Health

Summary

Mrs C developed deep vein thrombosis (DVT, a blood clot in one of the deep veins in the body) after having surgery at Forth Valley Royal Hospital. Mrs C was readmitted to hospital, where the diagnosis was confirmed and she was started on a medication to treat DVT. After she was discharged, Mrs C's GP referred her to an out-patient clinic at the hospital (the Clinical Assessment Unit), as Mrs C's legs were swollen and she was suffering pain. Mrs C was reviewed by a doctor, but not admitted to hospital. Mrs C then received an appointment for a scan at another hospital out-patient clinic (the Day Medicine Unit). When she arrived, the staff were not sure why she was there, and said she did not need a scan. However, a doctor reviewed Mrs C and arranged for her to be seen by a consultant vascular surgeon, who then took over Mrs C's care.

Mrs C complained about her overall care and the confusion about her appointment at the Day Medicine Unit. Mrs C was concerned that her DVT may have developed in her first hospital admission (and been misdiagnosed as an infection), that she may have been discharged too early after her second admission, and that she should have been given a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) or referred to a surgeon earlier.

The board apologised for a number of failings. The board took a number of actions to address the issues raised by Mrs C's complaint, including developing a ward checklist for checking the use of anti-embolism stockings (specially fitted elastic stockings used to compress the lower leg and reduce the risk of blood clots); developing a patient information leaflet on DVT; arranging for certain types of DVTs to be referred for a CT scan and discussed with a vascular surgeon as a matter of routine; reviewing the patient pathway for the provision of specialist hosiery; and establishing a seven-day service for management of DVTs within the Day Medicine Unit.

After taking independent medical advice, we upheld two of Mrs C's four complaints. We found that, while most of the care and treatment provided was reasonable, the overall approach to Mrs C's care was fragmented, with a number of different doctors and departments involved. This meant that Mrs C received inconsistent information about her condition and care. We also found the board failed to provide the correct anti-embolism stockings and gave inconsistent information about the medication prescription in Mrs C's discharge letter. While we accepted that the action identified by the board in response to Mrs C's complaint was reasonable, we recommended they demonstrate to us that this action is completed within the timeframes they gave.

Recommendations

We recommended that the board:

• demonstrate to us that a consistent pathway for the provision of specialist hosiery has been established;
• review the pharmacy process for checking discharge letters and prescriptions to ensure that any discrepancies in the instructions are clarified appropriately; and
• demonstrate to us that the arrangements for DVT management by the Day Medicine service are in place, including raising staff awareness and updated documentation.

Summary

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this. However, a further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process.

We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for their role in the decision to remove him from the ACT 2 Care process at the meeting in question, and also for the inappropriate entry made in his healthcare record;
• ensure all relevant staff are aware of the ACT 2 Care approach to self-harm;
• make the mental health nurse involved in this case aware of the adviser's comments and ensure that this is included for discussion at their next appraisal; and
• issue Mr C with a legible copy of the complaint form.

Summary

Mr C complained on behalf of his daughter (Mrs A) who injured her head and neck in a sporting incident. Mrs A was taken to A&E at Forth Valley Royal Hospital and admitted to the orthopaedic ward. X-rays were taken of her neck and finger, and an MRI scan (magnetic resonance imaging scan, used to diagnose health conditions that affect organs, tissue and bone) was taken of her neck. Medical staff did not consider she had a significant head injury and she was discharged after three days. Mrs A continued to suffer symptoms from her accident and was referred to a specialist a few months later. A head MRI was taken which showed she had suffered a head injury and she was referred to the neurology department. Mrs A was diagnosed with post-concussion syndrome. Mr C complained about the delay to Mrs A's diagnosis and expressed his concern that this may have affected her recovery.

We were critical of a number of aspects of Mrs A's care. We took independent medical advice from three advisers (a consultant in orthopaedic and trauma surgery; an emergency medicine consultant; and a nurse). We found that Mrs A's symptoms should have prompted a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) of her head in line with national guidance. We also found that Mrs A's condition was not monitored adequately in A&E, nor were her neurological symptoms adequately monitored in the orthopaedic ward. We were critical of a lack of record-keeping, which prevented us from commenting in detail with regard to a number of points Mr C had raised.

Recommendations

We recommended that the board:

• provide evidence of action taken in response to Mr C's complaint;
• issue a written apology to Mrs A for the failings our investigation found; and
• take steps to increase staff awareness of SIGN 110 (guidelines for the early management of patients with a head injury, written by Scottish Intercollegiate Guidelines Network), including the requirement for regular neurological monitoring and the indications for CT scans.

