Health

Summary

Mrs C's late husband (Mr C) was receiving treatment for prostate cancer. His condition deteriorated and Mrs C complained that GPs at the practice failed to take into account concerns that the medication to treat the cancer was the cause of the problems and that Mr C had a history of severe allergic reactions. Mrs C said that the GPs did not listen to her concerns and that Mr C rapidly deteriorated and died following a heart attack caused by an allergic reaction to the medication. She said that she and her husband were not warned about the possible side effects of the medication, and that staff failed to take reasonable action to resolve matters.

We took independent advice from one of our medical advisers. We found that the care and treatment provided to Mr C was reasonable, and that the practice took Mr C's symptoms into account and acted appropriately in addressing his concerns about his medication. We also found that Mr C had suffered an acute heart attack and there was no indication to suggest that this was imminent. As such, his condition could not have been anticipated.

Summary

Mr C complained about his treatment when he was admitted to Dumfries and Galloway Royal Infirmary for bowel surgery. He had been diagnosed with bowel cancer and underwent surgery to remove the right side of his colon. He became unwell following surgery, experiencing severe pain, and a scan three days later revealed a leak in the join in his bowel. He was taken back to theatre the same day for corrective surgery. He complained about the delay in diagnosing the complication arising from the initial surgery. He also raised concerns that the potential for this complication had not been explained to him in advance and that his wife was not informed of the severity of his condition prior to the corrective surgery.

We took independent clinical advice from a consultant colorectal surgeon who advised us that the risk of a leak was recorded on the consent form that Mr C had signed, thus suggesting that it had been discussed with him. It was our adviser's view, however, that the possibility of a leak should have been considered more closely and a scan arranged a day earlier. We, therefore, concluded that there was an avoidable delay in identifying the leak and carrying out the corrective surgery. Our adviser told us that earlier surgery would not have altered the clinical outcome, however, we noted that it would have minimised the distress caused to Mr C and his wife. We upheld the complaint. The board had already accepted that they should have given more information to Mr C's wife regarding his condition. They had apologised for this and discussed it with senior staff. However, they had not accepted that there was a delay in identifying the leak and we recommended that our findings in this regard be fed back to medical staff.

Recommendations

We recommended that the board:

• arrange for the learning from this decision to be discussed by medical staff at a relevant departmental meeting; and
• apologise to Mr C for failing to identify his post-surgical complication earlier.

Summary

Miss C, an advocacy worker, complained on behalf of Mr and Mrs A about the care and treatment their late daughter (Miss A) received during an admission to Dumfries and Galloway Royal Infirmary. Miss A, who was severely disabled, was admitted with breathing and swallowing difficulties, but she became increasingly unwell and died two weeks later. Mr and Mrs A complained about various aspects of her medical and nursing care. They also complained that staff failed to reasonably communicate with them, and they raised concerns about the way in which the board handled their complaint.

We took independent advice from a nursing adviser and one of our medical advisers, who is a consultant physician. We were advised that a reasonable standard of medical care was provided to Miss A and that her death could not have been prevented. We, therefore, did not uphold this aspect of the complaint. However, we noted that one of the recorded causes of death was not appropriate, which the board had already acknowledged, and we asked them to bring this to the attention of the relevant member of staff. We considered that most of the nursing care provided to Miss A was also of a reasonable standard, but we identified a failure in respect of her bowel management. Miss A required her bowels to be manually evacuated and this task unreasonably continued to fall to Mr and Mrs A during her admission. The board's manual evacuation, or digital removal of faeces (DRF), policy was not fit for purpose and staff failed to seek specialist advice to allow them to carry out this task. We upheld this aspect of the complaint.

We also found deficiencies in the recorded level of communication between staff and Mr and Mrs A. In particular, we noted that medical staff did not have a sensitive discussion with them regarding the fact that Miss A was approaching the end of her life. This lack of discussion regarding the severity of the situation left them to attribute the deterioration of her health to a lack of appropriate care and thus added to their distress. We upheld this aspect of the complaint. We also upheld the complaint regarding the way in which the board handled Mr and Mrs A's complaint to them. They unreasonably delayed in responding and, having met with Mr and Mrs A, they failed to follow this up with a full response showing that all the issues raised had been fully investigated.

