowledged and apologised to Mrs C that the 12 week treatment time guarantee had not been met. However, we found that it was an unusual procedure where there were exceptional circumstances for this. It had come to the board's attention that the risks, complications and outcomes of the procedure to treat a nerve related condition had not been properly reviewed. Therefore, we concluded that there was good reason on patient safety grounds for a comprehensive review to be carried out and formally reported on before offering the surgical procedure to Mrs C.

Summary

Mr and Mrs C complained that a consultant obstetrician and gynaecologist at Borders General Hospital unreasonably decided that Mrs C should undergo a caesarean section. Mrs C had previously given birth to two children by caesarean section, but was keen to have her third child by vaginal birth. When her waters broke, she was told that medical staff would allow 48 hours for the labour to progress before carrying out a caesarean section. However, she then saw the consultant who said that there would be high risks in waiting for another 48 hours and that a vaginal birth was unlikely anyway. He said that Mrs C should have the caesarean section as soon as possible.

We took independent advice on Mr and Mrs C's complaints from a medical adviser who is also a consultant obstetrician and gynaecologist. We found that it had been reasonable for her consultant to hold the view that Mrs C should undergo a caesarean section at that time, even if this conflicted with advice she had received from other medical staff who had been prepared to allow her to wait slightly longer. We did not uphold this aspect of Mr and Mrs C's complaint.

Mr and Mrs C also complained that the consultant had not communicated with them in a reasonable manner. We found that there was evidence, including a statement from a midwife, that the consultant's communication with the couple had not been reasonable and had lacked empathy. The consultant had also failed to acknowledge where his advice differed from others and the reasons for this. Whilst we upheld the complaint, we were satisfied that the board had apologised to Mr and Mrs C. They had also stated that this had been raised with the consultant and that the complaint would be included in his annual appraisal.

Summary

Mr C complained about the care and treatment he received at Ayr Hospital's A&E department after injuring his foot several years ago. Mr C said that no fracture was detected at the time, however, when he was reviewed a short time later a fracture was found. Mr C sustained a similar injury a year later and said that a doctor had told him he would not have needed surgery had his foot been put in plaster at the time of the original injury.

We were unable to complete our investigation into Mr C's complaint and reach a decision because he did not respond to our efforts to contact him.

Summary

Ms C raised a number of concerns about the care and treatment her father (Mr A) received at Biggart Hospital. Mr A had been transferred from another hospital for rehabilitation after he suffered a fracture to his right upper arm after a fall.

We took independent advice on the case from a medical adviser and a nursing adviser.

The medical adviser considered that while communication between ward staff and the fracture clinic fell below a reasonable level, the board had acknowledged this and apologised. The medical adviser said the length of Mr A's stay at the hospital was reasonable, based on the injury he had suffered and his particular circumstances. The medical adviser considered the initial assessment of Mr A's chest fell below a reasonable standard because, although in their complaints response the board stated that this was to treat a chest infection, Mr A's medical records did not record why he was prescribed antibiotics and how this treatment would be reviewed.

The medical adviser and the nursing adviser both considered that further investigation and assessment should have been made when swelling to Mr A's leg was identified by nursing staff.

The advisers also said that Mr A had not been provided with a reasonable amount of physiotherapy treatment and there was a lack of provision of physiotherapy for Mr A on weekends and bank holidays. They also considered the amount of occupational therapy provided to Mr A was below a reasonable level. Although the board had apologised to Ms C that the level of support fell short of her expectations, the medical adviser was critical of the board's failure to acknowledge that a lack of staff time and workload commitments had impacted on the service Mr A received.

Recommendations

We recommended that the board:

• feed back the findings about Mr A's swollen leg to the staff involved, for reflection and learning, including reminding nurse practitioners to highlight abnormal clinical findings to medical staff;
• feed back the failures in relation to record-keeping to the staff involved, for reflection and learning;
• provide evidence of the review of physiotherapy staffing levels and provision of their services;
• consider and report on steps taken to address the failings in provision of occupational therapy identified by this investigation; and
• issue a general written apology to Ms C, acknowledging the failings identified in this investigation.

