Health

Summary

Mrs C complained on behalf of Mr A that the vasectomy (where the tubes that carry sperm from a man's testicles to the penis are cut, blocked or sealed) operation he had at Dr Gray's Hospital was not performed properly and that his aftercare was inappropriate. We obtained independent medical advice from a surgeon experienced in carrying out this procedure, and found that there was evidence from the operation records and the samples taken during and after the surgery to show that the operation was carried out to a reasonable standard. We also considered that Mr A received appropriate care for persistent pain following his surgery and that the review appointments and treatment given were in line with national guidance. Whilst we noted that it took around four months for Mr A to be reviewed at a pain clinic, we found that this period was acceptable and with in the timescales set out in national guidance which acknowledges the constraints on pain clinic services.

Summary

Mrs C was referred to Aberdeen Royal Infirmary with pain on her left side, which her GP thought might be due to kidney problems. She was x-rayed, had an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and was discharged with a diagnosis of constipation with no planned follow-up. Mrs C continued to be unwell and was treated by her GP for constipation (as advised in her hospital discharge letter). Mrs C collapsed at home and was readmitted to the hospital several months later. At that time a computerised tomography (CT) scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) was performed and a large mass, thought to be an ovarian cyst, was found. Mrs C had surgery to remove this mass and was advised that primary cancer had been found in her colon and it was this that had spread. Mrs C was offered chemotherapy but was advised that this was only to relieve symptoms as the diagnosis was terminal.

Following surgery to remove the primary cancer from the colon, Mrs C was told she was not terminally ill and that the spread of the cancer had not occurred as had been previously suspected.

We took independent advice from a medical adviser who said that the board's initial actions and their diagnosis of constipation were reasonable. Our adviser also considered that the treatment provided once the cancer was detected was reasonable and appropriate.

Nevertheless, our adviser said that it would have been good practice to have a bowel surgeon present during Mrs C's surgery given the known presence of abnormalities in the colon. Our adviser was also of the view that the pathology report following this surgery did not suggest a terminal diagnosis and he did not consider that the terminal diagnosis given to Mrs C had been appropriate. For these reasons, we concluded that the care Mrs C received was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C for incorrectly diagnosing her condition as terminal;
• ensure the staff involved in the diagnosis reflect on their diagnosis in light of our medical adviser's comments, in particular to ensure pathology reports are appropriately taken into account; and
• review the surgery carried out in light of our medical adviser's view that a bowel surgeon should have been directly involved.

Summary

Mr C fractured his ankle which was put in a plaster cast for six weeks. He was told not to bear weight on the foot and was prescribed medication to prevent blood clots forming during this period.

When Mr C's cast was removed, the medication was stopped. He was referred for physiotherapy which took place one week later when he was provided with a sandal-type shoe to wear and given exercises to complete. A follow-up physiotherapy appointment was arranged for three weeks ahead.

Mr C died of a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) and deep vein thrombosis (DVT - a blood clot in a vein) a week before the follow-up physiotherapy appointment.

Mr C's wife (Mrs C) complained to us, and said that a failure to provide Mr C with appropriate and timely treatment following the removal of his plaster cast had allowed a blood clot to form. This caused him to suffer the pulmonary embolism and DVT which caused his death.

We took independent medical advice from a consultant orthopaedic surgeon who said there was no evidence that Mr C's medication should have been continued after the removal of the plaster cast. Our adviser also considered there was no difference between providing a patient with footwear and leaving the ankle completely free after the removal of the plaster cast. Furthermore, the adviser said that starting early physiotherapy treatment was not known to have any impact on the risk of developing a pulmonary embolism and a DVT.

Our adviser also said DVTs are difficult to diagnose. It was uncertain when Mr C's DVT had started, and fatal pulmonary embolism is a rare but an ever-present risk with surgery even if full prevention measures have been taken. On the basis of the advice we received, we found that the treatment Mr C received was reasonable.

