Health

Summary

Mrs C complained on behalf of her sister (Ms A) about the continence nursing care she had received during a stay in Campbeltown Hospital. During the first few months at the hospital, a catheter was used to manage Ms A's continence. Mrs C complained to the board about urinary care issues that arose during this period including urinary tract infections. Following their investigation of Mrs C's complaint, the board apologised for the lack of involvement of a specialist continence care nurse and, more generally, for the wider record-keeping for Ms A.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint. We found that, while many aspects of Ms A's urinary nursing care were appropriate, the lack of involvement of a specialist continence nurse and record-keeping matters (such as a lack of evidence that the continuing need for a catheter was reviewed) meant that, overall, the care could not be considered as reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C directly for the specific record-keeping issues they highlighted; and
• provide evidence of the action taken by the clinical services manager at Campbeltown Hospital to prevent recurrence of these events.

Summary

Mrs C complained about the care her late daughter (Miss C) received from her former GP practice between January and August 2011 after Miss C was diagnosed with a brain tumour in July 2012. Mrs C was concerned that Miss C was misdiagnosed with depression and, given that her symptoms (headaches, dizziness, tiredness and dilating pupils) were getting progressively worse, she should have been referred for a brain scan. Mrs C also provided evidence to show that Miss C had been unwell at college and had attended another medical facility.

We took independent advice from one of our medical advisers who is a GP. Based on their advice, we found that the initial diagnosis of vertigo was reasonable based on the symptoms of dizziness and abnormal eye movements. It was also noted that Miss C had described symptoms of anxiety which were explored by the practice, and the reasons for this were plausible. We did not find evidence in any of the records made of the eleven GP consultations, the records made by the college, or medical facility, that Miss C had reported suffering from headaches or that her condition was getting progressively worse. We found that Miss C's symptoms were not consistent with the symptoms of brain tumour set out in the relevant Scottish guidelines for referring patients for urgent assessment (such as for a brain scan). We concluded that this was a tragic case where Miss C's symptoms were not clearly typical of a brain tumour.

Summary

Mrs C complained about the pregnancy care she received from Raigmore Hospital. She said that the hospital failed to perform basic medical tests and that there was an inappropriate evaluation of her health which resulted in her pregnancy loss. Mrs C had a past history of thyroid problems and she complained that the management of this problem had been unreasonable. Mrs C also complained that no examination was carried out after her pregnancy loss to make sure everything was all right.

We took independent advice from a consultant obstetrician and gynaecologist. Our investigation found that overall the care and treatment given to Mrs C was reasonable, including the care and treatment Mrs C received when she attended the hospital with bleeding. The advice we received was that the hospital had also reasonably managed Mrs C's thyroid levels and there was no evidence that the loss of her pregnancy was caused by her thyroid condition or its treatment. We were also satisfied that, as Mrs C's pregnancy loss had occurred abroad, the hospital had not been aware of the situation until they contacted Mrs C when she missed a number of appointments. When responding to Mrs C's complaint, the board offered a further appointment to discuss what further investigations were appropriate at that time. In light of our findings, we did not uphold Mrs C’s complaint.

Summary

Mr C complained on behalf of his father (Mr A) who had suffered a stroke following a bleed in his brain which required specialist surgery. He was left with dense weakness in his left side with no active movement. Mr A was an in-patient at Raigmore Hospital for a number of months while he underwent rehabilitation in their stroke unit. When he was discharged, Mr A received physiotherapy at York Day Hospital. He was later seen by a consultant in stroke rehabilitation medicine and a specialist physiotherapist. Mr A also received other physiotherapy in the community. Mr C was unhappy with the range, intensity and frequency of the physiotherapy that Mr A received and complained that the board had failed to provide appropriate rehabilitation following his stroke. The board considered that the rehabilitation they provided was reasonable.

