Health

Summary

Ms C was referred by her GP for her painful right ankle to be reviewed. She complained that she experienced an undue delay in receiving appropriate treatment.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that Ms C's first appointment for treatment with a foot surgeon was just over 39 weeks after her referral. This was longer than the board's waiting time policy. However, in the meantime, Ms C had been sent on a different treatment pathway by being referred to a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb), a consultant orthopaedic surgeon and then finally a foot surgeon. She had also refused appointment times that had been offered and had been quite specific about where she would receive treatment. This all affected her waiting time.

We took the view that it would have been more appropriate, given the terms of her referral, for Ms C to have been referred directly to a foot surgeon and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the overall delay in providing a date for surgery; and
• bring the complaint to the attention of those staff who assess referrals of this type for them to reflect on the advice given.

Summary

Mr C complained that he had not received appropriate care following an operation on his urinary tract. He said that because the consultant had not examined him appropriately at a post-operative consultation, the consultant did not realise that Mr C's condition had deteriorated. Mr C said that meant that he was in significant discomfort until a further consultation six months later, when the problem was identified and he underwent a further operation. He was then taught a technique for self-help which aimed to support the work of the operation, to avoid a further recurrence. Mr C complained that the board had not referred him for this self-help technique after his first operation.

We sought independent advice from a urology consultant. Our adviser noted that there was limited information on file about what happened at the post-operative consultation, but that given the concerns expressed by Mr C (and referred to in the records) it would have been reasonable for the consultant to have examined Mr C in more detail, and undertaken various tests to identify how his condition had changed. Our adviser was critical of this, and of the limited information in the notes from the consultation. However, our adviser also noted that while some consultants may sometimes refer patients to the self-help technique after a first operation, it was reasonable that Mr C was not taught this until after his second operation.

We were critical of the level of follow-up Mr C was given following his first operation, particularly given the concerns he raised during his consultation. We noted that, while the clinical notes provided limited information about what was discussed, we were satisfied that Mr C raised concerns which were not sufficiently investigated. We were also critical of the level of record-keeping.

Recommendations

We recommended that the board:

• highlight the findings of this investigation to the consultant involved, and remind him of the General Medical Council's requirements in relation to record-keeping; and
• apologise to Mr C for failing to provide an appropriate level of treatment during his first post-operative consultation.

Summary

Ms C complained that she had not been provided with the appropriate post-operative treatment following a bunion operation in 2011. She had had a second procedure in 2014. This, however, had left her with nerve damage and requiring a brace on her foot to walk. Ms C said she had not been properly assessed for surgery in 2014 and that the appropriate treatment had not been carried out.

We took independent advice from a surgeon who specialised in operations on the foot and ankle. The advice we received was that Ms C's operations had been carried out properly and that she had received appropriate care and support after both operations. The risks had been explained to her before the operation, including the risk that the operation would make Ms C's foot condition worse. Our investigation found the evidence showed Ms C had been appropriately assessed for surgery and that the operation carried out was the appropriate treatment.

Summary

Mr C and Miss A complained about the care and treatment Miss A received during her antenatal period. In particular, they were concerned that their baby had been born at home rather than in hospital as planned. They complained that the responsibility for the birth of their baby occurring at home lay with the board and that the board had failed to stay in control of the birth. They were also concerned about the advice given when they contacted the Maternity Assessment Unit (MAU) at the Princess Royal Maternity Hospital (the hospital) just hours before the birth of their son. Miss A and Mr C also complained about the board's handling of their complaint.

We took independent medical advice from one of our advisers, a consultant obstetrician. We found that the care and treatment given to Miss A during her antenatal period was reasonable and appropriate and that appropriate observations were made at each antenatal clinic attendance which had occured at appropriate intervals. We also found that the advice given by the midwife when they contacted the MAU at the hospital was acceptable and appropriate.

When responding to their complaint, we found that the board had accepted that Miss A and Mr C had experienced poor communication during the antenatal period and following the birth of their baby. The advice we received was that the board had also provided a reasonable and appropriate response to the issues raised by Miss A and Mr C. The board explained that the concerns about communication had been discussed with staff. While we recognised that the board had already apologised to Miss A and Mr C, we made one recommendation.

Recommendations

We recommended that the board:

• provide details on the action taken in this case to ensure improved communication with patients and their families.