Summary

Ms C, who is a member of parliament, complained about the care and treatment Mrs A received at Peterhead Hospital. Ms C brought the complaint to us on behalf of two of her constituents, the late Mrs A's daughter (Mrs B) and sister (Mrs D). Mrs A had been admitted to hospital after suffering from sickness and diarrhoea for several days. Ms C said that staff at the hospital failed to provide Mrs A with appropriate clinical treatment and nursing care. Ms C raised a number of concerns, including that there was an overall lack of concern or anxiety about Mrs A's condition shown by nursing staff and the doctor involved, and not enough was done to help her. Mrs A died whilst in hospital.

We obtained independent medical advice about the complaint from a GP and a nurse. Both of our advisers said that Mrs A's SEWS score (Standardised Early Warning System – a system which uses special observation charts completed by nursing staff to recognise deterioration in patients) was such that medical assessment should have occurred, but nursing staff failed to request a review by a doctor.

Our nursing adviser explained that Mrs A's oxygen reading was very concerning and, along with Mrs A being 'clammy' and her 'limbs discoloured', this indicated a very serious deterioration in her condition. She said nursing staff should have been aware of the significance of these signs of shock and should have acted immediately.

Our GP adviser said that when the doctor saw Mrs A, he did not carry out a reasonable assessment, did not record accurate observations and did not take action upon these. She said that the doctor failed to respond appropriately to the abnormal and deteriorating observations recorded on Mrs A's SEWS recording chart and arrange further investigation.

We concluded that there were clear failings in the clinical and nursing treatment provided to Mrs A by the staff at Peterhead Hospital.

Recommendations

We recommended that the board:

• ensure the failings identified by the adviser are addressed with the doctor;
• confirm that the doctor has discussed his full report with the independent GP appraiser and confirm the outcome to us;
• remind nursing staff involved in this case of the importance of SEWS and the reason for using this across Scotland;
• provide us with an update regarding the current use, monitoring and any relevant accuracy of completion of SEWS and response audits;
• provide us with evidence of their on-going assessment and training for medical emergency, including sepsis; and
• provide the family with a written apology for the failings identified.

Summary

A Getting It Right For Every Child meeting (a meeting with multi-agency representatives in attendance to share information and to identify any potential risks or concerns) was held to discuss the welfare of Mr C's children. He complained that it was improperly convened and did not adhere to relevant protocols. He specifically complained about the actions of a health visitor who worked for the board and convened the meeting. He was unhappy that he had been excluded from the meeting.

We investigated the complaint and took independent advice from an experienced health professional. We found that the health visitor concerned (and, accordingly, the board) acted reasonably and that appropriate guidance was followed. We did not uphold Mr C's complaint.

Summary

Mr C complained about the decision taken by the prison health centre to stop his medication for nerve pain. He said he was told that the medication had been stopped because he was on methadone. In response to his complaint, the board said the prison health centre decided to stop his prescription because they did not think he needed the medication.

We sought independent medical advice from a GP adviser. She reviewed the evidence available and confirmed that Mr C had a history of past and current drug misuse including using a combination of drugs. She said the prison doctor had a responsibility to ensure they were prescribing medication to Mr C safely and responsibly. Our adviser considered that in view of Mr C's drug misuse (including misusing the medication for nerve pain) and the increased risk of addiction, it was appropriate for the prison doctor to try less harmful, alternative drugs for him. The adviser noted that Mr C had been started on an appropriate alternative medication. She said the actions taken by the prison health centre were consistent with General Medical Council guidance and, in her view, the care and treatment provided to Mr C was reasonable.

In light of the evidence available, we did not uphold Mr C's complaint.

Summary

Miss C complained to us about the care and treatment she had received when she attended the A&E department at Forth Valley Royal Hospital. Miss C had gone to A&E after injuring her ankle. She said that she also told staff that she had sickness and diarrhoea, and that she had a rash on her forehead.

Miss C returned to the A&E department two days later with shortness of breath, swelling in the right leg, bruising and a rash. She was assessed as requiring immediate attention and was then diagnosed as having myositis (inflammation of the muscles) caused by group A streptococcus (a bacterial infection). She required treatment in the intensive care unit and several emergency operations, including an above-the-knee amputation of her right leg. She also had surgery on her other limbs.

