Health

Summary

Mr C, who is an advice worker, complained to the board about the care and treatment Ms A received from Stobhill Hospital in relation to the fitting of a mirena coil (a contraceptive device inserted into the womb which can treat heavy bleeding). Six years later, there were difficulties in removing the device. It was found to be embedded in her womb and had to be removed under general anaesthetic. Ms A believed that she may not have been suitable for a mirena coil because of having a retroverted (backward-tilting) womb. She felt that this should have been taken into account before the device was implanted, and was concerned about not being properly informed of the risks.

We took independent advice from one of our medical advisers who is a consultant gynaecologist. We found that there were no clear records of a verbal discussion taking place with Ms A about the possible risks associated with the procedure. However, there were clear records showing that the doctor had given her a patient advice leaflet, which provided enough information for Ms A to make an informed decision. We also found that, before fitting the coil, the doctor had carried out a pelvic examination to check the positioning of Ms A's womb. This was in accordance with national guidelines and done to ensure that the mirena coil was appropriately positioned. It can be difficult to clearly identify the positioning of a woman's womb, and although it was likely in retrospect that the womb was retroverted, we did not consider this an unreasonable failing at the time.

Summary

Mrs C complained about the care and treatment she received at Glasgow Royal Infirmary in relation to breast reconstruction following a bilateral mastectomy (surgical removal of both breasts). Mrs C was concerned that her choice of reconstruction was interfered with by the specialist breast reconstruction nurse, that the medical choice of expander breast implants was inappropriate, and that the nurse who had inflated the implants had overfilled them, which led to additional treatment and surgery to address the problems.

During the board's investigation of the complaint, they identified the need to implement a protocol for the inflation process. However, they did not clearly acknowledge to Mrs C that the nurse had overfilled the implants well above the manufacturer's recommended guidelines.

We took independent advice on this case from two of our advisers, one of whom is a specialist surgeon in breast reconstruction and the other a specialist nurse. We did not find evidence to clearly show that Mrs C's decision about reconstruction options was unduly influenced by either the surgeon who was responsible for her care or the specialist breast reconstruction nurse. Whilst we considered that to proceed with implants was not unreasonable, we were critical of the size of expander implants used at her second operation. We were also critical that the higher risk of the implant failing was not discussed with Mrs C. We found that the nurse had overfilled the implants above the manufacturer's guidelines and had not sought permission from the surgeon as she should have done. The surgeon also failed to give clear instructions about the total volume of saline to be put into the implants, and the speed at which the filling was to be done. This was particularly important given Mrs C's previous radiotherapy, which makes the breast skin more vulnerable.

Recommendations

We recommended that the board:

• contact the surgeon to share these findings about the failure to discuss and document the higher risk of implant loss when increasing Mrs C's breast size;
• apologise to Mrs C for failing to inform her of the additional risks associated with a larger implant;
• apologise to Mrs C for overfilling her implants and for not including this information in their complaint response to her; and
• ensure the findings are shared with the nurse and the surgeon and that any training needs are appropriately dealt with.

Summary

Mrs C complained to us about the Glasgow Dental Hospital's decision to give her son (Mr A) colchicine (a medication normally used to treat gout) to treat his mouth ulcers. Mr A had mental health problems and subsequently died from an overdose of the medication. Mrs C said that the medication was not listed as a treatment for mouth ulcers. She also considered that the doctor who had recommended the prescription of the medication had failed to adequately assess the risks of giving this to Mr A, in view of his mental health problems and previous suicide attempts by overdosing.

We took independent advice on Mrs C's complaint from an adviser who is a consultant in oral medicine. We found that colchicine is an appropriate choice of drug for mouth ulcers. It had been reasonable to give this to Mr A because the ulcers extended into his throat and other treatments had not been successful. The doctor had been aware of Mr A's mental health problems and of his suicide attempts by overdosing. The doctor considered that the risks of this happening again were mitigated as Mr A received his medication on a daily basis to reduce the chance of overdosing. We considered that, based on the evidence available at the time, it had been reasonable for the doctor to decide that Mr A should be given colchicine. We did not uphold the complaint.

Summary

Mrs C, who is an advocacy worker, complained on behalf of her client (Mrs A). She said that Mrs A had complex medical conditions and that she began to suffer from seizures after the practice had prescribed indapamide (medication for high blood pressure). The practice said that Mrs A's blood pressure had risen due to her other medication and that they prescribed indapamide in order to control her blood pressure. They said they monitored her condition and also sought medical advice from a hospital specialist.

