Health

Summary

Miss C complained that the board had failed to put in place appropriate treatment for her mental health problems when psychotherapy (a type of therapy used to treat emotional problems and mental health conditions) she had been receiving for a fixed period ended. Whilst receiving psychotherapy, Miss C had been diagnosed with autistic spectrum disorder. She was also sensitive to change and had been concerned that she would receive inadequate support when the psychotherapy ended.

We took independent advice from one of our medical advisers, who is a psychiatrist. We found that the board had tried to take active steps to liaise with relevant services to try to ensure that there was adequate support in place for Miss C. However, when the psychotherapy ended, Miss C's community psychiatric nurse was not available and her consultant in the community mental health team had changed. In addition, an autism support group said that they could not support her. We found that inadequate co-ordination and transfer of Miss C's care left her with inadequate support in place for her identified needs at that time. In view of this, we upheld her complaint.

The board had already apologised to Miss C for their failings and had said that the learning points would be fed back to clinicians, but we made one recommendation.

Recommendations

We recommended that the board:

• provide evidence that steps have been taken to try to prevent the problems that arose in Miss C's case from recurring.

Summary

Ms C was a new patient at a dental practice where she presented with a chipped tooth. She saw a dentist who examined her mouth and did an x-ray which revealed some decay. She attended the dentist six times within two months and during this time, root canal treatment was commenced, she had one extraction and four fillings.

Ms C complained about the care and treatment she received. She said that it had been unnecessary and left her with damaged teeth and in pain. However, the dentist said that she had presented with extensively damaged teeth which required attention and that although Ms C had had a difficult time, this was as a consequence of extensive decay. Despite her best efforts, the dentist said that she had been unable to save one of Ms C's teeth.

We took independent dental advice, and found that Ms C's notes were poorly recorded and that while decay was present in some of Ms C's teeth for which treatment was necessary, it appeared that one of Ms C's teeth had been treated in error while a damaged tooth received no treatment. We also found that some of the decay was minimal, not requiring the extensive drilling that was undertaken. While the dentist recorded that she had had to give Ms C extensive treatment, the condition of Ms C's mouth as recorded in her notes suggested that she only required oral hygiene advice. We upheld Ms C's complaint.

Recommendations

We recommended that the dentist:

• make a full apology; and
• undergo additional training in record-keeping and address the concerns raised by the adviser as part of her continuing professional development. She should confirm to us that she has done so.

Summary

Mr C complained that the board failed to monitor the steroid treatment he was receiving for his chest condition and its consequences. He said the lack of monitoring systems in place resulted in him developing cataracts; his adrenal glands (two small hormone secreting glands, one located above each kidney) no longer functioning; and in him developing osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break). Mr C also complained that when he emailed the board three questions about the side effects of steroids, the points he raised were never answered.

We obtained independent advice on the case from our medical adviser, a consultant in respiratory and general medicine. Our adviser said the information available suggested that the steroid treatment Mr C received was in line with both formal guidelines and established clinical practice throughout the UK. He explained that there was no universal agreement as to whether, or how, to monitor patients who were receiving steroids for bone loss and said the guidelines indicated that it was only when courses of treatment lasted three months or more that any form of osteoporosis screening or treatment needed to be considered. In Mr C's case, it appeared that his steroid was prescribed in short courses, suggesting that monitoring was not required.

Our adviser said he was not aware of any guidelines which suggested that monitoring for adrenal suppression (where the adrenal glands do not produce adequate amounts of steroid hormones) or cataracts was a necessary component of steroid therapy for adults. He also said it was not usual practice to screen patients with Mr C's chest condition needing short course steroid treatment for cataracts.

In terms of Mr C's three questions to the board, they acknowledged that osteoporosis, cataracts and adrenal suppression were known side effects of steroid therapy. They explained their policy on screening/monitoring for osteoporosis and adrenal suppression. While we feel the board could have commented on screening/monitoring for cataracts, on balance, we considered their response covered the main points in Mr C's email.

Summary

Mrs C complained about the standard of treatment she received during her pregnancy and labour given that she had developed antibodies which can cause anaemia in babies during pregnancy. In particular, Mrs C was concerned about the way the pregnancy was managed, and the lack of urgency shown by staff in the antenatal ward and the delay in the delivery of her baby at the Southern General Hospital. As a result, she said that she and her baby had to remain in hospital during which time her baby had to have blood taken regularly. Mrs C said that the treatment she received was unacceptable and she remained extremely distressed about her experiences.

