Health

Summary

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and an extended hospital stay. She complained that the risks of the surgery were not adequately explained and that reasonable steps were not taken to avoid the complications encountered, such as infection. She also complained that the surgery resulted in Mr A developing a foot drop (a condition which impairs the ability to lift the front part of the foot).

We took independent advice from one of our medical advisers who noted that consent forms were completed both prior to Mr A's admission and on the day of the surgery. However, our adviser observed that the forms did not document the potential risks of the surgery. Our adviser stated that it was good practice to list common complications, or those which are rare but severe. In the absence of this, we could not find evidence that the risks were adequately discussed with Mr A and so we upheld this aspect of the complaint.

Our adviser confirmed that the complications encountered were recognised complications of this type of surgery, and did not consider that anything could reasonably have been done to prevent them in Mr A's case. In addition, our adviser considered it unlikely that Mr A's foot drop was related to the surgery. We accepted this advice and did not uphold the remaining aspects of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to improving the process for obtaining consent and, in particular, consider whether the consent form could benefit from revision; and
• apologise to Mr A for the failings in the process for obtaining his consent.

Summary

Ms C complained that the board had not managed her Individual Patient Treatment Request (IPTR) panel appropriately. She had been obliged to make an IPTR in order to obtain a drug which helped control the symptoms of her multiple sclerosis (MS) as the drug was not licensed for prescription in Scotland. Ms C had been prescribed a free trial of the drug and said her neurologist supported the prescription of it once the trial had finished.

She said there had been undue delay in arranging her hearings and that the board had not provided her with information about the panel's decisions appropriately. Ms C also complained that the panel had failed to consider the evidence she had presented appropriately. Ms C said this had caused her considerable distress and worsened her MS.

We took independent advice from one of our medical advisers who said he believed the panel had been conducted appropriately. He noted there were delays in the submission of the original IPTR request, and further delays caused by the departure from the board of Ms C's original neurologist. The board had acted to mitigate these delays, but were not responsible for them.

Our investigation found the board had arranged the IPTR process appropriately. Although Ms C had been successful on appeal, this was due to a change in Scottish Government guidance, rather than a reassessment or reinterpretation of the evidence by the IPTR Panel. The substantial delays in the IPTR process were due to the actions of Ms C's neurologists and the delays in submitting documents. We did not find the board failed to provide Ms C with information about the panel's decisions.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) had received from the board. Mrs A had taken lithium medication for many years for her bipolar disorder. This medication was changed in November 2012 and then changed back to lithium around six months later. Ms C was unhappy with these decisions as she felt they caused her mother to suffer from lithium poisoning, which caused Mrs A to attend Lorn and Islands Hospital. She was transferred to Argyll and Bute Hospital and then was moved between the hospitals again. Mrs A died within two months of her initial admission and Ms C was unhappy with the care her mother had received throughout this period.

We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We did not use the benefit of hindsight in making that decision and we took independent medical advice from a psychiatrist and a geriatrician (a doctor specialising in medical care for the elderly). Their advice confirmed that the original decision to change Mrs A's medication was reasonable in the circumstances, as was deciding to reintroduce lithium. In light of this clear advice, we did not uphold Ms C's first two complaints.

Our medical advice was that Mrs A appeared to have been suffering from lithium toxicity when she first attended Lorn & Islands Hospital, and that it was unreasonable to have transferred her to Argyll and Bute Hospital at that time. Mrs A was then transferred back to Lorn and Islands Hospital for a time before returning to Argyll and Bute Hospital. Our medical advice was that the potential severity of Mrs A's lithium toxicity appeared not to have been recognised during this time and her condition was not investigated sufficiently. We upheld Ms C's complaints about these admissions. However, in terms of Mrs A's final admission to Lorn and Islands Hospital, our medical advice was that care and treatment was by that point reasonable, so we did not uphold Ms C's complaint about that.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings identified in our investigation;
• remind relevant staff (including in A&E) of the possibility for lithium toxicity to occur in older patients at levels within the standard range of prescribed dosage;
• consider whether a shared protocol between Lorn and Islands Hospital and Argyll and Bute Hospital would be appropriate for management of lithium toxicity; and
• raise the medical advice we received about restarting lithium medication at the relevant psychiatrist's appraisal for reflection.

Summary

Ms C complained on behalf of Ms A, who was diabetic, that after she had a stent (a mesh tube) inserted into her kidney in April 2013, staff at the Southern General Hospital failed to monitor or remove it. As a result, Ms C said that Ms A was caused extreme pain, which led to her having an emergency operation early in 2014 to remove her kidney. Ms C believed that early intervention with regard to the stent could have avoided this.

