Health

Summary

Ms C complained that, during a phone consultation, an out-of-hours GP asked a care home nurse if Ms C's father (Mr A) had a do not attempt cardiopulmonary resuscitation (DNACPR) note in his records. Ms C said the GP asked about the DNACPR with the implication that, if there was one in place, the GP should not bother coming to visit Mr A. Ms C also complained that the GP inappropriately prescribed amoxicillin (an antibiotic drug used to treat bacterial infection) to Mr A, which she said was not effective for him, and could be detrimental to his health.

We looked at Mr A's clinical records and a copy of the board's complaint file, and we took independent advice from one of our medical advisers. We asked the board for the audio recording of the phone call between the GP and the care home nurse, but it was no longer available. We found that DNACPR refers to cardiopulmonary resuscitation in circumstances where a patient's heart stops, and does not refer to any other element of a patient's clinical care. We concluded that it was normal for a triaging doctor (triage is the process of deciding which patients should be treated first based on how ill or injured they are) to ask whether a DNACPR form has been completed for a patient.

We also found that there was nothing in the available medical records to indicate that Mr A was allergic to amoxicillin. We concluded that the final prescribing decision has to lie with the doctor who is assessing the patient at the time, that the GP prescribed medication in line with relevant guidance, and that Mr A was provided with a reasonable standard of care in the circumstances. We did not uphold Ms C's complaints.

Summary

Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for his treatment as they were visitors to the UK. Mrs C complained that it was unreasonable that she was charged for his care and treatment. Her concerns included that her son's treatment was not immediately necessary and the board's actions were contrary to Scottish Government Guidance CEL 09 (2010) (Overseas Visitors' Liability to Pay Charges for NHS Care and Services) as she was not given the opportunity to make an informed decision about whether, or to what extent, to proceed with treatment.

We obtained independent medical advice on the complaint from one of our medical advisers, a consultant in general medicine. The evidence showed that the initial impression provided to Mrs C by the board was that her son's treatment would be free. The board failed to follow the Scottish Government guidance with sufficient accuracy, and there were opportunities that should been taken to discuss the likely charges with Mrs C at the time of her son's admission to hospital.

However, the type of treatment her son received was chargeable. It seemed unlikely that, had Mrs C been presented with the 'undertaking to pay' form at the time of her son's admission to hospital, she would have refused to sign the form, as he was clearly very unwell and in need of medical treatment. We also noted that Mrs C signed the 'undertaking to pay' form at the time of her son's discharge. We therefore considered that, on balance, it was reasonable that Mrs C was charged for her son's care and treatment.

Recommendations

We recommended that the board:

• ensure that hospital staff receive training on when to discuss charging for NHS care and services with overseas visitors requiring treatment; and
• provide Mrs C with a written apology for failing to discuss the likely charges for her son's treatment with her at the time of his admission to hospital.

Summary

Mr C attended the hospital's minor injuries unit, having injured his knee while playing football. He complained that the nurse practitioner (a specially qualified senior nurse) whom he saw did not assess the injury adequately. We took independent advice from our medical adviser, who considered that the nurse practitioner had acted appropriately. For example, her diagnosis of a sprain of his lateral collateral ligament (one of the four main ligaments in the knee) was appropriate based on her findings; she arranged follow-up with a physiotherapist for the following week; and she gave appropriate advice about the use of pain relief, ice and crutches in the meantime. Mr C considered he should have been x-rayed, but the adviser explained that there were no grounds for x-ray, and that x-ray would not have shown damage to his ligaments or cartilage.

Summary

Miss C complained about three consultations with three of the GPs at her medical practice as she did not feel the questions asked by the GPs had been appropriate. We took independent advice from one of our GP advisers, who considered that the questions and actions of Miss C's GPs had been thorough and appropriate. For example, when Miss C reported an episode of self-harm, the GP appropriately asked, amongst other things, about her support network at home.

Summary

Ms C complained that her mother (Mrs A) had not been provided with a reasonable standard of treatment by her medical practice. She felt the practice had unreasonably handled much of Mrs A's contact over the phone and, following hospital investigations and tests, that the practice had failed to take the appropriate steps.

