Health

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.

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.