Health

Summary

Mr C had some of his medications reduced and stopped soon after entering prison (although he was still on one medication). He was then transferred to a different prison, where he raised concerns about his medication and asked to be put back on his original medication. The board arranged for Mr C to see his psychiatrist from the community (who had prescribed his initial medication). The psychiatrist increased Mr C's current medication, but did not return him to his previous medications. Mr C complained about the board's failure to return him to his previous medication, and their handling of his complaint.

After taking independent advice from an experienced psychiatrist, we did not uphold Mr C's complaint about medication. We found there was no clinical reason to restart Mr C's previous medications, particularly as several of these medications are addictive and not for long-term use. We also noted that Mr C's psychiatrist from the community had reviewed his medication and agreed with this.

In relation to the board's complaints handling, we found the board had taken appropriate action in response to Mr C's complaints by arranging review by his psychiatrist from the community. However, on two occasions the board did not respond to Mr C's complaint to confirm what was happening and check that he was satisfied with this, as required by their complaints procedure. Therefore, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the need to acknowledge or respond to all complaints within a three working day timeframe.

Summary

Miss C's MP complained to us on her behalf. Miss C was admitted to Aberdeen Royal Infirmary with an infected appendix, which was removed. She complained about aspects of her nursing care, including that she was not provided with anything to eat or drink on the day of her admission. She also complained that she was not given sufficient information on discharge. In addition, she was unhappy with the time the board took to respond to her complaint and she said their response contained inaccuracies, including the board's view that she was given tea and toast on the evening of her admission.

We took independent advice from one of our nursing advisers, who observed that there was no record of any food or fluids being given to Miss C on the evening of her admission. She said if tea and toast were provided she would have expected this to have been recorded. We upheld this aspect of the complaint.

While the adviser noted that, in light of Miss C's anxiety, the board could perhaps have provided her with extra information and reassurance, she considered that a reasonable level of information was provided to her at the time of her discharge. We did not uphold this aspect of the complaint.

We noted that there was a considerable delay in the board responding to Miss C's complaints correspondence. It appeared as though they had overlooked the complaint. We also noted that information relevant to their investigation was not contained within their complaint file, including notes of key discussions. Further, they failed to address all the points of complaint Miss C raised and some of the information they provided in their response did not appear to be supported by the available evidence. We, therefore, upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• remind nursing staff of the importance of good record-keeping;
• remind complaints handling staff of the importance of issuing full, evidenced and timely responses to complaints;
• remind complaints handling staff that complaint files should contain a complete record of their investigations, including notes of relevant discussions; and
• apologise to Miss C for the complaints handling failures this investigation has identified.

Summary

Ms C, an advice worker, complained on behalf of her client (Mrs A) that the care and treatment provided by her medical practice between June and August 2011 was unreasonable.

Mrs A had a history of abdominal and gynaecological (relating to the female reproductive system) problems and some stress-related illness. She saw three different GPs in June, July and August 2011 for recurrent symptoms of bloating and stomach pain. Some investigations were undertaken but no conclusive results were obtained. Mrs A was seen again by one of the GPs in November 2011 and was referred on a routine basis for a colonoscopy (examination of the intestines by a camera). Further investigations were undertaken in February 2012 and Mrs A was diagnosed with ovarian (part of the female reproductive system) cancer later that month. She has since undergone treatment that was ongoing at the time she complained to us.

Our investigation included taking independent medical advice from one of our GP advisers. They considered that in view of the symptoms reported by Mrs A, the 'watchful waiting' approach taken by the GPs between June and August 2011 was reasonable and in line with national guidance in place at the time. However, our adviser considered that, in view of the duration of Mrs A's symptoms by the time she was seen in November 2011, the referral made at that time should have been made on an urgent basis. This would have indicated a suspicion of cancer, which would have meant that she would have been seen within two weeks of the referral. The adviser did not, however, consider that the resultant six-week delay had an effect on the overall outcome or treatment for Mrs A. The complaint was not upheld but the findings were drawn to the attention of the GPs involved.

Summary

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer.

We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the error made in the administration of his medication;
• explain to us what steps have been put in place to prevent such an incident from occurring again; and
• provide us with a copy of a drug recording sheet.

Summary

Mrs C developed deep vein thrombosis (DVT, a blood clot in one of the deep veins in the body) after having surgery at Forth Valley Royal Hospital. Mrs C was readmitted to hospital, where the diagnosis was confirmed and she was started on a medication to treat DVT. After she was discharged, Mrs C's GP referred her to an out-patient clinic at the hospital (the Clinical Assessment Unit), as Mrs C's legs were swollen and she was suffering pain. Mrs C was reviewed by a doctor, but not admitted to hospital. Mrs C then received an appointment for a scan at another hospital out-patient clinic (the Day Medicine Unit). When she arrived, the staff were not sure why she was there, and said she did not need a scan. However, a doctor reviewed Mrs C and arranged for her to be seen by a consultant vascular surgeon, who then took over Mrs C's care.

