Health

Summary

Mrs C experienced numerous troubling symptoms over a number of years including impaired vision and muscle wasting. She underwent a range of investigations with the board's neurology department to establish the cause of her symptoms. Mrs C then complained about the standard of her care and treatment. She felt that, although her symptoms were getting worse, staff did not take her case seriously, dismissed her as anxious and provided contradictory information. Mrs C told us that she decided to have an MRI scan (magnetic resonance imaging scan: a detailed scan of her brain) carried out privately, which identified a small focal lesion (an area of tumour or other tissue damage) on her brain. She complained that this had been missed in scans taken by the board some years previously.

We took independent medical advice from a consultant neurology adviser, and we found that the focal lesion had been present in the earlier scans, but was not easily identified. MRI scanning technology advanced in the intervening period and the lesion was more readily identifiable in the more modern scan. It was only with hindsight and knowledge of its location that radiology staff could identify it in the earlier scans. We did not find the board's actions to be unreasonable in this respect and were satisfied that a number of relevant and appropriate investigations were carried out to establish the cause of Mrs C's symptoms. Ultimately, we found that the treatment she received was in line with that which would have been provided had her lesion been identified from the outset.

That said, we were critical of the board's handling of Mrs C's complaint and their failure to provide an independent review of her MRI scans, as had been promised during their investigation of her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for their inadequate communication about her complaint;
• contact Mrs C as a matter of urgency to discuss possible further actions to be taken to review her MRI scans outside of the board area, or provide us with evidence that this has been addressed; and
• review their handling of Mrs C's complaint to ensure that action points from meetings are properly recorded and followed-up and that the NHS complaints handling procedure is properly followed.

Summary

Mr C complained about the pain relief he was being prescribed by the prison health centre as he did not find it effective. He also complained about the way the board handled complaints and feedback he had submitted.

The board considered that Mr C was being prescribed appropriate medication to manage his pain. After taking independent advice from one of our GP advisers, we upheld this part of Mr C's complaint. The adviser did not consider that a thorough enough assessment of Mr C's pain had been recorded to determine if the pain relief he was prescribed was appropriate. In looking at the board's handling of Mr C's complaints, the evidence available confirmed that they did not respond to feedback that he had submitted in line with the relevant process and had failed to identify this during their investigation of his subsequent complaint. We also upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that heath centre staff consider and reflect on how they assess a patient's pain;
• ensure that health centre staff consider the use of alternative treatments like local anaesthetic patches for the treatment of isolated areas of pain such as Mr C's;
• ensure that staff update their learning by reading the revised Scottish Intercollegiate Guidelines Network guideline 136;
• apologise to Mr C for failing to respond in line with the relevant process; and
• review their complaints handling procedure alongside the prisoner healthcare feedback, concerns and complaints form to ensure they provide a consistent approach.

Summary

Ms C, who suffers from back problems, attended the practice as she had pins and needles in her foot. Hospital anaesthetists had previously advised her to contact her GP if she had any symptoms affecting her legs, bladder, bowel or back. She said that when she went to an appointment, the GP did not appear interested, prescribed inappropriate medication and failed to examine her legs.

Ms C complained to the practice, who said that the GP had suggested the medication as it could assist with nerve-related symptoms and that he was aware that Ms C already had an urgent neurology referral. The GP also advised Ms C to seek further medical assistance should her symptoms worsen. Ms C brought her complaint to us.

After taking independent medical advice from our GP adviser we upheld the complaint that the GP failed to adequately examine Ms C despite her reported symptoms and known medical history. We found that the GP should have carried out a more thorough examination which should have involved testing reflexes and muscle strength in the feet and legs; checking for loss of anal tone by performing a digital rectal examination; checking for numbness in the perineum (region between the thighs); and checking the location of the pain to see if it ran along the sciatic nerve.

Recommendations

We recommended that the practice:

• provide a written apology for the failings identified; and
• discuss the complaint at the GP's next annual appraisal.

Summary

Mr C had a shunt (a thin tube that drains fluid from the brain to another part of the body) in place in order to relieve his severe headaches. He complained to us that when he was having this replaced at Ninewells Hospital, he contracted an infection. Mr C was readmitted to the hospital several days after the operation, with a severe abdominal infection. It was thought that the infection came from the new shunt and this was subsequently removed. Mr C said that he had been unable to return to work after contracting the infection.

