Health

Summary

Mrs C said that following gastric band surgery (a procedure where a band is used to reduce the stomach's size, so a smaller amount of food is required to result in feeling full), her complaints about discomfort and difficulty swallowing were ignored by medical staff. The band then slipped, which caused her significant internal damage and, as a result, she required major surgery which involved removing her entire stomach. Mrs C said she had not been seen appropriately by the consultant responsible for her care and that much of her post-operative care had been provided via a nurse-led clinic.

The board said Mrs C was provided with the appropriate level of care, and that nurse-led clinics were standard practice. The board said they did not wish to minimise the seriousness of Mrs C's subsequent band slippage, but that this could not have been predicted from the symptoms she presented with following her operation.

We took independent medical advice. The advice we received was that Mrs C's concerns were taken seriously and that the appropriate investigations were carried out to identify the cause of her symptoms. Unfortunately the band slippage, whilst a recognised complication in a small number of cases, could not have been predicted. The nurse-led clinic was an appropriate setting for Mrs C's post-operative care and had, on occasion, accessed medical staff as required in order to assess her condition.

We found there was no evidence that the care provided was not appropriate and in line with the relevant clinical guidance.

Summary

Ms C complained that her medical practice unreasonably continued to prescribe a medication to her for significantly longer than they should have. She felt the practice should have informed her about the updated guidance on this medication, and she was also concerned that they had unreasonably failed to note that she was receiving double prescriptions.

We obtained independent advice from a GP adviser, who said that prescribing this medication long-term was appropriate for Ms C's condition, although this medication was not recommended for long-term use for other conditions. We found that the practice acted reasonably in prescribing this medication for Ms C. We also noted that Ms C's prescribing had been regularly reviewed in line with the relevant guidance. We noted that, for a period, Ms C was obtaining a double prescription but, when this was brought to the attention of the practice, they correctly stopped the repeat prescription, and placed her on a fortnightly acute prescription. As we were satisfied with the practice's actions in this case, we did not uphold the complaint.

Summary

Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission.

Miss C was concerned that many mistakes and problems had occurred during Mr A's admission to Glasgow Royal Infirmary. Miss C met with the board who accepted there had been a number of failures in Mr A's care and treatment, and offered apologies for these. They also shared information with Miss C about actions taken to discuss failings identified with staff, and the procedures put in place to help avoid any repeat for other patients in the future. Miss C, however, remained concerned.

We took independent advice from a medical adviser and a nursing adviser.

Our medical adviser said that on admission, Mr A was noted to have had a fall, underlying liver disease, vomiting and diarrhoea, and a new acute kidney injury. Our medical adviser said that Mr A's medical records were comprehensive and that, overall, his care was of a good standard. However, our medical adviser also said there was a failure to prescribe continuous fluids, and to record and monitor Mr A's fluid balance which, in a patient with vomiting and diarrhoea and a diagnosis of acute kidney injury, were serious failings.

Our nursing adviser said that, overall, Mr A's nursing records and charts were of a good standard and there was a reasonable level of communication with Mr A's family. However, she also considered there was a serious failure in the recording and monitoring of Mr A's fluids by nursing staff. Therefore, Mr A's nursing care had fallen short of the expected standard in relation to the recording and monitoring of his fluid balance.

Recommendations

We recommended that the board:

• provide evidence of policies for fluid balance documentation and of compliance with such policies for the A&E department and the ward involved in this case at Glasgow Royal Infirmary.

Summary

Mrs C complained that there were unreasonable delays in her being diagnosed and treated for functional neurological disorder (a problem with the functioning of the nervous system). She also felt that the board's response to her complaint was inadequate, mainly in that there were inaccuracies regarding her care.

The board did not identify any failings in the care but acknowledged that there had been some incorrect dates given in their response to her complaint.

We took independent advice from two of our medical advisers and concluded that Mrs C received timely assessments with treatment given within a reasonable timescale (about a month after the final diagnosis was reached). We also considered that the board's overall responses adequately responded to the complaint with an apology given for the minor inaccuracies.

Summary

Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he experienced two heart attacks and was noticed to have become increasingly more agitated. Mr A required the lavatory and was assisted there by two members of staff and, at his insistence, he was given privacy. However, he fell and broke his hip. After that his condition declined. Due to this, it was not possible for him to undergo surgery and he died. Mr C believed that Mr A should not have been left unattended and he considered that this contributed to his death.

We investigated the complaint and took independent advice from our nursing adviser. We found that while there was a difficult balance to strike between safety and allowing someone dignity and privacy, in this case, because of Mr A's blindness and medical conditions, he should not have been left alone. We upheld the complaint.

Recommendations

We recommended that the board:

• provide an update of the actions/action plan they instigated since the complaint in order to ensure that their staff have the skills and resources to manage older people with delirium.

Summary

Miss C attended an orthodontic clinic for treatment in 2008 and had braces fitted. She was discharged in 2011 but in 2014 returned to say that part of the retainer had cracked. The clinic offered to repair this but said that it would have to be paid for privately as Miss C had already had one course of paid-for NHS treatment. Miss C felt she should not have to pay for private treatment because she felt that her initial NHS treatment had not been completed adequately, and she was of school age when her treatment started in 2008.

We took independent advice from one of our dental advisers who found no evidence to show that Miss C's course of treatment between 2008 and 2011 was unreasonable. Furthermore, from the evidence available, we found that Miss C did not meet the criteria for NHS-funded treatment when she re-attended the practice in 2014.