Mrs C complained about her overall care and the confusion about her appointment at the Day Medicine Unit. Mrs C was concerned that her DVT may have developed in her first hospital admission (and been misdiagnosed as an infection), that she may have been discharged too early after her second admission, and that she should have been given a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) or referred to a surgeon earlier.

The board apologised for a number of failings. The board took a number of actions to address the issues raised by Mrs C's complaint, including developing a ward checklist for checking the use of anti-embolism stockings (specially fitted elastic stockings used to compress the lower leg and reduce the risk of blood clots); developing a patient information leaflet on DVT; arranging for certain types of DVTs to be referred for a CT scan and discussed with a vascular surgeon as a matter of routine; reviewing the patient pathway for the provision of specialist hosiery; and establishing a seven-day service for management of DVTs within the Day Medicine Unit.

After taking independent medical advice, we upheld two of Mrs C's four complaints. We found that, while most of the care and treatment provided was reasonable, the overall approach to Mrs C's care was fragmented, with a number of different doctors and departments involved. This meant that Mrs C received inconsistent information about her condition and care. We also found the board failed to provide the correct anti-embolism stockings and gave inconsistent information about the medication prescription in Mrs C's discharge letter. While we accepted that the action identified by the board in response to Mrs C's complaint was reasonable, we recommended they demonstrate to us that this action is completed within the timeframes they gave.

Recommendations

We recommended that the board:

• demonstrate to us that a consistent pathway for the provision of specialist hosiery has been established;
• review the pharmacy process for checking discharge letters and prescriptions to ensure that any discrepancies in the instructions are clarified appropriately; and
• demonstrate to us that the arrangements for DVT management by the Day Medicine service are in place, including raising staff awareness and updated documentation.

Summary

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this. However, a further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process.

We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for their role in the decision to remove him from the ACT 2 Care process at the meeting in question, and also for the inappropriate entry made in his healthcare record;
• ensure all relevant staff are aware of the ACT 2 Care approach to self-harm;
• make the mental health nurse involved in this case aware of the adviser's comments and ensure that this is included for discussion at their next appraisal; and
• issue Mr C with a legible copy of the complaint form.

Summary

Mr C complained on behalf of his daughter (Mrs A) who injured her head and neck in a sporting incident. Mrs A was taken to A&E at Forth Valley Royal Hospital and admitted to the orthopaedic ward. X-rays were taken of her neck and finger, and an MRI scan (magnetic resonance imaging scan, used to diagnose health conditions that affect organs, tissue and bone) was taken of her neck. Medical staff did not consider she had a significant head injury and she was discharged after three days. Mrs A continued to suffer symptoms from her accident and was referred to a specialist a few months later. A head MRI was taken which showed she had suffered a head injury and she was referred to the neurology department. Mrs A was diagnosed with post-concussion syndrome. Mr C complained about the delay to Mrs A's diagnosis and expressed his concern that this may have affected her recovery.

We were critical of a number of aspects of Mrs A's care. We took independent medical advice from three advisers (a consultant in orthopaedic and trauma surgery; an emergency medicine consultant; and a nurse). We found that Mrs A's symptoms should have prompted a CT scan (computerised tomography scan, which uses x-rays and a computer to create detailed images of the inside of the body) of her head in line with national guidance. We also found that Mrs A's condition was not monitored adequately in A&E, nor were her neurological symptoms adequately monitored in the orthopaedic ward. We were critical of a lack of record-keeping, which prevented us from commenting in detail with regard to a number of points Mr C had raised.

Recommendations

We recommended that the board:

• provide evidence of action taken in response to Mr C's complaint;
• issue a written apology to Mrs A for the failings our investigation found; and
• take steps to increase staff awareness of SIGN 110 (guidelines for the early management of patients with a head injury, written by Scottish Intercollegiate Guidelines Network), including the requirement for regular neurological monitoring and the indications for CT scans.

Summary

Mr C was taking rivaroxaban (medication that thins the blood in order to minimise the risk of a stroke) when he was scheduled for non-emergency surgery. Due to the possibility of excessive bleeding during a surgical procedure, Mr C was advised to stop taking his medication seven days prior to surgery. Four days after Mr C stopped taking his medication, he suffered a stroke.

