Health

Summary

Ms C complained about the care and treatment she had received from the board. She felt she was discharged too promptly following minor surgery at Glasgow Royal Infirmary and, when she was readmitted to the Western Infirmary, that she was given inadequate medication. Ms C was also unhappy about her follow up care following her second discharge.

Our role was to assess whether Ms C's treatment was reasonable in the circumstances. We took independent medical advice which said that clinical staff had, on each occasion, followed the relevant guidance. Our adviser did not think additional steps should reasonably have been taken either time or that Ms C's medical outcome would have been different had she remained in hospital longer. He also had no concerns about Ms C's medication.

Although the adviser noted that many surgeons would have discharged Ms C to her GP practice without planned follow-up, the fact was that follow-up care had been planned for Ms C after she was discharged from the Western Infirmary. We took account her difficulties contacting staff to obtain this care (there had been an administrative error booking her appointments), but recognised that Ms C was ultimately seen at a follow-up appointment. The board also confirmed the steps they had taken as a result of Ms C's complaint and so, although we took this shortcoming into account, we did not consider that Ms C's care as a whole had been unreasonable. We did not uphold her complaint.

Summary

Mr C experienced dizziness and balance problems after an operation on his ear in 2007. In 2012 he was referred to Glasgow Royal Infirmary's ear nose and throat (ENT) department. After examining Mr C, the ENT consultant wrote to the GP saying that he could find no physical cause of Mr C's symptoms. He referred Mr C to the Royal Alexandra Hospital for specialist tests, but commented that he felt some of Mr C's symptoms were not genuine. The specialist tests identified that Mr C had an almost complete loss of vestibular function (the system in the ear that contributes towards balance) in his left ear. Mr C complained that the ENT consultant in the first hospital did not carry out appropriate diagnostic tests or provide suitable treatment for his condition. He also complained that the second hospital did not keep his GP adequately informed of the tests that he was undergoing or his diagnosis.

We took independent advice from one of our medical advisers, who is a consultant ENT surgeon. Although we were critical of the ENT consultant's comments in his letter to Mr C's GP, we were generally satisfied that he assessed Mr C's condition appropriately and made a suitable referral for specialist treatment. That said, we took the view that he could have given more consideration to the need for a magnetic resonance imaging scan (used to diagnose health conditions that affect organs, tissue and bone), and the potential effects of Mr C's existing medication. We were satisfied that Mr C's GP was provided with adequate information about the investigations into his symptoms and his ongoing treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the ENT consultant's suggestion that his symptoms were not genuine; and
• share our decision with the ENT consultant with a view to identifying any points of learning.

Summary

Ms C complained about the care and treatment she received during the birth of her son. In particular, she complained that there was a delay in the decision being taken to deliver her baby by caesarean section, that midwives took too long to react to complications, and that she had been left without staff being present for long periods of time. Ms C was also unhappy with the level of information given to her during the birth of her son and complained that the board failed to communicate effectively with her.

We took independent medical advice from one of our advisers. Our investigation found that overall the care and treatment given to Ms C was unreasonable. The advice we received was that her observations should have been taken more frequently, especially following Ms C's raised temperature. We also found that there was a lack of close monitoring of her vital signs and that an obstetric early warning system chart should have been used to record Ms C's vital observations. The advice we received was that these observations are important signs that may suggest serious illness and warrant immediate medical referral. In the circumstances, we upheld the complaint that the board had failed to provide appropriate care and treatment to Ms C during labour.

Our investigation also found that, while the midwife had communicated with Ms C on some issues, there was no evidence that some of the examinations carried out were explained, or that concerns about her raised temperature or transfer to another ward was discussed with Ms C or that Ms C's ongoing treatment plan was discussed with her. We found that the board had failed to communicate effectively with Ms C and we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings we identified;
• provide us with an action plan which addresses the failings identified in the assessment, monitoring and evaluation of vital signs, which should include the use of the obstetric early warning system chart and the triggers for referral to an obstetrician; and
• provide us with an action plan which addresses the communication issues identified in this investigation, which should include involving women and their partners in the ongoing plan of care and any concerns about labour and recording information /communication.

Summary

Mr C complained about some dental work he had done. He was unhappy because he did not think he had been given sufficient information about the procedure. He had a replacement bridge fitted (a device to replace a missing tooth), and was unhappy with the colour and size of the crown. Mr C was also concerned that, when the dentist tried to remove the crown, he was unable to do so.

