Health

Summary

Mr C was concerned about the care and treatment given to his son (Mr A) by the University Hospital Crosshouse immediately before his death. Mr A had recently been diagnosed with terminal and inoperable cancer. He was told that his time was short. He was admitted to the hospital as an emergency with increasing pain and sickness but he died a few days later. Mr C complained to us that he had not been told how advanced his son's illness was; that his son had no treatment plan; that his son was treated without dignity or privacy; staff were inflexible about visiting times; and that communication was poor.

We took independent advice from a consultant clinical oncologist and from a nurse practitioner. We found that while Mr A's medical care and treatment had been reasonable, there had been poor communication by staff. Mr C should have been informed that Mr A was extremely ill and had very little time. We also found that while arrangements were confirmed with Mr C that he and his wife were able to visit on a more flexible basis, this instruction was not passed to all staff involved. In light of this, we upheld two of Mr C's complaints.

Recommendations

We recommended that the board:

• make a formal apology for their communication shortcomings;
• remind the medical team involved in Mr A's care and treatment of their obligations to keep families and carers informed particularly at the end of life; and
• confirm to us that they are satisfied that such an occurrence would not occur again.

Summary

Mrs C was concerned at the care and treatment given to her late mother (Mrs A) while she was a patient at University Hospital Ayr.

Mrs A had a history of heart problems and breathing difficulties and had not been eating. She had been vomiting for three weeks. She was admitted to hospital but her condition quickly deteriorated and she died a few days later. Mrs C believed that without her knowledge, her mother been placed on the Liverpool Care Pathway (LCP - an end of life care planning system for dying patients); that she was given too much fluid and that although diuretic treatment (medication to promote water loss from the body via the kidneys) was prescribed, it was not given. Despite complaining at the time, Mrs C said that action was not taken and as a consequence, Mrs A died. Mrs C also said that after she complained, she was told that her mother had been very seriously ill on arrival, however, she complained that she had not been given this information at the time.

We took independent advice from a consultant geriatrician and from a nurse practitioner. We established that Mrs A had not been placed on the LCP but we found a number of shortcomings with Mrs A's care and treatment: her medical and nursing records were not as complete as they should have been; there were failures in communication and staff did not properly engage with Mrs A and her family; medication was not administered and staff did not appear to have been alert to Mrs A's deteriorating condition. For all these reasons, we upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology for the clinical shortcomings identified;
• remind clinical staff involved in this case of their professional obligation to complete proper and detailed clinical notes;
• remind clinical staff involved in this case to communicate appropriately and in a timely manner with the patient and their family;
• ensure Mrs A's consultant considers this case as part of his next annual appraisal;
• make a formal apology for the nursing shortcomings identified;
• remind nursing staff of their professional obligation in so far as maintaining correct records in concerned;
• remind nursing staff of their professional obligation to communicate with family members; and
• reflect on the way the complaint was handled, particularly given its serious and significant nature, to prevent similar situations arising in the future.

Summary

Mr C complained that the GP who examined his late father (Mr A) at a consultation had not provided a reasonable standard of care and treatment.  When Mr C visited Mr A later the same day, he was distressed by his father’s condition and called an ambulance.  When Mr A was admitted to hospital he was found to be dehydrated, with a chest infection.  He died four days later from aspiration pneumonia (caused by a poor swallowing mechanism whereby foreign matter enters the lungs).  Mr C also complained that his father’s medication had been unreasonably increased, despite previous knowledge that an increased dose previously reduced Mr A's appetite and he would therefore lose weight.

We took independent advice from a GP adviser.  They found the increase in the medication dosage to have been reasonable.  However, they noted that there was not a documented consultation for the day Mr A was admitted to hospital.  The adviser said this was not in line with General Medical Council (GMC) guidance.

On balance, we upheld the complaint as the practice were unable to demonstrate they had provided a reasonable standard of care and treatment.  We also noted they had failed to refer Mr C to us at the end of their complaints investigation.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings identified in our investigation;
• remind relevant staff of the importance of completing accurate documentation in line with the GMC guidance;
• ensure future complainants are referred to us at the end of the complaint response letter; and
• confirm the GP concerned will discuss this case at their next appraisal.

Summary

Mr C complained about a GP during a home visit deciding not to refer his wife (Mrs C) to hospital. Mr C was particularly concerned that Mrs C had been treated with steroids during a recent hospital admission for a chest infection, and this was likely to affect her diabetes.

The GP said that, during the home visit, they considered Mrs C was suffering from diabetes and a flare-up of her chronic obstructive pulmonary disease (COPD - a disease of the lungs in which the airways become narrowed). However, they said there was no evidence of a chest infection. The GP said the steroid treatment was important for Mrs C’s COPD (although it had a negative impact on her diabetes control) and they encouraged Mr C to continue this treatment. The GP considered their actions were appropriate.

After taking independent medical advice from a GP adviser, we upheld Mr C’s complaint. In relation to Mr C’s concerns about the steroid treatment, we found that the GP acted appropriately by advising Mr C to continue this (as the benefit to Mrs C’s COPD outweighed the impact on her diabetes). However, the adviser explained that Mrs C had lower oxygen saturation levels than when tested 11 days earlier, and the GP should have arranged further investigation of this (which would usually be done in a hospital setting).

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings our investigation found;
• ensure that the GP familiarises themself with the National Institute for Health and Care Excellence (NICE) guideline on COPD, in particular in relation to the assessment of oxygen saturation; and
• ensure that the GP reflects on the findings of our investigation at their next annual appraisal.

