Health

Summary

Mr C phoned the Scottish Ambulance Service (the service) for an emergency ambulance as he was suffering from severe abdominal pains. He described his symptoms to one of the service's clinical advisors who told him to attend his local out-of-hours centre. He attended the centre and was examined by a doctor who immediately phoned for an ambulance and Mr C was taken to hospital where it was diagnosed that he had perforated ulcers. Mr C complained that the service should have sent an ambulance when he originally reported his symptoms.

We took independent advice from an adviser, who is a paramedic, and they explained that, although Mr C's condition was not immediately life threatening, the service's clinical advisor failed to ask sufficiently detailed questions about the character of the pain or associated symptoms. As a result, the service's clinical advisor failed to put himself in a position to safely judge whether or not to despatch an ambulance.

Although there was not a need to send an immediate ambulance, we upheld the complaint because there was a failure to assess Mr C's symptoms appropriately.

Recommendations

We recommended that the service:

• apologise to Mr C for the failure to ask appropriate and relevant questions regarding his abdominal pain; and
• share our decision with the clinical advisor involved and consider whether a training need has been identified.

Summary

Mrs A had fallen at home and sustained a head injury and suspected fractured hip. She had contacted the medical practice and a GP attended and decided that she required to be taken to hospital. The GP arranged that an ambulance should attend within an hour and left Mrs A with a neighbour to wait for the ambulance. Mrs A's daughter (Mrs C) complained that the GP should have arranged an emergency ambulance and should have waited with Mrs A, who is elderly, until its arrival. The practice maintained that Mrs A was stable and the situation was not life-threatening and the GP was satisfied that she did not need to wait for the arrival of the ambulance.

We took independent medical advice from one of our GP advisers, who said that given the situation, Mrs A required an immediate ambulance and the GP should have remained with her in case she deteriorated. The adviser noted that Mrs A was immobile; had symptoms of a hip fracture; had a significant head injury which was bleeding; was unable to recall how the fall occurred; and had a complex medical history. Our adviser was also concerned that the GP had noted the possibility that Mrs A may have required a brain scan to rule out any possible bleed to the brain. In light of this advice, we upheld Mrs C's complaint that the GP failed to provide Mrs A with appropriate medical treatment when she attended the home visit.

Recommendations

We recommended that the practice:

• apologise to Mrs A for the failure to arrange an emergency ambulance; and
• ensure the GP reflects on the comments made by our adviser and discusses the matter at their annual appraisal.

Summary

Miss A had provided a urine sample at the practice which was to be sent away for testing. Mrs C, who complained on behalf of Miss A, said that when a colleague called to check on the results for Miss A, the practice said that they could not trace the sample. Mrs C complained to the practice in August 2014 and received a response in October 2014. Mrs C complained to us that the practice had failed to properly process Miss A's urine sample and failed to properly handle her complaint.

We took independent medical advice from our GP adviser, who said that there was no recognised system to check that samples had left the practice and arrived at the laboratory, and that the sample going missing was likely due to an administrative difficulty which would be difficult to trace the origin of. In addition our adviser said that the response from the practice was reasonable and Miss A had come to no harm. Therefore, we did not uphold Mrs C's complaint about the loss of Miss A's urine sample.

We upheld Mrs C's complaint about the practice's handling of her complaint. We found that the practice had failed to observe their own policy in terms of timescales for responding to complaints, and had not made any apology for the delay in their response.

Recommendations

We recommended that the practice:

• issue Mrs C with an apology for failing to properly handle her complaint;
• ensure that all staff are made aware of the contents of the NHS Scotland 'Can I Help You?' guidance and use this to review their own procedure; and
• share the outcome of this investigation with all relevant complaints handling staff.

Summary

Mr C complained about the medical treatment he had received in prison and, in particular, about delays he had faced in getting medication. We took independent advice from one of our medical advisers, who is an experienced GP. Although there was no evidence that there was a three-week delay in prescribing his medication when he first arrived in the prison, the doctor failed to discuss with Mr C his decision at that time not to prescribe medication Mr C had previously been receiving on repeat prescription before entering prison. We found that this had been unreasonable, although, the doctor did subsequently decide to prescribe the relevant medication to Mr C. However, there were then delays in giving Mr C some of his medication due to staff shortages. Mr C was subsequently found to be stockpiling the medication. We found that it had been reasonable for staff to remove Mr C's stockpile of the medication, however, it was unreasonable that this medication was then stopped without a discussion about putting an alternative in place. In view of these failings, we upheld this aspect of Mr C's complaint.

Mr C also complained that the prison health centre had failed to appropriately maintain his medical records. We found that his records had been well-maintained and we did not uphold this aspect of his complaint.

In addition, Mr C said that the board's response had failed to address his complaint appropriately. We found that the board's response failed to indicate that an adequate investigation had taken place and that it failed to address the issues Mr C had raised. We also upheld this aspect of his complaint.