We took independent advice from one of our GP advisers. Our adviser was satisfied that the practice had prescribed the medication appropriately, and that they had sought specialist advice and monitored the situation. We did not uphold the complaint.

Summary

Mrs C, who is an advocacy worker, complained to us on behalf of her client (Mrs B) whose mother (Mrs A) had been a patient at Dr Gray's Hospital after being admitted with symptoms of abdominal pain, nausea, vomiting and with an infection. While in the hospital, Mrs B had concerns about her mother's clinical treatment and nursing care. These included a delay in diagnosing that Mrs A had fluid on her lungs and that the staff did not listen to the family's reported concerns about possible fluid build-up; that they did not provide Mrs A with assistance to mobilise; and that staff failed to communicate with them regarding Mrs A's condition and test results. Mrs B was also concerned that the board's formal response did not address all her concerns.

We took independent advice from a clinical adviser and a nursing adviser. We found that although the day-to-day clinical treatment which was provided was reasonable, there was a slow pace to the investigations and there was a clear lack of clinical direction. It was accepted that there were numerous medical specialties involved and that there was some uncertainty regarding a definitive diagnosis. However, there was a lack of any thoughtful or dynamic approach to Mrs A's care. We also found that the nursing care was appropriate but there were failings in communication by both nursing and clinical staff. We also found evidence of poor complaints handling as the board had not addressed all of Mrs C's concerns which were set out in the initial complaint letter to them. They had only generally referred to the communication issues and failed to address any of the concerns regarding the nursing care.

Recommendations

We recommended that the board:

• apologise to Mrs A for the way her clinical treatment was managed and for the subsequent delays to her treatment;
• share our findings with senior clinicians who were responsible for Mrs A's treatment in order that they can reflect on their actions;
• apologise to Mrs A for the failings in communication which we identified;
• share our findings with nursing and clinical staff in order that they can reflect on their actions;
• apologise to Mrs B for the inadequate response to her formal complaint; and
• remind all staff who are responsible for investigating complaints to ensure that all concerns are addressed in the final response.

Summary

Miss C complained regarding the care and treatment she received for a benign breast lump in 2011. In 2014, Miss C was diagnosed with breast cancer. The board said that the lump had been benign in 2011 and it was very unlikely that a benign lump becomes cancerous. Miss C said that she had not been provided with adequate follow-up or advice, and that the lump had become malignant. Miss C said the board should accept this was possible and that the lump should have been removed in 2011. Miss C also complained of an excessive delay in providing her with radiotherapy.

We took independent advice from one of our advisers, who is a consultant oncologist. Our adviser said there was no evidence to show benign lumps could become malignant. It was possible that despite the appropriate tests being carried out and the results from these showing no sign of cancer that it had in fact been malignant in 2011. Our adviser said that this did not constitute an unreasonable standard of care. However, the delay in the provision of radiotherapy was unreasonable, since it had breached Scottish Government targets and the board had been unable to provide evidence that they were taking steps to prevent a reoccurrence.

We found that the board had acted reasonably in 2011, both in terms of the tests carried out and the decision not to remove the lump from Miss C's breast at this time. When further tests in 2014 showed it to be malignant, the lump was appropriately removed, but the board unreasonably failed to provide radiotherapy within Scottish Government targets, so we made a recommendation about the delay.

Recommendations

We recommended that the board:

• provide evidence that the review being conducted into radiotherapy provision has addressed the delays experienced in this case.

Summary

Mrs C complained on behalf of her brother (Mr B) about the care and treatment his late partner (Ms A) received following a diagnosis of colorectal cancer.

Ms A's family said that had she received treatment sooner, the progression of the cancer could have been slowed. They also questioned whether shrinking her tumour with radiotherapy and concurrent chemotherapy was the best course of action, or whether the tumour should have been removed upon its discovery.

Ms A's family also complained there had been a failure to reasonably communicate her condition and prognosis throughout her care. In particular, they said that Ms A's consultant said she would be free of cancer by a certain date only later to be told her cancer had spread.

We took independent advice from a colorectal surgeon who said Ms A's treatment, based on her symptoms and condition at the time, was timely and had also been carried out within the appropriate national cancer treatment guidelines. The adviser also said the scans taken of Ms A were appropriate and the decision to use chemo-radiotherapy to shrink the tumour was the most reasonable treatment option and in line with the applicable guidance.

