Health

Summary

Mrs C complained to us on behalf of her late mother (Mrs A) about the care and treatment she received in the Royal Victoria Hospital during the last three months of her life. Mrs A had fallen while in hospital. Over subsequent weeks her mobility deteriorated and she complained about pain in her hip. Mrs A was referred for a psychiatric review and then a pain assessment that highlighted concerns about her condition. She was referred for an x-ray, which identified a fractured hip. Mrs C complained that this should have been identified earlier, and that staff did not do enough to adequately manage Mrs A’s pain. She said that if the hip pain had been appropriately investigated, Mrs A would have had better pain control in the final weeks of her life.

We sought independent advice from a nursing adviser and an adviser in elderly medicine. The nursing adviser highlighted significant concerns about the assessment and monitoring of Mrs A’s pain. They were also critical that nurses made negative remarks about Mrs A’s behaviour, without noting that the behaviour was a result of her pain.

The adviser in elderly medicine found that doctors had appropriately assessed Mrs A after her falls. They noted that Mrs A had complex care needs, and her pain had a number of sources. However, they were critical that when Mrs A started to complain of pain in her hip about a month after her last fall, this was not further investigated. They said that if the fracture had been identified then, Mrs A could have received better pain management in the weeks before she died.

We were critical that the nursing staff did not do enough to appropriately assess Mrs A’s pain as her condition deteriorated. This made it more difficult for doctors to assess her. However, medical staff also failed to identify significant signs of a potential hip fracture for several weeks, and this left Mrs A with poor pain management for longer than necessary.

Recommendations

We recommended that the board:

• undertake an independent nursing review of pain monitoring and assessment by nursing staff in the relevant wards;
• highlight the findings of this investigation with the staff involved, particularly in relation to the impact of an earlier x-ray and subsequent complaints handling; and
• apologise to Mrs C for the failures in Mrs A's care and treatment identified in our investigation, and for her time and effort in pursuing this complaint.

Summary

Mr C complained that the board provided him with unreasonable dental care and treatment. He also said that they delayed in dealing with his dental problems that developed as a result.

We took independent advice from a dental surgeon. We found that, although one of Mr C's teeth had to be removed shortly after it had been treated, an initial examination and x-ray before treatment had confirmed that it was deeply decayed. Mr C wanted to retain his tooth and so the decay had been removed and his tooth had been filled. The tooth did not settle and Mr C then asked for it to be removed. Mr C subsequently asked the board to provide him with an implant or a bridge, but these options were not available to him, mainly because his teeth were severely compromised by gum disease. We did not uphold his complaint.

Summary

Ms C complained on behalf of her father (Mr A) about a delay in transferring him home from hospital. Ms C complained that the ambulance service had not taken reasonable steps to ensure they could transfer Mr A home.

The transfer was booked by staff on the hospital ward. They advised the ambulance service that, if there were any steps at Mr A's home, they believed Mr A would be able to move from a stretcher to a wheelchair. When the crew arrived, they found that Mr A would not be able to do this and they cancelled the transfer.

We found this was a reasonable decision to have made, ensuring the safety of both the patient and the crew. Therefore, we did not uphold the complaint.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C) during an ambulance visit and, in particular, the decision not to take Mrs C to hospital. Mrs C had been recently admitted to hospital. Two days after discharge, Mr C became concerned about Mrs C’s symptoms and called 999. An ambulance crew attended and gave Mrs C oxygen treatment and advice about fluid intake. However, the paramedic decided not to take Mrs C to hospital immediately.

Mr C said the decision to leave Mrs C at home was made because the paramedic could not get through to the duty doctor for permission to bring her to hospital. He said Mrs C’s hospital admission later that day was arranged by a community nurse who visited shortly afterwards and raised concerns about Mrs C’s condition with the duty doctor. The ambulance service disagreed with this account. They said the paramedic spoke to the duty doctor and agreed that it would be appropriate to leave Mrs C at home to allow time for Mrs C’s recent insulin injection, and the advice about fluid intake, to take effect. The ambulance service said the paramedic arranged for an unscheduled care nurse to visit in four hours to check whether Mrs C had improved, and this was what prompted Mrs C’s admission later that day.

After taking independent advice from a paramedic adviser, we did not uphold Mr C’s complaint. There was evidence that the paramedic did call the duty doctor to discuss Mrs C’s condition and to arrange review. The adviser considered that, in these circumstances, the decision to leave Mrs C at home was reasonable.