Summary

Mr C's daughter (Ms A) was admitted to Ninewells Hospital three times with severe abdominal pain and swelling accompanied by nausea. Investigations and tests were negative. Mr C complained that Ms A was discharged from hospital unreasonably, and that doctors failed to reach a diagnosis, which led to a great deal of anxiety for Ms A and her family. As a result, Mr C said that Ms A’s health deteriorated.

We took independent advice from a medical adviser who is a specialist in gastroenterology (medicine of the digestive system and its disorders). We found that the board properly investigated Ms A's symptoms, and that the decision to discharge her on each occasion was reasonable because no abnormalities were found. The adviser said that a diagnosis had been reached by doctors. However, we found that this was not clearly relayed to Ms A so we understood Mr C's position that doctors had failed to reach a diagnosis. We therefore made a recommendation to put this right.

Recommendations

We recommended that the board:

• bring the adviser’s comments about functional disorders to the attention of relevant staff; and
• offer to meet with Ms A to fully explain the reasons for the referral to a chronic pain team.

Summary

Ms C, an advice worker, complained on behalf of Miss A, who had had surgery to her jaw at Ninewells Hospital. Following this surgery, Miss A had been diagnosed with a serious injury to her neck, which had required a second operation to correct. Ms C suggested that the first operation had been inappropriate and that Miss A's injury had taken too long to diagnose.

We received independent advice from a consultant maxillofacial (mouth, jaws, face and neck) surgeon and a consultant orthopaedic (concerning the musculoskeletal system) surgeon. The advice said that the injury was extremely rare and that it was not clear when the injury had occurred, although it was highly probable that it occurred during the operation. There were no signs before the surgery that Miss A was at risk of suffering this type of injury and the operation was the appropriate one for her condition. The advice said that the time taken to diagnose the injury was reasonable in the circumstances.

We found that Miss A had suffered a very rare complication. Although this was highly unfortunate and understandably traumatic, it did not mean that the treatment she had received was unreasonable.

Summary

Mrs C and her husband were participants in an egg-sharing programme (as donor) in the Assisted Conception Unit at Ninewells Hospital. As part of the programme, after fertility treatment, Mrs C retained some of her eggs and some were donated to a recipient. Mrs C complained that the care and treatment given to her was unreasonable, and that staff were primarily concerned with the recipient. She said that communication with the staff was also unacceptable, and that she was given information despite saying that she did not want it. She believed she had been looked down upon.

We obtained independent advice from a consultant obstetrician and gynaecologist (a doctor specialising in pregnancy, childbirth and the female genital tract) who was a reproductive medicine specialist. We found that all of Mrs C's treatment had been conducted in terms of the Human Fertilisation and Embryology Act code of practice. While there had been a slight delay in providing part of the treatment, this had been because the recipient's and Mrs C's menstrual cycles had to be synchronised. The delay was unavoidable. Similarly, the code of practice had been followed with regard to communication with Mrs C, but it seemed that she had not fully understood. We noted that the board had since made changes to prevent a similar occurrence. Mrs C's complaint was not upheld.

Recommendations

We recommended that the board:

• apologise for the delay in responding to the formal complaint.

Summary

Mrs C complained to us on behalf of Mrs A, in relation to an incident of potential contamination due to the use of unclean equipment. Mrs A attended Dundee Dental Hospital for treatment, and during the course of her treatment a microscope was put close to her mouth. She could see dirty marks on the microscope which looked like dried blood. After her treatment she raised concerns with staff. One nurse immediately wiped the microscope. Mrs A said that she was told it would be sent for analysis. Later that day staff contacted Mrs A to provide further information and advice.

Following Mrs A’s complaint to the board, they took further steps to investigate the situation, and identified failures in the board’s cleaning protocols, which were rectified.

We took independent advice from one of our nursing advisers, which indicated that, while it was not appropriate for dirty equipment to be in use, the board had identified gaps in their protocols and had made appropriate changes. She also considered that the information and advice provided to Mrs A and her husband were reasonable. The adviser was also satisfied that appropriate action was taken in cleaning the equipment, and did not express concerns that the wipe used to clean it had not been analysed.

We concluded that Mrs A was understandably upset by what had happened. However, we found that it had been appropriate to clean the equipment as soon as possible, and not taking a sample for analysis was in line with national policy. We also considered that the information and advice Mrs A was given were appropriate. We found that the board’s response to the complaints made and the action taken were reasonable.

Summary

Mr C complained about the way in which his pain relief medication was handled by the prison health centre. Mr C has osteoporosis (a condition causing weakness of the bones) and had been prescribed tramadol (a strong opioid painkiller). He was unhappy that there was little discussion or information about why it was being stopped. He was also unhappy that the board failed to provide relevant information in their response to his complaint.

We took independent advice from a medical adviser who is a GP. We found that, when reviewing Mr C's medication, the health centre acted in line with Scottish national guidelines on the management of chronic pain and on prescribing. Tramadol was not the only type of painkiller that could be used to treat Mr C's pain, and there is a lack of evidence for the long-term use of opioids for chronic pain. We considered it reasonable that the health centre tried alternative painkillers on the basis that further review took place.

We concluded that reasonable attempts were made by the health centre, and in the board's complaint response, to explain why the medication was being reduced and then stopped.

Summary

Mr C has had contact with mental health services in the board area since 1997, and his complaint concerned the care and treatment he received from 2004 until 2014. Mr C said it was clear he had suffered from post-traumatic stress disorder throughout his contact with mental health services during this period, but that the board failed to diagnose him with this or provide appropriate treatment, such as trauma-focussed cognitive behavioural therapy (CBT). Mr C complained this meant that he was unable to return to work and effectively 'lost' ten years of his life.

We took independent advice from one of our medical advisers who specialises in psychiatry. We found that the action taken by each mental health practitioner following contact was reasonable, and there had been no indication that trauma-focussed CBT should have been preferred to the treatment given.