Health

Summary

Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses

x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014.

Mr C questioned why early tests and investigations given to Mr A failed to show evidence of his illness and said that there had been delays in providing him with treatment. Mr C said that as a consequence, Mr A had lost time with his family. Mr C also complained that there had been delay in issuing correspondence to Mr A. On behalf of the hospital, the board said that it had been very difficult to diagnose Mr A's illness and that while tests showed that something was wrong, this could have been for a number of reasons; there had been a delay in getting biopsy results but this had been unavoidable. Similarly, they said that there had been a delay in sending out letters because of administrative problems but that this had not affected Mr A's treatment overall.

We took independent advice from a consultant clinical oncologist and found that it had been very difficult to diagnose Mr A's cancer and to establish information by biopsy to determine the type of treatment he needed. This was not unreasonable in the circumstances. However, it had not been reasonable not to have treated Mr A as a suspected case of cancer from the outset and thus provide him with this care and treatment at an earlier date. Because of this delay and confusion in correspondence sent to Mr A, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• provide a formal apology to Mrs A;
• provide a formal apology for the delays in correspondence;
• inform us of the outcome of their administrative review and the steps taken to avoid a similar situation; and
• ensure that the advice provided for this complaint is brought to the attention of those clinicians involved in the case.

Summary

Mr C complained about care and treatment provided to his daughter (Miss A) at Perth Royal Infirmary when she attended the eye clinic there. Mr C believed that her condition was misdiagnosed, and that the treatment prescribed may have aggravated her condition and led to her sudden death.

Mr C told us that Miss A was being treated by her GP for acute conjunctivitis. The common treatment is with antibiotic (drugs to fight infection) drops or ointment and in some cases also steroid (drugs to fight inflammation) drops or ointment. The GP prescribed an antibiotic only. When her condition worsened, Miss A went back to the GP and was referred urgently to the eye clinic. Miss A attended the clinic the following day and a specialist doctor there diagnosed marginal keratitis (MK - an eye condition), with a possible allergic reaction to the antibiotic prescribed by the GP. The specialist changed the antibiotic, added a steroid and arranged a follow-up appointment for a week later. Three days later, however, Miss A died suddenly. Mr C told us that he disagreed with the stated cause of her death. He was of the view that she had in fact been suffering from a more serious infective eye condition and that the treatment provided was not only wrong, but contributed to her death by increasing pressure and inflammation in the brain.

Our investigation included taking independent advice from one of our medical advisers, who was of the view that appropriate examinations and investigations were carried out and that Miss A had been correctly diagnosed with, and treated for, MK. The adviser said that although the two conditions have similar symptoms, sufferers of the more serious condition also experience other symptoms, which Miss A did not have. The adviser was, therefore, of the view that Miss A's diagnosis, care and treatment were reasonable, appropriate and timely and there was no evidence that these contributed to her sudden death.

Amendment to summary text

When it was originally published on 20 May 2015, the first sentence of the second paragraph read: Miss A was being treated by her GP for marginal keratitis (MK- an eye condition).

This has been amended to read: Mr C told us that Miss A was being treated by her GP for acute conjunctivitis.

The reference to ‘MK’ in the fifth line of the second paragraph has been amended to read marginal keratitis (MK – an eye condition).

4 June 2015

Summary

Mr C complained that the prison health centre had failed to change the dressing on his wound appropriately. In particular, he said his dressing should have been changed every day. In addition, Mr C was unhappy because the doctor did not assess his wound at an appointment and he said that was unreasonable.

We reviewed Mr C's medical record which confirmed that his dressing was changed frequently and his wound was assessed on a regular basis. We also took independent advice from one of our GP advisers, who advised that the decision on how to manage a patient's wound was determined by on-going clinical assessment and Mr C's wound was assessed as regular intervals. Our adviser also explained that nursing staff were responsible for the care and management of wounds. They said a doctor would be asked to prescribe an antibiotic if nursing staff felt the wound had become infected. In Mr C's case, his medical record confirmed a nurse had noted that his wound had become malodourous (offensive smelling) with increased swelling and because of that, Mr C was referred to the doctor who prescribed an antibiotic.

In light of the information available, and our adviser's view which we accepted, we were satisfied the prison health centre changed Mr C's dressing regularly which was appropriate. We were also satisfied that the doctor did not have to assess Mr C's wound at the appointment given a nurse had already done so. Therefore, we did not uphold the complaints.

Summary

Miss C complained that tear duct surgery carried out on her young daughter caused a deterioration in her daughter's vision. She raised concerns that no vision problems were detected at the preoperative assessment, however, problems were subsequently identified post-surgery and her daughter now needed glasses. The board maintained that the vision problems were not caused by the surgical procedure.

