Health

Summary

Mrs C complained that a trans-abdominal (TA) ultrasound scan (performed by passing the scanning device over the abdomen) she had received at Glasgow Royal Infirmary had not been properly carried out. As a result, she had been forced to seek private treatment. This had consisted of a gynaecological (relating to the female genital tract) examination and a trans-vaginal (TV) ultrasound scan (performed through the vagina, using a slim probe), as well as a TA scan. Three gynaecological problems were identified which Mrs C said the board would have identified if the scan had been done properly. Mrs C also complained that the board had failed to respond to her complaint properly.

We received independent advice from a consultant sonographer (a doctor who performs and analyses diagnostic ultrasound tests). The adviser said that the board's appointment times were too short to carry out the two separate types of scan needed in this case. The adviser noted, however, that of the problems identified during the private consultation, only one would have been apparent had Mrs C received both types of scan. We were advised that the outcome for Mrs C would not, therefore, have been different had she received both types of scan.

We found that, although there was no evidence the short appointment had caused Mrs C harm, she had not received the appropriate scans for her gynaecological condition. We found that the board had, however, responded appropriately to Mrs C's complaint.

Recommendations

We recommended that the board:

• review its standing operating procedures to ensure they provide greater clarity on when a trans-vaginal scan should be performed;
• review the time allocated for ultrasound appointments taking into account any relevant guidance; and
• apologise for the failings we identified.

Summary

Mrs C complained to us about the nursing care that her father (Mr A) received at the Royal Alexandra Hospital. We took independent advice on this complaint from a nursing adviser. We found that there had been some problems on the ward in relation to communication and drug administration. However, we found that the nursing care provided to Mr A had been reasonable overall, as were the arrangements made for his discharge. We did not uphold this aspect of the complaint.

Mrs C also complained that the board had not appropriately assessed her father for NHS continuing care (a package of care provided and solely funded by the NHS) when he had been discharged from hospital. She also considered that they had not dealt appropriately with her request for a review of the decision that her father was not entitled to NHS continuing care. We took independent advice on this aspect of the complaint from a medical adviser who is a consultant in acute medicine for older people and general medicine. We found that the initial assessment of Mr A for NHS continuing care and the subsequent reviews were all appropriate. Although some incorrect dates were used in the board's correspondence, and some of the documentation was not fully completed, we also found that the communication with the family had been reasonable overall. In view of this, we did not uphold this aspect of the complaint.

Summary

Mr C complained about the treatment provided for a wrist injury that his client (Mr A) suffered while overseas.

Mr A attended hospital overseas where his wrist was put in a cast. He was told to attend hospital on his return home, which he did. The doctor arranged x-rays of the fracture and changed the cast. Mr A was reviewed a week later, and the cast was changed again. Mr A was reviewed four weeks later and told his wrist had healed (although the joint was tilted back slightly). He was discharged. However, Mr A continued to suffer symptoms of pain and loss of movement in his wrist, which he said were worse than his pre-existing symptoms from an old injury. He attended a private hospital, where he was told that his fracture had healed badly, and he had corrective surgery, which improved his symptoms. Mr A complained to the board about his initial care.

The board acknowledged that Mr A’s fracture had healed with the wrist tilted slightly, but said this was satisfactory. The board noted Mr A’s history of wrist pain going back to his old injury, and said that his pain was due to the new fracture exacerbating his osteoarthritis from the old injury.

After taking independent advice from a consultant orthopaedic (relating to the musculoskeletal system) surgeon, we upheld Mr C’s complaint. The adviser said the early x-rays clearly showed Mr A’s fracture was unstable and likely to heal badly, and the board should have offered Mr A the option of surgery at that stage (to prevent the fracture healing badly). The adviser also said that the badly healed fracture was the likely cause of Mr A’s additional pain and symptoms, and the board should not have discharged Mr A without offering him corrective surgery.

Recommendations

We recommended that the board:

• issue a written apology to Mr A, acknowledging that the treatment for his wrist fracture was unsatisfactory; and
• ensure this complaint is raised with the consultants involved as part of their annual appraisals, and that any training needs are addressed.

Summary

Mrs C had a hysterectomy (surgery to remove the uterus (womb)) at Aberdeen Royal Infirmary. She was later discharged and made an appointment with her local hospital (which is in another NHS board area) to have her wound clips removed. A short time after the removal of the clips, once Mrs C had returned home, her wound split open and she had to be admitted to hospital for emergency surgery. Mrs C complained to the board that it was unreasonable that her wound had reopened and that the discharge arrangements were not reasonable.

We took independent advice from a medical adviser, who is a consultant gynaecologist. We did not uphold Mrs C's complaint about her wound reopening. The adviser agreed with the board's own view that this is a recognised, but rare, complication of abdominal surgery. We upheld Mrs C's second complaint regarding discharge arrangements. The adviser considered that there was evidence of leakage from the wound prior to Mrs C's discharge which was not acted on appropriately. During their own investigation, the board had identified failings with the information provided to Mrs C when she was discharged from hospital. However, the advice we received found some remaining issues with the discharge advice and the checklist that the board introduced as a result. We made three recommendations in relation to this.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C, acknowledging the failings our investigation has identified;
• ensure there is feedback to relevant staff on the findings of our investigation; and
• review their checklist and discharge advice for patients who have undergone hysterectomies, in view of the adviser’s comments.

Summary

Mr C complained about the physiotherapy and orthopaedic care he received from Forth Valley Royal Hospital after dislocating his knee-cap. He said that staff ignored his on-going symptoms and that he should have had a scan of his knee to identify what was causing him persistent pain. He was concerned that a locum orthopaedic specialist had wrongly diagnosed a meniscal tear (damage to cartilage in the knee) rather than a loose fragment under the knee-cap.

