Health

Summary

Mrs C suffered a fall when she was on holiday and attended Arran War Memorial Hospital on two occasions over a four day period. The doctors who examined Mrs C on both occasions thought that she had suffered a musculoskeletal injury to her chest and that she had possibly broken a couple of ribs. They prescribed painkillers which did not resolve the pain. Mrs C then returned to her home area where it was found that she had suffered a punctured lung. Mrs C believed that the punctured lung should have been identified by staff at the hospital prior to her having to travel back home. We took independent medical advice which showed that the doctors who treated Mrs C at the hospital provided her with appropriate treatment (painkillers and advised to rest). There was no indication at that time that Mrs C had suffered a punctured lung and there was no requirement to carry out an x-ray. We did not uphold the complaint.

Summary

Mrs C complained about her discharge from a private hospital, which she had been admitted to for NHS-funded hip replacement surgery. She felt she was not fit to be sent home as she had severe diarrhoea, which she blamed on being given too many laxatives on the day of discharge. She needed to be admitted to hospital a few days later, where she remained for over four weeks. The board said that she had not been given any laxatives on the day of discharge and they considered that she had been fit to go home.

We took independent advice from one of our medical advisers and he said there was no evidence of Mrs C having been given laxatives on the day of her discharge. However, he did not consider that her bowel symptoms had been properly investigated and treated prior to sending her home. He said there seemed to have been undue focus placed on meeting the planned discharge date rather than ensuring Mrs C was fit to go home. As such, Mrs C required prompt readmission to have her bowel symptoms addressed. The adviser also noted that the records from Mrs C's admission lacked the detail that could reasonably have been expected. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

• confirm that the identified failings will be discussed at the consultant's annual appraisal;
• remind staff of the importance of comprehensive record-keeping; and
• apologise to Mrs C for the identified failings in her care.

Summary

Mr C complained about the care and treatment his late wife (Mrs C) received at University Hospital Ayr. Mr C was concerned that mistakes had been made when his wife had attended A&E. In particular, he told us about his concerns in relation to the insertion of chest drains, the removal of oxygen and the loss of four pints (units) of blood. Mr C was also concerned about the standard of communication with him and his family and that, as a result of information given directly to his wife, she lost any fight for life.

During our investigation, we took independent advice from a consultant in respiratory medicine. The complaint was investigated and showed that the treatment given to Mrs C was reasonable and appropriate. While she had in total three chest drains inserted these were necessary according to the circumstances and as part of her symptoms. We found no evidence in Mrs C's medical records that she had lost four units of blood nor was there evidence that oxygen was removed. The advice we received was that the medical records demonstrated that Mrs C was closely monitored even a few hours before she passed away and that she was given the maximum treatment necessary. There was no evidence of service failure on the part of the board and we did not uphold the complaint that the treatment given to her was unreasonable.

The board accepted that there had been some failings in communication and while they met with Mr C and his son as a result of these failings we were concerned that there was no written record of the meeting. The board also explained that a medical decision was taken not to resuscitate Mrs C and this was discussed with her. While the advice we received was that it would be good practice to document that this would be discussed with the family when they were available, our adviser also said that Mrs C's critical condition and poor prognosis, including that she was too unwell to be considered transfer to the intensive care unit or for resuscitation, was communicated to Mr C and his family reasonably well.

Recommendations

We recommended that the board:

• remind relevant staff that it is good administrative practice to keep a record of any meeting held with a complainant as part of the complaints process.

Summary

Mrs C complained about the treatment her late father (Mr A) received from the board. Mr A had died soon after being diagnosed with cancer and Mrs C felt his treatment had been unreasonably delayed (she was aware that her father was very unwell but felt things could have been handled better, including providing end of life care sooner). Although the board had acknowledged certain delays to Mrs C and said they would recruit additional staff, she remained dissatisfied and brought her complaint to us.

We considered whether Mr A's treatment at University Hospital Ayr was reasonable in the circumstances at the time. We took independent medical advice which confirmed that Mr A's cancer had been a very rare and complex kind. Our adviser, having reviewed the records, also said that Mr A's initial treatment pathway had been reasonable and confirmed that Mr A had not fallen between the cracks of different clinical disciplines (Mrs C had been concerned about this). However, our adviser said the delay for a subsequent investigation that was needed for Mr A's diagnosis and treatment was unreasonable and also that end of life care should have been discussed sooner than it was.

We found the evidence indicated that Mr A's condition was complex and that his initial care was reasonable. However, we considered the delay to his subsequent investigation to have been unreasonable as was the delay in discussing end of life care. We upheld Mrs C's complaint and made three recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified;
• confirm to us that they have taken steps to recruit the staff detailed in their correspondence with Mrs C; and
• ensure that our adviser's comments about Mr A's end of life care are fed back to the relevant staff.

