Health

Summary

Mr C complained to us about the apparent lack of assessment of his late mother (Ms A) for NHS Continuing Care funding. Ms A was admitted to hospital from a care home with a broken ankle. However, she was not able to fully rehabilitate, and was subsequently transferred to a nursing home for ongoing care. Mr C complained that the board did not fully assess whether Ms A was eligible for NHS Continuing Care funding when she was discharged from hospital, or during her time at the nursing home.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care for the elderly) on the assessment of Ms A's care needs when she was discharged from hospital, and on the evidence of her care needs while she was in the nursing home. Our adviser said that Ms A's care needs had been appropriately assessed before her discharge, and she had been given appropriate opportunities to rehabilitate prior to discharge. He said that her care needs clearly did not meet the criteria for NHS Continuing Care, and that this was so obvious that it had not been documented. Given subsequent events, he noted that it would have been helpful if it had been documented, but he considered this to be a minor issue. He also noted that, from the evidence available, Ms A was not eligible for NHS Continuing Care at any time during her stay in the nursing home.

In our decision we noted that the board had provided information which showed that they had made a similar assessment to our adviser. However, this information had not been provided to Mr C. We were critical of this, though overall we were satisfied that the board had appropriately assessed Ms A's care needs, and that it had been reasonable not to document a full NHS Continuing Care assessment.

Summary

Mrs C complained about the treatment she received from the board in the lead up to the birth of her twins. During her pregnancy she developed HELLP Syndrome (this is the term used to describe a range of symptoms that can affect women with pre-eclampsia or eclampsia; HELLP Syndrome is characterised by the breakdown of red blood cells, elevated liver enzymes and low platelet count). Following diagnosis of her condition, Mrs C's caesarean section was brought forward. Whilst one of her daughters was born healthy, the other was stillborn. Mrs C complained that staff did not monitor her and her babies adequately, and that there was an unreasonable delay to the diagnosis of her HELLP Syndrome and to the delivery of her twins.

We took independent medical advice from a consultant obstetrician (a doctor specialising in pregnancy and childbirth) and gynaecologist (a doctor specialising in the female genital tract and its disorders). We were generally satisfied that Mrs C's condition, and that of her twins, was monitored adequately and in line with national guidance. Blood tests raised concerns for Mrs C's wellbeing but gave no indication of a problem with the twins. When abnormalities were identified, staff acted appropriately. However, we found that one of Mrs C's blood test results was checked and action taken by clinical staff before the full extent of the test results was known. Crucial information about Mrs C's liver enzyme levels was not identified until the day after the information was entered onto the hospital's system. Whilst appropriate action was taken to prioritise Mrs C's delivery once this information was highlighted, we accepted advice from our adviser who considered that the delivery would have taken place sooner had the blood test results been noted on the day they were reported. The available evidence suggested that, had this happened, both twins would likely have been alive at birth.

We were also critical of excessive delays and poor communication in the board's handling of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified;
• review their systems for reviewing blood results to ensure those taken in clinic and those taken on the ward are seen and acted upon in a timely fashion;
• take steps to ensure clear communication of the urgency of non-elective c-sections, and to develop a policy for escalation at times of high workload when c-sections are delayed longer than expected; and
• review their procedures for conducting root cause analyses to ensure they follow a structured process in keeping with the principles of the NHS Scotland complaints handling procedure.

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) when he was admitted to Monklands Hospital. Mrs C also had concerns about the handling of the complaint she subsequently made to the board.

Mr A was suffering from heart failure and was being cared for at home when he had a fall at home. He was seen by his GP who diagnosed a urinary tract infection and prescribed antibiotics (a range of drugs to fight bacterial infections). Mr A's condition deteriorated and he was referred by an out-of-hours GP to the hospital. The admission record noted his confusion, decreased mobility and the diagnosis by the GP. A urine sample was taken and x-rays were taken.

Mr A was reviewed the next morning and considered ready for discharge home with support from ASSET (a multi-disciplinary home care team) but the family were concerned that he was not well enough. Mr A was kept in hospital and given further antibiotics. He had a number of falls while in hospital that Mrs C felt contributed to his eventual death, which occurred less than three weeks after admission.

Our investigation included taking independent advice from two of our advisers, a physician specialising in the care of the elderly and a senior nurse. Our advisers were satisfied that the care and treatment provided were reasonable in the circumstances. Mr A was appropriately assessed and monitored for risk of falls, and the physician adviser was of the view that the initial consideration of discharge with support was reasonable.

On the matter of the complaints handling, we identified unreasonable delays which the board had already acknowledged and apologised for to Mrs C. Appropriate remedial action had been taken to minimise the risk of a recurrence. Although we upheld this complaint, no further recommendations were made.