Summary

Mrs C complained on behalf of Mr A that the vasectomy (where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) operation he had at Dr Gray's Hospital was not performed properly and that his aftercare was inappropriate. We obtained independent medical advice from a surgeon experienced in carrying out this procedure, and found that there was evidence from the operation records and the samples taken during and after the surgery to show that the operation was carried out to a reasonable standard. We also considered that Mr A received appropriate care for persistent pain following his surgery and that the review appointments and treatment given were in line with national guidance. Whilst we noted that it took around four months for Mr A to be reviewed at a pain clinic, we found that this period was acceptable and with in the timescales set out in national guidance which acknowledges the constraints on pain clinic services.

Summary

Mrs C was referred to Aberdeen Royal Infirmary with pain on her left side, which her GP thought might be due to kidney problems. She was x-rayed, had an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and was discharged with a diagnosis of constipation with no planned follow-up. Mrs C continued to be unwell and was treated by her GP for constipation (as advised in her hospital discharge letter). Mrs C collapsed at home and was readmitted to the hospital several months later. At that time a computerised tomography (CT) scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and a large mass, thought to be an ovarian cyst, was found. Mrs C had surgery to remove this mass and was advised that primary cancer had been found in her colon and it was this that had spread. Mrs C was offered chemotherapy but was advised that this was only to relieve symptoms as the diagnosis was terminal.

Following surgery to remove the primary cancer from the colon, Mrs C was told she was not terminally ill and that the spread of the cancer had not occurred as had been previously suspected.

We took independent advice from a medical adviser who said that the board's initial actions and their diagnosis of constipation were reasonable. Our adviser also considered that the treatment provided once the cancer was detected was reasonable and appropriate.

Nevertheless, our adviser said that it would have been good practice to have a bowel surgeon present during Mrs C's surgery given the known presence of abnormalities in the colon. Our adviser was also of the view that the pathology report following this surgery did not suggest a terminal diagnosis and he did not consider that the terminal diagnosis given to Mrs C had been appropriate. For these reasons, we concluded that the care Mrs C received was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for incorrectly diagnosing her condition as terminal;
• ensure the staff involved in the diagnosis reflect on their diagnosis in light of our medical adviser's comments, in particular to ensure pathology reports are appropriately taken into account; and
• review the surgery carried out in light of our medical adviser's view that a bowel surgeon should have been directly involved.

Summary

Mr C fractured his ankle which was put in a plaster cast for six weeks. He was told not to bear weight on the foot and was prescribed medication to prevent blood clots forming during this period.

When Mr C's cast was removed, the medication was stopped. He was referred for physiotherapy which took place one week later when he was provided with a sandal-type shoe to wear and given exercises to complete. A follow-up physiotherapy appointment was arranged for three weeks ahead.

Mr C died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and deep vein thrombosis (DVT - a blood clot in a vein) a week before the follow-up physiotherapy appointment.

Mr C's wife (Mrs C) complained to us, and said that a failure to provide Mr C with appropriate and timely treatment following the removal of his plaster cast had allowed a blood clot to form. This caused him to suffer the pulmonary embolism and DVT which caused his death.

We took independent medical advice from a consultant orthopaedic surgeon who said there was no evidence that Mr C's medication should have been continued after the removal of the plaster cast. Our adviser also considered there was no difference between providing a patient with footwear and leaving the ankle completely free after the removal of the plaster cast. Furthermore, the adviser said that starting early physiotherapy treatment was not known to have any impact on the risk of developing a pulmonary embolism and a DVT.

Our adviser also said DVTs are difficult to diagnose. It was uncertain when Mr C's DVT had started, and fatal pulmonary embolism is a rare but an ever-present risk with surgery even if full prevention measures have been taken. On the basis of the advice we received, we found that the treatment Mr C received was reasonable.

Summary

Ms C, who is a member of parliament, complained about the care and treatment Mrs A received at Peterhead Hospital. Ms C brought the complaint to us on behalf of two of her constituents, the late Mrs A's daughter (Mrs B) and sister (Mrs D). Mrs A had been admitted to hospital after suffering from sickness and diarrhoea for several days. Ms C said that staff at the hospital failed to provide Mrs A with appropriate clinical treatment and nursing care. Ms C raised a number of concerns, including that there was an overall lack of concern or anxiety about Mrs A's condition shown by nursing staff and the doctor involved, and not enough was done to help her. Mrs A died whilst in hospital.

We obtained independent medical advice about the complaint from a GP and a nurse. Both of our advisers said that Mrs A's SEWS score (Standardised Early Warning System – a system which uses special observation charts completed by nursing staff to recognise deterioration in patients) was such that medical assessment should have occurred, but nursing staff failed to request a review by a doctor.

Our nursing adviser explained that Mrs A's oxygen reading was very concerning and, along with Mrs A being 'clammy' and her 'limbs discoloured', this indicated a very serious deterioration in her condition. She said nursing staff should have been aware of the significance of these signs of shock and should have acted immediately.

Our GP adviser said that when the doctor saw Mrs A, he did not carry out a reasonable assessment, did not record accurate observations and did not take action upon these. She said that the doctor failed to respond appropriately to the abnormal and deteriorating observations recorded on Mrs A's SEWS recording chart and arrange further investigation.

We concluded that there were clear failings in the clinical and nursing treatment provided to Mrs A by the staff at Peterhead Hospital.

Recommendations

We recommended that the board:

• ensure the failings identified by the adviser are addressed with the doctor;
• confirm that the doctor has discussed his full report with the independent GP appraiser and confirm the outcome to us;
• remind nursing staff involved in this case of the importance of SEWS and the reason for using this across Scotland;
• provide us with an update regarding the current use, monitoring and any relevant accuracy of completion of SEWS and response audits;
• provide us with evidence of their on-going assessment and training for medical emergency, including sepsis; and
• provide the family with a written apology for the failings identified.