Health

Summary

Mr C was diagnosed with prostate cancer in 2013. A scan showed that the disease also caused obstruction to the right ureter (the tube draining from the kidney into the bladder). Furthermore, it showed inflammation of his lower bowel, and tests were performed in November 2013 and July 2014 to confirm a diagnosis of Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, in September 2013, Mr C had a stent (drain) inserted into his kidney to overcome the effects of the blockage. His treatment was carried out at Dumfries and Galloway Royal Infirmary.

Mr C complained about the care and treatment he received from the board. He complained that he was not told formally about the results of his test in November 2013; he was often kept waiting at appointments or for procedures without explanation; he received little treatment for his prostate and bladder problems; he was not given a timely diagnosis of Crohn's disease; administrative arrangements for his discharge from hospital in April 2014 were unreasonable; the board failed to reply to a letter from his GP; and that they failed to handle his complaint reasonably.

We investigated the complaint and took independent advice from consultants in urology (a speciality in medicine that deals with problems of the urinary system and the male reproductive system) and in general and colorectal surgery, and also from a senior nursing professional. We found evidence that Mr C's results had been discussed with him, although there were some shortcomings in communication with him and we made a recommendation to address this. We also found that he had been given an explanation for the delays (unexpected emergencies or appointments running over). We found that his urological treatment had all been appropriate but that some of the communication had been poor. We found that Mr C's diagnosis of Crohn's disease had been given after results and biopsies were known and, while there was a slight delay, his treatment had not been compromised while clinicians concentrated on his other diagnoses. We also established that Mr C's nurse-led discharge was appropriate and staff had been used efficiently to avoid hold-ups. We also found that Mr C's complaint was handled reasonably well. While we did not uphold these complaints, we found that there had been no reply from the board to a letter sent by his GP so we upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• bring the communication shortcomings to the attention of relevant staff.

Summary

Ms C attended her dental practice complaining of pain from her molar tooth. Ms C elected to have an extraction, which was performed under local anaesthetic. During the extraction, the tooth fractured and part of the root was displaced into the maxillary antrum (the space within the upper jaw bone). This had to be removed by surgery. Ms C said it was not reasonable that the tooth fractured during the extraction because the dentist had an x-ray showing the size of the tooth and its position before undertaking the procedure. Ms C complained that she had to attend hospital eight times because she suffered a severe infection which disfigured one side of her face and caused extreme pain.

We took independent advice from our dental adviser. We found that there was no indication that the fractured root would become dislodged and penetrate the antrum, and that this was a well recognised complication of this kind of extraction. However, there was no evidence in Mrs C's dental records that the possible complications of the extraction had been explained to her before the procedure had been carried out. While we were satisfied by the evidence that, overall, the treatment decisions and management were reasonable, we made a recommendation to the practice given the lack of evidence showing that possible complications were explained.

Recommendations

We recommended that the practice:

• take steps to ensure the possible risks of extraction are adequately explained to patients and recorded in their records.

Summary

Ms C complained to us about the treatment she received for a sore knee, and for delays in diagnosing and treating the problem. Ms C was referred to the orthopaedic (conditions involving the musculoskeletal system) department at Crosshouse Hospital for consideration, and was seen by a consultant shortly after. She was referred for an injection in her hip, as an initial approach to treatment, which took place three weeks later. She had a follow-up appointment six weeks later, and was seen by a junior doctor who referred her for an MRI scan (a magnetic resonance image – a special kind of scan). She had to wait a further six weeks for the scan. She had a follow-up appointment with the consultant ten weeks later, and was then referred to an orthopaedic surgeon. She waited 14 weeks to see the surgeon, who then put her on his list for a knee operation. The surgeon told her she could expect to wait around nine weeks for the operation. However, Ms C had an operation on her knee in England while she was waiting for her operation.

We sought independent orthopaedic advice on this case. Our adviser noted that the injection Ms C was given was an appropriate first line treatment for her knee pain. He said that it may have relieved her pain, and if it had, it would have helped to diagnose the source of the pain, so we did not uphold Ms C's complaint that this treatment had been unnecessary. In terms of the timescales for Ms C's diagnosis and treatment, our adviser noted two significant delays: the wait for a clinic appointment following her scan and the wait for an appointment with the surgeon; and concluded that these were both unreasonable delays.