We took independent medical advice from three advisers, who are specialists in obstetrics and gynaecology, paediatric haematology and midwifery. We found that the antenatal care was reasonable and that Mrs C was monitored and managed appropriately in light of the complication. We also found that while there was a delay between admitting Mrs C to hospital to an antenatal ward, and then admitting her to a labour ward to induce labour, this was reasonable given Mrs C's and her baby's clinical condition at the time. Overall, we found that the standard of in-patient care and treatment was reasonable but made a recommendation in light of one of the adviser's concerns about staffing levels.

Recommendations

We recommended that the board:

• review how frequently patients' transfer to the labour ward at the hospital during induction of labour have been delayed to ensure they are satisfied the unit has sufficient capacity for its workload.

Summary

Ms C complained about the care and treatment she had received from the board. She felt she was discharged too promptly following minor surgery at Glasgow Royal Infirmary and, when she was readmitted to the Western Infirmary, that she was given inadequate medication. Ms C was also unhappy about her follow up care following her second discharge.

Our role was to assess whether Ms C's treatment was reasonable in the circumstances. We took independent medical advice which said that clinical staff had, on each occasion, followed the relevant guidance. Our adviser did not think additional steps should reasonably have been taken either time or that Ms C's medical outcome would have been different had she remained in hospital longer. He also had no concerns about Ms C's medication.

Although the adviser noted that many surgeons would have discharged Ms C to her GP practice without planned follow-up, the fact was that follow-up care had been planned for Ms C after she was discharged from the Western Infirmary. We took account her difficulties contacting staff to obtain this care (there had been an administrative error booking her appointments), but recognised that Ms C was ultimately seen at a follow-up appointment. The board also confirmed the steps they had taken as a result of Ms C's complaint and so, although we took this shortcoming into account, we did not consider that Ms C's care as a whole had been unreasonable. We did not uphold her complaint.

Summary

Mr C experienced dizziness and balance problems after an operation on his ear in 2007. In 2012 he was referred to Glasgow Royal Infirmary's ear nose and throat (ENT) department. After examining Mr C, the ENT consultant wrote to the GP saying that he could find no physical cause of Mr C's symptoms. He referred Mr C to the Royal Alexandra Hospital for specialist tests, but commented that he felt some of Mr C's symptoms were not genuine. The specialist tests identified that Mr C had an almost complete loss of vestibular function (the system in the ear that contributes towards balance) in his left ear. Mr C complained that the ENT consultant in the first hospital did not carry out appropriate diagnostic tests or provide suitable treatment for his condition. He also complained that the second hospital did not keep his GP adequately informed of the tests that he was undergoing or his diagnosis.

We took independent advice from one of our medical advisers, who is a consultant ENT surgeon. Although we were critical of the ENT consultant's comments in his letter to Mr C's GP, we were generally satisfied that he assessed Mr C's condition appropriately and made a suitable referral for specialist treatment. That said, we took the view that he could have given more consideration to the need for a magnetic resonance imaging scan (used to diagnose health conditions that affect organs, tissue and bone), and the potential effects of Mr C's existing medication. We were satisfied that Mr C's GP was provided with adequate information about the investigations into his symptoms and his ongoing treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the ENT consultant's suggestion that his symptoms were not genuine; and
• share our decision with the ENT consultant with a view to identifying any points of learning.

Summary

Ms C complained about the care and treatment she received during the birth of her son. In particular, she complained that there was a delay in the decision being taken to deliver her baby by caesarean section, that midwives took too long to react to complications, and that she had been left without staff being present for long periods of time. Ms C was also unhappy with the level of information given to her during the birth of her son and complained that the board failed to communicate effectively with her.

We took independent medical advice from one of our advisers. Our investigation found that overall the care and treatment given to Ms C was unreasonable. The advice we received was that her observations should have been taken more frequently, especially following Ms C's raised temperature. We also found that there was a lack of close monitoring of her vital signs and that an obstetric early warning system chart should have been used to record Ms C's vital observations. The advice we received was that these observations are important signs that may suggest serious illness and warrant immediate medical referral. In the circumstances, we upheld the complaint that the board had failed to provide appropriate care and treatment to Ms C during labour.

Our investigation also found that, while the midwife had communicated with Ms C on some issues, there was no evidence that some of the examinations carried out were explained, or that concerns about her raised temperature or transfer to another ward was discussed with Ms C or that Ms C's ongoing treatment plan was discussed with her. We found that the board had failed to communicate effectively with Ms C and we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings we identified;
• provide us with an action plan which addresses the failings identified in the assessment, monitoring and evaluation of vital signs, which should include the use of the obstetric early warning system chart and the triggers for referral to an obstetrician; and
• provide us with an action plan which addresses the communication issues identified in this investigation, which should include involving women and their partners in the ongoing plan of care and any concerns about labour and recording information /communication.