After obtaining independent medical advice from a consultant neurosurgeon, we found that it had been reasonable to carry out the operation. It was difficult to be sure about the origin and type of infection that Mr C experienced, but our adviser thought it likely that bacteria from the skin had transferred to the shunt during the surgery. There is always a risk of infection in these types of operations, and we found that this risk was included in the consent form Mr C signed before the operation. The surgical team had prepared Mr C's skin correctly before the operation and had given him an antibiotic to try to prevent infection, in line with the relevant guidelines.

As we found no evidence of any failings by the surgical team and there was nothing they could have done differently to prevent the infection, we did not uphold the complaint.

Summary

Ms C, an advocate, told us that her client (Mr A) was referred to the neurology department at Ninewells Hospital because of continuing back pain. In November 2012, a neurologist (a specialist in diseases of the nerves and the nervous system) decided that further investigations, including an magnetic resonance imaging scan (MRI scan - used to diagnose health conditions that affect organs, tissue and bone), would not be beneficial as it was extremely unlikely that further back surgery would be considered. The following month, Mr A was admitted to hospital for a different problem but his back and leg pain were noted. An anaesthetist suggested that the neurosurgical team review him but they declined, saying he had been seen three weeks previously. Mr A continued to suffer back pain and in March 2013 his GP wrote to the neurosurgical team requesting an MRI scan, who responded saying that this would not be helpful. In June 2013, because of the level of his pain, Mr A paid for a private MRI scan which was forwarded to the neurosurgical team. Several weeks later, an out-of-hours (OOH) doctor saw Mr A, again because of his pain, and phoned the hospital about admitting him. Mr A was not, however, admitted and said that a member of the neurosurgical team refused to see him again. However, after reviewing the MRI scan the neurosurgical team did then arrange decompression surgery (used to treat some conditions affecting the lower back that have not responded to other treatments), which was carried out at the end of July.

Ms C complained that Mr A had to organise and pay for the MRI scan himself. He was concerned that his assessment in November 2012 was inadequate, and that a scan should have been arranged then. He felt that his pain and distress was not taken seriously and that the neurosurgical team should have acted on the reports from the anaesthetist and the OOH doctor. He was also concerned that his records said that he was to be treated for sciatica, which he believed unreasonably influenced his treatment, and about the length of time it took the board to respond to his complaint.

We took independent advice on this complaint from one of our medical advisers, who is a specialist consultant spinal surgeon. The adviser said that it was unreasonable not to order a scan in November 2012, and that a neurosurgeon should have ordered the test based on the evidence available at that point. The medical adviser also said there may have been undue reliance on the results of a test (the Hoover test) used by the neurosurgeon, which the adviser did not consider was an evidence-based diagnostic tool. The results of the private MRI scan informed subsequent treatment decisions by the board's neurosurgery team, and it was clear to us that they should have arranged this earlier. Their failure to do so meant that Mr A both paid for a test that was required for his NHS treatment, and endured prolonged suffering. We also found that there were several missed opportunities to consider requesting a scan and that it would have been reasonable to have referred Mr A to a spinal specialist in light of the evidence of his condition. However, the reference to sciatica was reasonable.

We found too that, given the complexity of Mr A's complaint, it was clear from the beginning that the investigation and response would take time and that the board should have better managed his expectations around this. The holding letters they sent him did not give him likely timescales for responses, and the delay in responding to his further concerns was unreasonable.

Recommendations

We recommended that the board:

• consider the use of the Hoover test as a diagnostic tool in light of our medical adviser's comments and advise us of the outcome;
• ensure the findings of this investigation are fed back to the relevant clinicians and the learning points discussed at their next appraisal;
• refund Mr A the cost of his private MRI scan; and
• apologise to Mr A for the failings this investigation identified.

Summary

Mr C complained that staff at Perth Royal Infirmary refused him permission to take his elderly mother (Mrs A) out of hospital on a specific occasion, and about the board's handling of his complaint.