Summary

Mrs C complained about the care and treatment provided when she underwent surgery at Wishaw General Hospital to remove several adhesions (where organs are stuck to each other and/or the pelvic wall).

Mrs C had surgery. The following day she became unwell and a CT (computerised tomography - a special type of x-ray using computerised images) scan was done to eliminate the possibility that her urinary tract had been damaged during surgery. No evidence of this was seen. When her condition continued to deteriorate and bilious fluid (from the digestive system) was seen in her surgical drain, she underwent further surgery three days after the first operation. A perforation of the bowel was discovered and repaired. Mrs C's condition continued to deteriorate and she was operated on again three days later. A second perforation was found, and Mrs C's appendix and part of her bowel were removed. Mrs C was admitted to the adult critical care unit following the third operation and spent two months in hospital in total. She then had a six-month recovery at home.

Our investigation included taking independent advice from three of our medical advisers: a gynaecologist (specialist in disorders of the female reproductive system); a general surgeon; and a radiologist (specialist in imaging). No evidence of any failures was found in the original surgery, or the post-operative care. Although the CT scan did not reveal the perforations, the radiologist stated that this was reasonable in the circumstances. Similarly, the general surgeon considered that it was appropriate to have repaired only the visible perforation at the second operation. Inspecting the whole length of the bowel would have needed more invasive surgery and risked creating more adhesions. The fact that Mrs C required a third operation was not, in the view of the advisers, due to any failings in Mrs C's care and treatment.

Summary

Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and an extended hospital stay. She complained that the risks of the surgery were not adequately explained and that reasonable steps were not taken to avoid the complications encountered, such as infection. She also complained that the surgery resulted in Mr A developing a foot drop (a condition which impairs the ability to lift the front part of the foot).

We took independent advice from one of our medical advisers who noted that consent forms were completed both prior to Mr A's admission and on the day of the surgery. However, our adviser observed that the forms did not document the potential risks of the surgery. Our adviser stated that it was good practice to list common complications, or those which are rare but severe. In the absence of this, we could not find evidence that the risks were adequately discussed with Mr A and so we upheld this aspect of the complaint.

Our adviser confirmed that the complications encountered were recognised complications of this type of surgery, and did not consider that anything could reasonably have been done to prevent them in Mr A's case. In addition, our adviser considered it unlikely that Mr A's foot drop was related to the surgery. We accepted this advice and did not uphold the remaining aspects of the complaint.

Recommendations

We recommended that the board:

• review their handling of this case with a view to improving the process for obtaining consent and, in particular, consider whether the consent form could benefit from revision; and
• apologise to Mr A for the failings in the process for obtaining his consent.

Summary

Ms C complained that the board had not managed her Individual Patient Treatment Request (IPTR) panel appropriately. She had been obliged to make an IPTR in order to obtain a drug which helped control the symptoms of her multiple sclerosis (MS) as the drug was not licensed for prescription in Scotland. Ms C had been prescribed a free trial of the drug and said her neurologist supported the prescription of it once the trial had finished.

She said there had been undue delay in arranging her hearings and that the board had not provided her with information about the panel's decisions appropriately. Ms C also complained that the panel had failed to consider the evidence she had presented appropriately. Ms C said this had caused her considerable distress and worsened her MS.

We took independent advice from one of our medical advisers who said he believed the panel had been conducted appropriately. He noted there were delays in the submission of the original IPTR request, and further delays caused by the departure from the board of Ms C's original neurologist. The board had acted to mitigate these delays, but were not responsible for them.

Our investigation found the board had arranged the IPTR process appropriately. Although Ms C had been successful on appeal, this was due to a change in Scottish Government guidance, rather than a reassessment or reinterpretation of the evidence by the IPTR Panel. The substantial delays in the IPTR process were due to the actions of Ms C's neurologists and the delays in submitting documents. We did not find the board failed to provide Ms C with information about the panel's decisions.

Summary

Ms C complained about the care and treatment her late mother (Mrs A) had received from the board. Mrs A had taken lithium medication for many years for her bipolar disorder. This medication was changed in November 2012 and then changed back to lithium around six months later. Ms C was unhappy with these decisions as she felt they caused her mother to suffer from lithium poisoning, which caused Mrs A to attend Lorn and Islands Hospital. She was transferred to Argyll and Bute Hospital and then was moved between the hospitals again. Mrs A died within two months of her initial admission and Ms C was unhappy with the care her mother had received throughout this period.

We considered whether Mrs A's treatment was reasonable in the circumstances at the time. We did not use the benefit of hindsight in making that decision and we took independent medical advice from a psychiatrist and a geriatrician (a doctor specialising in medical care for the elderly). Their advice confirmed that the original decision to change Mrs A's medication was reasonable in the circumstances, as was deciding to reintroduce lithium. In light of this clear advice, we did not uphold Ms C's first two complaints.

