Health

Summary

Mr C complained that the board had not been able to evidence or explain the decision to regard his mother-in-law as not suitable for continuing care. There had been protracted correspondence between Mr C and the board, however, he remained of the view that the board could not document their decision.

Our investigation, which included taking independent advice from one of our medical advisers, found that Mr C had been provided with all the available medical records relating to his mother-in-law. These medical records showed that Mr C had been invited to participate in the meetings between medical and social work staff at which they decided to transfer his mother-in-law to social care. Mr C had declined to participate in these and declined to pursue legal guardianship for his mother-in-law. The guidance in force at the time did not require the board to provide Mr C with a written decision or reasons for their decision. We found the evidence showed the family were aware that Mr C's mother-in-law would be transferred to social care and that they understood the decision. There was no evidence they had objected to it at the time.

Summary

Mr C complained that clinical staff at The Royal Hospital for Sick Children (Yorkhill Hospital) had not diagnosed his newly born son's illness. Mr C said he took his son to the hospital three times (he left the second time without being seen due to concerns about cleanliness), but it was only on a family holiday some weeks later in England that his son's pyloric stenosis (tightness of the muscle that connects the stomach to the small bowel, thus causing problems with digesting food and vomiting) was identified.

We considered whether the evidence indicated that clinical staff had acted reasonably. We took independent advice from our medical adviser, who confirmed that pyloric stenosis evolves over time. He said there was no specific guidance that staff should have followed in such a case and, on the basis of the information available at the time, he said it was not unreasonable that staff did not carry out additional investigations for pyloric stenosis. Although we took Mr C's concerns into account, we did not consider that the evidence indicated that the care was unreasonable. We did not uphold this complaint, but we did make one recommendation because a urine test had been misinterpreted by a junior doctor as pointing to an infection.

In terms of Mr C's complaint about the cleanliness of the hospital on his second visit (when he left before being seen), the evidence was limited to the signed cleaning checklists for that day and Mr C's version of events. Although we did not in any way doubt his honesty, and we recognised that the cleaning logs did not absolutely prove the level of cleanliness at any one time, on the basis of the limited paperwork available, we did not uphold this complaint.

Recommendations

We recommended that the board:

• consider reviewing their staff guidance for interpreting urine culture results.

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent pain over about two years, following a fall. Mrs C said Mr C attended A&E at Glasgow Royal Infirmary on numerous occasions, as well as being seen by colorectal (bowel) and gastroenterology (digestive system) specialists. Mr C's cancer was first diagnosed over two years after his fall, following a scan which showed possible cancer in his liver. Mrs C raised concerns that Mr C should have been given this scan earlier.

The board considered that Mr C received appropriate treatment and investigations. They said they only had records of Mr C attending A&E on two occasions, although Mrs C said he attended numerous times.

After taking independent medical advice from A&E, colorectal and gastroenterology specialists, we upheld Mrs C's complaint. We did not find any evidence that Mr C attended A&E on more than two occasions, and we found that the care and treatment at A&E was mostly reasonable. However, on one occasion the A&E doctor did not specifically record checking whether Mr C was losing weight (which would have been a 'red flag' symptom), and we were critical of this. We found the investigations carried out by the colorectal service were reasonable and timely, and there would have been no reason for them to arrange a scan, based on Mr C's symptoms and the results of other tests and examinations at that time. We also found the gastroenterology clinic arranged appropriate investigations. However, we found there was a delay of several weeks in performing the initial investigations (including the scan) and reviewing the results, which meant that Mr C's care did not meet the Scottish Government's standards for cancer waiting times (HEAT targets).

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings our investigation found;
• raise our findings about the A&E review with the doctor involved for reflection and learning; and
• review their processes for scheduling investigations arising from suspected cancer referrals, taking into account the 62-day HEAT standard.

Summary

Mr C, who was diagnosed with a personality disorder, had some of his medications reduced and stopped soon after entering prison (although he was still on one anti-psychotic medication). He was then transferred to a different prison, where he raised concerns about his medication and asked to be put back on his original medication. Mr C's lawyers also wrote to the prison and his psychiatrist, asking for him to be returned to this medication. Mr C complained about the board's failure to return him to his previous medication.

The board said that Mr C's medication had been assessed on several occasions, including by his psychiatrist from the community (who had prescribed his previous medications), and his medication was prescribed and reviewed as recommended by the psychiatrists.

After taking independent advice from an experienced psychiatrist, we did not uphold Mr C's complaint. We found that Mr C's medication had been appropriately reviewed by psychiatrists, and there was no clinical reason to restart Mr C's previous medications, particularly as several of these medications were addictive and not for long-term use. We also found that Mr C's psychiatrist from the community had reviewed Mr C while he was in a previous prison, and was in agreement with his current medication.

Summary

Mr C complained on behalf of the family of Miss A that the care and treatment she received from the Royal Aberdeen Children's Hospital was unreasonable in so far as it was decided not to provide her with further Intravenous Immunoglobulin Treatment (IVIG, the administration of blood plasma containing antibodies intravenously/into the veins).