Recommendations

We recommended that the board:

• bring this decision to the attention of the member of staff who certified Miss A's death in order that they can learn from the identified discrepancy;
• review their policy for manual evacuation/DRF, taking account of any appropriate national guidance in this area;
• bring this case to the attention of relevant staff with a view to improving future communication with patients and their families/carers, particularly around end-of-life care;
• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the Can I Help You? guidance; and
• apologise to Mr and Mrs A for the failings this investigation has highlighted.

Summary

Mrs C complained on behalf of her husband (Mr C). She said that after he was referred to hospital for knee problems, the board failed to provide Mr C with appropriate treatment. She said that it must have been obvious following the results of an x-ray, taken a few months later, that an arthroscopy (a minimally-invasive surgical procedure to examine, and sometimes treat, joint damage) would not solve Mr C's problems, and that he required a total knee replacement. Nevertheless, an arthroscopy was carried out. Mrs C said that her husband continued to experience unacceptable levels of pain and was told to return to his GP to be referred back to hospital. It was later decided that he required a total knee replacement. Mrs C said that it was unreasonable to require her husband to go back to the bottom of the waiting list.

We took independent advice from a consultant in orthopaedic and trauma surgery and found that, at the time of Mr C's x-ray, his knee did not require replacement. In the circumstances, it was reasonable to first undertake the alternative, conservative treatment of an arthroscopy, even though a successful outcome was not guaranteed (and this was explained to him). Some time later, after his knee was shown to have deteriorated, his GP referred him back to hospital for consideration. At that point, Mr C was recommended to have a total knee replacement and, in accordance with policy and practice, he was required to join a waiting list for his operation. In these circumstances, the complaint was not upheld.

Summary

Mrs C complained to the board about how her elderly aunt (Miss A) had been cared for in University Hospital Ayr. Mrs C complained to us that Miss A was not given a bed with rails, that hospital staff did not monitor Miss A's movements, and that they did not respond in a reasonable time to Miss A falling in her ward. Miss A died shortly after the fall. Mrs C also complained about the delay in the board investigating and responding to her complaint.

We looked at the board's file on Mrs C's complaint and at Miss A's medical records. We also took independent advice from two of our advisers, one specialising in nursing, the other in general medicine. We found that when Miss A was admitted to hospital, an assessment was made that she needed bedrails. However, on the night Miss A fell, the bedrails on one side of her bed were not in use, apparently at her request. This change was not recorded by hospital staff, and is significant because they should, when making decisions like lowering the bedrails, have borne in mind that Miss A had delirium.

We found that staff failed to follow a procedure, called the bedrails algorithm, for dealing with the lowering of bedrails, which meant that Miss A was not supervised at the time she fell. Without bedrails, an alternative should have been put in place, such as close monitoring, to compensate for the lowering of the bedrails on one side. We concluded that staff did not take sufficient account of Miss A's delirium and risk of falls in providing care to her. We upheld these aspects of Mrs C's complaint. However, we did not find evidence that staff failed to respond immediately when Miss A fell.

We found, and the board acknowledged, that there was a significant delay in responding to Mrs C's complaint. We also found that updates to Mrs C were not in line with the national NHS complaints guidance. We upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• remind relevant nursing staff of the bedrails algorithm;
• provide us with details of the actions taken to ensure there has been learning from this complaint; and
• remind all staff involved in dealing with Mrs C's complaint of the national NHS complaints guidance, and of the importance of updating complainants in reasonable time.

Summary

Mr C complained about the medical treatment and nursing care that his late wife (Mrs C) had received from the board at University Hospital Crosshouse and University Hospital Ayr. Mrs C as admitted to Crosshouse Hospital four times in seven months, as well as being seen at the accident and emergency department on another occasion. She was initially diagnosed with both chest and urinary tract infections. Later, delirium became a significant issue for Mrs C. She was transferred to University Hospital Ayr so that her urology (concerned with the urinary system) symptoms could be investigated. She was discharged when this was completed but was readmitted to Crosshouse Hospital a short time later.

In relation to the medical treatment that Mrs C received, we took independent advice from a consultant physician. We found that the majority of the care that Mrs A had received at Crosshouse Hospital was reasonable. However, the adviser noted some concerns about the way that Mrs C's delirium had been managed, as changes that had been made to her medication could potentially have affected this. The adviser also highlighted concerns about the level of discharge planning that had taken place. On balance, we found that there was enough evidence to uphold Mr C's complaint about the treatment that his wife received at Crosshouse Hospital. The advice stated that the treatment provided at Ayr Hospital was reasonable. There were some concerns about the level of discharge planning that had taken place but, on balance, we did not uphold this part of Mr C's complaint.