Summary

Mr C complained that the GPs at the practice had failed to provide adequate care to his wife (Mrs C) resulting in the late diagnosis of her pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mr C said that this late diagnosis had led to subsequent serious health problems for Mrs C. He said she had repeatedly attended the practice with symptoms consistent with a pulmonary embolism, but that GPs had failed to refer her for the appropriate investigations. He added that on one occasion his wife had been asked to contact a hospital by herself, despite a dangerously elevated heart rate.

We obtained independent advice from an adviser on general practice medicine. They found that Mrs C was appropriately investigated initially. The advice also said that Mrs C's symptoms were non-specific and appeared to resolve for extended periods following treatment, so it was reasonable of the practice to have adopted a policy of watchful waiting. The advice noted that Mrs C's incidents of elevated heart rate were in fact in keeping with the monitored limits as defined by her pacemaker clinic and that it was, therefore, appropriate for her not to be referred as an emergency on that occasion.

We found that although Mr C had repeatedly referred to alternative medical opinion having been provided which supported his complaint, no attributed submissions were contained within his complaint. We found the actions of the practice were reasonable and appropriate, although we acknowledged the experience had been distressing for Mr C and his family.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mr B) about the care and treatment given to his late sister (Miss A). After a hysterectomy in February 2013, Miss A was diagnosed as having endometrial cancer (cancer in the lining of the womb) from which she made a good recovery. However, in May 2014, her GP referred her urgently back to hospital as she was suffering from nausea. She was seen shortly afterwards and it was considered that her symptoms related to her recent cancer treatment and the drugs she required to take. Miss A then began to complain of pains in her hip and was referred for a CT scan (which uses x-rays and a computer to create detailed images of the inside of the body). The scan results showed that Miss A had a recurrence of cancer and that it was inoperable. Miss A died in November 2014.

Mr B complained that after her initial cancer treatment in February 2013, the board failed to provide his sister with adequate follow-up. He also said that following Miss A's terminal diagnosis in August 2014, she was not given adequate palliative care.

We took independent advice from a consultant gynaecologist. This showed that after Miss A was first diagnosed with endometrial cancer, her case was discussed by a multi-disciplinary team and on their recommendation, she was given radiotherapy and a number of cycles of chemotherapy. She also attended out-patient clinic appointments in April and November 2013 and then again in April 2014. There was also evidence to show that once she was given a terminal diagnosis, palliative care was instituted for Miss A and Macmillan nurses became involved. She was given pain relief and other medication to reduce her symptoms, but the advice we received was that the extent of Miss A's illness was such that her death could not have been prevented. We did not uphold the complaint.

Summary

Mr C's father (Mr A) had a complex medical history and was admitted to Aberdeen Royal Infirmary with a suspected heart attack, which was believed to have been caused by an infection in his leg. Surgery to amputate his leg below the knee was delayed to minimise post-operative risks, but carried out two months later. A few weeks after surgery, Mr A's health began to deteriorate, but there was a delay in admitting him to the intensive care unit and he died of a cardiac arrest. Mr C complained that staff failed to provide a reasonable standard of medical and nursing care and treatment, and that there was a failure to admit Mr A to the intensive care unit within a reasonable time. Mr C also complained about the length of time it took the board to respond fully to his complaint.

We took independent advice from a nursing adviser and an adviser who is a specialist in end-of-life care. We found that the medical and nursing treatment provided was reasonable and that there was relatively prompt recognition of Mr A's problems. However, we also found that the delay in admitting Mr A to the intensive care unit was unacceptable. We found that, while it may not have altered the outcome for Mr A, an earlier admittance would have improved his chances of survival. Also, while the board's investigation of the complaint was thorough and comprehensive, the delay in responding was unreasonable, as it caused further distress to Mr C and his family at a difficult time.

Recommendations

We recommended that the board:

• ensure the action plan is implemented in full;
• review their processes to ensure that investigations into complex complaints are completed within a reasonable time and that complainants are regularly updated and told of their right to contact us; and
• apologise for the failures in complaints handling this investigation identified.

Summary

Mr C complained that the prison health centre's handling of his pain medication was unreasonable. He had been prescribed a medicated patch for nerve pain for a trial period of one month. Mr C said that the doctor did not review his treatment throughout the trial period or when the prescription ended. Because of that, he said he was left in pain.