We took independent medical advice from a consultant urologist (a doctor who treats disorders of the urinary tract). We found that after the insertion of the stent, it was planned to remove it in July 2013. However, at her anaesthetic pre-assessment for the removal of the stent, Ms A was found to have poor diabetic control, which meant that her operation could not go ahead. Her GP was asked to inform the hospital when Ms A's condition improved so that her operation could be rescheduled. However, the hospital was never updated. The investigation also showed that Ms A's name continued on the waiting list for stent removal and this should have provided an adequate safety net, but it did not. In the meantime, Ms A's stent was removed in England. In these circumstances, we upheld the complaint about the monitoring of the stent. However, in reaching our decision we did not conclude that the failure to monitor the stent ultimately led to Ms A losing her kidney, as there was no evidence that this had been the case.

Recommendations

We recommended that the board:

• make a formal apology in recognition of the failures identified; and
• advise us of the processes that have since been put in place as a consequence of the complaint made.

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent left-sided pain after a fall and attended the practice on numerous occasions over the next two years. Although Mr C had a number of tests and investigations, he was not diagnosed with cancer until a scan over two years after the fall.

The practice apologised that it took so long to diagnose Mr C's cancer, but explained that his case was a challenging one and diagnosis was difficult. They said Mr C did not have symptoms suggesting a serious underlying problem until about two years after his fall, and also did not start losing weight until after this. While they immediately referred Mr C to the colorectal service (specialising in the colon and rectum), it took three specialist referrals (two to the colorectal service and one to the gastroenterology clinic (specialising in the digestive system) before Mr C's cancer was diagnosed about five months later.

After taking independent medical advice, we did not uphold Mrs C's complaint. We found that Mr C's symptoms did not suggest a serious underlying problem until about two years after his fall. We found the practice then acted appropriately and timeously in referring Mr C to specialists for investigations. Our adviser explained that Mr C's symptoms first suggested an underlying colorectal problem, and it was appropriate to refer Mr C for colorectal investigations and a colorectal clinic review. However, when nothing was found but Mr C's problems persisted and he experienced ongoing weight loss, the practice acted appropriately in referring him to the gastroenterology clinic.

Summary

Mr C complained that after breaking a bone in his foot, despite four visits to hospital over a six month period, staff at the Southern General Hospital failed to diagnose and treat him properly. As a consequence, he said that he suffered prolonged and unnecessary pain. Mr C subsequently had an operation abroad to remedy his foot problem. He then complained to the board. The board said that, generally, with the exception of his final attendance at hospital, he had been treated appropriately. However, they apologised that his final visit had been below the standard expected. They said that they had since learned from the situation.

The complaint was investigated and we took independent advice from a consultant in emergency medicine. We found that when Mr C first went to hospital after injuring his foot, he had been diagnosed with a low risk, undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) and treated accordingly. Although it was more rare, we found that he had actually suffered a high-risk, complex fracture (a Jones fracture) which required significantly different management as the blood supply to his foot could have been affected. His further attendances at hospital also failed to establish the nature of Mr C's fracture, so we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology recognising the failures in care and treatment identified; and
• ensure that appropriate staff in the A&E department are made aware of the circumstances of this case and the failures identified, particularly with reference to a Jones fracture.

Summary

Ms C's second child was stillborn. She said that for a number of weeks prior to the birth she had expressed concern but had not been listened to. She said that staff at the Southern General Hospital failed to respond appropriately when she told them that her waters had broken, and that she was not properly assessed or seen by a doctor. Ms C believed that these failures led to her child's stillbirth.

We took independent advice from a consultant obstetrician. We found that Ms C's temperature had not been monitored as it should have been and that, after two examinations following the rupture of her membranes, she should have been immediately induced. There was also confusion about the responsibility of her care and, thereafter, there were failures in providing her with information. We upheld these complaints.

Although Ms C further complained about the quality of information she received about her child's post mortem, it was considered that reasonable explanations were given, so we did not uphold this part of her complaint.

Recommendations

We recommended that the board:

• make a formal apology for these failures;
• confirm to us that the recommendations made as a consequence of their Significant Clinical Incident Investigation report have since been carried out; and
• recognise this shortcoming in their apology.

Summary

Mr C, an advice worker, complained on behalf of his client (Mr A) who had injured his back at home while breaking wood. Mr A was seen at the practice and complained of pain, pins and needles, and numbness. Mr A asked for an MRI scan (magnetic resonance imaging scan), but was referred for an x-ray which raised no concerns. He continued to experience severe pain and numbness in his legs. Following further consultations at the practice he was advised to attend the local A&E department. He was admitted to hospital and diagnosed with a compressed disc which required surgery.