Summary

Ms C complained about the care and treatment that her late brother (Mr A) received during two admissions to University Hospital Ayr. She felt he was inappropriately discharged on the first occasion and that the board had not communicated adequately or provided appropriate treatment during his second admission. During that admission, Mr A died and, although Ms C explained that her family were aware that he had been most unwell, she felt the board's care was unreasonable.

As part of our investigation we took independent advice from one of our medical advisers. He explained that Mr A had been suffering from serious liver disease and the outlook for him was poor. However, it was unclear from the medical records why a proposed course of treatment during his first admission was not administered. The notes said Mr A would be given medication if a particular test result was above a certain level, which it was. On balance, therefore, we upheld Ms C's first complaint and made two recommendations.

In terms of Mr A's second admission, our adviser explained that in such situations it is difficult to decide when it is appropriate to move to palliative care (care to prevent or relieve suffering only). However, staff had acted in line with appropriate guidance. Although we recognised the significance of this for Mr A's family, we found no evidence that Mr A's care was unreasonable or of an unreasonable delay in moving to palliative care. The evidence about communication was limited, but our adviser said that the records pointed to conversations with Mr A's family that reflected his condition at those times. Although we took Ms C's concerns into account we did not find that the evidence, viewed as a whole, indicated that the board failed to communicate adequately. We did not uphold these complaints.

Recommendations

We recommended that the board:

• ensure the staff involved in this case reflect on the need to communicate and consider all relevant test results prior to discharge; and
• remind clinical staff of the importance of ensuring records reflect a patient's treatment plan, particularly where the plan changes (where reasonably practicable in the circumstances).

Summary

Mr C complained about the care and treatment provided to his mother-in-law (Mrs A) in Crosshouse Hospital before her death. Mrs A had dementia and had contracted clostridium difficile (C diff - a common healthcare-associated infection), which caused severe diarrhoea. Mr C complained that staff had failed to maintain Mrs A's personal hygiene. He said that they had not changed her often enough and that her hands were covered in her own faeces.

We took independent advice from our nursing adviser. The combination of Mrs A's dementia and severe diarrhoea had caused problems for staff and distress for her family. However, we found that staff had carried out frequent checks on Mrs A and had taken reasonable steps to maintain her personal hygiene. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that staff failed to ensure that Mrs A's food or fluid was provided at the appropriate consistency. We found there had been problems with fluid consistency, and that there was delay in prescribing a dietary supplement. In view of these failings, we upheld this aspect of Mr C's complaint. However, the board sent us an action plan showing that refresher training on the provision of thickened fluids had been provided to staff. They had also apologised to Mr C for the shortcomings in Mrs A's care.

Finally, Mr C complained that staff failed to make adequate arrangements for Mrs A's discharge. We found that there should have been a multi-disciplinary meeting with social work and the family invited to attend before Mrs A was discharged, but that staff had failed to arrange this. In view of this, we also upheld this aspect of Mr C's complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to ensure that, where appropriate, patients are promptly referred to the dietician for review;
• provide evidence to confirm that steps have been taken to ensure that, when appropriate, discharge planning meetings take place for patients in the ward and that relatives are included in the discharge planning process; and
• offer to meet with Mrs A's family to discuss the complaint and the steps taken to address the failings identified.

Summary

Mrs C complained about her treatment at A&E at Ninewells Hospital. She told us that when she attended with a broken foot she was fitted with a moon boot (a removable cast) and told, since it was the weekend, she was to return home and wait for a phone call on Monday. Mrs C said that she was in extreme pain at home and she said she noted trauma blisters on her foot. She said she phoned the hospital for some advice. She said that the staff member that answered the phone did not give any guidance and said that it was Mrs C's choice as to whether she went back to the hospital or not. Mrs C received a call from an orthopaedic consultant the following day who told Mrs C that she should not have been sent home and asked her go to hospital immediately. Mrs C believed that the delay in treatment had contributed to having to spend more time in hospital and having to have two operations.

As part of our investigation we took independent advice from one of our medical advisers, who said that the doctor reviewing the initial x-ray failed to correctly act on the information that identified that Mrs C’s foot was indeed broken. In relation to Mrs C’s complaint about the phone advice she was given following her discharge from A&E, our adviser also said was also of the opinion that all requests for clinical advice should be recorded and that when Mrs C reported on-going symptoms, clear advice about returning for further review should have been given. The board apologised and described the action they would take to avoid a re-occurrence of this situation, although our adviser expressed disappointment that it had taken a formal complaint to identify a training need.

Recommendations

We recommended that the board:

• remind staff about the procedure to be followed when a patient phones for medical advice.

Summary

Mr C complained that the board unreasonably advised the Scottish Prison Service (SPS) that it was safe for him to be subject to metal detecting equipment, although he has an implantable cardioverter defibrillator (ICD) (a device that regulates irregular heart rhythms). Mr C also complained about the board’s handling of his medication. He said that staff altered his medication inappropriately, and made mistakes in administration. He also said that there was no reason for his medication to be supervised (taken in front of prison staff, rather than given into the patient’s keeping), as it was degrading to be required to open his mouth to show he had taken the medication, and this supervision resulted in him being harassed and bullied for his medication.

