Health

Summary

Ms C complained that her mother (Mrs A) had not been provided with a reasonable standard of treatment by her medical practice. She felt the practice had unreasonably handled much of Mrs A's contact over the phone and, following hospital investigations and tests, that the practice had failed to take the appropriate steps.

We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We took independent advice from one of our medical adviers, who explained that managing contact over the phone is common practice, and that there was nothing to indicate it had been done unreasonably in this case. Our adviser also said that it was the hospital doctor's responsibility to explain hospital test results and, in any event, the practice had not misinterpreted hospital correspondence as Ms C felt they had.

Although we took Ms C's concerns into account and recognised her strength of feeling, the medical advice we received was that the records did not indicate that Mrs A's treatment had been unreasonable. We did not consider the evidence indicated that Mrs A's practice had failed to provide her with a reasonable standard of medical treatment, and so we did not uphold this complaint.

Summary

Miss C complained about the medical and nursing care that her late mother (Mrs A) received at the Royal Infirmary of Edinburgh after she was admitted with upper abdominal pain. Miss C felt there had been a delay in a scan being performed which contributed to Mrs A's premature death from cancer; that there was a lack of communication from the staff about the severity of Mrs A's illness; that a decision had been made not to resuscitate Mrs A without this being discussed with the family; and that nursing staff should have monitored her mother's condition more closely.

We took independent advice from our medical adviser who found that there had been an unreasonable delay in the scan being done, although an earlier scan was unlikely to have altered Mrs A's prognosis. Had the scan been done two days earlier, Mrs A and the family could have been informed of the diagnosis in a more timely manner before her death several days later. The board said that the delay was due to the ward being closed because of an infection. However, we concluded that infection control measures could have been put in place, so we upheld the complaint. We also found that there was a lack of records to provide evidence that the medical team clearly communicated, to either Mrs A or the family, about the strong suspicion of cancer. Furthermore, we considered it was unreasonable that the family were not given the opportunity to be involved in the medical decision about resuscitation. In terms of the nursing care, we found evidence that reasonable checks were carried out. Furthermore, the medical staff noted that nursing staff had raised concerns with them about Mrs A's deteriorating condition. We did not uphold the complaint but recommended the board share with nursing staff the importance of recording when such action is taken.

Recommendations

We recommended that the board:

• apologise for the delay in performing the scan;
• share the findings about the delay in the scan with relevant staff to prevent this recurring;
• share with relevant nursing staff the need to make accurate records in line with guidance issued by the Nursing and Midwifery Council;
• ensure that doctor 1 reflects on the failings in relation to communicating with patients about suspected diagnosis at his next appraisal; and
• draw the findings about the lack of discussion about the decision not to resuscitate Mrs A to the attention of doctor 2.

Summary

Mr C complained that he was not given his prescribed medications on his first days in prison, and that all his medications were stopped soon after entering prison. Mr C also complained that the board did not investigate when he complained about this.

The board said Mr C's medications were stopped in accordance with his signed medications agreement after he was found concealing suboxone (a medication used to manage addictions) and after he refused to open his mouth to let staff check that he had taken his medication. The board said that, as Mr C had raised these issues with healthcare staff rather than complaining to complaints handling staff, they had treated this as a 'concern' rather than a 'complaint'. They also said that, in any case, they had responded to Mr C's verbal complaints reasonably, by discussing the complaints with him directly on each occasion.

After taking independent advice from a psychiatrist, we upheld Mr C's complaints. We found there was no evidence the health centre had given Mr C his prescribed medication on his first days in prison, aside from one drug, for which there were two conflicting prescriptions (and he had been given one of these). We also found Mr C had been given incorrect medication on several other occasions. However, we found that it was reasonable for the health centre to decide to stop Mr C's medications when they did. Two medications were stopped or reduced soon after Mr C arrived in prison, and the adviser said this was appropriate, as these medications were addictive and not intended for long term use. Mr C's suboxone was stopped after he was found concealing this, and we found this was reasonable, as suboxone is used for addictions management, and there is a risk of overdose or harm if it is taken other than as directed. However, we were critical that the health centre were not able to show that Mr C had been warned about the consequences of concealing medications, as he had been asked to sign the wrong medications agreement (for 'in possession' medications, rather than 'supervised' medications). Mr C's remaining medications were stopped when he refused to comply with instructions to open his mouth. We found this was reasonable, as these medications were not essential for Mr C's condition and there is a risk of harm when medications are taken other than as directed.

We found that the board did not investigate Mr C's complaints appropriately. Although we found it was reasonable for the board to treat these issues as a 'concern' when Mr C initially raised them, when Mr C continued to raise these issues, and was not satisfied with the board's response, they should have been fully investigated.

Recommendations

We recommended that the board:

• remind nursing staff of the need to take care when administering medications (particularly where there are multiple prescriptions);
• review the processes for issuing prescriptions for incoming patients to the prison to ensure that existing prescriptions (from the community and/or time in custody) are continued or amended without delay, and the patient’s agreement is obtained to the applicable medication process ('supervised' or 'in possession');
• apologise to Mr C for the failings our investigation found; and
• take steps to ensure that complaints raised verbally with healthcare staff at the prison are appropriately handled and reported in accordance with the 'Can I help you?' guidance.