We considered the evidence of the delays in the clinic appointments, and concluded that there had been unreasonable delays and that the board could have managed the appointments differently.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in diagnosing and treating the source of her pain; and
• review their procedures for making appointments within orthopaedics to minimise any delays during or following requests for scans.

Summary

Mrs C was scheduled to undergo a flexible sigmoidoscopy (a procedure whereby the rectum is examined by a camera). She had experienced pain during a similar procedure in the past and said that she requested sedation. Mrs C complained that, when the surgeon arrived, he advised that she would not require sedation and started the procedure. Mrs C experienced pain during the procedure and asked for sedation, however, the surgeon carried on. Mrs C was subsequently diagnosed with a perforated bowel. She complained that her requests for sedation before and during the procedure were ignored. Mrs C also complained that the board failed to answer points raised in her formal complaint regarding the procedure.

We took independent medical advice from a consultant general and colorectal surgeon. We found that Mrs C's records indicated she consented to the procedure commencing without sedation, so we did not uphold this aspect of her complaint. However, her care plan noted that she may require sedation during such a procedure so we were critical of the board, as the surgeon proceeded with the procedure despite Mrs C's discomfort and requests for sedation. This went against pre-operative advice given to patients that they can ask for the procedure to be halted at any time and request sedation. We concluded that the surgeon proceeded based on what he considered was best for Mrs C, rather than taking her own views into account.

Whilst we were satisfied that the board responded to the questions that Mrs C raised in her complaint, we considered that the response failed to demonstrate that her core concerns had been taken on board and appropriate action taken to avoid similar problems for other patients.

Recommendations

We recommended that the board:

• bring the failings our investigation has found to the attention of the surgeon for reflection as part of his next annual appraisal;
• remind relevant surgical staff of the contents of the patient leaflet, including that the patient may request sedation at any point; and
• issue Mrs C with an apology, acknowledging that it was not acceptable for the surgeon to override her request for sedation.

Summary

Mrs C complained that she had contacted the practice in the late afternoon to request that a GP attend and assess her partner (Mr A)'s mental health condition as she was seriously concerned that he was having a psychotic episode. Mr A was at another address and she was concerned about his safety. The GP listened to Mrs C's concerns and sought advice from the mental health services. It was decided that it would not be appropriate for them to visit Mr A that evening and that a visit would be made the following morning. Mrs C subsequently reported Mr A missing to police and he was found dead near to the address that Mrs C had highlighted. The GP explained that he had taken Mrs C's concerns seriously, and that he had sought specialist advice and reviewed Mr A's previous medical history and, as there was no immediate risk to Mr A or others, a visit the following morning was appropriate.

We took independent advice from a GP adviser who felt that the GP had not put himself in a position to obtain a first hand assessment of Mr A's mental health condition. The adviser felt that Mrs C's information was concerning enough to warrant action that evening. However, after careful consideration we felt that the GP had acted appropriately by seeking advice from the mental health services about Mr A's previous contact with them, and that there was no indication that Mr A was at risk to himself or others at the time. We found that the GP had treated Mrs C's concerns seriously and that a mental health assessment was appropriate, but that it could wait until the following morning. We did not uphold the complaint.

Summary

Mrs C complained about the board because she said she had concerns about the way in which it managed her waiting time before she received a clinic appointment. She also complained about the appointment itself, the examination and conclusions. Mrs C said she was left frustrated and depressed as a consequence, and sought private treatment to have a knee operation. She said that, if the board had treated her appropriately, this should have been the outcome of her clinic appointment.

We investigated the complaint and took independent advice from a consultant orthopaedic surgeon (a surgeon specialising in the musculoskeletal system). We found that in relation to waiting times, the board followed Scottish Government guidance. As Mrs C had informed the board that she would not be available for three periods of time during the indicated waiting time period (12 weeks), her waiting time was put back by a similar time. In the event, she was seen 13 weeks after the appointment was requested. Similarly, notwithstanding her private treatment, Mrs C's examination and management of her knee problem was in accordance with National Institute for Health and Care Excellence guidance. We did not uphold her complaint.