Summary

Mr C complained about some dental work he had done. He was unhappy because he did not think he had been given sufficient information about the procedure. He had a replacement bridge fitted (a device to replace a missing tooth), and was unhappy with the colour and size of the crown. Mr C was also concerned that, when the dentist tried to remove the crown, he was unable to do so.

We took independent dental advice on this complaint. The adviser noted that it was not clear exactly what information Mr C had been given in relation to his proposed treatment, because there was not enough detail in his notes. However, he said that from the evidence available, it was reasonable for the dentist to have suggested that a new bridge was necessary. He also said that, while the replacement bridge had not been an appropriate fit, the dentist had taken appropriate action in offering to replace it. He also noted that crowns can be difficult to remove, and that the dentist had acted with appropriate caution in choosing to drill the crown off, rather than try and remove it by force.

On the basis of the advice we received, we were satisfied that, while Mr C's dental treatment was not as straightforward as Mr C would have liked, the dentist's actions were reasonable, and he acted in Mr C's best interests.

Recommendations

We recommended that the dentist:

• review current record-keeping standards and take steps to ensure these are applied in practice.

Summary

Mrs C complained on behalf of her client (Mrs B) whose late partner (Mr A) was treated in Dr Gray's Hospital and the Fleming Hospital. Mr A was admitted to Dr Gray's hospital after wandering from his home in a confused state. He was subsequently transferred to the Fleming hospital where he reported severe abdominal pain to Mrs B. Although Mrs B reported this to nursing staff, she conceded that she did not think they had heard her. Mrs C complained that Mr A's pain was not investigated by staff until the following day. She also complained that there was a delay in treating Mr A.

Mr A had previously been diagnosed with a duodenal ulcer (an ulcer in the first part of the small intestine). A doctor at the Fleming hospital considered that this may have perforated and arranged for Mr A to be transferred back to Dr Gray's hospital. A chest x-ray was carried out to check for free air in the abdomen which would indicate a perforated ulcer. No free air was identified and Mr A was diagnosed as having a chest infection. His condition was too severe for any invasive treatment so he was treated with antibiotics and fluids until his death the following morning.

We found no evidence of abdominal pain on the day that Mrs B raised this with the nursing staff. Whilst there was no record of her report to the staff, there was evidence of regular reviews of Mr A and his condition was reasonably stable. Once his abdominal pain was identified the following day, along with a marked deterioration of his condition, we were satisfied that staff took appropriate and timely action. We took independent advice from one of our medical advisers, who told us that the chest x-ray did show free air in Mr A's abdomen, however, we found that his treatment was not affected by this oversight, so we did not uphold the complaint.

Summary

Mrs C was diagnosed with a condition where pressure is exerted on the spinal cord. She said she was told by a consultant neurosurgeon that without surgery she would become bedridden and doubly incontinent possibly within a period of three months and, therefore, she required urgent surgery which would take place within weeks.

Mrs C accepted the board's offer of having her surgery at a private hospital (paid for by the board) to meet treatment time targets. Mrs C said the private hospital then told her no decision had been made to accept her referral and gave her no indication when the surgery might take place. Mrs C paid to have her surgery carried out at a different private hospital shortly thereafter.

We took independent medical advice from a consultant neurosurgeon who said there had been a failure to give Mrs C a realistic prognosis and the board had handled her referral to the private hospital unsatisfactorily. We accepted Mrs C genuinely believed a failure to have urgent surgery would have dire consequences for her and she reasonably did not know for certain whether and when her treatment would take place at the private hospital the board had said they would refer her to. We considered the board had not clearly communicated with Mrs C and explained what was to happen with her treatment. Given the board's failings and as they had agreed to meet the cost of Mrs C's surgery we did not consider it reasonable that she, rather than the board, should be out of pocket.

We also found no evidence Mrs C was informed about her removal from the waiting list or that any clinician had approved her removal from the list.

However, we considered the board had apologised to Mrs C for delay in the handling of her complaint and had reasonably responded to correspondence.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this complaint in relation to delay and poor communication;
• reimburse Mrs C with the cost of the private surgical treatment undertaken;
• improve communication and record-keeping between them and other external care providers where patients are referred for treatment;
• provide evidence of the action taken to address the lack of availability of access to theatres; and
• apologise to Mrs C for the failure to inform her that her name was removed from the waiting list for surgery.