Health

Summary

Mr C complained to us about the care and treatment his father (Mr A) received at the Southern General Hospital. Mr A was admitted to hospital following a failed catheter change with a medical history including angina, heart attack and chronic kidney disease. A urinary tract infection was suspected and Mr A's kidneys were also found to be working abnormally. Treatment with intravenous (IV) fluids (administered directly into the veins) and antibiotics was started. Due to Mr A's cardiac history, he was prescribed IV fluids at a reduced rate. Mr A became breathless and was treated for fluid overload. Mr A's condition deteriorated and after some delay he was transferred to the Coronary Care Unit (CCU). Mr A died some weeks later.

Mr C complained about Mr A's fluid intake and that there was an unreasonable delay in transferring him to the CCU. The board advised that both Mr A's heart and kidney conditions had been considered but that it can be difficult to balance treatment in these situations. They provided an apology that no parameters or guidance had been given around oral fluid intake. In relation to delay, the board advised that there had been a breakdown in communication between staff. They assured Mr C that their processes had been reviewed to ensure that this would not happen in future.

After taking independent advice from one of our medical advisers, who is a consultant physician, we found that Mr A's treatment in relation to fluids was consistent with established good practice and we did not uphold this part of the complaint. However, the second element of Mr C's complaint was upheld as our adviser was critical of the delays in referring Mr A to the CCU and we found that this should have taken place at an earlier stage than the board identified.

Recommendations

We recommended that the board:

• make staff aware of the need to consider whether parameters and guidance for oral fluid intake may be required in specific cases;
• apologise to Mr C for the delay in referring Mr A for a cardiology assessment;
• draw the findings of this investigation to the attention of appropriate staff; and
• provide full details of their referral escalation process and confirm how awareness of this has been raised with staff.

Summary

Miss C attended an emergency dental appointment, as she was concerned about a large lump in her mouth that had become extremely painful and caused her face to swell. The swelling had been developing for a week, and had worsened despite receiving antibiotics and starting root canal treatment with her regular dentist.

The dentist at the emergency appointment immediately referred Miss C to hospital, and gave her a letter of referral to take with her. Miss C asked where exactly she should go, and the dentist told her to go to A&E, as they would transfer her to the right unit. However, when she got to A&E, staff told Miss C she was given the wrong advice and the dentist should have phoned the maxillofacial unit (a unit specialising in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) and sent her there directly. At the unit, Miss C had an infected tooth removed and the abscess in her mouth was drained. While she was there, hospital staff called the practice to advise them of the correct referral process for that unit.

Miss C complained about the care and treatment she had received. In particular, Miss C was concerned that the dentist had not taken an x-ray, or tried to drain the abscess or remove the tooth themselves. She said that staff at the hospital told her this was a simple procedure, and the dentist could have phoned the hospital and received advice over the phone about this. The dentist explained that in Miss C's condition he thought it was appropriate to refer her for hospital treatment immediately. He apologised for not knowing the correct referral process for the unit, and explained that dentists at the practice had now been made aware of this. Miss C was not satisfied with the dentist's response, and brought her complaint to our office.

After taking independent dental advice, we did not uphold Miss C's complaint. We found that the dentist had acted correctly in referring her immediately to hospital, and it would not have been appropriate for the dentist to take an x-ray or attempt treatment himself (even with advice from the hospital). Although the dentist should ideally have referred Miss C directly to the specialist unit, we found that the important thing was for her to be transferred to hospital as soon as possible, so it was not unreasonable to tell her to go to A&E.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Miss A) that the board failed to carry out her hysterectomy at Glasgow Royal Infirmary to an appropriate standard. She said this caused significant and irreparable damage to Miss A's bladder and ureter. Ms C said the surgeon who performed the operation unreasonably failed to identify the damage and remedy this during the operation. She said that as a result, repairs which might have prevented exacerbation of the damage were not carried out.

We obtained independent medical advice from a consultant in obstetrics and gynaecology. Our adviser explained that Miss A experienced an uncommon but recognised complication of hysterectomy. She said that injuries to the bladder and ureter could occur during surgery or it was possible for injuries as a result of surgery to be delayed. Our adviser said it was unlikely that the damage in Miss A's case occurred due to cutting or tearing during surgery and it was more likely to have been caused by compromised blood supply resulting in tissue/cells dying and a fistula (an abnormal passageway between two organs) forming after the surgery was complete. As such, the surgeon could not have reasonably been expected to rectify damage which was not immediately visible at the end of surgery and would only have become apparent some days later.