Recommendations

We recommended that the board:

• review the prison's processes for repeat prescriptions in order to try to ensure that all patients receive their repeat prescriptions in a timely fashion;
• remind the GP in the prison health centre that he should discuss changes in prescriptions directly with patients;
• provide evidence to confirm that steps have been taken to ensure that complaints from prisoners are investigated and responded to in line with the Scottish Government's guidance; and
• issue a written apology to Mr C for the failings identified.

Summary

Mr C complained about the care and treatment his late father (Mr A) received during two admissions to St John’s Hospital. Mr C felt staff had not considered his father's electronic test results appropriately, particularly in relation to the level of sugar in his blood and whether he had an infection. Mr C also said that the board had failed to provide his father with appropriate medical treatment, and that this had contributed to Mr A’s death (which occurred during his second hospital admission).

As part of our investigation we took independent medical advice from one of our advisers, who explained that Mr A had been an elderly man who was most unwell. Although Mr C felt the test results showed his father had an untreated infection and diabetes, our adviser said this was only one possible explanation. Our adviser acknowledged it was possible that Mr A had an infection but he also said there were other possible explanations. In his professional view, Mr A’s test results neither pointed to an infection nor meant additional steps should reasonably have been taken. Our adviser did, however, say the board’s communication could have been better because Mr C appeared not to have realised just how unwell his father had been.

Mr C had made his concerns clear and we fully acknowledged the importance of this matter for him and his family. However, our role was to consider the reasonableness of the board’s care and treatment. We acknowledged that this was already a difficult time for Mr C, and that this would not have been aided by a lack of clear communication by clinical staff. However, taking everything into account, we did not find the evidence indicated the board failed to consider Mr A’s test results or provide appropriate medical treatment, so we did not uphold Mr C's complaint.

Summary

Ms C complained about the care provided to her when she was admitted to the Western General Hospital (the hospital). Ms C, who lives within another board area, was visiting Edinburgh when she became ill with abdominal pain, severe constipation, and vomiting. She attended the A&E department of another hospital in the board's area and was transferred to the hospital. Ms C was seen by one consultant on admission who said that he planned to do a sigmoidoscopy (an investigation of her intestines by way of a flexible camera) the following day.

The next day Ms C was reviewed by a different consultant who said that the sigmoidoscopy was not necessary and that it would be better for her treatment to be undertaken at her home hospital, where she had previously been treated for a condition involving her intestines. No treatment was provided for Ms C's constipation; her pain was not sufficiently addressed; and when she was discharged on the Saturday, she was told to self-refer to the hospital nearer her home (in another board area) for treatment on the following Monday.

We took independent advice from one of the our medical advisers and a nursing adviser who were of the view that Ms C's condition could and should have been investigated and treated at the hopsital. The medical adviser was of the view that if the team at the hospital felt specialist input was needed from a hospital in another board, Ms C should have been transferred there in a formal process rather than told to self-refer. The result was that Ms C's condition went untreated from Thursday to the next Tuesday as Ms C was admitted to the hospital in another board area on the Monday but there was then a delay in sending the result of a scan done in the hospital to another hospital nearer Ms C’s home.

Ms C also complained that some of the responses from the board to her complaint were inaccurate and this was upheld as some of the matters referred to were not documented in the clinical notes.

Recommendations

We recommended that the board:

• take action to remind all staff involved in this complaint of the importance of effectively monitoring, recording and addressing patients' pain;
• ensure all the staff involved are made aware of the findings in this case;
• give consideration to formulating guidelines on adequate arrangements for patients being discharged for on-going care which is expected to take place at a different institution;
• remind all staff involved in this complaint of the importance of effectively monitoring, investigating, recording and addressing patients' care and treatment;
• remind all staff involved in this complaint of the importance of accurately responding to complaints, based on the clinical records and other evidence available; and
• issue an additional written apology for the failings identified during this investigation.

Summary

Mrs C complained about the care and treatment that her husband (Mr A) received from the practice. Mr A, who had a history of anxiety, had been suffering from episodes of breathlessness. Mr A was diagnosed with panic attacks and adjustments were made to his existing anxiety medication to treat this. He was later prescribed further medication following a phone consultation and when this proved ineffective, he was seen at home as his anxiety was preventing him from going outdoors. During this visit, no abnormal findings were made during a physical examination and a referral to the community mental health team was declined. Two days later, Mr A suffered a stroke. When he was admitted to hospital, he was also found to be suffering from a chest infection. Mr A did not recover from the stroke and passed away around three weeks later.

