Health

Summary

Mrs C complained about the mental health care and treatment provided to her late son, as well as the lack of support for her and her family, the lack of family involvement in the critical incident review (CIR) following her son's death, and the delay in providing her with a copy of the CIR report. Mrs C also complained to the General Medical Council (GMC) about the psychiatrist involved in her son's care. The GMC investigated, and decided to take no action.

We decided not to re-investigate those matters which had already been considered by the GMC. However, we agreed to investigate some issues which had not been looked at by the GMC, including the conduct of a mental health assessment, the support provided to the family, and the complaints about the CIR.

After taking independent mental health advice, we upheld three of Mrs C's complaints. We found that the board unreasonably failed to include Mrs C in the CIR process and that the delay of over six months in providing Mrs C with a copy of the CIR report was unreasonable. However, we accepted that the board had apologised for this delay and taken appropriate steps to improve their CIR process.

We also found the board had not provided reasonable support for Mrs C and her family as carers. While the board had since amended their paperwork to improve involvement of carers at the assessment stage, we did not consider this was sufficient to prevent a recurrence, as the meaningful involvement of a person's relatives should be on-going, rather than completed as a one-off exercise.

In relation to the mental health assessment of April 2011, we found this had been conducted reasonably, and we did not uphold this complaint. However, we were concerned that there had been a delay in arranging a referral to a psychiatrist following this assessment, and we raised our concerns about this with the board.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings our investigation found; and
• advise us how they will ensure on-going carer involvement, in light of our adviser's comments.

Summary

Mr C complained that the prison health centre unreasonably refused to prescribe him detoxification medication. The board advised that a nurse carried out a number of assessments on Mr C which confirmed that he was not showing signs of withdrawal from drugs. Therefore, it was decided there was no medical need for him to be prescribed detoxification medication. We took independent advice from one of our GP advisers who confirmed that the care provided to Mr C appeared to be appropriate. Therefore, we did not uphold his complaint.

Summary

Miss C complained to her mother (Mrs A)'s medical practice about how they dealt with Mrs A in the last two days of her life. Miss C then complained to us that a GP failed to diagnose and treat Mrs A's condition; that reception staff wrongly referred her mother to NHS 24 rather than arranging for a house call from a GP; and about the practice's handling of her complaint.

We looked at the practice's file on Miss C's complaint and at Mrs A's medical records, and we took independent advice from one of our GP advisers. We found that Mrs A had a number of risk factors for a heart condition, and we decided that the GP should have taken these into account by reviewing Mrs A's blood pressure and pulse, given the possibility of a heart-related cause for her symptoms. We concluded that the assessment and treatment provided by the GP was not of a reasonable standard. We also concluded, on the balance of the available evidence, that reception staff were wrong to refer Mrs A to NHS 24, rather than offering an emergency appointment at the practice or a home visit from the on-call GP. We also found that the practice's handling of Miss C's complaint was not in keeping with the principles set out in the national NHS complaints handling guidance. We upheld Miss C's complaints.

Recommendations

We recommended that the practice:

• apologise to Miss C for not providing a reasonable standard of care, treatment and service to Mrs A;
• apologise to Miss C for the failure to deal with her complaint adequately;
• provide us with evidence of how practice medical staff learned from this case;
• review the practice protocol for late calls and emergency appointments; and
• refresh their understanding of national complaints guidance and review their complaints procedure to ensure that the procedure, and staff practice in dealing with complaints, is in line with the guidance.

Summary

Mr C complained on behalf of his brother (Mr A) that the board failed to diagnose Mr A's testicular torsion (the twisting of a testicle, which shuts off the blood supply and can result in the loss of the testicle) and inappropriately discharged him from the Southern General Hospital. Mr A later had to have a testicle surgically removed. Mr C was also unhappy with the board's handling of his complaint.