There was evidence that Miss A was made aware that damage to the bladder and ureter were recognised complications of the surgery she consented to receive. Our adviser said the records showed that the surgeon demonstrated a reasonable level of care during the surgery to avoid these complications and there was no evidence that Miss A's hysterectomy was performed unreasonably.

Summary

Mr C said the board unreasonably failed to provide the correct care and treatment on two occasions when he attended Stobhill Hospital with an ankle injury. He said that a piece of bone below his ankle bone should have been recognised and he should have been referred to a consultant orthopaedic surgeon much sooner. Mr C also said that during his first attendance, the board failed to tell him that he had a piece of bone below his ankle bone.

We obtained independent advice on the complaint from an emergency medicine consultant. The adviser said that the examination and investigation Mr C received at the hospital, leading to the conclusion of a soft tissue injury, was reasonable on both occasions. He said there were no failings by the board in Mr C's management, as on both occasions his x-rays were reported as normal by the radiology department, this was reported back to Mr C's GP and he did not need to be recalled. The adviser said that if Mr C had ongoing problems with his ankle the appropriate action would have been review by his GP and referral to the orthopaedic service.

Mr C's medical records did not indicate that the emergency nurse practitioner who saw him on his first attendance advised him about the piece of bone. However, the adviser said there were no failings by the board in the management of Mr C's case and the conclusion that he had a soft tissue injury was reasonable. Therefore, on balance, we did not find it unreasonable that the board did not tell Mr C about the piece of bone.

Summary

Mr C complained about the treatment he had received from the board for problems he had with his nose and breathing. Mr C had two operations on his nose, but this did not resolve the problems. We took independent advice from one of our medical advisers, who is an experienced ear, nose and throat surgeon. We found that it had been reasonable to carry out the operations on Mr C's nose. He had also been given appropriate information about the procedures before they were carried out. The operations had been carried out appropriately, but the symptoms Mr C complained of were rarely completely resolved by the surgery. It was also reasonable that the board had decided that that no further surgical options were possible. We found that the board had provided a reasonable standard of medical treatment to Mr C and we did not uphold his complaint.

Summary

Mrs C complained about the care and treatment her late husband (Mr C) received from the practice in the final months of his life. Mr C died after a period of illness and Mrs C felt he did not get the level of care he required as his health deteriorated. In particular, she raised concerns that her requests for GPs to attend were ignored despite Mr C having been very ill and in a lot of pain. Mrs C was also unhappy that the practice recorded the cause of Mr C's death as dementia, as she considered that he had shown signs of many other illnesses.

We took independent advice from one of our GP advisers. Our adviser considered that the practice provided a reasonable standard of care and treatment to Mr C. She said there was a good level of multi-disciplinary involvement, particularly in the last 24 days of his life when he had multiple visits from a range of clinicians. She also considered that the recorded cause of death was appropriate, advising that Mr C's deterioration was consistent with the decline exhibited by patients with dementia. She acknowledged that Mr C had other illnesses that could potentially have been listed in part 2 of the death certificate. However, she explained that this part should not be used to list all conditions present at death but rather only those felt to have directly contributed to the death. She noted that this was a matter of clinical judgement and considered that the practice acted reasonably, and in line with national guidance, in this instance. We accepted the advice we received and did not uphold these complaints.

Summary

Ms C's mother (Mrs A) had been admitted to Stirling Community Hospital for palliative care (care provided solely to prevent or relieve suffering). Ms C complained that one day her mother was very distressed, saying she had been forced to get out of bed and stand, despite her begging them not to make her do so, as she had not been out of bed for a long time. Ms C said her mother, therefore, fell on the floor and had to be moved back into bed by a hoist. The board told Ms C that two staff members were moving Mrs A from her bed to a chair, but as she sank down towards the floor, they helped her to the floor, and from there they transferred her back to bed with a hoist. Ms C said her mother would never have agreed to stand or sit, feeling so ill that she simply wanted to lie down all the time.

We considered the medical records, which showed that staff wanted to assess Mrs A's mobility needs to see whether it might be possible to meet her wish to return home. The records also said that Mrs A had sat up on occasion. We took independent advice from our nursing adviser, who considered that, although we could not know whether Mrs A had wanted to be moved on the day in question, it was appropriate that staff should try to move her and also, when she moved towards the floor, that they should assist her in doing so, to prevent any injury. We did not uphold this part of the complaint.

Ms C also complained about the communication with the family during the admission. The records showed no discussion about necessary end of life planning issues after a certain date - for example, discussions about where Mrs A might want to die. Our adviser considered such discussions were important. In the absence of documentation to show that such discussions took place, we upheld the complaint. The board themselves had already acknowledged that communication could have been better and had taken action to help prevent a recurrence. Our adviser considered that such action was appropriate, and, therefore, we decided against making any recommendation for further action.