Summary

Ms C complained that, during a phone consultation, an out-of-hours GP asked a care home nurse if Ms C's father (Mr A) had a do not attempt cardiopulmonary resuscitation (DNACPR) note in his records. Ms C said the GP asked about the DNACPR with the implication that, if there was one in place, the GP should not bother coming to visit Mr A. Ms C also complained that the GP inappropriately prescribed amoxicillin (an antibiotic drug used to treat bacterial infection) to Mr A, which she said was not effective for him, and could be detrimental to his health.

We looked at Mr A's clinical records and a copy of the board's complaint file, and we took independent advice from one of our medical advisers. We asked the board for the audio recording of the phone call between the GP and the care home nurse, but it was no longer available. We found that DNACPR refers to cardiopulmonary resuscitation in circumstances where a patient's heart stops, and does not refer to any other element of a patient's clinical care. We concluded that it was normal for a triaging doctor (triage is the process of deciding which patients should be treated first based on how ill or injured they are) to ask whether a DNACPR form has been completed for a patient.

We also found that there was nothing in the available medical records to indicate that Mr A was allergic to amoxicillin. We concluded that the final prescribing decision has to lie with the doctor who is assessing the patient at the time, that the GP prescribed medication in line with relevant guidance, and that Mr A was provided with a reasonable standard of care in the circumstances. We did not uphold Ms C's complaints.

Summary

Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for his treatment as they were visitors to the UK. Mrs C complained that it was unreasonable that she was charged for his care and treatment. Her concerns included that her son's treatment was not immediately necessary and the board's actions were contrary to Scottish Government Guidance CEL 09 (2010) (Overseas Visitors' Liability to Pay Charges for NHS Care and Services) as she was not given the opportunity to make an informed decision about whether, or to what extent, to proceed with treatment.

We obtained independent medical advice on the complaint from one of our medical advisers, a consultant in general medicine. The evidence showed that the initial impression provided to Mrs C by the board was that her son's treatment would be free. The board failed to follow the Scottish Government guidance with sufficient accuracy, and there were opportunities that should been taken to discuss the likely charges with Mrs C at the time of her son's admission to hospital.

However, the type of treatment her son received was chargeable. It seemed unlikely that, had Mrs C been presented with the 'undertaking to pay' form at the time of her son's admission to hospital, she would have refused to sign the form, as he was clearly very unwell and in need of medical treatment. We also noted that Mrs C signed the 'undertaking to pay' form at the time of her son's discharge. We therefore considered that, on balance, it was reasonable that Mrs C was charged for her son's care and treatment.

Recommendations

We recommended that the board:

• ensure that hospital staff receive training on when to discuss charging for NHS care and services with overseas visitors requiring treatment; and
• provide Mrs C with a written apology for failing to discuss the likely charges for her son's treatment with her at the time of his admission to hospital.

Summary

Mr C attended the hospital's minor injuries unit, having injured his knee while playing football. He complained that the nurse practitioner (a specially qualified senior nurse) whom he saw did not assess the injury adequately. We took independent advice from our medical adviser, who considered that the nurse practitioner had acted appropriately. For example, her diagnosis of a sprain of his lateral collateral ligament (one of the four main ligaments in the knee) was appropriate based on her findings; she arranged follow-up with a physiotherapist for the following week; and she gave appropriate advice about the use of pain relief, ice and crutches in the meantime. Mr C considered he should have been x-rayed, but the adviser explained that there were no grounds for x-ray, and that x-ray would not have shown damage to his ligaments or cartilage.

Summary

Miss C complained about three consultations with three of the GPs at her medical practice as she did not feel the questions asked by the GPs had been appropriate. We took independent advice from one of our GP advisers, who considered that the questions and actions of Miss C's GPs had been thorough and appropriate. For example, when Miss C reported an episode of self-harm, the GP appropriately asked, amongst other things, about her support network at home.