Health

Summary

Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) had received. Mrs A had been referred to an orthopaedic consultant (a doctor who specialises in conditions involving the musculoskeletal system) and was seen in January 2013. She was re-referred by her GP practice in May 2013 but was not seen again until late July 2013. Mrs A died of widespread secondary cancer in October 2013, having been diagnosed a matter of weeks previously.

Our role was to assess whether the evidence indicated that Mrs A’s treatment was reasonable in the circumstances at the time. We took independent advice from our medical adviser, who said the steps taken by the orthopaedic consultant had been reasonable. In light of the symptoms Mrs A displayed in January 2013, the advice we received was that it would not have been normal practice to have carried out additional investigations for cancer.

The board did, however, acknowledge their delay in arranging Mrs A’s second appointment (the GP practice’s re-referral appeared not to have been acted upon promptly). We considered this to have been unreasonable and, although the advice was that this did not affect Mrs A’s overall outcome, the board acknowledged that earlier diagnosis would have led to better pain control and palliative care. We recognised the importance of receiving such care and so, on balance, we upheld Mrs C’s complaint because of the delayed second appointment and its possible impact on Mrs A’s palliative care. We also made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• send us evidence of the steps taken to address referrals promptly and their effect.

Summary

Mrs C complained that the board had delayed in arranging an appointment for her to have a tooth extracted. She had seen a dentist from the board about the tooth and the dentist considered that the tooth needed to be taken out. Mrs C wanted to know if there was any way that the tooth could be saved and the dentist referred her to a consultant in restorative dentistry to discuss this. The consultant examined the tooth and then wrote to the dentist to say that the tooth should be taken out as soon as possible. After receiving the letter, the dentist contacted Mrs C to say that the tooth would be extracted at her next arranged appointment, a few weeks later. Mrs C considered that the tooth should have been extracted without delay. She contacted NHS 24 for advice over the following weekend and an emergency hospital appointment was arranged for her to have the tooth extracted.

We took independent advice on the complaint from a dental adviser. We found that it had been reasonable for the dentist to decide to wait until Mrs C's next appointment to extract the tooth. There was no evidence in the records to suggest that Mrs C was in such pain that an emergency appointment was required. We did not uphold this aspect of her complaint.

Mrs C also complained that the board had failed to phone her back when she contacted them for advice after the tooth had been taken out. There was no evidence that staff did call Mrs C back about this and we upheld this aspect of her complaint. We also upheld Mrs C's complaint about how the board had handled her complaint. However, we were satisfied that the board had apologised and learned lessons from these failings, and we did not make any recommendations.

Summary

Mr C complained about the way he was treated by an ambulance crew who attended his home following a fall. He felt that the crew had handled him badly, and said that they did not fit a neck brace or transport him to the ambulance using a stretcher. On arrival at hospital it was established that Mr C had suffered a fracture of the second vertebra. The board explained that the crew had carried out a thorough assessment and could not detect any tenderness to the vertebrae of Mr C's neck or back, and there were no signs of nervous system damage. There was some mild tenderness on the left side of the neck but this was over the soft tissue area. Current UK guidelines say immobilisation is not required if there is no central spinal tenderness. The crew decided there was no requirement for a neck brace based on the symptoms reported, and no detectable signs of spinal injury at the time.

We sought independent advice from a medical adviser with experience in the training of paramedics. The adviser had no concerns about the actions of the ambulance crew, and was satisfied that they had acted in accordance with the guidelines concerning the treatment of patients with neck and back injuries.

Summary

Mr C underwent a magnetic resonance imaging (MRI) scan (scan used to diagnose health conditions that affect organs, tissue and bone) at the Western General Hospital to investigate back pain he was experiencing. The report of the scan did not mention the presence of an aortic aneurysm (a swelling of the main blood vessel leading away from the heart, down the body). It was only when a further MRI scan was taken two years later that the aneurysm was noted and operated on. Mr C complained that this was unreasonable.

We found that, in their response to the complaint, the board had recognised the error. The error occurred because, while the aneurysm was visible on initial scans (taken to ensure that the full MRI scan would be taken in the correct place), in the main images the aneurysm was largely obscured by images of the spine. The board had discussed this finding with the reporting radiologist (a doctor specialising in medical imaging) and submitted it to the department meeting for wider discussion about the importance of assessing the initial images thoroughly. The board had apologised to Mr C.