We looked at the board's file on Mr C's complaint and at Mrs A's medical records, and took independent advice from one of our medical advisers. Where there are differing accounts of what was said or what took place during a particular event or incident, it can be difficult to prove what actually happened. Although this does not mean we believe one account over another, given the differing accounts of what happened on the day Mr C complained about, we were unable to resolve exactly what was said and so we based our findings on the written records. We found that the medical and nursing records were consistent and provided sufficient evidence to allow us to conclude that it was reasonable in the circumstances for staff to advise against Mrs A leaving hospital that day, taking into account her state of health, their concerns and their responsibility to care for Mrs A.

The board's file on Mr C's complaint showed that they conducted a reasonable investigation by contacting relevant staff and referring to Mrs A's medical records. Their letter to Mr C accurately reflected Mrs A's medical records and, although it could have contained additional information that Mr C might have found helpful, it was reasonable in the circumstances. There was a delay in the board dealing with Mr C's complaint, but we found that they had accepted this, explained why, and apologised to Mr C.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care and treatment she received at the Princess Alexandra Eye Pavilion. Mr C said that mistakes were made during an operation, and that his wife was left virtually blind in her left eye. Mr C also complained about the board's response when his wife complained about this.

During our investigation, we took independent medical advice from an experienced cataract surgeon. The advice we received was that the care and treatment Mrs C received was appropriate and that no mistakes were made during the surgery. Mrs C had, however, suffered two rare complications. While the advice we received was that, in general, both complications were handled well, there was a small error in relation to the first one, in that the vitrector (a machine used in eye surgery) used as a result of the complication was not tested before it was used on Mrs C's eye, and was not working. Our adviser said that this was unlikely to have had a material impact on the outcome and was not the cause of the second complication, but we were concerned that the machine was not fully tested before it was used. We were satisfied that there was no evidence that work continued on Mrs C's eye after it was discovered that the machine was not working.

We did, however, find that the complications that arose in Mrs C's case were not discussed with her before the surgery and were not included in the information leaflets that she was given. In addition, we were concerned that Mrs C was not given enough time to make a considered decision about the surgery. We were also concerned about the handling of Mrs C's complaint - in particular that the response she received to her representations contained unnecessary, confusing details and did not meet her needs.

Recommendations

We recommended that the board:

• ensure that the relevant staff members are made aware of our adviser's view that it is wise, where a vitrector has been set up, that the flow of fluid through the vitrector is checked and that a check is carried out to ensure the guillotine cutter is working before it is used;
• consider the process for informed consent for cataract surgery to ensure that it complies with guidance about informed consent, in particular, in relation to the information provided about serious or frequently occurring risks;
• draw to the attention of relevant staff our adviser's comments that where potentially serious complications have occurred it would be wise to make a note in the medical records of the discussions held with patient/relatives;
• apologise to Mrs C for the handling of her representations; and
• ensure that their written responses to complaints meet the needs of the patient in relation to tone and language etc.

Summary

Mr C complained to us about the care and treatment his mother (Mrs A) received from the medical practice after a GP visited Mrs A's home as she had abdominal pain. Mr C told us that the GP examined his mother, gave her a injection for pain and called an ambulance. He said that the GP spent approximately 15 minutes with his mother before leaving. Mr C said that the ambulance arrived two and a half hours later and during this time his mother's pain worsened. He said that the ambulance crew expressed shock at Mrs A's condition and gave her more pain medication before taking her to hospital. When he went to the practice to complain, he felt that the GP was aggressive towards him. He also said that he asked for information on making a complaint and was told there were no specific forms and that each practice is different.

The practice said that they provided proper care and treatment. The GP said that as Mrs A had family support and her condition was not considered life threatening, it was appropriate to leave and return to other patients at the surgery. The practice said that Mrs A's family did not call them to say that she was worse. They apologised for confusion about the complaints form and explained that although they do not have such forms they do have a procedure, and complaints can be made in writing. They said that they were not aggressive towards Mr C – they in fact felt that he had been aggressive towards them, and they had sent him a formal warning.