Summary

Mr C complained about the care and treatment he received from a prison health centre in relation to his eye condition. He was concerned that he received various different medications, none of which helped and some of which appeared to worsen his condition. He, therefore, felt that he had been inaccurately diagnosed, and he complained that he was not referred to an eye specialist sooner.

We took independent advice from one of our medical advisers, who observed that Mr C had been seen on a number of occasions by healthcare staff and examined repeatedly. Our adviser noted that examinations did not reveal any serious underlying problems and that this mirrored the subsequent findings of the eye specialist. As such, she did not consider there to have been an earlier indication for a referral to a specialist. We fully accepted this advice and did not uphold this aspect of the complaint.

Mr C also raised concerns about the way his complaint was handled. We noted that he submitted multiple complaint forms on the issue, and the prison health centre continued to try to resolve these informally. The guidance only allows a three-day window for informal resolution, following which the complaint should be formally acknowledged and investigated. This did not happen for several weeks and, seemingly, only upon Mr C's prompting. We identified other failings to follow due process, such as an initial failure to inform Mr C of his right to approach this office. In the circumstances, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the ‘Can I help you?’ guidance; and
• apologise to Mr C for the identified failings in their handling of his complaint.

Summary

Mr C complained that the operation on his foot performed by the board at St John's Hospital to help his dropped foot (a muscular weakness or paralysis that makes it difficult to lift the front part of the foot and toes) was not carried out to a reasonable standard. Mr C said that, prior to the operation, he had restricted up-and-down movement in his foot but full side-to-side movement, and he tripped and fell regularly because of his foot. Mr C said that after the operation, he had no movement either way in his foot, and he tripped and fell on almost a daily basis. Mr C also complained that there was an unreasonable delay in him receiving physiotherapy treatment.

We obtained independent medical advice on Mr C's complaint from a consultant orthopaedic and trauma surgeon, with special interest in foot and ankle surgery. Our adviser said that the procedure failed in Mr C's case, but the documentary evidence suggested that Mr C was advised that this could happen. Our adviser explained that a standard technique was used during Mr C's operation, and the treatment provided did not seem unreasonable.

The evidence showed that Mr C was referred for physiotherapy treatment six weeks after surgery. Our adviser said there was no significant avoidable delay in Mr C's physiotherapy treatment and that, given the failure in his surgery, the apparent delay in physiotherapy would not have made a significant difference to the outcome in his case.

Summary

Mrs C complained that her husband (Mr C), who suffered from multiple sclerosis, had received inadequate care and treatment from the District Nursing Team. He had developed a pressure ulcer on his back, and Mrs C said she believed that had she not insisted her husband phone his GP, then the pressure ulcers would have continued to deteriorate. Mrs C said that when he examined the pressure ulcer, the GP had been surprised at how bad it was, and her husband had been admitted for hospital treatment. Mr C had spent an extended period in hospital with a serious infection, which she attributed to the poor care he had received at home.

The board said that the nurses treating Mr C had made a number of suggestions to him that would have helped to treat his pressure ulcer, but he had refused them. The board said that successful treatment of pressure ulcers was dependent on the patient following the advice of staff, and that treatment would be limited if this did not happen. Nurses had attempted to obtain a medical opinion prior to Mrs C's contact with the GP, but Mr C had refused this.

We took independent advice from our nursing adviser, who said that the nursing record was appropriately completed and showed that a good standard of wound care had been provided. The adviser said that the wound had improved at times and then deteriorated, and it was reasonable for the nurses to persist with home treatment. Our investigation found that on the basis of the advice received, Mr C had been provided with a reasonable standard of care and treatment.

Summary

Mr C complained to us about the apparent lack of assessment of his late mother (Ms A) for NHS Continuing Care funding. Ms A was admitted to hospital from a care home with a broken ankle. However, she was not able to fully rehabilitate, and was subsequently transferred to a nursing home for ongoing care. Mr C complained that the board did not fully assess whether Ms A was eligible for NHS Continuing Care funding when she was discharged from hospital, or during her time at the nursing home.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) on the assessment of Ms A's care needs when she was discharged from hospital, and on the evidence of her care needs while she was in the nursing home. Our adviser said that Ms A's care needs had been appropriately assessed before her discharge, and she had been given appropriate opportunities to rehabilitate prior to discharge. He said that her care needs clearly did not meet the criteria for NHS Continuing Care, and that this was so obvious that it had not been documented. Given subsequent events, he noted that it would have been helpful if it had been documented, but he considered this to be a minor issue. He also noted that, from the evidence available, Ms A was not eligible for NHS Continuing Care at any time during her stay in the nursing home.