The information available confirmed that Mr C did not raise any concerns with healthcare staff about pain whilst receiving the treatment or after the treatment ended. We took independent advice from one of our GP advisers who noted that Mr C's mental health at the time the medication was being trialled was unstable and he did have episodes of self harm which involved him creating more damage to his wound. Because of that, our adviser considered that a routine review of Mr C's treatment for pain was not feasible at that time, and management of his acute and unpredictable mental health was the priority. In addition, our adviser noted that it was not practicable or common practice for doctors to contact patients routinely to enquire whether their prescribed medication was sufficient. Therefore, we did not uphold Mr C's complaint.

Mr C also complained that the board failed to respond appropriately to his complaint but we did not agree.

Summary

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mrs B). Mrs B's mother (Mrs A) had been admitted to Forth Valley Royal Hospital with swallowing difficulties, and there was a problem when a nurse was performing an endoscopy (a procedure where a tube-like instrument is put into the body to look inside). A consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) was called to continue the procedure and Mrs A's oesophagus was perforated, which meant the procedure had to be cancelled. Mrs A was transferred to the intensive care unit (ICU) and Mrs B complained that Mrs A suffered problems with her catheter, blockages of her NJ tube (nasojejunal tube - a small tube that is passed through the nose and into the small intestine), inappropriate management of her chest drain, and poor communication from staff.

The board maintained that the perforation of the oesophagus was a rare but recognised complication of an endoscopy procedure and that Mrs A was transferred to ICU for close monitoring. They said Mrs A had received appropriate care and treatment, and that it was appropriate for the catheter to have been fitted. They said the blockages in the NJ tube were addressed in a timely manner, and explained that staff dealt appropriately with problems of fluid build-up by managing chest drains correctly.

After taking independent advice from a gastroenterologist adviser and a nursing adviser, we did not uphold the complaint about the care and treatment which Mrs A received. We found that Mrs A had suffered a recognised complication of an endoscopy procedure which was not caused by failings by the staff involved. We were also satisfied that the staff provided Mrs A with appropriate care and treatment in relation to the problems with her catheter, NJ tube and chest drain management. However, we did find that, although communication from the staff to the family was generally good, there was a four-day period after Mrs A's transfer to ICU when senior staff did not provide her family with an update.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings in communication from ICU staff;
• take steps to ensure the relevant staff are made aware of the importance of communication with relatives, in line with General Medical Council guidance; and
• remind staff who compile draft complaint response letters to ensure that all relevant issues are included.

Summary

Mrs C complained to us on behalf of her husband (Mr C), following surgery he had at Victoria Hospital. Mr C was given morphine for post-operative pain, administered through a Patient Controlled Analgesia device (PCA - a special syringe allowing pain relief on demand). Over the subsequent 18 hours Mr C administered his own morphine, within limited doses, via the PCA. Nursing staff contacted the Hospital at Night team when they were concerned about the amount of morphine he had received, but he was not seen by a doctor until ward rounds the next morning. Concern over his pain relief led to a referral to the pain team. Mr C was seen by a pain nurse, who stopped his PCA and prescribed alternative, morphine based pain relief. Three hours after his PCA was stopped Mr C started to show clear signs of opiate toxicity (overdose). A doctor was called and he was given medication to reverse the overdose.

We sought independent advice from nursing, anaesthetic and general medical advisers. The nursing adviser was satisfied that nursing staff had appropriately monitored Mr C's condition. The anaesthetic adviser noted that Mr C had shown signs of mild opiate toxicity before his overdose, and that a review by an anaesthetist should have been requested either at those times or when he was seen by the pain nurse. The general medical adviser agreed with this assessment.

The signs of opiate toxicity which Mr C displayed in the hours after his surgery were short-lived, and his observations on charts remained reasonable. While nursing staff monitored him appropriately, and it was reasonable to refer him to the pain team, we decided he should have been reviewed by an anaesthetist to identify whether alternative medication was more appropriate. We found that this could have eliminated the risk of an overdose. We upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• discuss this case in an appropriate multi-disciplinary setting, to identify alterations to current procedures to assist staff in identifying when they should seek an anaesthetic review; and
• apologise to Mr and Mrs C for the failings identified and the distress caused as a result.