Summary

Mr C was taking rivaroxaban (medication that thins the blood in order to minimise the risk of a stroke) when he was scheduled for non-emergency surgery. Due to the possibility of excessive bleeding during a surgical procedure, Mr C was advised to stop taking his medication seven days prior to surgery. Four days after Mr C stopped taking his medication, he suffered a stroke.

When Mr C complained, the board and Mr C's consultant appeared unclear about whether Mr C was on rivaroxaban or warfarin (another drug used to prevent blood clots, which Mr C had previously been taking). The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication. They also said Mr C was classed as 'low risk' of stroke and the advice he was given was accurate. They said that, in light of his complaint, they would develop further protocols for staff.

Mr C complained he should not have been classified as low risk, and should not have been advised to stop his medication. We sought independent advice from one of our advisers, who is a consultant geriatrician with specific experience in stroke medicine. The adviser was clear that Mr C was given incorrect advice about stopping his medication. Warfarin guidelines are not applicable to rivaroxaban, and Mr C should only have been advised to stop his medication for 24 to 48 hours prior to the surgery. The adviser accepted rivaroxaban was a relatively new drug, however, he stressed that this meant clinicians should be more cautious and seek guidance from colleagues if they were unclear. The adviser also noted that the board did have specific guidelines for the drug and there were many more available online. The adviser also concluded, in light of Mr C's previous medical history, that he should have been classified as being at 'moderate risk' of stroke.

For these reasons we upheld Mr C's complaints. We were also critical of the complaint investigation, which was unable to clarify whether or not Mr C's consultant was aware of the type of medication Mr C was on.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• provide us and Mr C with the updated protocols regarding rivaroxaban;
• ensure Mr C's consultant discusses this complaint as part of their annual appraisal; and
• feed back to staff the importance of clarifying at the time why a situation occurred, not retrospectively.

Summary

Mrs C had been admitted to Dumfries and Galloway Royal Infirmary for pelvic floor repair, as she had a prolapse of the wall between her vagina and rectum. She said that she was only told that she might need a vaginal hysterectomy (surgery to remove the womb through the vagina) on the morning that the surgery was to be carried out. She then had a vaginal hysterectomy later that day. Mrs C complained about the action taken in relation to consent for the procedure. We took independent advice from one of our medical advisers, who is an experienced consultant gynaecologist. We found that it was unreasonable that Mrs C was only told about the possibility of such a significant procedure on the day of the surgery and that she was given little time to consider this. We considered that Mrs C should have been told about the possibility that she needed a vaginal hysterectomy at an earlier stage, and we upheld this aspect of her complaint.

Mrs C also complained about the procedure that was carried out. Although we had concerns about the consent process and considered that Mrs C should have been told about the possibility of a vaginal hysterectomy earlier, we found that it had been appropriate for this to be carried out.

Mrs C also complained about the pain relief she had received after the operation. We found that the pain relief had been reasonable. Finally, she complained that the standard of medical and nursing record-keeping was unreasonable. Although there were some missing/incorrect dates and times in the documentation, we found that the notes were of an acceptable standard. Consequently, we did not uphold these aspects of her complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to ensure that the possibility of a vaginal hysterectomy is discussed at an early stage with patients who are to undergo pelvic floor repair; and
• issue a written apology to Mrs C for the failure to mention the possibility of a hysterectomy to her at an earlier stage.

Summary

Ms C's daughter (Miss A) was born with hydrocephalus (a build-up of fluid on the brain causing pressure), and from the age of about two years old, she began to suffer multiple infections and seizures. She was admitted to hospital on many occasions and Ms C was informed that her daughter was likely to have epilepsy. Miss A was diagnosed as having gastroenteritis (inflammation of the stomach and intestines) when she was three. Meanwhile, her seizures continued and Ms C was advised that they were probably due to her underlying fever and gastroenteritis. Ms C was unhappy as she considered that no progress was being made to establish the cause of her daughter's symptoms or to treat her properly. In the circumstances, she took Miss A to a children's hospital in another board area where she was diagnosed with a cerebral abscess and where she remained for five months.

Ms C complained of the delay in diagnosing her daughter and of the board's failure to refer her to the children's hospital in another board area for treatment. She was unhappy with the way they responded to her complaint.

We investigated the complaint and took independent advice from one of our medical advisers, who is a consultant paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there had been a delay in diagnosing Miss A and that there may have been a missed opportunity to do this sooner. We also found that, while the board had intended to refer Miss A to the children's hospital in another board area, for reasons unknown, no appointment was made. We also found that there had been undue delay in providing a response to Ms C's concerns and that although a detailed letter was drafted, it was not sent. A meeting arranged to replace the letter took place months later. The complaint was upheld.