Mr C complained that the practice had ignored serious red flag symptoms of spinal injury on three occasions and considered that Mr A should have been referred for an MRI scan.

We took independent medical advice from one of our GP advisers, and found that the practice would not have been able to refer directly for an MRI scan. However, the GPs at the practice followed the wrong diagnostic pathway and, as such, failed to identify three red flag symptoms. We concluded that, had the correct pathway been followed, Mr A would have been referred urgently to a specialist.

Recommendations

We recommended that the practice:

• apologise to Mr A for failing to make the appropriate referral during his initial consultations; and
• ensure that all the practitioners involved in reviewing Mr A in this case undertake a review of their practice in relation to management of patients with lower back pain. This should include familiarising themselves with the scope of the relevant Pathway for Management of Lower Back Pain referred to in our decision.

Summary

Mrs C's husband (Mr C) had previously suffered from a brain tumour and had a craniotomy (surgery to remove the tumour). However, his symptoms returned about a year later, and he was diagnosed with another brain tumour. Mr C had another craniotomy, followed by six weeks of radiotherapy. Mr C died a few days after his radiotherapy.

Mrs C raised concerns about the delay in diagnosing Mr C's second tumour, as well as the level of support provided during his radiotherapy treatment. Mrs C was dissatisfied that the GP did not arrange admission to hospital during Mr C's radiotherapy (although she asked about this); that the GP did not arrange district nurses or a care plan for Mr C, or carry out more home visits; and that the GP did not manage Mr C's medication appropriately, or provide reasonable care for his diabetes. Mrs C also raised concerns about the practice's communication. She said the GP never told her or Mr C that his condition was terminal, and refused to answer when she asked how much time Mr C had left to live. She was also unhappy that the GP told her it would be fine to go to work the next day when she asked about this, and Mr C died that day.

The practice apologised to Mrs C for several aspects of their care, including not being more proactive about contacting the hospital on Mrs C's behalf, and for advising that it would be fine for Mrs C to go to work on the day Mr C died. In relation to district nurses, the practice said they had offered this, but Mr C had declined. The practice undertook a significant event analysis, and identified steps to improve their communication about palliative care in the future.

After taking independent medical advice, we upheld one of Mrs C's complaints. Although most aspects of the practice's care and treatment were reasonable, we found the GPs failed to take action in response to a letter from the oncologists suggesting medication to help manage Mr C's aggression, and this was unreasonable. We also found the GP used poor judgment in advising Mrs C that she could go to work the day that Mr C died. However, we accepted that the GP had taken appropriate action in response to Mrs C's complaint, including apologising, reflecting on their practice and carrying out a significant event analysis. We did not uphold Mrs C's complaints about communication, as the prognosis would normally be communicated by the oncologists, and there was also evidence that the GP spoke with Mr and Mrs C about the terminal nature of his illness. We also found it was reasonable for the GP to refuse to give an estimate of how long Mr C had left to live, as the GP could not accurately predict this.

Recommendations

We recommended that the practice:

• bring our findings about the failure to consider the oncologist's suggestion about medication to the attention of the relevant GP for reflection and learning.

Summary

Mr C complained about the board's role in the decision-making that he should be taken to a respite care facility (run by a private care provider) for 24 hours when he had already told them that he did not want to go, and then kept there against his express wishes. Mr C told staff when they arrived at the facility that he did not want to be there, but was persuaded to stay until the following day when his father picked him up. Mr C also raised concerns about an earlier decision by the board to instruct members of staff from the private care provider to covertly befriend him at a radio station where he was volunteering given the effect this had on him, particularly when he saw the staff members at the facility the following year.

We took independent advice from our medical adviser. We found that the board failed to act in line with the relevant legislation, which meant that Mr C's rights were not respected. We also said that it was not reasonable that Mr C was told he was going to the facility on the journey there and that this posed a risk. In relation to Mr C's stay at the facility, we found that there was a responsibility on board staff to ensure that Mr C would be returned to his home if that was his wish. The board had accepted that Mr C told staff when he arrived that he did not want to go in and refused initially to leave the car. We found that most of the healthcare professionals involved were doing everything they could to provide Mr C with treatment, despite his clearly stated wishes to the contrary, believing it was in his best interests. We were critical of the board's actions in relation to the decision that staff should befriend Mr C covertly. In doing so the board failed to respect his autonomy. It was our view that the board failed to act in a reasonable way in respect of Mr C's stay at the facility.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure that decision-making capacity is assessed and clearly documented;
• review their actions in light of our findings and bring our decision to the attention of relevant board staff;
• consider using this decision as a case study to inform current practice in similar circumstances; and
• apologise to Mr C for the failings we found.