Health

Summary

Mr C complained about an ambulance crew that attended his wife (Mrs C). After Mrs C was taken to hospital, she was diagnosed with a ruptured abdominal aortic aneurysm (a weak point in a blood vessel), which was a life-threatening condition. Mr C said the crew did not diagnose his wife's condition or provide treatment for it, and did not regard the situation as an emergency. In addition, Mr C was unhappy with the ambulance service's response to his complaint.

We took independent advice from an adviser who is a consultant in emergency medicine. Although we would not expect the crew to make a definitive diagnosis of an abdominal aneurysm, we found that they should be able to recognise when a patient is seriously unwell. In this case, the crew assumed that Mrs C's symptoms were due to sciatica (back and leg pain caused by irritation or compression of the sciatic nerve) or muscular back pain, and they failed to recognise that she had a life-threatening condition. We upheld this part of Mr C's complaint. Once the crew decided to take Mrs C to hospital they gave her morphine. In this respect, they provided treatment to Mrs C and so we did not uphold this part of Mr C's complaint.

The crew did not use blue lights when taking Mrs C to hospital, which was reasonable as it was the early hours of the morning. However, doing this was another indication that the crew did not recognise Mrs C was seriously unwell, as was their discussion about leaving Mrs C at home for review by her local doctor. We upheld Mr C's complaint that the crew failed to regard the situation as an emergency. In addition, we had concerns about the accuracy of the ambulance service's response to Mr C, and we upheld this aspect of his complaint.

Recommendations

We recommended that the ambulance service:

• apologise to Mr C for the failings identified by our investigation;
• ensure that staff are aware of the signs and symptoms of leaking abdominal aortic aneurysms, including atypical presentations;
• ensure that staff are aware that normal vital signs do not exclude serious and life-threatening medical and surgical conditions;
• ensure that, when making a decision not to transport patients to hospital, their staff document detailed history and examination findings which confirm the diagnosis of a minor illness. Documentation in these circumstances should demonstrate that significant clinical findings, both positive and negative, have been interpreted within the context of the clinical history and inform the clinical outcome;
• ensure that, when making a decision not to transport a patient to hospital, their staff reference which alternative pathway route is being followed; and
• ensure that staff investigating complaints use appropriate reference material, such as clinical textbooks, when considering matters of clinical judgement.

Summary

Mr C complained about the care and treatment of his wife (Mrs C). Mr C was particularly concerned that the clinical notes showed Mrs C had symptoms of a stroke late on the evening of her admission to the Balfour Hospital (and doctors were told about this), but her stroke was not diagnosed until the doctor reviewed her early the next morning. Mr C was concerned that the delay meant that Mrs C was not able to receive thrombolysis treatment (a kind of treatment that can only be used within 4.5 hours after the onset of a stroke), and this may have impacted on her subsequent condition.

The board explained that thrombolysis treatment was not suitable for Mrs C, because it was not clear at the time that Mrs C's condition was due to an acute stroke and in any case the 4.5 hour window for treatment had already passed by the time of admission. The board also explained that doctors are cautious in offering thrombolysis to patients with diabetes (which Mrs C had) because there is a higher risk of complications, and because low blood sugars can sometimes 'mimic' the effect of a stroke.

After taking independent medical advice, we upheld Mr C's complaints. We agreed that thrombolysis would not have been suitable for Mrs C, because there was no clear time of onset for her stroke and by the time her symptoms were clear it was over 4.5 hours from when she was last known to be well. However, we found that staff should have considered the possibility of a stroke when Mrs C was admitted, and this should have been diagnosed that evening when the symptoms became clearer. This would have enabled staff to explain the decision about thrombolysis to Mr and Mrs C at the time, and put in place appropriate monitoring and assessment of her deterioration overnight, as well as better managing her diabetes the next day.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in diagnosing Mrs C's stroke; and
• ensure that staff involved reflect on Mrs C's care and discuss our findings, with reference to the specific points raised by the adviser.

Summary

Mr C's mother (Ms A) had ingrowing toenails. Following a house call from her GP, she was referred to the board's podiatry service for treatment. Mr C said Ms A was in pain and called the podiatry service. He was told the waiting time could be up to 12 weeks. He was not prepared to wait that long so he paid for the treatment to be done privately. When Mr C complained to the board about the length of time Ms A would have had to wait, the board explained that the GP referral had contained no indication that Ms A was in pain. Had it done so, she would have been seen sooner.

We sought independent advice from a hospital adviser. The adviser considered that, in the absence of any indication of urgency in the GP referral, it was reasonable that the podiatry service deemed the referral to be routine rather than urgent. We accepted the adviser's view and did not uphold the complaint.

Summary

Ms C was booked in at the Western General Hospital for a colonoscopy (examination of the bowel with a camera on a flexible tube). She phoned the board in advance to let them know that, as she required sedation for this procedure, she would need an overnight stay in hospital. However, when she attended, she was told that no beds were available and that she would either need to reschedule or have the procedure using gas and air. Ms C has a history of suffering serious pain during these procedures and her records noted that she would require sedation. As a result of her symptoms, the time since her last colonoscopy and her family history of bowel cancer, Ms C felt that she could not reschedule and agreed to go ahead with the procedure. She found the procedure very painful. Although she was asked a number of times during the procedure whether she would like them to stop, she agreed to it proceeding. She felt that the board had placed her in an impossible situation. She brought her complaint to us.