When Mr C complained, the board and Mr C's consultant appeared unclear about whether Mr C was on rivaroxaban or warfarin (another drug used to prevent blood clots, which Mr C had previously been taking). The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication. They also said Mr C was classed as 'low risk' of stroke and the advice he was given was accurate. They said that, in light of his complaint, they would develop further protocols for staff.

Mr C complained he should not have been classified as low risk, and should not have been advised to stop his medication. We sought independent advice from one of our advisers, who is a consultant geriatrician with specific experience in stroke medicine. The adviser was clear that Mr C was given incorrect advice about stopping his medication. Warfarin guidelines are not applicable to rivaroxaban, and Mr C should only have been advised to stop his medication for 24 to 48 hours prior to the surgery. The adviser accepted rivaroxaban was a relatively new drug, however, he stressed that this meant clinicians should be more cautious and seek guidance from colleagues if they were unclear. The adviser also noted that the board did have specific guidelines for the drug and there were many more available online. The adviser also concluded, in light of Mr C's previous medical history, that he should have been classified as being at 'moderate risk' of stroke.

For these reasons we upheld Mr C's complaints. We were also critical of the complaint investigation, which was unable to clarify whether or not Mr C's consultant was aware of the type of medication Mr C was on.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• provide us and Mr C with the updated protocols regarding rivaroxaban;
• ensure Mr C's consultant discusses this complaint as part of their annual appraisal; and
• feed back to staff the importance of clarifying at the time why a situation occurred, not retrospectively.

Summary

Mrs C had been admitted to Dumfries and Galloway Royal Infirmary for pelvic floor repair, as she had a prolapse of the wall between her vagina and rectum. She said that she was only told that she might need a vaginal hysterectomy (surgery to remove the womb through the vagina) on the morning that the surgery was to be carried out. She then had a vaginal hysterectomy later that day. Mrs C complained about the action taken in relation to consent for the procedure. We took independent advice from one of our medical advisers, who is an experienced consultant gynaecologist. We found that it was unreasonable that Mrs C was only told about the possibility of such a significant procedure on the day of the surgery and that she was given little time to consider this. We considered that Mrs C should have been told about the possibility that she needed a vaginal hysterectomy at an earlier stage, and we upheld this aspect of her complaint.

Mrs C also complained about the procedure that was carried out. Although we had concerns about the consent process and considered that Mrs C should have been told about the possibility of a vaginal hysterectomy earlier, we found that it had been appropriate for this to be carried out.

Mrs C also complained about the pain relief she had received after the operation. We found that the pain relief had been reasonable. Finally, she complained that the standard of medical and nursing record-keeping was unreasonable. Although there were some missing/incorrect dates and times in the documentation, we found that the notes were of an acceptable standard. Consequently, we did not uphold these aspects of her complaint.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to ensure that the possibility of a vaginal hysterectomy is discussed at an early stage with patients who are to undergo pelvic floor repair; and
• issue a written apology to Mrs C for the failure to mention the possibility of a hysterectomy to her at an earlier stage.

Summary

Ms C's daughter (Miss A) was born with hydrocephalus (a build-up of fluid on the brain causing pressure), and from the age of about two years old, she began to suffer multiple infections and seizures. She was admitted to hospital on many occasions and Ms C was informed that her daughter was likely to have epilepsy. Miss A was diagnosed as having gastroenteritis (inflammation of the stomach and intestines) when she was three. Meanwhile, her seizures continued and Ms C was advised that they were probably due to her underlying fever and gastroenteritis. Ms C was unhappy as she considered that no progress was being made to establish the cause of her daughter's symptoms or to treat her properly. In the circumstances, she took Miss A to a children's hospital in another board area where she was diagnosed with a cerebral abscess and where she remained for five months.

Ms C complained of the delay in diagnosing her daughter and of the board's failure to refer her to the children's hospital in another board area for treatment. She was unhappy with the way they responded to her complaint.

We investigated the complaint and took independent advice from one of our medical advisers, who is a consultant paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there had been a delay in diagnosing Miss A and that there may have been a missed opportunity to do this sooner. We also found that, while the board had intended to refer Miss A to the children's hospital in another board area, for reasons unknown, no appointment was made. We also found that there had been undue delay in providing a response to Ms C's concerns and that although a detailed letter was drafted, it was not sent. A meeting arranged to replace the letter took place months later. The complaint was upheld.

Recommendations

We recommended that the board:

• make a formal apology to recognise the delay in diagnosis;
• advise us what actions have been taken since the meeting to improve the two-way flow of communication between the hospitals identified;
• make a formal apology for their failure to respond adequately to the complaint; and
• emphasise to the staff concerned the importance of adhering to their complaints process and of the necessity for good, clear and timely communication.