We took independent advice from one of our medical advisers. They confirmed that the board should have noted the presence of the aneurysm. The adviser was satisfied that the action taken by the board since the error was brought to their attention was reasonable. However, they suggested that the reporting radiologist discuss the case at their annual appraisal. We agreed with this view. We recommended that this happen and upheld the complaint.

Recommendations

We recommended that the board:

• ensure the radiologist concerned discusses this case at their annual appraisal.

Summary

Ms C complained that she had been provided with an unreasonable service by the board's orthotic service (service that designs, makes and fits devices to support or control a part of the body). She said she had been provided with substandard footwear, and that she had suffered unacceptable delays whilst trying to arrange an appointment. Ms C was unhappy that the board had failed to communicate with her properly, resulting in unnecessary travel for appointments which were cancelled on her arrival. She also complained that it had taken an unreasonable length of time to fit her orthotic footwear when it was delivered.

We took independent advice on this complaint, which stated that the standard of communication with Ms C was not acceptable and that Ms C's notes were not maintained to a professional standard. There was, however, no set time-frame for fitting specialist footwear and Ms C had not been treated unreasonably in this respect.

Our investigation found the board had unreasonably delayed in providing Ms C with an appointment, although there was no evidence the delay was as severe as Ms C suggested. We also found that the board had failed to communicate appropriately with Ms C. We did not find the length of time taken to fit Ms C's specialist footwear was unreasonable.

Recommendations

We recommended that the board:

• remind staff involved in this case of the importance of communicating timeously with patients, especially when an appointment requires cancellation;
• remind all staff of the importance of responding timeously to requests for appointments;
• remind staff of the importance of recording any delays in requesting appointments; and
• apologise for the failures identified in this investigation.

Summary

Mrs C complained that the board had failed to carry out appropriate investigations to identify the cause of her severe weight loss, decline in cognition and reduced mobility, when she was admitted to the Royal Infirmary of Edinburgh on two occasions. She said that staff only seemed to be interested in her brain injury, which was already being dealt with by staff at another hospital. We took independent advice on this part of her complaint from one of our medical advisers, who is a consultant in geriatric and general medicine.

We found that staff in the hospital had carried out appropriate levels of investigations and had made appropriate referrals to other specialities. They had considered Mrs C's condition and problems appropriately and there was no evidence that they focused unreasonably on one part of her health and failed to address others. Other aspects of her care were reasonable and, consequently, we did not uphold the complaint.

Mrs C also complained that staff had failed to provide her with an appropriate level of nursing care. We obtained independent advice from a nursing adviser on this complaint and found that some aspects of her nursing care had been reasonable. However, Mrs C had developed a pressure ulcer whilst in the hospital and we found that she should have received better care in relation to this. There should also have been further discussion with Mr and Mrs C about her personal hygiene needs. In addition, her food charts had not been fully completed. We upheld this aspect of Mrs C's complaint. That said, we did not make any recommendations to the board, as we found that they had apologised to Mrs C for these failings, and we had made recommendations to the board that addressed these failings in similar cases previously.

Summary

Ms C complained that her GP practice had failed to diagnose her or refer her appropriately, despite consistent reports of stomach pain. This pain persisted until she was diagnosed with Helicobacter infection (Helicobacter pylori is a germ that can live in the stomach), and it was successfully treated. Ms C said she felt she had been ignored and treated with a lack of respect. Ms C added that, even once Helicobacter infection had been diagnosed, she felt the practice had not treated her within a reasonable time-frame.

We took independent advice from one of our GP advisers. The advice received was that the practice had followed national guidelines in its attempts to diagnose and treat Ms C for the pain she was experiencing. The practice performed the appropriate tests on Ms C and it was noted that, on occasion, she had declined medical advice and declined appropriate referrals, which would have speeded up her diagnosis.

On the basis of the advice received, we found that the practice had acted reasonably and that they had not delayed in referring Ms C for specialist opinion.

Summary

Mrs C complained on behalf of her husband (Mr C) about his care and treatment in Monklands Hospital. In particular, she believed that an x-ray taken immediately before his admission showed sufficient evidence of respiratory problems that he should not have been allowed home, only to be admitted the next day as an emergency. She further complained that, once in hospital, Mr C should have been kept in either intensive care or in a high-dependency unit, and not moved between wards as he was. Mrs C also said that insufficient care was taken to prevent him falling, and that a nil-by-mouth (NBM) instruction was ignored.