We considered the evidence available and noted that she had followed the board's guidance for those requiring sedation for colonoscopies. However, we also noted that there are times where procedures have to be cancelled due to a lack of beds. Ms C was advised, when she booked her overnight stay, that this could not be guaranteed and she was given the option of rescheduling. We acknowledged the distress this situation had caused her, but we found that the board's actions were reasonable under the circumstances. Therefore, we did not uphold her complaint.

Summary

Mr C complained that the prison health centre unreasonably failed to prescribe him with appropriate pain medication. We reviewed his clinical records and we took independent advice from a GP adviser. The information available confirmed that Mr C was caught concealing his medication and because of that, the decision was taken to stop his pain medication. However, he was prescribed an alternative and referred to the pain clinic. The adviser said the decision to stop his pain medication was reasonable given that Mr C was caught concealing his medication. The adviser also confirmed that, in their view, Mr C had been prescribed an appropriate alternative medication for his pain.

Mr C also complained that there was an unreasonable delay in the health centre removing an item from his ear. In their response to his complaint, the board said they checked Mr C's records and they could not see anything about him raising concerns about something being stuck in his ear. Following our review of Mr C's record, it appeared that the board's response was incorrect. We noted that a nurse had recorded in Mr C's clinical record that he had approached her about having something stuck in his ear. The nurse also recorded that she successfully removed the item the same day as Mr C reported it to her by flushing his ear. In light of this information, we did not uphold Mr C's complaint, but we did make a recommendation relating to the way the board responded to his complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to respond appropriately to his complaint.

Summary

Mrs C, an advocacy worker, submitted a complaint on behalf of her client (Ms A) regarding the care and treatment received by Ms A's late brother (Mr A) from his medical practice. Ms A complained about the time taken for the practice to diagnose her brother's cancer and about a failure to involve her in his care and listen to her concerns about his deteriorating condition. Mr A had a history of mental and physical health problems and had been diagnosed with renal cancer several months after being discharged from hospital, where he had been an in-patient for over 15 years. After being diagnosed with cancer, Mr A died the following month.

We took independent medical advice from a GP. The adviser did not consider that there were any unreasonable delays in investigating Mr A's symptoms and referring him to a hospital specialist. They noted that the practice took reasonable steps to try to have hospital investigations happen sooner and remained alert to the potential need for hospital admission. The adviser observed that Mr A had capacity and was entitled to decline investigation, as he did on occasion. However, they considered that the relevant investigations were carried out and that additional assessments, at the times these were declined, would not have changed Mr A's diagnosis or treatment plan. They also considered that, from the available evidence, Mr A's care appeared to have been appropriately discussed with Ms A and her concerns taken into account. We accepted the advice received and did not uphold the complaints.

Summary

Mrs C, an advocacy worker, submitted a complaint on behalf of Ms A regarding the care and treatment received by her late brother (Mr A). Mr A had a history of mental and physical health problems and was an in-patient in the Royal Edinburgh Hospital for more than 15 years. He was discharged into supported accommodation. Daily support was provided by a voluntary sector organisation and his psychiatric care was overseen by the board's community rehabilitation team (CRT). Mr A's physical health deteriorated following discharge and he was diagnosed with renal cancer around five months later. Mr A died the following month. Ms A complained about the time taken to diagnose her brother's cancer and about a failure to involve her in his care and listen to her concerns about his deteriorating condition.

We obtained independent advice from a mental health professional. They noted that the primary responsibility for monitoring Mr A's health following his discharge lay with his GP practice. However, they noted that the CRT had a role in liaising with the GP practice and monitoring Mr A's engagement with them. The adviser considered that the discharge plan lacked clarity surrounding these roles and responsibilities and lacked focus on Mr A's physical health, despite his history of physical health problems and known difficulties engaging with healthcare providers. The plan did not set out a schedule for visits from Mr A's key worker and the adviser observed that there were long gaps between visits, despite Mr A's carers contacting the CRT to raise concerns about his wellbeing.

The adviser also considered that the discharge plan should have set out strategies for involving Ms A in her brother's care and observed that the key worker did not contact Ms A directly until five months after discharge. In light of the advice received, we concluded that the CRT could have been more proactive in overseeing Mr A's care following discharge and in engaging with his family. Arrangements for doing so should have been set out in the discharge plan and we considered that closer monitoring of Mr A's physical health and evident deterioration might have resulted in medical assessments being requested earlier. We therefore upheld the complaints. We could not say that closer monitoring would have led to an earlier diagnosis or altered the outcome for Mr A but we noted that it could have allayed some of the family's distress. We obtained additional independent advice from a GP who noted that, when Mr A was referred for investigation of his deteriorating condition, he was thoroughly assessed and managed appropriately.