We accepted that Mr B and Ms A believed that when they met with the consultant they were told she would be free of the cancer by a certain date. The board, however, said that the consultant would not have given Ms A this information. We consider that it is essential that communication at an important consultation when there is discussion about a patient's prognosis is clear and the patient clearly understands what is being said. It was unsatisfactory this did not appear to have happened in this case. Given the different accounts and in the absence of further evidence, we were unable to conclude that the consultant miscommunicated Ms A's diagnosis during the consultation, but we made a recommendation about communication.

However, taking account of the evidence overall, on balance we did not find there was a failure by the board to reasonably communicate Ms A's condition and prognosis throughout her care, so we did not uphold Mrs C and Mr B's complaints.

Recommendations

We recommended that the board:

• ensure this case is discussed with the consultant as a learning point and consideration is given by them to undertaking communication training as part of their continuing professional development.

Summary

Ms C attended her GP with swelling and hardening tissues between her vagina and rectum. The GP prescribed antibiotics to be taken for seven days. She was told to return in one week, or sooner if her symptoms became worse. Three days later, she returned to the practice and saw a different GP as the pain was worse. The medical notes also state that she was experiencing diarrhoea and vomiting. She was examined and the medical records indicate that her vaginal symptoms were no worse, and that the GP considered the diarrhoea and vomiting to be side effects of the antibiotics. On Ms C's request the GP prescribed anti-sickness medication. The GP told her to take the antibiotics for only five days, recorded that there was no sign of infection and gave her a one-week sick note. Six days later, Ms C attended the first GP again, who diagnosed a perianal (situated in or affecting the area around the anus) abscess. Ms C was admitted to hospital. Ms C complained that, at her second appointment, the GP had failed to provide adequate medical advice, care and treatment.

We obtained independent advice from one of our GP advisers. We concluded that, while the care and treatment provided to Ms C was reasonable, it was unreasonable that Ms C was not given any specific instructions by the GP at the second appointment about what to do if her vaginal symptoms did not improve or got worse. As this particular failure was significant, we upheld Ms C's complaint. During our investigation, the practice apologised to Ms C and the GP reflected on her practice. The GP explained that, in future, she would try to give more specific instructions for patients so they are sure they can come back if they need to. Therefore, we did not consider that we needed to make any specific recommendations.

Summary

Mr C complained about the care and treatment provided to his wife (Mrs C) by her GP practice in relation to her stomach problems. The practice investigated her stomach problems by carrying out blood tests and arranging for further investigations in hospital. When she was admitted to hospital, it was subsequently established that she had a mass on her liver, and it was confirmed that she had secondary cancer of the liver. Mr C complained of a lack of treatment and investigations into Mrs C's symptoms by the practice, and said that if they had taken her abdominal problems more seriously, then the cancer would have been diagnosed sooner.

We took independent advice from one of our medical advisers, who specialises in general practice. We found that the practice properly investigated Mrs C's symptoms, including making referrals to secondary care within a reasonable time, and that, overall, the treatment provided was reasonable.

Summary

Mr C complained about the care and treatment provided to his daughter (Miss A) at Forth Valley Royal Hospital. He was dissatisfied that she was not reviewed by a cardiologist (doctor specialising in disorders of the heart) when she reached the age of two, despite concerns about her heart when she was born. He complained that he was not informed about the change of plan about reviewing her. Mr C was also unhappy that the board's complaints team had access to Miss A's clinical records without his consent, that they took an unreasonable length of time to respond to his complaint, and that they did not respond reasonably to his questions.

We took independent advice on this case from one of our medical advisers who is a consultant paediatric cardiologist. We did not identify clear evidence that Mr C had been told Miss A would be reviewed at the age of two. We considered that the care given to Miss A was in accordance with established good practice, and there was no evidence of a heart defect requiring further review. It would have been difficult for the board's complaints team to respond fully to Mr C's concerns without access to Miss A's clinical records. However, there was no evidence that Mr C was clearly informed of the possibility that relevant health records would be handled by a member of the complaints team (in accordance with national complaints handling guidance and the board's procedures). Therefore, we upheld this part of the complaint.

We considered, on balance, that the board's responses were reasonable and were issued to Mr C without undue delay.

Recommendations

We recommended that the board:

• draw to relevant staff's attention the failings identified.