We found that, as acknowledged by the board, there was a series of failings when Mr A was in hospital. The main issue was that an on-call urologist (a doctor who treats conditions of the urinary tract) should have examined Mr A in person to exclude or confirm testicular torsion. We also found that hospital staff who were asked to comment on Mr C's complaint agreed that Mr A should not have been discharged without being examined by the urologist and being given an ultrasound scan (a scan that uses sound waves to create images of structures inside the body). A lack of available beds may have been a factor in Mr A's discharge.

We found that the board's investigation of Mr C's complaint was reasonably thorough, and their letter to him acknowledged failings and apologised for them. However, we found that the investigation was missing a statement from the doctor who took the decision to discharge Mr A. This was an important aspect of the events in question because it was this doctor who raised the issue about there being no available beds. In our view, the lack of evidence from this doctor compromised the board's investigation. We upheld all of Mr C's complaints.

Recommendations

We recommended that the board:

• share widely within the urology service the circumstances of Mr A's care;
• discuss the details of this case with the on-call urologist;
• share the circumstances of Mr A's care with the out-of-hours service and the emergency department;
• explain to us why a statement was not obtained from the doctor who discharged Mr A;
• ensure that the details of this case are discussed with the doctor who discharged Mr A; and
• provide us with confirmation regarding the availability of beds in relation to Mr A's discharge.

Summary

Ms C was referred by her GP for her painful right ankle to be reviewed. She complained that she experienced an undue delay in receiving appropriate treatment.

We took independent advice from a consultant orthopaedic and trauma surgeon. We found that Ms C's first appointment for treatment with a foot surgeon was just over 39 weeks after her referral. This was longer than the board's waiting time policy. However, in the meantime, Ms C had been sent on a different treatment pathway by being referred to a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb), a consultant orthopaedic surgeon and then finally a foot surgeon. She had also refused appointment times that had been offered and had been quite specific about where she would receive treatment. This all affected her waiting time.

We took the view that it would have been more appropriate, given the terms of her referral, for Ms C to have been referred directly to a foot surgeon and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the overall delay in providing a date for surgery; and
• bring the complaint to the attention of those staff who assess referrals of this type for them to reflect on the advice given.

Summary

Mr C complained that he had not received appropriate care following an operation on his urinary tract. He said that because the consultant had not examined him appropriately at a post-operative consultation, the consultant did not realise that Mr C's condition had deteriorated. Mr C said that meant that he was in significant discomfort until a further consultation six months later, when the problem was identified and he underwent a further operation. He was then taught a technique for self-help which aimed to support the work of the operation, to avoid a further recurrence. Mr C complained that the board had not referred him for this self-help technique after his first operation.

We sought independent advice from a urology consultant. Our adviser noted that there was limited information on file about what happened at the post-operative consultation, but that given the concerns expressed by Mr C (and referred to in the records) it would have been reasonable for the consultant to have examined Mr C in more detail, and undertaken various tests to identify how his condition had changed. Our adviser was critical of this, and of the limited information in the notes from the consultation. However, our adviser also noted that while some consultants may sometimes refer patients to the self-help technique after a first operation, it was reasonable that Mr C was not taught this until after his second operation.

We were critical of the level of follow-up Mr C was given following his first operation, particularly given the concerns he raised during his consultation. We noted that, while the clinical notes provided limited information about what was discussed, we were satisfied that Mr C raised concerns which were not sufficiently investigated. We were also critical of the level of record-keeping.

Recommendations

We recommended that the board:

• highlight the findings of this investigation to the consultant involved, and remind him of the General Medical Council's requirements in relation to record-keeping; and
• apologise to Mr C for failing to provide an appropriate level of treatment during his first post-operative consultation.

Summary

Ms C complained that she had not been provided with the appropriate post-operative treatment following a bunion operation in 2011. She had had a second procedure in 2014. This, however, had left her with nerve damage and requiring a brace on her foot to walk. Ms C said she had not been properly assessed for surgery in 2014 and that the appropriate treatment had not been carried out.

We took independent advice from a surgeon who specialised in operations on the foot and ankle. The advice we received was that Ms C's operations had been carried out properly and that she had received appropriate care and support after both operations. The risks had been explained to her before the operation, including the risk that the operation would make Ms C's foot condition worse. Our investigation found the evidence showed Ms C had been appropriately assessed for surgery and that the operation carried out was the appropriate treatment.