We took independent advice from one of our GP advisers, who said that the GP provided reasonable care. Our adviser was of the view that the pain relief given and the decision to request an ambulance within a two hour window were reasonable. The Scottish Ambulance Service provided evidence during our investigation that their crew that day had no recollection of criticising the GP and or of expressing shock at Mrs A's condition. We did not uphold this complaint.

We did uphold Mr C's complaint about the practice's complaints handling. Although they responded to his complaint well, he had asked for complaints handling information and been told there was none. They should have referred to the NHS Scotland 'Can I help you?' guidance and provided information on the process they would use to deal with his complaint.

Recommendations

We recommended that the practice:

• ensure that all practice staff are aware of the NHS Scotland 'Can I help you?' guidance and ensure that the practice leaflets on the complaints handling process, detailed on the practice website, are available to patients and staff.

Summary

Mr C was treated for appendicitis at Monklands Hospital. As part of his treatment, he was given antibiotics, including gentamicin, intravenously (directly into a vein) for ten days. During and after this treatment, Mr C experienced symptoms of dizziness and difficulty with his balance. He saw an ear, nose and throat consultant, who diagnosed him with permanent damage to his hearing and balance, possibly as a result of gentamicin poisoning. Mr C complained that the decision to administer gentamicin was inappropriate, and that he was not told of the side effects or asked for his consent before the drug was administered.

We investigated Mr C's complaint and took independent advice from a consultant in general medicine. We did not uphold Mr C's complaints, as we found that gentamicin was the appropriate treatment for his symptoms and condition at the time. We also found that there was no requirement to explain the side effects or seek Mr C's consent before administering gentamicin, given that the side effects are extremely rare. However, we found that the board failed to monitor Mr C for signs of gentamicin poisoning, and failed to consider referral to an audiologist, as required by their guidance. Although we did not uphold his complaint, we made recommendations about this.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the gentamicin guidance in relation to monitoring for ototoxicity (ear poisoning) and considering audiology assessment where gentamicin is administered for more than seven days.

Summary

Mrs C complained about the care and treatment that her late husband (Mr C) received at Wishaw General Hospital. Mr C had advanced cancer and was admitted to the hospital because he was vomiting blood. He was in the hospital for about a week before being transferred to a hospice, where he died shortly after. Mrs C complained that the hospital did not adequately assess and treat her husband's bladder and bowel problems and failed to take adequate precautions to prevent him from falling out of bed. She also complained that neither she nor Mr C had been involved in discussions about the withdrawal of his medical treatment and his future management plans.

We took independent medical advice from an experienced hospital doctor, who reviewed Mr C's records. Our adviser said that although it was clear that Mr C was most unwell when he was admitted, there were a number of steps the hospital should have taken sooner. Viewed as a whole, he said that Mr C's care fell below a reasonable standard and we upheld this complaint.

We also took independent advice from our nursing adviser, who said that a falls assessment was completed when Mr C was admitted. This indicated that he was not at risk of falling and, in her view, there was no reason for the hospital to have suspected he might do so. Our adviser said the hospital's assessment was reasonable and the board had acted reasonably, based on the information available at the time. In her view, Mr C's fall could not have been avoided, and we did not uphold this complaint.

In terms of Mrs C's complaint about the lack of discussions, our medical adviser pointed to an apparent lack of clarity around the approach being taken with Mr C's care. He was moved to the hospital's high dependency unit for treatment – despite the notes indicating he would not be moved – but it was then decided to move him onto palliative care (care provided solely to prevent or relieve suffering). Our adviser said that this decision was appropriate but should have been discussed sooner than it was. We took the view that the evidence showed a lack of certainty over the direction of Mr C's care and that his family were given mixed messages. We considered this unreasonable and upheld this complaint.

Recommendations

We recommended that the board:

• discuss this case at the next departmental meeting to ensure early recognition of kidney dysfunction and infection, so appropriate steps are taken in such cases;
• ensure that the failings in care and treatment identified are fed back to the relevant staff;
• provide us with a copy of their local action plan for the relevant Scottish Government guidance and confirm the steps in place in acute wards to support patients and families receiving end of life care including staff communication;
• use this case in Mr C's consultant's appraisal with reflection on the issues identified, including the decision on when to move to palliative care, communication and consultant supervision; and
• apologise to Mrs C for the failings we identified.