Health

Summary

Ms C complained that she had not been provided with pain relieving injections for her chronic back pain within the 18 week referral to treatment target. Ms C was initially offered injections to block the nerve with a combination of steroids and anaesthetic. A trial was carried out first, however, using just the anaesthetic, in order to ensure she would respond to these injections, as not all patients find them effective. The board did not accept her treatment had missed this target significantly, as Ms C had received the trial injection some 20 weeks after referral.

Although Ms C did respond to the trial injections, she did not wish to continue with this treatment pathway as she said she wished to proceed with surgical denervation (the blocking of a nerve supply through surgical intervention), which she had discussed as an option at an earlier consultation. When she was told a referral would need to be made to another board area for this procedure, Ms C also complained to us that she had been unreasonably refused a denervation procedure locally.

We took independent advice from a medical adviser, who is a specialist in pain medicine. The adviser said the board's definition of what constituted treatment was unreasonable and contradicted their own patient pathway information. Ms C's assessment of the delay she had experienced in receiving the injection was reasonable. We found that the board had already taken some action to address the delays experienced by Ms C, but that it was unreasonable for them not to accept that her delay had exceeded 30 weeks before she received the full injection treatment. We found the board had failed to write to Ms C as they were obliged to by NHS Scotland guidance when the 18 week target was breached, so we upheld Ms C's complaint about the unreasonable delay in treatment. However, our adviser said that it had not been unreasonable for the board not to provide a denervation service locally, as this was a specialised procedure, which needed to be carried out regularly to ensure optimum results, so we did not uphold Ms C's complaint about this.

Recommendations

We recommended that the board:

• provide details of their review into the delays Ms C experienced and evidence of the action they are taking to avoid a reoccurrence including the information provided to patients; and
• apologise unreservedly for the failure to provide treatment within a reasonable timescale.

Summary

Mrs C complained about the care and treatment she received for endometrial cancer (cancer in the lining of the womb) between April 2011 and March 2012 at Raigmore Hospital. Specifically, she was concerned that she was not given enough information about the cancer and her treatment options. She also raised concerns about the treatment she received in 2011 and about delays in surgery going ahead after evidence of cancer was identified in 2012. Mrs C also complained about inaccuracies in the board's response to her complaint.

We found the record-keeping by the staff involved in Mrs C's care and treatment was of an appropriate standard and reflected reasonable attempts to help her understand the diagnosis and treatment plan. We considered that this was done within a reasonable timescale after she presented with abnormal symptoms in 2011. The board also ensured Mrs C had the opportunity to discuss her concerns about her care with relevant specialists.

We took independent advice on her case from one of our medical advisers who found that the treatment given in 2011 was appropriate and in line with national guidance. Our adviser said that there were certain factors that had to be properly considered before decisions could be made regarding Mrs C's care, because of the risk to her life. Whilst we noted a slight delay in a second opinion being sought after it was indicated in 2012 that there was residual evidence of the cancer, this did not impact on Mrs C's outcome as the cancer was in the early stages and had not spread. We also found that it was not clear whether the results of an abnormal scan were highlighted to the gynaecology team through the multi-disciplinary team process. Although the subsequent delay did not have any impact on Mrs C's prognosis, it is important that radiology staff acknowledge that the referring team may not have the experience to interpret any identified abnormalities and action these appropriate. Whilst we made a recommendation to address this, we concluded that there were justified reasons why the management of her care took time to consider and did not uphold the complaint.

We did not identify any significant inaccuracies in the board's written response to the complaint.

Recommendations

We recommended that the board:

• review the current arrangements for multi-disciplinary team meetings to ensure that there are processes in place for abnormal scan or x-ray results to be flagged and actioned as appropriate.

Summary

Miss C complained that when she attended the out-of-hours service at the Royal Alexandra Hospital with chest pains the doctor diagnosed that she was suffering from flu-like symptoms. The following day the chest pains remained and she was admitted to hospital having suffered a heart attack. Miss C said that she had reported a family history of heart trouble and that she had had ECGs (electrocardiographs - tests to record the electrical activity of the heart) taken previously at the hospital. She felt the doctor should have taken note of this and conducted further tests.

We took independent advice from one of our GP advisers and determined that the doctor who saw Miss C when she attended the out-of-hours service had carried out an appropriate assessment based on the symptoms which were recorded. There was no indication from the medical records that Miss C had reported the previous ECGs or family history of heart problems. The symptoms which Miss C presented with were not indicative of a patient suffering a heart attack. We did not uphold the complaint.

