Health

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.

Summary

Mr C said he had been referred to the ear, nose and throat clinic by his GP. He had been offered an appointment at a Raigmore Hospital which was too far from his home and had requested an appointment at Belford Hospital closer to where he lived. Despite this he had been offered a second appointment at Raigmore Hospital, before being offered an appointment at Belford Hospital. Mr C complained he was seen outside the waiting time guarantee of 18 weeks from referral to treatment. Mr C also complained that he had been offered an appointment with psychological services some 18 months after his referral, which also breached the referral to treatment target.

We found the offer of an appointment to Mr C of an appointment at Raigmore was within the board’s published policies for appointment management. The board had mitigation in place due to the distances patients had to travel to attend these appointments. When Mr C refused this appointment, he was no longer covered by the Scottish Government waiting time target, so we did not uphold his complaint about delay for the ear, nose and throat clinic. We found there was an unreasonable delay in providing an appointment with psychological services and upheld his complaint about this. The board had, however, provided evidence that they had made significant improvements to their waiting list management and that waiting times had consequently been substantially reduced.

Recommendations

We recommended that the board:

• apologise for the failure to properly explain the actions they had taken to improve patient access to psychological services.

Summary

Mr C complained on behalf of Mr A. Mr C said Mr A suffered from spinal damage which had required an operation but his treatment at Raigmore Hospital had been significantly delayed following his referral as it was unreasonably downgraded from urgent to routine and because the board lacked surgical capacity. Mr C was concerned that Mr A had not been examined properly. Mr A eventually underwent surgery outside the board area. Mr A had then required a second operation, which he felt had also been delayed. During his treatment, Mr A had not been communicated with adequately and Mr C's attempts to make a complaint on his behalf had been frustrated by the board's failure to follow its complaints procedures appropriately. Mr C said there was concern the delay had affected Mr A's recovery.

We took independent advice from two medical advisers. They said Mr A was not an urgent case and it was appropriate for him to be seen as a routine referral. He had been examined appropriately and there was no evidence Mr A had suffered permanent damage between his referral and his first operation. The advice also stated the board lacked the capacity to perform this type of surgery within an acceptable clinical timeframe. It was also noted there was doubt over whether a second operation would provide Mr A with further significant improvements. The advice noted that the clinical correspondence with Mr A regarding his treatment had been of a reasonable standard.

We found that Mr A had experienced an unreasonable delay in the provision of his surgery, but that there had not been an unreasonable delay in providing his second operation. We accepted the advice that Mr A had received a reasonable standard of communication from the board. We concluded that the board had failed to follow its complaints procedure appropriately and there had been an unacceptable delay in responding to Mr C.

Recommendations

We recommended that the board:

• review the non-urgent referral process for cervical surgery to ensure the delays experienced in obtaining an appointment in this case are addressed;
• provide evidence they have reviewed the handling of this complaint to establish the cause of the delays; and
• apologise for the failure in providing timeous treatment.

Summary

Mr and Mrs C complained to us on behalf of their teenage son (Mr A), following his stay in an adult psychiatric unit. They complained that he had been held in the adult unit for an unreasonable length of time, that he had been given medication without their consent, that he had been denied the company of his mother on his transfer to another unit, and that their complaints had been inappropriately handled.

We began our investigations, including discussions with the Mental Welfare Commission who had also looked into Mr A's care and treatment. However, during the course of our investigations, Mr A moved away from home, and was not in contact with his parents. Therefore, we took the decision to close the complaint in line with our procedures, as we had no way of contacting him, and considered that we no longer had his consent to share his personal information with his parents.