Mrs C complained that Mr A had not been properly examined by doctors from the practice as they had failed to diagnose his chest infection. After taking independent advice from one of our GP advisers, we found that the actions taken by the practice were reasonable. Mr A's symptoms suggested that he was suffering from anxiety/panic attacks and there was no evidence that he had a chest infection at either of the consultations with doctors from the practice. We did not uphold Mrs C's complaint but made a single recommendation as a result of record-keeping issues identified during our investigation.

Recommendations

We recommended that the practice:

• ensure the relevant GP reviews his medical record-keeping to ensure that both normal and negative findings are noted as part of normal practice.

Summary

Mrs C said that although her husband (Mr C) first attended Wishaw General Hospital for investigations in February 2013, it was not until early June 2013 that he was advised that he had a terminal illness. Mr C died a few weeks later after receiving his diagnosis.

Mrs C complained about the care and treatment Mr C received and that it had taken an unreasonable time to provide him with a diagnosis. She said that communication, particularly with the family, had been poor.

We took independent advice from consultants in colorectal surgery and radiology, and also from one of our nursing advisers. We found that Mr C's medical care and nursing treatment had been reasonable so we did not uphold Mrs C’s complaints about this. However, there had been a delay in making a diagnosis because a scan taken in April 2013 had shown subtle changes that had been overlooked. As a consequence, Mr C could have been diagnosed earlier (although, his outcome would have remained the same) and his palliative care started sooner. Our investigation also showed that communication with the family had been poor causing even further distress to the family at a difficult time. In light of what we found, we upheld Mrs C’s complaints about the board’s communication and the delay in diagnosis.

Recommendations

We recommended that the board:

• make a formal apology;
• confirm to us that as a consequence of their discrepancy meeting, they are satisfied that there is an increased liklihood of such an abnormality being detected in the future;
• make specific recognition of the failures in communication by way of a formal apology; and
• provide us with details of specific actions they have taken to show that staff have learned from the shortcomings in this case.

Summary

Mr C complained to the board about the care and treatment that his wife (Mrs A) received. Mrs A was being investigated for lung disease when an error in interpreting a scan referral in December 2011 resulted in a delay in the diagnosis of lung cancer. Mrs A underwent surgery to remove a tumour in June 2012 but was not considered to be suitable for chemotherapy. Mrs A attended at follow-up appointments with the board where weight loss was noted. In May 2013 it was discovered that Mrs A had cancer in her right kidney. Although she was initially given a diagnosis of primary kidney cancer, tests found that it was in fact the spread of lung cancer and her treatment plan was changed accordingly. Following a stay in a hospice, Mrs A was admitted to hospital and passed away in October 2013.

Mr C complained about delays in diagnosing his wife's cancer, the incorrect diagnosis of primary kidney cancer and the standard to which the board had kept Mrs A's medical records. After taking independent advice on this case from a consultant physician and a consultant specialising in cancer care and treatment, we upheld Mr C's complaint regarding delay in diagnosis. Our cancer specialist adviser said that the initial delay could have affected Mrs A's prognosis. Issues with record-keeping around the completion of DNACPR (do not attempt cardiopulmonary resuscitation) forms were highlighted and consequently, Mr C's complaint about record-keeping was also upheld. However, we did not uphold Mr C’s complaint about the diagnosis of primary kidney cancer as we were advised that this was a difficult diagnosis to make.

Recommendations

We recommended that the board:

• apologise for the delay in diagnosing Mrs A's cancer, particularly its spread in 2013;
• take steps to contact the locum consultant to ensure he is fully aware of our findings;
• ensure that this case is included for discussion at the relevant consultant's next appraisal;
• raise awareness of this case amongst staff involved in the booking of imaging to highlight the potential impact of errors;
• review how the care of patients requiring input from multiple specialities is managed and led;
• make staff aware of our findings in this case to allow reflection on the impact inaccurate diagnoses can have on patients and their families; and
• ensure that this case is included for discussion at the relevant doctor's next appraisal.

Summary

Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement.

When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing toenail and surgery was delayed until this was treated. When the operation was re-scheduled, additional testing was undertaken to establish if Mr A had any on-going underlying infection and all the tests were negative. The operation took place and during the surgery samples of fluid and tissue were taken for laboratory analysis and Mr A was also given precautionary antibiotics (drugs used to fight bacterial infections). The samples taken were positive for infection which proved very difficult to eradicate, resulting in a long recovery period for Mr A, including that his hip replacement implant had to be removed while the infection was treated and then a new implant put in.

We took independent advice from one of our medical advisers who was satisfied that the board's infection control procedures were compliant with national guidance and that these procedures were followed appropriately. The adviser commented that no testing can fully eliminate the possibility of deep-seated infection and the adviser was of the view that the infection present in Mr A's hip during his operation had probably originated from his previous in-growing toenail. The adviser also considered that the fact that Mr A was a diabetic contributed to the lengthy recovery period as diabetics do not fight infections as quickly as non-diabetics.