We took independent advice from one of our medical advisers. He noted that the test carried out at the preoperative assessment was a standard test for very young children. He explained that it was common for children who could only initially manage this level of testing to be able to undergo more advanced testing when they returned a little older and more able to cooperate. This was the case with Miss C's daughter and the more rigorous testing carried out at the postoperative assessment identified a modest need for glasses. The adviser said the vision problems were likely to have been caused by the underlying problem of the blocked tear duct. He did not consider there to be any evidence to suggest that they were attributable to the surgery itself.

We accepted the advice we received and we did not uphold the complaint. However, our adviser raised some concerns about the number of doctors involved in Miss C's daughter's care. He considered that there should have been one doctor overseeing the care and he felt this lack of continuity might have contributed to confusion surrounding the complaint. He also noted that, while Miss C's daughter's vision was checked postoperatively, this does not appear to have happened automatically. He advised that it would be good practice to routinely carry out vision checks following this type of surgery. We, therefore, made some recommendations.

Recommendations

We recommended that the board:

• consider mechanisms for introducing a level of continuity of consultant care into the care pathway for tear duct surgery; and
• consider the need for vision to be routinely assessed postoperatively in children following tear duct surgery.

Summary

Mrs C complained to us about the care and treatment her husband (Mr C) had received from the Royal Edinburgh Hospital before his death. She said that staff had failed to take symptoms Mr C had been experiencing over a number of years into account and this had led to a delay in diagnosing cerebral atrophy (shrinkage of the brain). Mr C had been receiving treatment from the hospital for a number of years for depression and obsessive compulsive disorder and had been admitted there on a number of occasions. His physical condition then deteriorated significantly and he was admitted to another hospital for treatment. He died there six weeks later. The cause of death recorded on his death certificate was acute delirium with cerebrovascular disease (disease of the blood vessels in the brain).

We took independent advice from one of our medical advisers, who is an experienced psychiatrist. They said they did not consider that cerebral atrophy had been the major cause of Mr C's relatively rapid physical decline and subsequent death. Although a CT scan (a scan that uses a computer to produce an image of the body) taken a number of years before Mr C's death had shown cerebral atrophy, this was of normal appearance for a man of Mr C's age. There had been no reason to provide treatment or to take further scans to monitor this.

Our adviser said that the care provided to Mr C by the hospital had been well documented and had been delivered in an appropriate multi-disciplinary manner. We also found that the relevant treatment plans were clear and logical and that Mr C and his family had been involved in the care he received. The diagnoses were discussed with the family and their views were taken into account. We did not, therefore, uphold the complaint.

Summary

Mr C complained about his treatment when he attended a stroke clinic. He was unhappy that he was sent home the same day, having been assessed and a stroke diagnosis made. He said he lived alone in a third floor flat and the board did not ask how he would get home or check that there was someone there to look after him. He also complained that no follow-up was arranged, particularly in relation to the psychological impact of the stroke, noting that he previously suffered from mental health difficulties.

The board responded indicating that they carried out appropriate investigations to arrive at the diagnosis and sent a results letter to Mr C's GP with a care plan. They noted that Mr C was independent both before and after the stroke and that he had made his own way to the stroke clinic. They assumed, therefore, that he was able to make his own way home. They assured Mr C that a referral would have been made to the appropriate services had the clinical team believed there to be any ongoing physical or psychological problems arising from his stroke.

We took independent advice from one of our medical advisers, who said there was no evidence to suggest that Mr C required admission following his attendance at the stroke clinic. Our adviser considered that the assessment carried out was reasonable in terms of how thorough it was, noting that appropriate recommendations were made to Mr C's GP regarding his future treatment and monitoring. However, our adviser did not agree with the board's position that there were no ongoing psychological difficulties, stating that there was clear evidence of Mr C's previous and current mental health problems at the time of his attendance at the clinic. Our adviser, therefore, considered that Mr C should have been referred to psychology services by the clinic doctor and considered that the care he received in this regard was unreasonable. We also identified a later breakdown in communication which resulted in the neuropsychology department appearing not to have made an onward referral to the mental health team. On balance, we upheld the complaint and made some recommendations.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings that this investigation has identified;
• arrange for Mr C to be seen again in the stroke clinic for review of his symptoms; and
• highlight to relevant staff the importance of referring stroke patients to psychology services, where appropriate.

Summary

Ms C complained about a delay in diagnosing and treating an ovarian cyst (a fluid-filled sac on part of the reproductive system) between 2008 and 2013.

Ms C complained of abdominal symptoms in 2008 and various investigations, including an ultrasound scan (a special x-ray using sound waves) were undertaken. In January 2009 she saw a physician at Roodlands Hospital who told her that nothing had been seen on the scan. She continued to experience abdominal symptoms and further investigations took place until 2010. In April 2013 Ms C experienced severe abdominal pain and was referred urgently by her GP to the A&E department of another hospital, where she had emergency surgery to remove the cyst.