We took independent clinical advice from two advisers, a consultant respiratory and general physician and a nursing adviser. We found that Mr C had been discharged after his x-ray without the results being seen or taken into account, and without him being given appropriate treatment. In light of this, this part of his complaint was upheld. Similarly, we found that staff did not adhere to an NBM instruction and this complaint was also upheld. However, after he was admitted to hospital, all ward transfers were made with Mr C's medical condition in mind and were all appropriate. The evidence also showed that staff took all reasonable steps to prevent Mr C from acquiring pressure ulcers or from falling.

Recommendations

We recommended that the board:

• bring the comments of the consultant respiratory and general physician to the attention of the consultant neurologist concerned;
• make a formal apology for their communication failures;
• remind relevant staff (nurses and doctors) of the necessity of good, clear communication;
• apologise to Mr and Mrs C for their failure to follow Mr C's NBM instruction; and
• emphasise to relevant staff the importance of following a NBM instruction.

Summary

Mrs C complained on behalf of her mother (Mrs A) about the care and treatment she received at Monklands Hospital in 2013 and 2014 for liver-related disease. Specifically, she complained that a specialist procedure was not performed in 2013 and the aftercare arrangements were poor; that during a second admission in 2014 Mrs A's condition continued to deteriorate until she was transferred to a different hospital where a liver transplant was performed; and that she was malnourished prior to the transplant.

In their complaint response, the board did not identify failings in the care and treatment but acknowledged that communication with the family could have been better.

We took independent advice from two of our medical advisers, a consultant gastroenterologist (who specialises in the treatment of conditions affecting the liver, intestine and pancreas) and a consultant gastroenterologist and hepatologist (who specialises in liver disease). We found that the treatment given in 2013 was in line with national guidance and, whilst there were records to show that there was an appropriate discharge plan in place, there was no evidence to demonstrate that this had been explained to either Mrs A or her family. Furthermore, given that Mrs A had abnormal blood tests, we were critical that the consultant who discharged her failed to reasonably monitor her. Therefore, we upheld this aspect of the complaint and made three recommendations. We considered that the care given in 2014 was appropriate and, having also taken independent advice from our nursing adviser, we found that there were factors that impacted on Mrs A's ability to take oral nutrition and we did not uphold this aspect.

Recommendations

We recommended that the board:

• apologise to Mrs A for the lack of communication surrounding her discharge plan;
• review their procedures for arranging follow-up clinic appointments and for reviewing abnormal blood results, specific to this case, to identify any learning; and
• share the failings identified with relevant staff.

Summary

Mrs C complained about the treatment her father (Mr A) received from the board. In 2013 Mr A began to experience difficulties with his mobility and memory. Mr A was referred to the board's Falls, Stroke and Memory clinic at Coathill Hospital where he was seen by a consultant. A CT scan (computerised tomography scan) was arranged, which showed some shrinkage of the brain. The consultant referred Mr A for an MRI scan (magnetic resonance imaging scan - a more detailed scan than the CT scan). However, the radiologists questioned whether the scan was required, as they did not feel that an MRI would provide any additional useful information. They suggested a discussion with the referring consultant, however, Mrs C said that this did not take place.

Mr A was disappointed that the MRI scan did not go ahead and arranged for the scan privately. This resulted in a diagnosis of vascular Parkinsonism (a form of Parkinson's disease, a progressive neurological condition in which part of the brain becomes more damaged over many years). Mrs C complained that the radiologists inappropriately rejected a test that had been identified as necessary by Mr A’s consultant.

We took independent medical advice from one of our advisers. We accepted the advice that the consultant's decision to request an MRI scan was reasonable but that it is a radiologist’s duty to ensure that patients are not subjected to unnecessary imaging. When a radiologist believes imaging might be unnecessary, they should get clarification on the need for it. We were satisfied that a discussion did take place between the referring consultant and radiology, and that it was agreed that the MRI would not necessarily add anything to the diagnosis that had already been made. Whilst we found that Mr A’s treatment may have differed slightly had the MRI been carried out, we did not consider there to be a significant impact on his treatment.

We were critical of the board’s handling of Mrs C’s formal complaint and made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings in complaints handling which have been identified in this report.