Summary

Mr C complained that for a period of over three months he attended the practice with symptoms of a painful and swollen foot and that they did not refer him to hospital for specialist advice. Initially he was referred to A&E where he was diagnosed as suffering from deep vein thrombosis (a blood clot in the vein). The pain became so unbearable that Mr C again attended A&E where an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) was arranged and this showed that he had peripheral artery disease (narrowing of the arteries which affects the legs). Mr C had had to endure surgery and believed that the practice should have referred him back to the hospital sooner.

We took independent advice from a GP adviser. The adviser said that it appeared that Mr C had developed acute ischaemia (lack of blood supply) of his right limb and that this usually occurs as a sudden event on the background of a patient having peripheral vascular disease (a common condition in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles). However, although the practice had recorded Mr C's continuing symptoms (indicative of peripheral vascular disease) they failed to undertake appropriate investigations themselves or make a referral to the vascular clinic. Our adviser pointed out that although the practice failed to provide Mr C with reasonable care for his peripheral vascular disease his requirement for surgery was as a result of an acute event which could not have been predicted. We upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failings we identified; and
• share this report with all GPs at the practice and reflect on the adviser's comments.

Summary

Mr C attended his dentist for a routine check-up. During this check-up the dentist intended to scale and polish Mr C's teeth (a procedure where tartar build-up is removed from the gumline). Mr C refused, as a previous treatment had caused sensitivity to his teeth. The dentist advised Mr C that if he was unable to perform the treatment necessary then he could no longer provide treatment to Mr C and would remove him from his patient list.

Mr C complained that the dentist had not followed the correct procedures in de-registering him and the reason for de-registering him was unreasonable.

We sought independent advice from a dental adviser. The adviser explained the procedure for de-registering a patient, which involves contacting the local health board. The dentist was unable to provide evidence the correct procedure was followed and we upheld this complaint and made recommendations.

The adviser said that it was an individual clinical decision for the dentist to make about whether the relationship had broken down to the point where they could no longer treat the patient. Therefore, we did not uphold Mr C's second complaint.

Recommendations

We recommended that the dentist:

• revise the guidance on de-registering patients; and
• put in place a system for evidencing that the correct procedure is followed.

Summary

Mr C complained about the care his father (Mr A) received at the Royal Alexandra Hospital's A&E department after attending there with a severe headache. Specifically, Mr C complained that Mr A was not reviewed by a doctor for several hours and there was a delay in taking a CT scan of his head (computerised tomography scan: a specialised x-ray). Mr A had a subarachnoid haemorrhage (SAH: a bleed on the brain). He was transferred to a hospital with specialised services where he suffered a seizure and died.

The board said that Mr A was seen by a doctor within ten minutes of arriving at A&E and that an immediate CT scan had not been performed as Mr A's neurological examination was normal. However, he was admitted to a medical ward with the intention of carrying out a CT scan. The board considered whether there were any lessons to be learned. Consequently, the department have lowered the threshold for when a CT scan should be arranged if a SAH is suspected when neurological examination is normal.

We took independent advice from two of our medical advisers and found that Mr A was assessed promptly by an emergency doctor who had suspected a SAH. However, we were critical that the board would normally only arrange a scan if there was a neurological decline. We considered a scan should have been arranged as soon as the doctor suspected a SAH in line with national guidance. In any case, when Mr A's condition declined in A&E, a CT scan was not arranged until a further decline happened several hours later on the ward.

We were also critical that there was no record to show that the doctor had discussed the merits of arranging a CT scan with the on-call consultant. This was not in line with the General Medical Council's good practice guidance on record-keeping.

Recommendations

We recommended that the board:

• apologise to the family for failing to arrange a timeous CT scan in line with national guidance;
• review their local protocol on the management of headaches to ensure it is in accordance with national guidance; and
• draw to the attention of the emergency doctor the importance of recording discussions about the management of patients in line with good practice.

Summary

Miss C complained that the board had failed to put in place appropriate treatment for her mental health problems when psychotherapy (a type of therapy used to treat emotional problems and mental health conditions) she had been receiving for a fixed period ended. Whilst receiving psychotherapy, Miss C had been diagnosed with autistic spectrum disorder. She was also sensitive to change and had been concerned that she would receive inadequate support when the psychotherapy ended.