We took independent advice on this case from two of our advisers, one of whom is a physiotherapist and the other a consultant orthopaedic surgeon. We found that the physiotherapy management of Mr C's injury was in accordance with guidance on managing patients who have dislocated their knee-cap for the first time.

Whilst the board said that it would have been appropriate for Mr C to have had a scan prior to surgery, we did not consider that the diagnosis of a meniscal tear was unreasonable given that loose fragment can have similar symptoms. Furthermore, both meniscal tears and loose fragments can be treated by the surgery that Mr C underwent. We also considered that it was reasonable to proceed to surgery without a scan given that Mr C's symptoms were not resolving and were affecting his ability to work.

Summary

Mr C complained on behalf of his mother (Mrs A). He said Mrs A's GP practice had not diagnosed quickly enough that the symptoms she was suffering from were side effects of the medication she had been prescribed. Mr C said these side effects were well known. He did not believe the practice had been as aware as they should have been of these side effects, which had caused Mrs A unnecessary and prolonged suffering.

We took independent advice from a GP adviser on the care and treatment provided. The adviser said that the practice had reasonably considered Mrs A's ill health to be the result of a possible reoccurrence of breast cancer and had sought to rule this out. However, under national guidance for prescribing this medication, the practice should have been monitoring Mrs A's lung and liver function and they had failed to do so. The adviser noted the practice had subsequently taken all reasonable steps to address the failings in this case.

We found that the practice had not provided reasonable care and treatment, but they had taken the appropriate action to address this. We made no further recommendations.

Summary

Mr C complained about Victoria Hospital on behalf of his mother (Mrs A). He said that Mrs A had been prescribed a drug which had had serious side effects, causing liver damage and breathing difficulties. Mr C believed that these side effects were well known enough that they should have been considered sooner. Mrs A had been admitted to hospital by ambulance due to breathlessness, but was discharged with antibiotics. She was admitted again a few days later, but it took a further six days for the cause of her symptoms to be accurately identified.

We took independent advice from a specialist in emergency medicine, who said that Mrs A had been appropriately assessed on both admissions to hospital. The side effects she had were very rare, and it had been reasonable for medical staff to rule out more immediately dangerous and common causes for her breathlessness.

Summary

Ms C had gallbladder surgery at the Victoria Hospital. She was discharged without further follow-up but started to experience pain from a wound site. She was referred back to the board by her GP and had further surgery to address this. She was discharged the same day by nursing staff. Ms C complained that she had not been given a follow-up appointment following her initial surgery. She complained that her discharge at the second procedure was inappropriate as she was not reviewed by a member of the medical team. Ms C was also concerned that the board had failed to provide her with appropriate treatment following a further referral from her GP.

After taking independent advice from a nursing adviser and a consultant surgeon, we did not uphold Ms C's complaint about discharge. In relation to her concerns about the lack of follow-up after the first surgery, the surgical adviser confirmed that it is established practice not to offer a clinic appointment in such cases. Regarding the second procedure, we found that it is normal practice for patients to be discharged from day surgery cases without being seen by a doctor. The nursing adviser confirmed that appropriate checks had been carried out before Ms C's discharge. We noted that the board had taken learning from Ms C's complaint and were addressing her concerns about information that was provided to patients at discharge. Although we did not uphold this complaint, we made two recommendations to the board about the action they have taken.

We also did not uphold Ms C's complaint about the treatment she received following her GP referral. The surgical adviser considered that this had been appropriately managed.

Recommendations

We recommended that the board:

• provide evidence to confirm what action has been taken to improve the provision of information to patients on discharge; and
• advise us on the outcome of deliberations on offering patients the choice to see a doctor before discharge.

Summary

Mr C complained to the board about the care and treatment he received from a prison health centre for on-going back pain. He was unhappy that the doctor had not done enough to manage his pain or deal with the cause of it. The pain relief medication and physiotherapy were not helping, and he wanted another back operation.

We took independent advice from a GP adviser. We found that the doctor had followed Scottish guidance on the management of back pain, and prescribing painkillers and physiotherapy was appropriate given his symptoms. When Mr C reported that his pain was not improving with these measures, the doctor then referred him for surgical review. We concluded that the care and treatment was reasonable.

Summary

Miss C took her young son to A&E at Crosshouse Hospital as he was suffering from breathing problems and chest pain. A doctor arranged for a chest x-ray. He said there was no infection and discharged Miss C's son. Nearly a month later, Miss C's GP contacted her about a letter from the hospital stating that her son's x-ray had been misread. It said that he had pneumonia and required antibiotics. Miss C complained to the board about the delay in being told the x-ray had been misread. She said that her son's health had suffered as a result of this.

The board wrote to Miss C and apologised for the delay in notifying the GP of the x-ray report. While the x-ray had been interpreted initially by a doctor in A&E, this interpretation was incorrect. This was only found when the x-ray was formally reported on some 25 days later. A letter was then sent to the GP with the accurate report. The board offered an unreserved apology for the delay in reporting the x-ray, which was due to a combination of staff vacancies and demand on the service at that time. The board have since obtained additional support in an effort to reduce waiting times for imaging reports. The board said that the doctor who incorrectly interpreted the x-ray would be spoken to about their actions. They also said that the case would be discussed at clinical governance and audit meetings in order that lessons could be learned.

We took independent advice from a medical adviser who is a specialist in emergency medicine. The adviser confirmed that the time taken to formally report the x-ray was unacceptable even if there were staffing issues. We upheld the complaint. As the board had already apologised for the delay and had taken action to prevent a repeat occurrence, no recommendations were made.