After taking independent advice from a nursing adviser, we did not uphold either of Mr C's complaints about the standard of nursing care provided at Crosshouse or Ayr hospitals. We found that the care Mrs C had received was reasonable.

Recommendations

We recommended that the board:

• review how patients with delirium are managed in light of the adviser's comments;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Crosshouse;
• ensure that effective discharge planning is taking place on the relevant ward at University Hospital Ayr;
• apologise for the failings identified by this investigation.

Summary

Mrs C complained about the mental health care and treatment that her child had received. Mrs C considered that her concerns about autistic spectrum disorders and physical factors had not been taken into account by the board. She was also concerned that her child was not seen soon enough and was not assessed by appropriate staff. While recognising the complexity and severity of her child's condition, the board did not find evidence to support Mrs C's concerns during their consideration of her complaint.

After taking independent advice from a psychiatric adviser specialising in child and adolescent mental health, we found that the actions taken by the board were reasonable. There was no evidence that there had been unreasonable delays in the assessment of Mrs C's child, or that the care and treatment provided was inappropriate. The adviser highlighted that the board’s liaison with another service was good and found nothing to suggest that the child had been misdiagnosed.

Summary

Mrs C, who is an advice worker, complained on behalf of Mr A about the care and treatment he received from the medical practice. Mrs C said Mr A, who has cerebral palsy, was seen by doctors at the practice for a year with sharp abdominal pains but the practice failed to diagnose that Mr A had a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall). Mrs C also complained that one of the doctors at the practice failed to carry out a physical examination of Mr A at one of the appointments.

We obtained independent medical advice from one of our GP advisers. They said that they could see no evidence in Mr A’s medical records that he had either the symptoms or signs of a hernia during the 12 months that he was seen by the practice, and that the hernia identified at the end of the 12 months was most likely a new presentation. We found that Mr A was provided with a reasonable standard of care by the practice.

Our adviser also explained that there was no requirement for a patient to be examined for a chronic condition every time they attended a GP practice and that if a patient presented with new symptoms or a significant change, then an examination would be reasonable. When Mr A was seen by the doctor, he did not present with any new symptoms, and as he had been seen 24 hours previously by a senior surgical doctor at Perth Royal Infirmary for an examination, we did not consider it unreasonable that the doctor did not physically examine Mr A. We did not uphold Mrs C's complaints.

Summary

Mr C complained that when he called the out-of-hours (OOH) service, the first GP he spoke to did not provide proper care or treatment. Mr C said the GP had been unable to access his medical records and had refused to admit him to hospital, offering an appointment at the OOH centre, which Mr C could not attend because of the level of pain he was suffering. When Mr C had called the OOH service the following morning, a second GP arranged for an ambulance to take him to hospital, where his knee was then treated. Mr C said the second GP had told him that the first GP would have been able to access his medical records and that hospital admission was the only appropriate treatment for his knee.

We took independent advice from one of our GP advisers. They said that Mr C did not constitute an emergency case, and that the first GP had acted appropriately by not admitting him to hospital. The second GP had not followed procedure in arranging Mr C's admission for treatment which meant that Mr C had an unreasonable expectation of what the first GP should have done. We found that the first GP had acted reasonably and in line with the board's policies in the care and treatment he had provided. Therefore, we did not uphold Mr C's complaint.

Summary

Mr C complained that there was a delay in his GP practice diagnosing him with skin cancer. He also said that they did not take his concerns seriously and that there was a delay in him receiving medication for nerve damage.

We took independent advice from one of our medical advisers who is a GP and found that the GP practice provided Mr C with a reasonable standard of treatment, making referrals to hospital specialists based on his symptoms. Whilst we were critical that Mr C could have been referred to a dermatology specialist sooner, this was not a significant delay. Furthermore, we did not consider it had any material impact on the time it would have taken for him to be seen. In addition, there was evidence to show that reasonable attempts were made by the GP practice to communicate with Mr C following his surgery. Although the GP practice apologised for the delay in giving Mr C his medication, we found that they were not entirely at fault. However, we upheld Mr C's complaint that the GP practice did not provide him with appropriate explanations about the reasons for the delay in prescribing his medication.