We took independent advice from one of our medical advisers, who is a psychiatrist. We found that the board had tried to take active steps to liaise with relevant services to try to ensure that there was adequate support in place for Miss C. However, when the psychotherapy ended, Miss C's community psychiatric nurse was not available and her consultant in the community mental health team had changed. In addition, an autism support group said that they could not support her. We found that inadequate co-ordination and transfer of Miss C's care left her with inadequate support in place for her identified needs at that time. In view of this, we upheld her complaint.

The board had already apologised to Miss C for their failings and had said that the learning points would be fed back to clinicians, but we made one recommendation.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to prevent the problems that arose in Miss C's case from recurring.

Summary

Ms C was a new patient at a dental practice where she presented with a chipped tooth. She saw a dentist who examined her mouth and did an x-ray which revealed some decay. She attended the dentist six times within two months and during this time, root canal treatment was commenced, she had one extraction and four fillings.

Ms C complained about the care and treatment she received. She said that it had been unnecessary and left her with damaged teeth and in pain. However, the dentist said that she had presented with extensively damaged teeth which required attention and that although Ms C had had a difficult time, this was as a consequence of extensive decay. Despite her best efforts, the dentist said that she had been unable to save one of Ms C's teeth.

We took independent dental advice, and found that Ms C's notes were poorly recorded and that while decay was present in some of Ms C's teeth for which treatment was necessary, it appeared that one of Ms C's teeth had been treated in error while a damaged tooth received no treatment. We also found that some of the decay was minimal, not requiring the extensive drilling that was undertaken. While the dentist recorded that she had had to give Ms C extensive treatment, the condition of Ms C's mouth as recorded in her notes suggested that she only required oral hygiene advice. We upheld Ms C's complaint.

Recommendations

We recommended that the dentist:

• make a full apology; and
• undergo additional training in record-keeping and address the concerns raised by the adviser as part of her continuing professional development. She should confirm to us that she has done so.

Summary

Mr C complained that the board failed to monitor the steroid treatment he was receiving for his chest condition and its consequences. He said the lack of monitoring systems in place resulted in him developing cataracts; his adrenal glands (two small hormone secreting glands, one located above each kidney) no longer functioning; and in him developing osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break). Mr C also complained that when he emailed the board three questions about the side effects of steroids, the points he raised were never answered.

We obtained independent advice on the case from our medical adviser, a consultant in respiratory and general medicine. Our adviser said the information available suggested that the steroid treatment Mr C received was in line with both formal guidelines and established clinical practice throughout the UK. He explained that there was no universal agreement as to whether, or how, to monitor patients who were receiving steroids for bone loss and said the guidelines indicated that it was only when courses of treatment lasted three months or more that any form of osteoporosis screening or treatment needed to be considered. In Mr C's case, it appeared that his steroid was prescribed in short courses, suggesting that monitoring was not required.

Our adviser said he was not aware of any guidelines which suggested that monitoring for adrenal suppression (where the adrenal glands do not produce adequate amounts of steroid hormones) or cataracts was a necessary component of steroid therapy for adults. He also said it was not usual practice to screen patients with Mr C's chest condition needing short course steroid treatment for cataracts.

In terms of Mr C's three questions to the board, they acknowledged that osteoporosis, cataracts and adrenal suppression were known side effects of steroid therapy. They explained their policy on screening/monitoring for osteoporosis and adrenal suppression. While we feel the board could have commented on screening/monitoring for cataracts, on balance, we considered their response covered the main points in Mr C's email.

Summary

Mrs C complained about the standard of treatment she received during her pregnancy and labour given that she had developed antibodies which can cause anaemia in babies during pregnancy. In particular, Mrs C was concerned about the way the pregnancy was managed, and the lack of urgency shown by staff in the antenatal ward and the delay in the delivery of her baby at the Southern General Hospital. As a result, she said that she and her baby had to remain in hospital during which time her baby had to have blood taken regularly. Mrs C said that the treatment she received was unacceptable and she remained extremely distressed about her experiences.

We took independent medical advice from three advisers, who are specialists in obstetrics and gynaecology, paediatric haematology and midwifery. We found that the antenatal care was reasonable and that Mrs C was monitored and managed appropriately in light of the complication. We also found that while there was a delay between admitting Mrs C to hospital to an antenatal ward, and then admitting her to a labour ward to induce labour, this was reasonable given Mrs C's and her baby's clinical condition at the time. Overall, we found that the standard of in-patient care and treatment was reasonable but made a recommendation in light of one of the adviser's concerns about staffing levels.

Recommendations

We recommended that the board:

• review how frequently patients' transfer to the labour ward at the hospital during induction of labour have been delayed to ensure they are satisfied the unit has sufficient capacity for its workload.