Summary

Mr C complained about a misdiagnosis of cancer. He said staff at Ninewells Hospital told him about three years ago that he had six to nine months to live, but then told him about a year ago that he did not have cancer. Mr C was concerned about the misdiagnosis, and that the board did not follow up to determine the correct diagnosis for his symptoms. Mr C also raised concerns about the board's handling of his complaint, as they had still not responded to him four months after he complained.

We asked the board when they would respond to his complaint, and they said they aimed to do so within three weeks. Mr C did not receive a response within this timeframe, and we began considering his complaint. However, the board then sent Mr C the final response from their investigation. We asked Mr C if he was satisfied with this response, or if he wished us to keep investigating. Mr C said he did not want us to keep investigating, and we closed our file on the complaint.

Summary

Mr C complained because he said the board failed to respond appropriately to his complaint about scheduled appointments with the pain clinic. In particular, Mr C said the board had responded to his complaint saying that there was nothing documented about planned appointments with the pain clinic. However, before receiving the board's response, Mr C said a nurse gave him a written note. The note showed that his medical record had been checked and noted that he was due to attend pain clinic appointments.

We made enquiries with the board but before finalising our investigation, Mr C was freed from prison. We tried contacting Mr C to confirm his new contact details but he did not respond to us. Therefore, we closed his complaint without reaching a finding.

Summary

Mr and Mrs C complained on behalf of their son (Mr A) about care he received on two visits to A&E at Gilbert Bain Hospital. Mr A attended the hospital and was diagnosed with a viral infection. He returned two days later and was again diagnosed with a continuing viral infection. A further three days later, Mr A became very unwell and was admitted to hospital. He was later transferred to a hospital in another board area and diagnosed with osteomyelitis (a bone infection caused by bacteria).

Mr and Mrs C complained that Mr A had not been reasonably assessed and treated. We took independent advice from an adviser in emergency medicine. They said that Mr A was given a thorough and appropriate examination on both occasions. The adviser said the symptoms were consistent with a viral infection and there were no symptoms which indicated further tests should have been carried out. The adviser also noted that osteomyelitis is a very rare condition and one not often seen in children Mr A's age.

Considering the advice we received, we did not uphold this complaint.

Summary

Mr C complained about the care his mother (Mrs A) received from the Scottish Ambulance Service (the ambulance service). Mrs A had a history of vertigo and migraine but she had been recently advised that she had symptoms of having suffered a transient ischaemic attack (TIA, often referred to as a mini-stroke, where blood supply to the brain is interrupted). Mrs A's GP had advised her to stop taking her migraine medication.

When Mrs A collapsed, her husband (Mr A) called for an ambulance. The crew arrived, assessed Mrs A's condition and decided against hospital admission. The crew believed Mrs A had suffered a migraine and advised her to take her medication, despite being informed her GP had told her to stop taking it. Six days after this Mrs A suffered a stroke. She died two days later.

Mr C complained about the ambulance service's decision not to transport Mrs A to hospital. We took independent advice from a medical adviser who is a GP. They said that there was enough evidence to give suspicion that Mrs A had suffered a further TIA and conclude that she required hospital assessment. The adviser also commented on the crew's advice to Mrs A to take her migraine medication. The adviser said this was unreasonable and outside the scope of their expertise. The adviser said that non-prescribers should not advise patients to take medication without medical advice, particularly medication recently stopped by the patient's own GP. We upheld the complaint and made recommendations.

We also identified problems with the way Mr C's complaint was handled. We were not given evidence that the recommendations made by the ambulance service during their own investigation had been carried out. We also noted that when Mr C raised new questions with the contact listed on the ambulance service's final response letter, that person declined to correspond on the complaint further. We did not believe this to be reasonable.

Recommendations

We recommended that the ambulance service:

• apologise to Mr C and his family for the failings identified in this letter;
• provide us with the outcome of their own recommendations;
• review the role of named contacts at the end of complaints letters; and
• remind non-prescribers of their role in advising patients on medication.