After taking independent advice from a medical adviser who is a consultant in stroke medicine and rehabilitation, we found that the clinical rehabilitation treatment that Mr A had received was appropriate. The advice highlighted an area where communication with the family could have been better but, overall, we considered this element of Mr A's care to be reasonable. We also took independent advice from a physiotherapist specialising in neurological rehabilitation and acute neurology (the science of the nerves and the nervous system, especially of the diseases affecting them). Overall, the range, intensity and frequency of Mr A's physiotherapy was found to be reasonable and the adviser considered that a holistic approach had been taken in relation to his treatment. The physiotherapy advice highlighted a single area of concern where there was no record that an issue identified during an assessment at York Day Hospital was monitored. After taking all the information about Mr A's rehabilitation care and treatment into account, we did not uphold Mr C's complaint but made a recommendation to the board to ensure that lessons are learned from the advisers' comments.

Recommendations

We recommended that the board:

• draw the comments of the medical adviser on communication and the physiotherapy adviser on best practice to the attention of relevant staff.

Summary

Mrs C had a hysterectomy (surgery to remove the womb) for a fibroid uterus at the Royal Alexandra Hospital. She said she then suffered an infection, was in severe pain, and had bladder problems. Mrs C was discharged home and later visited her GP who gave antibiotics for a urine infection. The following month, Mrs C attended a follow-up appointment at the hospital and was diagnosed with a vesico-vaginal fistula (an abnormal opening connecting the vagina to the urinary tract). She had to have further surgery to repair it. She was dissatisfied with her treatment and that a fistula had occurred, which had a very detrimental effect on many aspects of her life. Mrs C complained that the fact that she had suffered a vesico-vaginal fistula should have been discovered while she was an in-patient, and she should not have been discharged given her condition.

We took independent advice from a medical adviser. We found that the post-operative care and treatment provided was reasonable, as was the decision to discharge Mrs C, and that it was also reasonable to assume that the fistula developed as a later complication.

Summary

Ms C complained that when she first registered with her new GP she had difficulty in getting an appointment. When she first saw a GP, two weeks after joining the medical practice, she was refused a prescription for regular medication for various conditions as her medical notes had not yet been transferred from her old practice. Ms C also complained that she was removed from the practice list for alleged abusive behaviour, and that the practice failed to deal with her subsequent complaints.

We took independent advice from one of our GP advisers. They told us that records can sometimes take up to 12 weeks to be transferred between NHS practices when a patient changes GP. Therefore, it is common practice for basic information, including details of repeat medications, to be faxed over to the new practice to prevent any delays in prescriptions being issued. The adviser was particularly concerned that Ms C was on medication that can have serious withdrawal symptoms if stopped suddenly. We upheld this aspect of Ms C's complaint.

On the issue of Ms C being removed from the practice list, there was evidence that the staff at the practice found Ms C's behaviour, at times, to be unacceptable. While there does not have to be any intention to behave in an unacceptable way by the patient, where a GP considers that a patient's behaviour is unacceptable, they have the right to ask for that patient to be removed from their list. We did not uphold this aspect of Ms C's complaint.

In relation to the handling of the complaint, Ms C said that she had hand-delivered four letters of complaint between October and December 2014 but the practice said they had no record of the letters being received by any staff member. Following contact with our office, the letters were copied to the practice and were dealt with within the timescales laid down by the NHS guidance on complaints handling. We did not uphold this aspect of Ms C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified; and
• implement a system for contacting the previous practice of NHS patients transferring to them to obtain basic details of previous medical history and regular medications.

Summary

Mrs C complained about the care and treatment she received in relation to a range of unexplained neurological (relating to the nerves and nervous system) symptoms. During our consideration of the complaint, Mrs C advised that she had decided to pursue the matter by other means. We decided, in the circumstances, and under the provisions of the Scottish Public Services Ombudsman Act 2002, that we would not consider the matter further.

Summary

Mr C complained about aspects of the medical and nursing care and treatment provided to his brother (Mr A) during four admissions to Glasgow Royal Infirmary. Mr A was diagnosed with lung cancer. His deterioration was sudden and significant, and he died within four weeks of diagnosis. Mr C said that Mr A's cancer was not diagnosed within a reasonable time, and that his various discharges and the management of his pain was not reasonable. Mr C was particularly concerned about an attempt to resuscitate Mr A when they had agreed with nursing staff the night before that, as he was at the end of his life, he should not be resuscitated. Mr C also said that communication with nursing and medical staff was not reasonable, and that the family had explained to staff that they should be present when staff talked to Mr A because he had a fear of hospitals.