Summary

Mrs C complained about the aftercare provided to her father (Mr A) at the Royal Infirmary of Edinburgh following hip replacement surgery. She said a student nurse had removed some stitches while cleaning his wound and, on discharge from hospital, Mr A was not fitted with compression stockings. Mr A's leg then began to swell. As there was a possibility he would suffer a blood clot, he had to reattend hospital. Mrs C was unhappy the board had maintained that the stockings were fitted on discharge.

The board apologised that the stitches were removed in error. They said that the prompt action of arranging a medical review resolved the mistake. They also said that the records showed evidence that the stockings were fitted on discharge.

We took independent advice from a nursing adviser. The adviser said that the action taken after the accidental removal of the stitches was appropriate. However, the medical records contained confusing and contradictory information about whether the compression stockings were fitted on discharge. Stockings had been fitted immediately following surgery but, as Mr A's heels were becoming marked, their use had to be reassessed before he was discharged. However, there was no evidence that they were reassessed. We upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the failure to keep clear and accurate hospital records; and
• remind the staff involved of the importance of keeping clear and accurate hospital records.

Summary

Miss C complained about the care and treatment her baby son received from the GPs at the practice. Miss C said she attended the practice a dozen times over a three-month period as her son was continually crying and was in great distress. Miss C raised a number of issues about her son’s care. She said that the GPs at the practice unreasonably failed to listen to her concerns about her son’s health. She said that they failed to ask relevant questions which might have helped get to the bottom of her son’s problems sooner. She also said that they did not recognise when they were out of their depth and needed to refer her son to more specialist medical staff. Miss C said that eventually a referral was made to the Royal Hospital for Sick Children, where severe reflux and colic was diagnosed as the cause of her son’s symptoms.

We obtained independent medical advice on the complaint from a GP adviser. The adviser said that the GPs at the practice listened to Miss C’s concerns and tried reasonable medication options. The adviser said that, when there was no evidence of consistent improvement, they arranged specialist referral to a dietician and a paediatrician (a doctor dealing with the medical care of infants, children and young people). The adviser said that the practice’s response was reasonable, referral occurred early on in the consultation history and there was no evidence of delay in referral.

The adviser found no evidence that the GPs failed to ask relevant questions which might have helped diagnose Miss C’s son’s medical problems sooner, or that the GPs treated him beyond their competencies. The adviser also indicated that the GPs acted in accordance with relevant national guidelines and Lothian NHS board’s policy.

Summary

Ms C complained about the care and treatment she received when she attended St John's Hospital in 2000. In particular, Ms C maintained that she should not have been discharged following her consultation with a consultant cardiologist, due to a family history of sudden death from hypertrophic cardiomyopathy (HCM - a disease where the heart muscle thickens abnormally).

During our investigation, we took independent advice from a consultant cardiologist. We found that while it was not clear in 2000 whether or not Ms C had HCM, the results of tests carried out at that time were not quite normal. It was possible that the results could have been due to the early signs of HCM. The advice we received and accepted was that while no further investigation or treatment was appropriate at that time, Ms C should have been offered a two-year review. We found that Ms C should possibly have been given more information about her condition at that time. If Ms C had been followed up, it was possible that a definitive diagnosis of HCM might have been made sooner.

However, the advice we also received was that the lack of follow-up made no difference to Ms C's treatment. Ms C had an implantable cardioverter defibrillator (ICD - a device implanted in the body that can reestablish a normal heart rhythm) fitted in 2014. However, the advice we received was Ms C did not fulfil criteria for primary prevention ICD implantation either in 2000 or in 2014. The adviser noted that the decision to implant an ICD is always difficult and may be based on additional factors such as anxiety. However, we were concerned about the lack of communication between the clinical genetics team and cardiologists about whether an ICD had been recommended in 2014.

Recommendations

We recommended that the board:

• apologise that follow-up investigation was not arranged in 2000;
• make relevant staff aware of the adviser's comments about the need for follow-up investigation in cases such as this, and provide details of the action taken as a result;
• make relevant staff aware of the adviser's comments about the adequacy of information given to a patient about their condition, and determine if there are any lessons to be learned from this case; and
• review the standard of communication between the clinical genetics team and cardiologists, and provide details of the action taken.