Miss C said that she had not received reasonable care and treatment when she had first attended the A&E department, and had been seen by an emergency nurse practitioner. We took independent advice from one of our nursing advisers, who is an emergency nurse practitioner. The medical records that were completed when Miss C had initially attended the A&E department only referred to an injury to her left ankle. No other symptoms were documented. We found that it had been appropriate for the emergency nurse practitioner to diagnose and treat this minor injury, and that the care and treatment the nurse practitioner had provided had been reasonable and appropriate. As there was no evidence that Miss C had reported sickness, diarrhoea or a rash when she attended the hospital on the first occasion, we did not uphold the complaint.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at Forth Valley Royal Hospital. Mrs A was admitted with kidney failure and, further to treatment, was discharged eight days later. However, she became ill again the following day and required re-admission. She responded well to treatment, this time for heart failure, but subsequently suffered a sudden heart attack and died. Mrs C raised concerns that the board did not take reasonable account of Mrs A's pre-existing heart problems when treating her kidney failure during her first admission. She felt that this led to them overloading her with fluids, thus contributing to her subsequent heart failure and eventual death. She also questioned the appropriateness of the discharge following Mrs A's first admission, raising concerns that her heart failure should have been detected prior to this and noting that Mrs A had been vomiting on the day of discharge.

We took independent advice from one of our medical advisers, with experience in the acute hospital care of elderly patients with multiple illnesses. He explained that the treatment of kidney failure involves fluids being provided, whereas the treatment of heart failure requires fluid restriction. He advised that a careful balancing act was required where a patient has both kidney and heart problems. He considered that the doctors caring for Mrs A were mindful of this and said the treatment provided to her during both admissions was reasonable. He also considered the interim discharge to have been clinically appropriate at the time. He said Mrs A's sudden heart attack could not have been predicted and was not connected to her treatment. We accepted this advice and did not uphold the complaints.

Summary

Mr C complained that, due to a high staff turnover within the practice, he had been seen by a number of different dentists over the years. He said that each dentist changed his treatment plan and, as a result, his gum disease was never treated. In responding, the practice noted that the staff turnover was outwith their control. They confirmed that a treatment plan should continue from one dentist to the next unless there were clinical grounds for changing it. They did not comment specifically on Mr C's treatment plan as they did not have his records to hand.

We took independent advice from one of our dental advisers. He said the treatment carried out by the various dentists appeared consistent in that the primary aim was to address Mr C's chronic gum disease. He explained that this was a longstanding condition which progressed to the position where loss of the teeth was inevitable, despite the treatment carried out. He concluded that the treatment provided by the practice was reasonable. We accepted this advice and did not uphold the complaint.

We were concerned, however, that the practice had responded to Mr C's complaint about his dental treatment without specifically referring to his dental records. We also noted that their response had not told Mr C that he could complain to us in the event that he remained dissatisfied. In addition, we noted that the practice sent Mr C's original dental records to us and did not use a secure postal method. In light of these observations, we made some recommendations.

Recommendations

We recommended that the practice:

• apologise to Mr C for the identified shortcomings in their handling of his complaint;
• review their handling of Mr C's complaint with a view to making improvements for future complaints handling. In particular, they should ensure that all available information relevant to the complaint is considered as part of their investigation and all complaint issues raised are fully responded to. They should also ensure that the complaint response includes information about the right to refer a complaint to us and our contact details; and
• review their process for handling secure data with a view to avoiding a repeat occurence of the issues raised during the course of this investigation.

Summary

Mrs C complained about the dental treatment she received for a swelling in her mouth, which was subsequently found to be cancerous, and about the delay in referring her to a specialist for further investigation.

When we investigated Mrs C's complaint, we found that she had received the treatment as a private patient, rather than under the NHS. Under our legislation, we are not able to consider complaints about private dental treatment, and we closed our investigation of this complaint.