We took independent dental advice on this complaint. The adviser noted that it was not clear exactly what information Mr C had been given in relation to his proposed treatment, because there was not enough detail in his notes. However, he said that from the evidence available, it was reasonable for the dentist to have suggested that a new bridge was necessary. He also said that, while the replacement bridge had not been an appropriate fit, the dentist had taken appropriate action in offering to replace it. He also noted that crowns can be difficult to remove, and that the dentist had acted with appropriate caution in choosing to drill the crown off, rather than try and remove it by force.

On the basis of the advice we received, we were satisfied that, while Mr C's dental treatment was not as straightforward as Mr C would have liked, the dentist's actions were reasonable, and he acted in Mr C's best interests.

Recommendations

We recommended that the dentist:

• review current record-keeping standards and take steps to ensure these are applied in practice.

Summary

Mrs C complained on behalf of her client (Mrs B) whose late partner (Mr A) was treated in Dr Gray's Hospital and the Fleming Hospital. Mr A was admitted to Dr Gray's hospital after wandering from his home in a confused state. He was subsequently transferred to the Fleming hospital where he reported severe abdominal pain to Mrs B. Although Mrs B reported this to nursing staff, she conceded that she did not think they had heard her. Mrs C complained that Mr A's pain was not investigated by staff until the following day. She also complained that there was a delay in treating Mr A.

Mr A had previously been diagnosed with a duodenal ulcer (an ulcer in the first part of the small intestine). A doctor at the Fleming hospital considered that this may have perforated and arranged for Mr A to be transferred back to Dr Gray's hospital. A chest x-ray was carried out to check for free air in the abdomen which would indicate a perforated ulcer. No free air was identified and Mr A was diagnosed as having a chest infection. His condition was too severe for any invasive treatment so he was treated with antibiotics and fluids until his death the following morning.

We found no evidence of abdominal pain on the day that Mrs B raised this with the nursing staff. Whilst there was no record of her report to the staff, there was evidence of regular reviews of Mr A and his condition was reasonably stable. Once his abdominal pain was identified the following day, along with a marked deterioration of his condition, we were satisfied that staff took appropriate and timely action. We took independent advice from one of our medical advisers, who told us that the chest x-ray did show free air in Mr A's abdomen, however, we found that his treatment was not affected by this oversight, so we did not uphold the complaint.

Summary

Mrs C was diagnosed with a condition where pressure is exerted on the spinal cord. She said she was told by a consultant neurosurgeon that without surgery she would become bedridden and doubly incontinent possibly within a period of three months and, therefore, she required urgent surgery which would take place within weeks.

Mrs C accepted the board's offer of having her surgery at a private hospital (paid for by the board) to meet treatment time targets. Mrs C said the private hospital then told her no decision had been made to accept her referral and gave her no indication when the surgery might take place. Mrs C paid to have her surgery carried out at a different private hospital shortly thereafter.

We took independent medical advice from a consultant neurosurgeon who said there had been a failure to give Mrs C a realistic prognosis and the board had handled her referral to the private hospital unsatisfactorily. We accepted Mrs C genuinely believed a failure to have urgent surgery would have dire consequences for her and she reasonably did not know for certain whether and when her treatment would take place at the private hospital the board had said they would refer her to. We considered the board had not clearly communicated with Mrs C and explained what was to happen with her treatment. Given the board's failings and as they had agreed to meet the cost of Mrs C's surgery we did not consider it reasonable that she, rather than the board, should be out of pocket.

We also found no evidence Mrs C was informed about her removal from the waiting list or that any clinician had approved her removal from the list.

However, we considered the board had apologised to Mrs C for delay in the handling of her complaint and had reasonably responded to correspondence.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this complaint in relation to delay and poor communication;
• reimburse Mrs C with the cost of the private surgical treatment undertaken;
• improve communication and record-keeping between them and other external care providers where patients are referred for treatment;
• provide evidence of the action taken to address the lack of availability of access to theatres; and
• apologise to Mrs C for the failure to inform her that her name was removed from the waiting list for surgery.

Summary

Mr C's GP had referred him to the board in November 2014 as he required the removal of his gallbladder. Although Mr C was not a resident in the board area he had received previous treatment there and his daughter lived nearby. The plan was that Mr C would stay with his daughter on his discharge following the surgery and the board had indicated that they were willing to accept him for surgery on this basis. Mr C emailed the board three times in January 2015 as he had heard nothing more. He was then advised that the board could not accommodate the GP's referral, and that the board had referred him to the health board where Mr C was resident. Mr C complained about the delay by the board in responding to his GP referral.

The board apologised for the delay in responding to Mr C's emails and explained that the reason they could not carry out the surgery was due to pressure on their services and that to accept a referral from another health board would put added pressure on an already pressured system. We upheld the complaint and found that between November 2014 and January 2015 there was no action taken regarding the GP referral as two staff members thought the other was dealing with the matter.