Recommendations

We recommended that the board:

• ask relevant staff to reflect on the failings highlighted in this investigation and advise us of identified actions to improve future discharge planning, with a specific focus on monitoring physical health and engaging with family/carers; and
• apologise to Ms A and her family for the identified failure to monitor Mr A more closely following his discharge from hospital.

Summary

Mr C and his father (Mr A) complained about the care and treatment provided to Mr A in relation to an operation to fit a pacemaker. They were unhappy about treatment Mr A received at the Royal Infirmary of Edinburgh when the pacemaker was fitted and said that there was inadequate information about possible complications of the surgery and incorrect treatment during the surgery. They also complained about the response and aftercare following surgery when Mr A reported his levels of pain and concerns. They said that as a result of the failures, Mr A's quality of life had been adversely affected and that he had to undergo another operation to repair the incorrectly positioned pacemaker.

We took independent advice from a medical adviser. We found that there was no evidence that sufficient information was given to Mr A about the procedure and possible complications or that staff took account of his additional needs (given his anxiety and loss of hearing). We also found that while there were problems with the pacemaker that had to be rectified, this does not mean that it was incorrectly implanted in the first place. Having said that, we were critical that staff failed to address Mr A's anxiety or ensure he was adequately sedated which may have contributed to an increased likelihood of lung puncture during the procedure. Moreover, while we found that clinical staff dealt with Mr A's concerns technically following the operation, staff failed to address his anxiety which may have exacerbated his symptoms. We therefore upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• review their procedures around consent and ensure that the process accommodates patients with additional needs;
• bring the failures related to consent and additional needs to the attention of relevant staff;
• bring the failures related to managing anxiety during the surgical procedure to the attention of relevant staff;
• ensure relevant staff consider referral to rehabilitation in similar circumstances; and
• apologise to Mr A for the failures this investigation identified.

Summary

Mr C complained on behalf of his daughter (Ms C) about the treatment that her mother (Mrs A) received at the Royal Infirmary of Edinburgh. Mrs A was admitted to A&E suffering with back pain, vomiting and palpitations. It was considered that she may have had a kidney infection with systematic septic response (a potentially life-threatening condition triggered by an infection). Mrs A was treated with antibiotics and fluids before being admitted to the acute medical unit where she was assessed. It was then decided to withhold the antibiotics until the source of the infection had been identified. Mrs A was admitted to a ward the following morning and test results showed that she was suffering from a urinary tract infection which was then treated. Mrs A's condition deteriorated and she had to be admitted to intensive care. As Mrs A's liver was failing, a transplant was organised. However, she remained very ill following this and later developed a perforation in her bowel. Mrs A died in hospital as a result of her illness.

Mr C asked us to investigate his concerns about Mrs A's treatment, particularly the prescription of antibiotics during the initial stages. Mr C was also concerned about record-keeping and communication with the family during Mrs A's time in hospital. After taking independent advice on this case from a consultant in general medicine, we upheld Mr C's complaint about medical treatment. We found that there had been a delay in the initial administration of antibiotics in the A&E department. Our adviser said that it would have been reasonable to continue to treat Mrs A with antibiotics while awaiting test results to determine the source of the infection. Our adviser found that the board had not followed their sepsis protocol as, in addition to the issues around administration of antibiotics, blood cultures were not taken until two days after Mrs A's admission to the hospital. We found that other aspects of Mrs A's treatment were reasonable. We did not uphold the second part of Mr C's complaint as we found no evidence that the communication with family members was unreasonable.

Recommendations

We recommended that the board:

• apologise to Mr C and Ms C for the failures identified in the initial management of Mrs A's condition;
• ensure that this case is included for discussion at the next appraisals of the doctors who made the antibiotic prescription decisions; and
• ensure that staff at the acute medical unit are reminded of the need to maintain accurate contemporary records.

Summary

Ms C complained on behalf of her son (Mr A) about the treatment he had received from his dentist. Mr A had x-rays taken of his teeth and an area of decay was identified in a tooth. The dentist considered that this required a filling and carried out the treatment at a later appointment. Mr A experienced some pain following the filling and returned to have this assessed on two occasions. He then continued his treatment at a different dental practice. Ms C complained to the dentist about the size and shape of the filling. She also questioned why no attempt had been made to protect the nerve before proceeding with the filling, and commented on attempts to treat Mr A's pain with the use of toothpaste for sensitive teeth.

In the response from the practice, the dentist advised that the tooth had been lined before it was filled and that at no time had the nerve been exposed. The dentist considered the size and shape of the filling to be reasonable and in proportion to the decay. As a goodwill gesture, a refund was offered for the cost of the NHS treatment Mr A had received.

After taking independent advice on this case from a dental adviser, we did not uphold Ms C's complaint. We found that the treatment that had been provided to Mr A represented reasonable practice. Our adviser agreed that the filling was of a reasonable size and shape. They also considered that steps had been taken to protect the nerve and that while toothpaste for sensitive teeth may have had minimal effect, it would not have worsened the situation.