After investigating Mr C’s complaints and taking independent medical advice from several specialists, we upheld Mr C’s complaint about the administration of his medication. We found that, although a doctor decided to stop Mr C’s naproxen (a drug used for pain relief and anti-inflammation, which can contribute to poor kidney function), Mr C’s prescription record (kardex) was not updated to reflect this. This was because the kardex had to be recalled from the prison halls, and a different doctor was on duty when the kardex was returned to the health centre. As a result, Mr C was inappropriately given a further dose of naproxen in the next weekly medications. We also found that it was unreasonable for a hospital doctor to decide to restart Mr C’s naproxen, although his clinical history showed that this had been stopped due to poor kidney function. Finally, we found that Mr C had been given incorrect dosages of medications on one occasion.

We did not uphold Mr C’s complaint about security screening. Although health centre staff gave slightly different advice about this to prison staff at different times, we found that all of the advice given was reasonable. We also did not uphold Mr C’s complaint about supervision of some of his medications (dihydrocodeine and tramadol – both prescribed for pain relief). In relation to dihydrocodeine, we found the board had complied with their local process for administering medication to prisoners who had recently arrived at the prison. In relation to tramadol, we found that the board’s decision to administer this as supervised was reasonable, as tramadol is an abusable drug and the medication was supervised for Mr C's own safety and for general prison safety. We also found that it was reasonable for nurses to ask Mr C to open his mouth to show that he had taken the medication, as they needed to ensure that he took his prescribed medication and that this was not diverted, and the nurses were supported by prison staff who are able to request this kind of search under the prison rules.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings our investigation found;
• remind nursing staff of the need for care to be taken in administering and recording medications correctly;
• ensure there are clear and robust procedures for updating prescriptions to reflect GP decisions, including where kardexes need to be recalled from halls and/or where a different GP may need to amend the prescription; and
• raise our findings in relation to the restarting of naproxen to the attention of the relevant doctor for reflection as part of his next annual appraisal.

Summary

Ms C complained on behalf of her late partner (Mr A) about his care and treatment at A&E at Ninewells Hospital. She said that Mr A was not assessed properly and she was unhappy that he was referred under the board's redirection policy to a primary care doctor (a doctor providing day-to-day medical care, such as a GP) rather than being seen and treated in A&E. Ms C said that the board had refused to treat Mr A.

During our investigation, we took independent medical advice from two emergency medicine consultants and from a consultant neurologist. The advice we received was that overall Mr A’s care and treatment was reasonable. The emergency medicine consultants said that it was reasonable and appropriate, after triage (the process of deciding which patient should be treated first based on how sick or seriously injured they are) and assessment by a senior doctor, to refer Mr A to primary care for further assessment. They were also satisfied that an adequate medical history was taken in the triage room and sufficient information gathered to decide that Mr A should be referred to a primary care doctor. We also received advice that the senior doctor who assessed Mr A had the skills and experience to assess the urgency of his case and that the clinical notes detailed the rationale for redirecting Mr A.

However, we were concerned that, given Mr A's symptoms, there was no measurement of his vital signs when he attended A&E. Although our advisers said that this did not compromise his care, they also said that measurement of these vital signs may in some cases reveal a condition meriting emergency care. Documentation of the vital signs would also add weight to the decision to redirect a patient from A&E after assessment by a senior doctor.

Recommendations

We recommended that the board:

• ensure that the relevant staff members in A&E are made aware of our adviser's comments in relation to the need to measure vital signs when deciding whether to redirect a patient from A&E and are given the opportunity to reflect on these for their future practice.

Summary

Mrs C complained about the care and treatment Mr A was given by his medical practice in the weeks and days prior to his death.

We took independent advice from one of our advisers who is a GP. We found that Mr A, who had a history of pulmonary disease, was seen by a GP at home after complaining of nausea and dyspepsia and of being giddy for three days. We found his treatment to be appropriate. A month later, Mr A attended the practice again complaining of having had nausea and stomach pain for four days. He was examined appropriately and prescribed paracetamol with a plan to see him in five days. However, before this, the practice received a call to see Mr A at home as he had been vomiting. It was planned to visit him after the regular surgery but within a short time another call was made to the practice because Mr A was still vomiting and he had pains in his upper abdomen. A GP attended at Mr A's home and decided that he should be admitted to hospital and he returned to the practice to make the necessary arrangements for Mr A's transfer to hospital. An ambulance attended shortly afterwards but Mr A died before he could be transferred to hospital. Our investigation confirmed that none of this could have been predicted and that, despite Mr A's sudden death, he had been treated reasonably and appropriately, so we did not uphold Mrs C's complaint.