In our decision we noted that the board had provided information which showed that they had made a similar assessment to our adviser. However, this information had not been provided to Mr C. We were critical of this, though overall we were satisfied that the board had appropriately assessed Ms A's care needs, and that it had been reasonable not to document a full NHS Continuing Care assessment.

Summary

Mrs C complained about the treatment she received from the board in the lead up to the birth of her twins. During her pregnancy she developed HELLP Syndrome (this is the term used to describe a range of symptoms that can affect women with pre-eclampsia or eclampsia; HELLP Syndrome is characterised by the breakdown of red blood cells, elevated liver enzymes and low platelet count). Following diagnosis of her condition, Mrs C's caesarean section was brought forward. Whilst one of her daughters was born healthy, the other was stillborn. Mrs C complained that staff did not monitor her and her babies adequately, and that there was an unreasonable delay to the diagnosis of her HELLP Syndrome and to the delivery of her twins.

We took independent medical advice from a consultant obstetrician (a doctor specialising in pregnancy and childbirth) and gynaecologist (a doctor specialising in the female genital tract and its disorders). We were generally satisfied that Mrs C's condition, and that of her twins, was monitored adequately and in line with national guidance. Blood tests raised concerns for Mrs C's wellbeing but gave no indication of a problem with the twins. When abnormalities were identified, staff acted appropriately. However, we found that one of Mrs C's blood test results was checked and action taken by clinical staff before the full extent of the test results was known. Crucial information about Mrs C's liver enzyme levels was not identified until the day after the information was entered onto the hospital's system. Whilst appropriate action was taken to prioritise Mrs C's delivery once this information was highlighted, we accepted advice from our adviser who considered that the delivery would have taken place sooner had the blood test results been noted on the day they were reported. The available evidence suggested that, had this happened, both twins would likely have been alive at birth.

We were also critical of excessive delays and poor communication in the board's handling of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified;
• review their systems for reviewing blood results to ensure those taken in clinic and those taken on the ward are seen and acted upon in a timely fashion;
• take steps to ensure clear communication of the urgency of non-elective c-sections, and to develop a policy for escalation at times of high workload when c-sections are delayed longer than expected; and
• review their procedures for conducting root cause analyses to ensure they follow a structured process in keeping with the principles of the NHS Scotland complaints handling procedure.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) when he was admitted to Monklands Hospital. Mrs C also had concerns about the handling of the complaint she subsequently made to the board.

Mr A was suffering from heart failure and was being cared for at home when he had a fall at home. He was seen by his GP who diagnosed a urinary tract infection and prescribed antibiotics (a range of drugs to fight bacterial infections). Mr A's condition deteriorated and he was referred by an out-of-hours GP to the hospital. The admission record noted his confusion, decreased mobility and the diagnosis by the GP. A urine sample was taken and x-rays were taken.

Mr A was reviewed the next morning and considered ready for discharge home with support from ASSET (a multi-disciplinary home care team) but the family were concerned that he was not well enough. Mr A was kept in hospital and given further antibiotics. He had a number of falls while in hospital that Mrs C felt contributed to his eventual death, which occurred less than three weeks after admission.

Our investigation included taking independent advice from two of our advisers, a physician specialising in the care of the elderly and a senior nurse. Our advisers were satisfied that the care and treatment provided were reasonable in the circumstances. Mr A was appropriately assessed and monitored for risk of falls, and the physician adviser was of the view that the initial consideration of discharge with support was reasonable.

On the matter of the complaints handling, we identified unreasonable delays which the board had already acknowledged and apologised for to Mrs C. Appropriate remedial action had been taken to minimise the risk of a recurrence. Although we upheld this complaint, no further recommendations were made.

Summary

Mrs C complained about the care and treatment provided when she underwent surgery at Wishaw General Hospital to remove several adhesions (where organs are stuck to each other and/or the pelvic wall).

Mrs C had surgery. The following day she became unwell and a CT (computerised tomography - a special type of x-ray using computerised images) scan was done to eliminate the possibility that her urinary tract had been damaged during surgery. No evidence of this was seen. When her condition continued to deteriorate and bilious fluid (from the digestive system) was seen in her surgical drain, she underwent further surgery three days after the first operation. A perforation of the bowel was discovered and repaired. Mrs C's condition continued to deteriorate and she was operated on again three days later. A second perforation was found, and Mrs C's appendix and part of her bowel were removed. Mrs C was admitted to the adult critical care unit following the third operation and spent two months in hospital in total. She then had a six-month recovery at home.

Our investigation included taking independent advice from three of our medical advisers: a gynaecologist (specialist in disorders of the female reproductive system); a general surgeon; and a radiologist (specialist in imaging). No evidence of any failures was found in the original surgery, or the post-operative care. Although the CT scan did not reveal the perforations, the radiologist stated that this was reasonable in the circumstances. Similarly, the general surgeon considered that it was appropriate to have repaired only the visible perforation at the second operation. Inspecting the whole length of the bowel would have needed more invasive surgery and risked creating more adhesions. The fact that Mrs C required a third operation was not, in the view of the advisers, due to any failings in Mrs C's care and treatment.