Summary

Mr C complained to us about his care and treatment during an assessment for psychological therapy. He was seen by a junior clinical psychologist at St John's Hospital to identify what form of treatment he might be suitable for. However, the psychologist was concerned about some of the issues he raised, and referred Mr C for a psychiatric review. Mr C was seen by a junior psychiatrist later that day, and had a home visit the following day from two psychiatric nurses. He was also seen the next day by a consultant psychiatrist. The consultant was satisfied that, while Mr C had disturbing thoughts, he did not have any plans to act on them, and was fully in control of his behaviour. The consultant therefore discharged him from psychiatric services, but noted his referral for psychological treatment. Mr C said that this succession of different assessments by various professionals had been distressing, and had not been necessary.

We took independent advice from a medical adviser who is a psychiatrist. The adviser was satisfied that, given the issues raised by Mr C during his initial consultation, it was reasonable for the psychologist to refer him for psychiatric review. The adviser said that the initial psychiatric consultation had covered some of the same issues as the psychologist had, but in greater detail. Overall, they considered that this consultation was reasonable. They noted the need for some assessments to be carried out over a number of days to assess fluctuations in symptoms. They considered the visit by psychiatric nurses to have been reasonable. They were satisfied that the consultation with the consultant psychiatrist had been reasonable, and had appropriately considered the stability of Mr C’s mental health.

We noted the distress that this assessment process had caused Mr C. However, given the assurances of the adviser, we were satisfied that this process was reasonable, and did not uphold the complaint.

Summary

Mr C, who is an advice worker, complained on behalf of Mr A about the care and treatment he received at the Royal Infirmary of Edinburgh's A&E department, when he injured his shoulder. In particular, Mr A maintained that the hospital failed to carry out a proper assessment of his injury, and that they delayed in offering follow-up appointments.

During our investigation, we took independent advice from a consultant in orthopaedic and trauma surgery. We found that the treatment given to Mr A was reasonable and appropriate. The advice we received was that there was no evidence the hospital had failed to carry out a reasonable medical assessment of Mr A's injury. We found that the injury was diagnosed by A&E in a reasonable manner and he was appropriately referred for further specialist assessment and management. We also found no evidence that there was any delay in the follow-up appointments for his injury.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received from St John's Hospital and the Royal Infirmary of Edinburgh. Mrs C attended the emergency department at St John's Hospital where she had tests carried out that suggested that she may be suffering from a viral illness and/or a urinary infection. She was discharged home with antibiotics but remained unwell. She visited her GP four days later who arranged for her to be seen by the medical assessment unit at St John's Hospital. There were delays in Mrs C being seen by a doctor and she was found to have had a small heart attack. Further tests revealed that she had significant coronary artery disease (blockages of the arteries) and so she was transferred to the cardiology team at the Royal Infirmary of Edinburgh. It was further identified that she had an overactive thyroid. Surgery to address the blocked arteries was carried out a few days later. However, within 24 hours Mrs C's condition continued to deteriorate and further investigations were difficult to perform given her poor state of health. Mrs C was transferred to another hospital but died shortly afterwards.

We took independent advice on this case from three medical advisers who are specialists in emergency medicine, endocrinology (hormone-related diseases) and cardiology. On Mrs C's first visit to the emergency department of St John's Hospital, a junior doctor failed to refer her to a more senior doctor before discharging her. We therefore found that the care provided was unreasonable. We were also critical that, on Mrs C's second visit to St John's Hospital, there was a delay in her being admitted and seen by a doctor. The board accepted and apologised for this. We considered that the treatment given thereafter at St John's Hospital was reasonable. We concluded that the care provided by the Royal Infirmary of Edinburgh was appropriate and in accordance with national guidelines. However, we found that communication with Mr and Mrs C about Mrs C's condition was unreasonable by both hospitals.

Recommendations

We recommended that the board:

• ensure the junior doctor reflects on the failings identified at their next appraisal;
• ensure St John's Hospital reviews its policy for patients who should be reviewed by a more senior doctor before discharge from the emergency department, taking account of high-risk presenting symptoms;
• review its pathway for patients referred from their GP to the medical assessment unit at St John's Hospital to ensure that patients who should be seen urgently do not experience an excessive wait;
• share with relevant staff involved in Mrs C's care at the Royal Infirmary of Edinburgh the importance of explaining to patients and their family relevant matters related to their condition, and document that this has been done; and
• apologise to Mr C for the failings identified in relation to Mrs C's initial visit to the emergency department and for the communication failures identified.