Summary

Mr C and Miss A complained about the care and treatment Miss A received during her antenatal period. In particular, they were concerned that their baby had been born at home rather than in hospital as planned. They complained that the responsibility for the birth of their baby occurring at home lay with the board and that the board had failed to stay in control of the birth. They were also concerned about the advice given when they contacted the Maternity Assessment Unit (MAU) at the Princess Royal Maternity Hospital (the hospital) just hours before the birth of their son. Miss A and Mr C also complained about the board's handling of their complaint.

We took independent medical advice from one of our advisers, a consultant obstetrician. We found that the care and treatment given to Miss A during her antenatal period was reasonable and appropriate and that appropriate observations were made at each antenatal clinic attendance which had occured at appropriate intervals. We also found that the advice given by the midwife when they contacted the MAU at the hospital was acceptable and appropriate.

When responding to their complaint, we found that the board had accepted that Miss A and Mr C had experienced poor communication during the antenatal period and following the birth of their baby. The advice we received was that the board had also provided a reasonable and appropriate response to the issues raised by Miss A and Mr C. The board explained that the concerns about communication had been discussed with staff. While we recognised that the board had already apologised to Miss A and Mr C, we made one recommendation.

Recommendations

We recommended that the board:

• provide details on the action taken in this case to ensure improved communication with patients and their families.

Summary

Mr C complained that the GPs at the practice had failed to provide adequate care to his wife (Mrs C) resulting in the late diagnosis of her pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs). Mr C said that this late diagnosis had led to subsequent serious health problems for Mrs C. He said she had repeatedly attended the practice with symptoms consistent with a pulmonary embolism, but that GPs had failed to refer her for the appropriate investigations. He added that on one occasion his wife had been asked to contact a hospital by herself, despite a dangerously elevated heart rate.

We obtained independent advice from an adviser on general practice medicine. They found that Mrs C was appropriately investigated initially. The advice also said that Mrs C's symptoms were non-specific and appeared to resolve for extended periods following treatment, so it was reasonable of the practice to have adopted a policy of watchful waiting. The advice noted that Mrs C's incidents of elevated heart rate were in fact in keeping with the monitored limits as defined by her pacemaker clinic and that it was, therefore, appropriate for her not to be referred as an emergency on that occasion.

We found that although Mr C had repeatedly referred to alternative medical opinion having been provided which supported his complaint, no attributed submissions were contained within his complaint. We found the actions of the practice were reasonable and appropriate, although we acknowledged the experience had been distressing for Mr C and his family.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mr B) about the care and treatment given to his late sister (Miss A). After a hysterectomy in February 2013, Miss A was diagnosed as having endometrial cancer (cancer in the lining of the womb) from which she made a good recovery. However, in May 2014, her GP referred her urgently back to hospital as she was suffering from nausea. She was seen shortly afterwards and it was considered that her symptoms related to her recent cancer treatment and the drugs she required to take. Miss A then began to complain of pains in her hip and was referred for a CT scan (which uses x-rays and a computer to create detailed images of the inside of the body). The scan results showed that Miss A had a recurrence of cancer and that it was inoperable. Miss A died in November 2014.

Mr B complained that after her initial cancer treatment in February 2013, the board failed to provide his sister with adequate follow-up. He also said that following Miss A's terminal diagnosis in August 2014, she was not given adequate palliative care.

We took independent advice from a consultant gynaecologist. This showed that after Miss A was first diagnosed with endometrial cancer, her case was discussed by a multi-disciplinary team and on their recommendation, she was given radiotherapy and a number of cycles of chemotherapy. She also attended out-patient clinic appointments in April and November 2013 and then again in April 2014. There was also evidence to show that once she was given a terminal diagnosis, palliative care was instituted for Miss A and Macmillan nurses became involved. She was given pain relief and other medication to reduce her symptoms, but the advice we received was that the extent of Miss A's illness was such that her death could not have been prevented. We did not uphold the complaint.