Miss A has suffered a rare, slow progressive peripheral nerve dysfunction since she was small. It was not able to diagnose this definitively until 2012. Before that, Miss A had been treated with IVIG on the basis that there was nothing to lose by doing so. Her mother, Mrs A, thought that IVIG made a significant improvement to her condition and wished the treatment to continue. However, the board were of the view that once a diagnosis had been made which indicated Miss A's inability to process vitamin B2, she should be treated with riboflavin.

The complaint was investigated and we took independent advice from a paediatric neurologist. This showed that Miss A's treatment was in accordance with current medical practice and was reasonable; there would be no benefit from her receiving IVIG. Accordingly, we did not uphold Mr C's complaint.

Summary

Mr C had some of his medications reduced and stopped soon after entering prison (although he was still on one medication). He was then transferred to a different prison, where he raised concerns about his medication and asked to be put back on his original medication. The board arranged for Mr C to see his psychiatrist from the community (who had prescribed his initial medication). The psychiatrist increased Mr C's current medication, but did not return him to his previous medications. Mr C complained about the board's failure to return him to his previous medication, and their handling of his complaint.

After taking independent advice from an experienced psychiatrist, we did not uphold Mr C's complaint about medication. We found there was no clinical reason to restart Mr C's previous medications, particularly as several of these medications are addictive and not for long-term use. We also noted that Mr C's psychiatrist from the community had reviewed his medication and agreed with this.

In relation to the board's complaints handling, we found the board had taken appropriate action in response to Mr C's complaints by arranging review by his psychiatrist from the community. However, on two occasions the board did not respond to Mr C's complaint to confirm what was happening and check that he was satisfied with this, as required by their complaints procedure. Therefore, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the need to acknowledge or respond to all complaints within a three working day timeframe.

Summary

Miss C's MP complained to us on her behalf. Miss C was admitted to Aberdeen Royal Infirmary with an infected appendix, which was removed. She complained about aspects of her nursing care, including that she was not provided with anything to eat or drink on the day of her admission. She also complained that she was not given sufficient information on discharge. In addition, she was unhappy with the time the board took to respond to her complaint and she said their response contained inaccuracies, including the board's view that she was given tea and toast on the evening of her admission.

We took independent advice from one of our nursing advisers, who observed that there was no record of any food or fluids being given to Miss C on the evening of her admission. She said if tea and toast were provided she would have expected this to have been recorded. We upheld this aspect of the complaint.

While the adviser noted that, in light of Miss C's anxiety, the board could perhaps have provided her with extra information and reassurance, she considered that a reasonable level of information was provided to her at the time of her discharge. We did not uphold this aspect of the complaint.

We noted that there was a considerable delay in the board responding to Miss C's complaints correspondence. It appeared as though they had overlooked the complaint. We also noted that information relevant to their investigation was not contained within their complaint file, including notes of key discussions. Further, they failed to address all the points of complaint Miss C raised and some of the information they provided in their response did not appear to be supported by the available evidence. We, therefore, upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• remind nursing staff of the importance of good record-keeping;
• remind complaints handling staff of the importance of issuing full, evidenced and timely responses to complaints;
• remind complaints handling staff that complaint files should contain a complete record of their investigations, including notes of relevant discussions; and
• apologise to Miss C for the complaints handling failures this investigation has identified.

Summary

Ms C, an advice worker, complained on behalf of her client (Mrs A) that the care and treatment provided by her medical practice between June and August 2011 was unreasonable.

Mrs A had a history of abdominal and gynaecological (relating to the female reproductive system) problems and some stress-related illness. She saw three different GPs in June, July and August 2011 for recurrent symptoms of bloating and stomach pain. Some investigations were undertaken but no conclusive results were obtained. Mrs A was seen again by one of the GPs in November 2011 and was referred on a routine basis for a colonoscopy (examination of the intestines by a camera). Further investigations were undertaken in February 2012 and Mrs A was diagnosed with ovarian (part of the female reproductive system) cancer later that month. She has since undergone treatment that was ongoing at the time she complained to us.

Our investigation included taking independent medical advice from one of our GP advisers. They considered that in view of the symptoms reported by Mrs A, the 'watchful waiting' approach taken by the GPs between June and August 2011 was reasonable and in line with national guidance in place at the time. However, our adviser considered that, in view of the duration of Mrs A's symptoms by the time she was seen in November 2011, the referral made at that time should have been made on an urgent basis. This would have indicated a suspicion of cancer, which would have meant that she would have been seen within two weeks of the referral. The adviser did not, however, consider that the resultant six-week delay had an effect on the overall outcome or treatment for Mrs A. The complaint was not upheld but the findings were drawn to the attention of the GPs involved.

Summary

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer.

We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the error made in the administration of his medication;
• explain to us what steps have been put in place to prevent such an incident from occurring again; and
• provide us with a copy of a drug recording sheet.

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.