Health

Summary

In January 2013, Mr A attended the medical practice as he had ongoing chest pain and a cough. A chest x-ray and blood tests were arranged and the results came back normal. However, as his pain was continuing he was given painkillers. In March 2013, Mr A attended the practice again because his symptoms were continuing and he was referred to hospital for a specialist opinion. Mr A was seen in hospital in May 2013 although, in the meantime, the practice prescribed him increasing painkillers and his tests were repeated but again with no result. After a difficult diagnosis pathway, Mr A was advised over the phone by his GP in September 2013 that he had cancer, and he died in May 2014.

Mr C complained to the practice on behalf of Mr A's widow (Mrs A) that it had taken the practice too long to refer Mr A for appropriate tests and opinion and that there was a lack of urgency to provide him with any meaningful treatment. He further complained that a GP within the practice told Mr A of his diagnosis over the phone, which he said was inappropriate and showed a lack of compassion.

We took independent advice from one of our GP advisers and we found that while Mr A was treated reasonably and appropriately and that efforts were made to treat his pain, he was not referred to hospital in line with national guidelines for suspected cancer. His referral should have been urgent rather than routine. Because of this, there was a delay in him being seen in hospital and a delay in his treatment being started. While it was confirmed that Mr A had been told of his diagnosis over the phone, this was for the best of intentions in order to explain his increasingly strong painkillers. Nevertheless, this should not have happened and arrangements should have been made for a house call or for Mr A to attend the practice. In light of the advice we received, we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• make a formal apology to Mrs A for this failure;
• ensure that all medical staff familiarise themselves with the national referral guidelines for suspected lung cancer; and
• ensure that the GP reflects on the distress caused and he ensures that the matter is raised at his next formal appraisal. He should advise us that he has done so.

Summary

Mrs C complained on behalf of her client (Mrs A) who was unhappy with the care and treatment she received from her GP practice in relation to a finger injury.

After injuring her finger, Mrs A attended the hospital minor injuries and illnesses unit, but she was discharged. A week later, she attended the practice as she was still unable to bend her finger. The GP examined her finger and prescribed antibiotics. Mrs A returned a week later and a different GP prescribed different antibiotics. Mrs A returned again another week later, and at this appointment she mentioned that soon after the first injury, she had had a second injury which stretched her finger. The third GP then considered that Mrs A might have an injury to her flexor tendon (the tendon that connects the muscles in the forearm to the bones in the finger), and referred her to the orthopaedic clinic as a routine referral. After further investigations, Mrs A was diagnosed with an incomplete tear of the flexor tendon.

After taking independent medical advice from a GP adviser, we upheld the complaint. We found that, although the first two GPs did not know about the second injury, in view of Mrs A's symptoms they should still have considered the possibility of a flexor tendon injury and referred her for specialist assessment. Although the third GP acted appropriately in referring Mrs A to orthopaedics, this should have been an urgent referral, rather than routine. We were concerned that the GPs' failures to refer Mrs A appropriately led to a delay of over three weeks in her treatment, which our adviser said was significant as flexor tendon injuries are normally treated within a few days.

Recommendations

We recommended that the practice:

• issue a written apology to Mrs A for the failings our investigation found; and
• draw our findings to the attention of the GPs involved, for reflection as part of their annual appraisal.

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury.

Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Recommendations

We recommended that the board:

• remind staff in the minor injuries and illnesses unit of the 'Tayside Hand Unit – Trauma Referral Guidelines' (in particular the guidance on assessment of wounds on page 7);
• consider options for improving the tracking of similar referrals in the general medical clinic;
• bring our findings to the attention of relevant staff for reflection and learning;
• issue a sincere written apology to Mrs A, acknowledging the failings our investigation found; and
• remind relevant staff of the need to ensure complaints are fully investigated in line with the complaints procedure and the responses provide full explanations of the matters raised.

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.