Summary

Mr C, who is an advocate, complained on behalf of his client (Mrs A) about the care and treatment provided to Mrs A's late husband (Mr A) by his medical practice. Mr A had a history of chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed). Mr A called the practice and during the phone consultation reported having strained a muscle. The practice advised Mr A to take painkillers and prescribed him co-codamol (a painkiller formed of a mixture of paracetamol and codeine). They told him to contact them again if the condition got worse. Three days later Mr A attended the practice. The GP examined him and considered the possibility of a lung infection, however, decided it was more likely to be muscle strain and prescribed a stronger pain killer. Later that day Mr A was taken into hospital and died three days later from pneumonia (a serious lung infection).

Mr C complained that Mr A's condition was not assessed properly by the GP. Mrs A also raised specific concerns that at Mr A's COPD review the practice did not have a pulse oximeter (an instrument used to measure oxygen levels in the blood). Mrs A also raised concerns that Mr A was prescribed co-codamol and that this medication is not recommended for patients with COPD. When Mr C complained to the practice the GP who had examined Mr A responded to the complaint and Mrs A and Mr C said this was not impartial.

During our investigation we sought independent advice from one of our GP advisers. The adviser was satisfied that when Mr A attended the practice his symptoms were indicative of muscle strain and that the GP's actions were reasonable. The adviser was also satisfied that co-codamol is an appropriate painkiller to prescribe to patients with COPD as long as the prescriber is aware of the patient's COPD condition, as they were in this case.

The practice told us that they are a small practice of only one GP. As the complaint related to clinical matters, the complaint needed to be responded to by a doctor. We found this to be a reasonable position and for the reasons above did not uphold the complaints.

However, our adviser did say the practice should have had access to a pulse oximeter. The practice told us that they had already purchased one and we recommended that they ensure it is used appropriately.

Recommendations

We recommended that the practice:

• provide us with evidence of the steps taken to ensure the pulse oximeter is utilised as required.

Summary

Ms C had been referred to a hospital specialist by the practice as she had reported having blood in her sputum (spit). She was told that she had developed terminal cancer. Ms C complained to the practice that she had reported the same symptoms to them for a number of years and that they had only prescribed antibiotics for a burst blood vessel in her throat.

We took independent advice from a GP adviser and found that Ms C had a long history of chronic blood streaked throughout her sputum and that it had previously been investigated by specialists. The presumed diagnosis was inflammation of Ms C's pharynx (back of throat) aggravated by a chronic cough. The plan was that further investigations were not required unless there was a significant change in her symptoms or that new symptoms had developed. When a GP arranged a further x-ray for a possible diagnosis of lower respiratory infection, it was noted that Ms C had a lesion in her chest which was not present in a previous x-ray. This resulted in a further referral for specialist investigations and it was then discovered that Ms C had a lung tumour. There was no evidence to suggest that there had been a previous significant change in Ms C's symptoms which the practice had not taken action on and, when it became clear that the situation had altered, timely and appropriate action was taken in order to reach a definitive diagnosis. We did not uphold the complaint.

Summary

Mr C complained that his pain medication was stopped unreasonably following a medication spot check (a check carried out by prison staff to ensure a prisoner has the correct type and amount of medication prescribed to them). Mr C also complained he had not been provided with reasonable alternative medication.

We took independent advice from one of our GP advisers. The adviser was satisfied that as Mr C had failed the medication spot check it was reasonable to have removed and stopped the prescription of the medication. The adviser was also satisfied the alternative medication provided was appropriate. For these reasons, we did not uphold Mr C's complaints.

Summary

Mr C complained that the prison health centre's handling of his medication for nerve pain was unreasonable. He said he had been prescribed pain medication but when he was admitted to the prison, his prescription was stopped.

We obtained a copy of Mr C's medical records and we also sought independent advice from one of our GP advisers. Mr C's medical records confirmed that the prison health centre carried out an assessment prior to taking the decision to stop his medication. Our adviser said the assessment was appropriate and the decision to stop Mr C's medication had been taken in line with the relevant guidance issued by the General Medical Council.

In light of the evidence available, and given the view of our adviser which we accepted, we did not uphold Mr C's complaint.