Recommendations

We recommended that the board:

• make a formal apology to recognise the delay in diagnosis;
• advise us what actions have been taken since the meeting to improve the two-way flow of communication between the hospitals identified;
• make a formal apology for their failure to respond adequately to the complaint; and
• emphasise to the staff concerned the importance of adhering to their complaints process and of the necessity for good, clear and timely communication.

Summary

Mrs C had a complex medical history including undergoing brain surgery in 2004. She continued to experience a variety of symptoms that were very concerning, and she complained about aspects of the care and treatment she received from her medical practice in 2013 and 2014 in relation to medication and communication.

We took independent advice from one of our medical advisers. We found that the practice communicated with Mrs C in a reasonable way in that they attempted to explain treatment decisions. We also found that the practice took reasonable steps to explore the possibility of a link between Mrs C's previous surgery and her current symptoms, and that the medication they had prescribed was reasonable.

Summary

Mrs C complained about the care the treatment her late mother (Mrs A) had received from the medical practice in the months prior to her death. Mrs A had been admitted to hospital as it appeared she had suffered mini strokes. However, following her admission she was diagnosed with metastatic cancer (cancer that spreads to other parts of the body), and died shortly thereafter.

We took independent advice from one of our GP advisers, who said that Mrs A had been suffering from anxiety symptoms and memory problems for which she had been prescribed medication. Our adviser considered that Mrs A had been regularly reviewed by the practice, and there was no pattern or evidence to suggest Mrs A had an underlying diagnosis of metastatic cancer or the medication she had been prescribed masked any symptoms of metastatic cancer or strokes.

Although we considered the care and treatment Mrs A received was mostly reasonable, we found certain aspects of her care fell below this standard.

While, generally, the medication Mrs A was prescribed and its monitoring was appropriate, one of Mrs A's medications which had been stopped was still being prescribed.

We found a failure to action the results of a liver function test result although we accepted the result would not have triggered any concerns of underlying metastatic disease.

While communication with Mrs A's family was of a reasonable standard, we found that one of the doctors had used insensitive and inappropriate language during a home visit to Mrs A, and the practice could have done more to ensure that they had complied with a specific request from Mrs A's family to be present during a home visit given Mrs A's memory problems and that they were her carers.

Recommendations

We recommended that the practice:

• ensure they discuss Mrs A's case and the complaint as a significant event review, paying particular attention to safe acute and repeat prescription prescribing for the elderly and in their communication with carers of patients;
• share with relevant staff our adviser's comments concerning the apparent failure to action and follow-up the abnormal liver test result, and advise what action has been taken to ensure this does not recur;
• provide confirmation that the doctor in question will discuss the inappropriate use of colloquial language at his yearly appraisal; and
• apologise to Mrs C and her sister for those aspects of Mrs A's care which fell below a reasonable standard.

Summary

Mr C complained that his dental practice had failed to make a referral to the dental hospital within a reasonable timescale. Mr C had teeth which required extraction, and he said that it had taken a long time to get an appointment for this procedure to be carried out. Mr C had other health conditions which meant that once they had received his referral, the dental hospital had made contact with other health professionals involved in Mr C's care to ensure that his treatment could take place. Whilst we recognised that the delay was frustrating for Mr C, we did not find any evidence that any delay was caused by the practice.

Mr C also complained that he had been asked to make a payment to secure an appointment with his dentist and was told this was because he had previously cancelled appointments. Mr C was unhappy with this as he said he had always had good reason to cancel and had given sufficient notice. We considered that the dentist had acted reasonably as Mr C had cancelled a number of appointments late or failed to attend. It was, therefore, not unreasonable for the dentist to apply the practice's policy of charges for failed appointments.

Summary

Mr C told us that when he attended Ninewells Hospital after he was referred by his GP he was told on arrival by a doctor that he should be at a different hospital. He said that another doctor then arrived in the waiting area, apologised for the mix-up and referred him to the phlebotomy department (which deals with taking blood samples). Mr C wrote to the board to complain about the conduct of staff on duty whilst he was at the hospital. Mr C disagreed with the board's response that the staff concerned could only remember limited information, and brought his complaint to us.

We did not take Mr C's complaint about staff conduct any further as there was no way for us to independently verify the truth of statements given.

We upheld Mr C's complaint about the board's handling of his complaint as we found the board failed to deal properly with Mr C's complaint about staff conduct. The board failed to seek clarification on Mr C's specific concerns and consider all points. We did not make any recommendations as the board have already taken steps to prevent a re-occurrence of the problems Mr C experienced.