After taking independent advice from one of our medical advisers, we found that the treatment decisions and discharges were reasonable, as was the time it took to diagnose Mr A's cancer. Also, we could not reconcile the different accounts of the level of pain Mr C said Mr A experienced in light of the evidence from the medical records. However, in relation to the attempted resuscitation, we found that there were significant failings which resulted in a serious injustice to Mr A and his family, who were traumatised by the attempt. We also found communication failures between nursing and medical staff, which then affected communication with the family.

Recommendations

We recommended that the board:

• bring to the attention of relevant staff the medical adviser’s comments in relation to senior clinical review for distressed patients at the end of their lives;
• review their process in relation to end of life care to ensure that inappropriate CPR (cardiopulmonary resuscitation) attempts are avoided;
• bring the shortcomings in record-keeping to the attention of relevant staff;
• ensure the failures around the attempted resuscitation are raised with relevant nursing staff in the annual appraisal process;
• ensure the failings in communication are raised with relevant staff in the annual appraisal process;
• take steps to ensure the involvement of senior clinicians with seriously ill patients and their families in light of the medical adviser’s comments; and
• apologise for all the failings this investigation identified.

Summary

Mrs C complained that her mother (Mrs A) had received inadequate medical supervision and nursing care whilst in Stobhill Hospital. Mrs C said there were not enough medical staff available on the rehabilitation ward Mrs A had been placed on and that Mrs A's consultant had been uninterested in her case. She said Mrs A had been fed inappropriate food, and treated without dignity or respect. Mrs C said the family had fought to have her discharged into their care and they were unhappy about the board's failure to take their complaint seriously. Mrs C noted that it had taken months for the board to produce minutes of the meeting held with the family to discuss the complaint.

Our investigation took independent medical and nursing advice. The medical advice noted that the specific complaints raised by Mrs C were mostly nursing issues. The level of clinical supervision was adequately documented, and showed regular and appropriate recordings of medical review. The nursing advice received was that the level of nursing care overall was reasonable, although the board had admitted there were deficits in the care. The nursing adviser suggested that the board should provide evidence of the actions taken to improve nursing care.

The board provided a comprehensive and detailed action plan, showing improvements to patient care following the complaint. We found that the board had apologised appropriately and taken reasonable steps to improve patient care, and that no further action would be appropriate.

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A's family about the care and treatment provided to Mrs A by Southern General Hospital when her life-support machine was switched off. Mrs A was admitted to hospital after sustaining a severe injury at home, and put on a life-support machine. After being told by hospital staff that she could not survive, the family agreed to switch off the life-support machine. However, unexpectedly, Mrs A continued to live for a further 20 days. During this period, the family said there were communication failures; they did not know what was being done and what to expect in terms of care. They were also concerned that staff failed to provide appropriate care, particularly in relation to pain relief, fluids and nutrition. At the end of Mrs A's life, she was transferred to another hospital (Glasgow Royal Infirmary). The family said that her medical records were not transferred with her which meant that appropriate care could not be provided within a reasonable time at the second hospital. Finally, the family complained about the way the board had handled the complaint.

We took independent advice from one of our medical advisers. We found that the standard of care provided in relation to medication, nutrition and fluids was reasonable, and that sufficient information accompanied Mrs A when she was transferred to the second hospital. We were also satisfied that the evidence indicated that the family were kept fully informed of Mrs A's condition and prognosis. However, we found that the language the board used in their response to the complaint was inappropriate and insensitive, and that the response was overly technical and difficult for a layperson to understand.

Recommendations

We recommended that the board:

• take steps to ensure that Glasgow Royal Infirmary are complying with Records Management: NHS Code of Practice (Scotland);
• ensure that appropriate and sensitive language is used in complaint responses; and
• apologise for the failures this investigation identified.