We took independent advice from one of our medical advisers who was satisfied that the care and treatment provided to Ms C was reasonable and timely. We found that the cyst had shown up on the scan taken in 2009 but that following consultation with the gynaecology (disorders of the female reproductive system) department it was thought that the cyst was not the cause of Ms C's symptoms. The board acknowledged that this was not discussed with Ms C as further investigation of the cyst had been delegated to her GP. The GP told the physician that they had discussed the matter again with the gynaecologists who advised that no action was required. Our adviser was of the view that it was reasonable to delegate the further investigation to the GP, and also commented that the sudden onset of symptoms from the cyst after a long period of having no direct symptoms was a known and common complication of ovarian cysts.

Summary

Ms C complained on behalf of her daughter (Ms A) about the treatment Ms A received at the Western General Hospital. She said that the reporting of a scan was unreasonable, and that the arrangements for follow-up appointments after this scan and an operation carried out some nine months later were unreasonable. Finally Ms C was unhappy with the board's handling of her representations.

During our investigation, we took independent advice from a consultant neurosurgeon and a consultant neuroradiologist, after which we upheld Ms C's complaints. In responding to the complaints, the board had accepted that the written report prepared after the scan failed show that there was a significant abnormality and they had apologised for this error. They had suggested improvements as a result, and our adviser said that these should be implemented.

We also found there was a delay in Ms A receiving a follow-up appointment after the scan, for which the board had also apologised. The advice we received was that Ms A's clinical pathway had not changed as a result of this, but it did lead to a considerable delay in telling her about her new diagnosis. The adviser also said that there was no delay in the follow-up appointment after Ms A's operation but we were concerned that she was not provided with the findings reported at the time of her operation during her in-patient stay in hospital. We were satisfied that there was no delay in arranging a further scan after her operation.

The board had apologised that Ms A had not received details of the oncology (cancer) team including the clinical nurse specialist in a timely manner. As a result of these communication problems the board had taken action to improve coordination of neurology patients and their care by establishing a new multi-disciplinary team. Finally, they had accepted failings in their handling of Ms C's complaints and had taken action as a result.

Recommendations

We recommended that the board:

• report back to us on the action taken to implement the improvements proposed; and
• ensure the staff involved in this case are made aware of the importance of ensuring findings reported at the time of the operation are appropriately reported to patients and/or their relatives.

Summary

Miss C complained that the care and treatment she received for her hand after a cycling injury were unreasonable. She raised a number of issues, including that the consultant orthopaedic surgeon, who she saw nearly four weeks after her injury, failed to operate and refer her to physiotherapy at that time. Miss C also complained that the physiotherapy she received after the board did decide to operate, two and a half months after her injury, was unreasonable. She said the physiotherapist only checked her progress and explained what exercises she should do.

We obtained independent advice on this case from two of our medical advisers, a consultant trauma and orthopaedic surgeon (adviser 1) and a consultant physiotherapist (adviser 2). Adviser 1 explained there were different ways to treat hand fractures and that professional opinions on how best to do this could vary. He said that the extent of Miss C's injury was such that, on balance, surgery should have been considered when she initially presented with her injury. Because of this, we upheld the complaint and were critical of the board. However, adviser 1 said that by the time Miss C saw the consultant, the advantages of early surgery had been lost and it was then not unreasonable to see if conservative treatment was successful. Although early surgery would have shortened the time from injury to recovery for Miss C, it was unlikely to have affected the final result. Adviser 1 also explained that a referral to physiotherapy nearly four weeks after injury would not have achieved anything, and had no adverse impact in Miss C's case. Adviser 2 noted that when Miss C did receive physiotherapy treatment, she had good assessment, a comprehensive exercise programme, sensible advice on self-management between treatments and regular reviews on progress.

Recommendations

We recommended that the board:

• feed back our decision on this complaint to the staff involved; and
• provide Miss C with a written apology for the failings identified.

Summary

Mr C, who is an advocate, complained to us on behalf of his client (Ms A) that the board had failed to provide her daughter (Miss B) with appropriate clinical treatment when she was admitted to the Royal Infirmary of Edinburgh with chest pain and other symptoms. We took independent advice on this complaint from one of our medical advisers. Although the board had been unable to provide an explanation for Miss B's symptoms, we found that they had appropriately assessed her chest pain and that she had been appropriately investigated. The medical records also indicated that there had been a reasonable and appropriate attempt to provide her with pain relief. No abnormal cardiac rhythms were found when tests were carried out and there was no evidence that a treadmill test that she had was not carried out or recorded properly. Staff also appropriately involved the relevant specialists in relation to Miss B's earache and hearing problems. We found that the care and treatment provided was reasonable in view of the symptoms that she presented with and we did not uphold the complaint.

Mr C also complained that staff had failed to provide Miss B with an adequate level of occupational and physiotherapy treatment. We found, however, that the assessment and ongoing physiotherapy treatment provided was reasonable and in line with her care plan. We did not uphold this aspect of the complaint.

Finally, Mr C complained that staff failed to communicate adequately with Ms A about her daughter's condition and treatment. We did not uphold this complaint, as we found that they had communicated adequately with Ms A.