We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We took independent advice from one of our medical adviers, who explained that managing contact over the phone is common practice, and that there was nothing to indicate it had been done unreasonably in this case. Our adviser also said that it was the hospital doctor's responsibility to explain hospital test results and, in any event, the practice had not misinterpreted hospital correspondence as Ms C felt they had.

Although we took Ms C's concerns into account and recognised her strength of feeling, the medical advice we received was that the records did not indicate that Mrs A's treatment had been unreasonable. We did not consider the evidence indicated that Mrs A's practice had failed to provide her with a reasonable standard of medical treatment, and so we did not uphold this complaint.

Summary

Miss C complained about the medical and nursing care that her late mother (Mrs A) received at the Royal Infirmary of Edinburgh after she was admitted with upper abdominal pain. Miss C felt there had been a delay in a scan being performed which contributed to Mrs A's premature death from cancer; that there was a lack of communication from the staff about the severity of Mrs A's illness; that a decision had been made not to resuscitate Mrs A without this being discussed with the family; and that nursing staff should have monitored her mother's condition more closely.

We took independent advice from our medical adviser who found that there had been an unreasonable delay in the scan being done, although an earlier scan was unlikely to have altered Mrs A's prognosis. Had the scan been done two days earlier, Mrs A and the family could have been informed of the diagnosis in a more timely manner before her death several days later. The board said that the delay was due to the ward being closed because of an infection. However, we concluded that infection control measures could have been put in place, so we upheld the complaint. We also found that there was a lack of records to provide evidence that the medical team clearly communicated, to either Mrs A or the family, about the strong suspicion of cancer. Furthermore, we considered it was unreasonable that the family were not given the opportunity to be involved in the medical decision about resuscitation. In terms of the nursing care, we found evidence that reasonable checks were carried out. Furthermore, the medical staff noted that nursing staff had raised concerns with them about Mrs A's deteriorating condition. We did not uphold the complaint but recommended the board share with nursing staff the importance of recording when such action is taken.

Recommendations

We recommended that the board:

• apologise for the delay in performing the scan;
• share the findings about the delay in the scan with relevant staff to prevent this recurring;
• share with relevant nursing staff the need to make accurate records in line with guidance issued by the Nursing and Midwifery Council;
• ensure that doctor 1 reflects on the failings in relation to communicating with patients about suspected diagnosis at his next appraisal; and
• draw the findings about the lack of discussion about the decision not to resuscitate Mrs A to the attention of doctor 2.

Summary

Mr C complained that he was not given his prescribed medications on his first days in prison, and that all his medications were stopped soon after entering prison. Mr C also complained that the board did not investigate when he complained about this.

The board said Mr C's medications were stopped in accordance with his signed medications agreement after he was found concealing suboxone (a medication used to manage addictions) and after he refused to open his mouth to let staff check that he had taken his medication. The board said that, as Mr C had raised these issues with healthcare staff rather than complaining to complaints handling staff, they had treated this as a 'concern' rather than a 'complaint'. They also said that, in any case, they had responded to Mr C's verbal complaints reasonably, by discussing the complaints with him directly on each occasion.

After taking independent advice from a psychiatrist, we upheld Mr C's complaints. We found there was no evidence the health centre had given Mr C his prescribed medication on his first days in prison, aside from one drug, for which there were two conflicting prescriptions (and he had been given one of these). We also found Mr C had been given incorrect medication on several other occasions. However, we found that it was reasonable for the health centre to decide to stop Mr C's medications when they did. Two medications were stopped or reduced soon after Mr C arrived in prison, and the adviser said this was appropriate, as these medications were addictive and not intended for long term use. Mr C's suboxone was stopped after he was found concealing this, and we found this was reasonable, as suboxone is used for addictions management, and there is a risk of overdose or harm if it is taken other than as directed. However, we were critical that the health centre were not able to show that Mr C had been warned about the consequences of concealing medications, as he had been asked to sign the wrong medications agreement (for 'in possession' medications, rather than 'supervised' medications). Mr C's remaining medications were stopped when he refused to comply with instructions to open his mouth. We found this was reasonable, as these medications were not essential for Mr C's condition and there is a risk of harm when medications are taken other than as directed.

We found that the board did not investigate Mr C's complaints appropriately. Although we found it was reasonable for the board to treat these issues as a 'concern' when Mr C initially raised them, when Mr C continued to raise these issues, and was not satisfied with the board's response, they should have been fully investigated.