Recommendations

We recommended that the board:

• ensure that the staff members who considered whether to action the GP referral reflect on their actions and discuss the complaint at their next appraisal.

Summary

Mr C complained to us that the board had unreasonably refused to give him braces when he entered prison. The prison dentist originally told Mr C that he could not have braces because his oral hygiene was poor. He gave Mr C advice about improving this. When Mr C's oral hygiene had sufficiently improved, the dentist took impressions of Mr C's teeth for study models in order that the models could be scored for the Index of Orthodontic Treatment Need (IOTN). However, both the dentist and an orthodontist considered that Mr C did not achieve the minimum score for orthodontic treatment on the IOTN and that he did not meet the criteria for NHS orthodontic treatment.

We took independent advice on the complaint from a dental adviser with experience in orthodontics. We found that if Mr C's oral hygiene had remained poor during orthodontic treatment, there would have been a risk of the development of decay and further damage to his teeth around the brace. Mr C was also given reasonable advice and the opportunity to improve his oral hygiene. Mr C's oral hygiene had subsequently improved, however, the impressions that were taken showed that he did not meet the criteria for NHS orthodontic treatment, as he did not achieve the minimum score for orthodontic treatment on the IOTN. Consequently, we found that it had been reasonable for the board not to give Mr C braces and we did not uphold his complaint.

Summary

Mrs C complained about the care provided to her late mother (Mrs A) by Forth Valley Royal Hospital. Mrs A had dementia and was admitted to the hospital suffering from a urinary tract infection and increased confusion; she was noted to be generally unwell. One evening, Mrs A fell out of bed just before 21:00 but Mrs C was not told about this until the following morning.

Mrs A had been reviewed by a doctor and her head and shoulder were x-rayed, but despite having pain in her leg this was not x-rayed. Three days later, after Mrs C pointed out to nursing staff that Mrs A's foot was at an odd angle and she was in severe pain, an x-ray was done and it was found that Mrs A had broken her hip. Remedial surgery was considered but due to Mrs A's on-going and recurrent infection and her general frailty, it was agreed with the family that only palliative (end of life) care was appropriate. Mrs A died less than a fortnight after her fall.

Our investigation included taking independent medical advice from two of our advisers, a doctor specialising in care of the elderly and a senior nurse. The advisers found some evidence of reasonable care, especially in Mrs A's initial care - but they were critical of the lack of communication with Mrs C about Mrs A's fall and later about what happens when a patient dies in hospital; the delay in diagnosing Mrs A's broken hip; that at one time Mrs A's notes were missing and later found in another patient's room - resulting in a delay in prescribing pain relief for Mrs A; and that when surgery was still being considered, Mrs A was found to have an incorrect identification wristband on.

Recommendations

We recommended that the board:

• ensure that all staff involved in this complaint are made aware of our findings and reflect on them to inform their future practice;
• consider the introduction of an information leaflet for relatives explaining the procedure when a patient dies in hospital;
• remind staff involved in this complaint of the requirements of the General Medical Council and Nursing and Midwifery Council guidance on record-keeping, and in particular with regard to protecting patients' confidential information;
• ensure that staff involved in this complaint are reminded of the importance of good, and timely, communication with relatives where patients have sustained a fall and/or injury while in hospital; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop the treatment, but they did not tell Mr A's GP that they had done so. The GP didn't found out that Mr A required palliative care until a home visit three weeks later.

In response to Mrs C's complaint, the board said the consultant in charge was unable to locate the letter he dictated after meeting with the family. The board apologised for this and said that the consultant would try to ensure that in future information is passed on appropriately. Mrs C was dissatisfied with the response, as the board did not explain whether the letter was in fact dictated or typed, or whether the consultant had any recollection of signing it. Mrs C also considered that the board's response was not robust enough to prevent a reoccurrence of the situation, and she brought her complaint to us.

After taking independent medical advice, we upheld Mrs C's complaint. We found that the consultant had failed in his responsibility to inform the GP of Mr A's discharge (with the most likely explanation being that the letter was never dictated). We were also critical that the consultant did not give a clearer response to Mrs C's complaint, as this could have resolved it at an earlier stage. We noted that the board had already apologised to Mrs C and taken steps to improve their system for signing letters. As the failing in this case appeared to be caused by human error, rather than a system failure, we considered that asking the consultant to reflect on his practice was an appropriate and proportionate response.

Recommendations

We recommended that the board:

• bring the findings of our investigation to the attention of the relevant consultant, for reflection as part of his next annual appraisal.