Summary

Miss C complained to us that the time taken by the board to begin an assessment of her son for possible autistic spectrum disorder (ASD) was not reasonable.

Miss C told us that she had raised concerns about her son's development and behaviour with his nursery teacher and her health visitor, and, in particular, her concerns that her son may have ASD. Various referrals for her son to be assessed were then made to the board's community child health services. Miss C considered there was an unreasonable delay by the board in carrying out these assessments.

We took independent advice from our adviser, an experienced paediatrician who specialises in autism and communication disorders, who told us that the community paediatrician involved in assessing Miss C's son and the other professionals involved including speech and language therapy and occupational therapy had provided continued, frequent and supportive contact with Miss C. However, our adviser considered the wait Miss C had for her son's first developmental assessment, a period of ten months, was excessive. Furthermore, our adviser was of the view that it would have been appropriate to consider ASD as a potential diagnosis and to have referred Miss C's son immediately to the board's Autistic Spectrum Community Assessment (the ASCA pathway) at that time.

However, the ASCA pathway was not initiated for four months and, thereafter, Miss C waited another seven months for a diagnostic discussion about her son with the community paediatrician followed by a further lengthy wait for a specialist ASD assessment with the Fife Autism Spectrum Team (FAST), which the adviser considered was unreasonable, particularly in a pre-school child. The adviser also considered that, as a process, the ASCA pathway did not address sufficiently promptly the question of a diagnosis and did not appear sufficiently collaborative with Miss C and her partner as parents.

Although the adviser could not fault the community paediatrician's care of Miss C's son, he was of the view that a multi-disciplinary assessment at an earlier stage would have been helpful, possibly saved time and meant that Miss C and her family would have been better satisfied with the process and the outcome.

In light of the advice we received, we found there was unreasonable delay in the assessment of Miss C's son and, therefore, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Miss C for the unreasonable delays identified in this investigation;
• provide evidence of the action taken to address waiting times for assessment and diagnosis for children and young people with suspected ASD; and
• ensure that the comments of our adviser, including the ASCA process, are shared with the relevant staff for consideration.

Summary

Early in 2013, Mr C was seen at Dumfries and Galloway Royal Infirmary as he had been experiencing throat discomfort. The consultant he saw said that no abnormality had been revealed and he discharged him with an assurance that all was well. However, Mr C's throat problems continued and, in July 2013, he found a lump on the side of his neck. His GP referred him urgently to hospital where, on examination, he was found to have throat cancer requiring urgent surgery. Mr C complained to the board who acknowledged that the consultant should have had greater suspicion about Mr C's symptoms and done a more extensive examination. These findings were discussed with the consultant but he remained of the view that it had been appropriate not to diagnose Mr C as having throat cancer.

Mr C complained to us. We investigated and took independent advice from a consultant surgeon who specialised in ear, nose and throat surgery. Our investigation confirmed the board's own findings about Mr C's complaint that the consultant did not show enough suspicion about his symptoms given current accepted risk factors; did not examine him appropriately; and that furthermore, as Mr C's symptoms were untypical of the diagnosis initially given, Mr C should not have been discharged without follow-up. Later, Mr C was not seen within an appropriate timescale as dictated by the urgent GP referral.

Mr C also complained about the board's delay in dealing with his complaints on this matter and we found that this had been the case and that he had not been kept fully updated. In light of this, we also upheld this complaint.

Recommendations

We recommended that the board:

• provide a formal apology for failures in care and treatment;
• ensure that the case is reviewed by the consultant as part of his next appraisal;
• discuss the case at the next Ear, Nose and Throat department's clinical governance meeting so that all members of staff are made aware of the circumstances and can learn from them;
• make a formal apology for the delay and lack of information; and
• consider current complaint response times and assure us that they meet the targets required in stated policy.

Summary

Mr C complained to us that his medical practice had failed to diagnose his heart condition. We took independent advice on this complaint from one of our medical advisers and found that there was no evidence in the medical notes that indicated that the practice had failed to follow up on the symptoms Mr C had reported. There were no recorded symptoms of possible heart problems and so we did not uphold the complaint.

Mr C then wrote to us to complain that some of his consultations with the practice had not been recorded accurately. In view of this, we decided to reopen the case to investigate his complaint that his medical records were inaccurate. We obtained a full historical print out of Mr C's computer record from the practice and considered this along with the information he provided to us. However, there was no evidence that the practice had altered or deleted any of the records of the consultations that he had referred to. Our adviser also considered that the GPs had acted reasonably in summarising the consultations in the computer records. In view of all of this, we did not uphold this complaint.