Our medical advice was that Mrs A appeared to have been suffering from lithium toxicity when she first attended Lorn & Islands Hospital, and that it was unreasonable to have transferred her to Argyll and Bute Hospital at that time. Mrs A was then transferred back to Lorn and Islands Hospital for a time before returning to Argyll and Bute Hospital. Our medical advice was that the potential severity of Mrs A's lithium toxicity appeared not to have been recognised during this time and her condition was not investigated sufficiently. We upheld Ms C's complaints about these admissions. However, in terms of Mrs A's final admission to Lorn and Islands Hospital, our medical advice was that care and treatment was by that point reasonable, so we did not uphold Ms C's complaint about that.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings identified in our investigation;
• remind relevant staff (including in A&E) of the possibility for lithium toxicity to occur in older patients at levels within the standard range of prescribed dosage;
• consider whether a shared protocol between Lorn and Islands Hospital and Argyll and Bute Hospital would be appropriate for management of lithium toxicity; and
• raise the medical advice we received about restarting lithium medication at the relevant psychiatrist's appraisal for reflection.

Summary

Ms C complained on behalf of Ms A, who was diabetic, that after she had a stent (a mesh tube) inserted into her kidney in April 2013, staff at the Southern General Hospital failed to monitor or remove it. As a result, Ms C said that Ms A was caused extreme pain, which led to her having an emergency operation early in 2014 to remove her kidney. Ms C believed that early intervention with regard to the stent could have avoided this.

We took independent medical advice from a consultant urologist (a doctor who treats disorders of the urinary tract). We found that after the insertion of the stent, it was planned to remove it in July 2013. However, at her anaesthetic pre-assessment for the removal of the stent, Ms A was found to have poor diabetic control, which meant that her operation could not go ahead. Her GP was asked to inform the hospital when Ms A's condition improved so that her operation could be rescheduled. However, the hospital was never updated. The investigation also showed that Ms A's name continued on the waiting list for stent removal and this should have provided an adequate safety net, but it did not. In the meantime, Ms A's stent was removed in England. In these circumstances, we upheld the complaint about the monitoring of the stent. However, in reaching our decision we did not conclude that the failure to monitor the stent ultimately led to Ms A losing her kidney, as there was no evidence that this had been the case.

Recommendations

We recommended that the board:

• make a formal apology in recognition of the failures identified; and
• advise us of the processes that have since been put in place as a consequence of the complaint made.

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent left-sided pain after a fall and attended the practice on numerous occasions over the next two years. Although Mr C had a number of tests and investigations, he was not diagnosed with cancer until a scan over two years after the fall.

The practice apologised that it took so long to diagnose Mr C's cancer, but explained that his case was a challenging one and diagnosis was difficult. They said Mr C did not have symptoms suggesting a serious underlying problem until about two years after his fall, and also did not start losing weight until after this. While they immediately referred Mr C to the colorectal service (specialising in the colon and rectum), it took three specialist referrals (two to the colorectal service and one to the gastroenterology clinic (specialising in the digestive system) before Mr C's cancer was diagnosed about five months later.

After taking independent medical advice, we did not uphold Mrs C's complaint. We found that Mr C's symptoms did not suggest a serious underlying problem until about two years after his fall. We found the practice then acted appropriately and timeously in referring Mr C to specialists for investigations. Our adviser explained that Mr C's symptoms first suggested an underlying colorectal problem, and it was appropriate to refer Mr C for colorectal investigations and a colorectal clinic review. However, when nothing was found but Mr C's problems persisted and he experienced ongoing weight loss, the practice acted appropriately in referring him to the gastroenterology clinic.

Summary

Mr C complained that after breaking a bone in his foot, despite four visits to hospital over a six month period, staff at the Southern General Hospital failed to diagnose and treat him properly. As a consequence, he said that he suffered prolonged and unnecessary pain. Mr C subsequently had an operation abroad to remedy his foot problem. He then complained to the board. The board said that, generally, with the exception of his final attendance at hospital, he had been treated appropriately. However, they apologised that his final visit had been below the standard expected. They said that they had since learned from the situation.

The complaint was investigated and we took independent advice from a consultant in emergency medicine. We found that when Mr C first went to hospital after injuring his foot, he had been diagnosed with a low risk, undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) and treated accordingly. Although it was more rare, we found that he had actually suffered a high-risk, complex fracture (a Jones fracture) which required significantly different management as the blood supply to his foot could have been affected. His further attendances at hospital also failed to establish the nature of Mr C's fracture, so we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology recognising the failures in care and treatment identified; and
• ensure that appropriate staff in the A&E department are made aware of the circumstances of this case and the failures identified, particularly with reference to a Jones fracture.