Recommendations

We recommended that the board:

• remind nursing staff of the need to take care when administering medications (particularly where there are multiple prescriptions);
• review the processes for issuing prescriptions for incoming patients to the prison to ensure that existing prescriptions (from the community and/or time in custody) are continued or amended without delay, and the patient’s agreement is obtained to the applicable medication process ('supervised' or 'in possession');
• apologise to Mr C for the failings our investigation found; and
• take steps to ensure that complaints raised verbally with healthcare staff at the prison are appropriately handled and reported in accordance with the 'Can I help you?' guidance.

Summary

Mr C complained about the care and treatment he received from a prison health centre in relation to his eye condition. He was concerned that he received various different medications, none of which helped and some of which appeared to worsen his condition. He, therefore, felt that he had been inaccurately diagnosed, and he complained that he was not referred to an eye specialist sooner.

We took independent advice from one of our medical advisers, who observed that Mr C had been seen on a number of occasions by healthcare staff and examined repeatedly. Our adviser noted that examinations did not reveal any serious underlying problems and that this mirrored the subsequent findings of the eye specialist. As such, she did not consider there to have been an earlier indication for a referral to a specialist. We fully accepted this advice and did not uphold this aspect of the complaint.

Mr C also raised concerns about the way his complaint was handled. We noted that he submitted multiple complaint forms on the issue, and the prison health centre continued to try to resolve these informally. The guidance only allows a three-day window for informal resolution, following which the complaint should be formally acknowledged and investigated. This did not happen for several weeks and, seemingly, only upon Mr C's prompting. We identified other failings to follow due process, such as an initial failure to inform Mr C of his right to approach this office. In the circumstances, we upheld this part of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to making improvements and ensuring compliance with their statutory responsibilities, as set out in the ‘Can I help you?’ guidance; and
• apologise to Mr C for the identified failings in their handling of his complaint.

Summary

Mr C complained that the operation on his foot performed by the board at St John's Hospital to help his dropped foot (a muscular weakness or paralysis that makes it difficult to lift the front part of the foot and toes) was not carried out to a reasonable standard. Mr C said that, prior to the operation, he had restricted up-and-down movement in his foot but full side-to-side movement, and he tripped and fell regularly because of his foot. Mr C said that after the operation, he had no movement either way in his foot, and he tripped and fell on almost a daily basis. Mr C also complained that there was an unreasonable delay in him receiving physiotherapy treatment.

We obtained independent medical advice on Mr C's complaint from a consultant orthopaedic and trauma surgeon, with special interest in foot and ankle surgery. Our adviser said that the procedure failed in Mr C's case, but the documentary evidence suggested that Mr C was advised that this could happen. Our adviser explained that a standard technique was used during Mr C's operation, and the treatment provided did not seem unreasonable.

The evidence showed that Mr C was referred for physiotherapy treatment six weeks after surgery. Our adviser said there was no significant avoidable delay in Mr C's physiotherapy treatment and that, given the failure in his surgery, the apparent delay in physiotherapy would not have made a significant difference to the outcome in his case.

Summary

Mrs C complained that her husband (Mr C), who suffered from multiple sclerosis, had received inadequate care and treatment from the District Nursing Team. He had developed a pressure ulcer on his back, and Mrs C said she believed that had she not insisted her husband phone his GP, then the pressure ulcers would have continued to deteriorate. Mrs C said that when he examined the pressure ulcer, the GP had been surprised at how bad it was, and her husband had been admitted for hospital treatment. Mr C had spent an extended period in hospital with a serious infection, which she attributed to the poor care he had received at home.

The board said that the nurses treating Mr C had made a number of suggestions to him that would have helped to treat his pressure ulcer, but he had refused them. The board said that successful treatment of pressure ulcers was dependent on the patient following the advice of staff, and that treatment would be limited if this did not happen. Nurses had attempted to obtain a medical opinion prior to Mrs C's contact with the GP, but Mr C had refused this.

We took independent advice from our nursing adviser, who said that the nursing record was appropriately completed and showed that a good standard of wound care had been provided. The adviser said that the wound had improved at times and then deteriorated, and it was reasonable for the nurses to persist with home treatment. Our investigation found that on the basis of the advice received, Mr C had been provided with a reasonable standard of care and treatment.