Health

Summary

Mr C complained that the board failed to diagnose his condition properly when he attended an out-of-hours (OOH) service at Raigmore Hospital. Mr C was diagnosed with a viral infection, and he was discharged. A few days later, however, he became very unwell and was admitted to hospital where he was later diagnosed with legionnaires' disease.

Mr C said that the OOH service should have considered this as a possible diagnosis, particularly as he had mentioned recent travel abroad. We took independent advice from one of our medical advisers, who is a GP. The adviser said that the examination of Mr C was thorough and well recorded. The adviser also reviewed the Health Protection Scotland (a government body that monitors infectious and environmental hazards) website, and noted that at the time of Mr C's admittance there were no notifications of increased incidents of legionella (the bacteria that causes legionnaires' disease) in the location Mr C had visited. Therefore, no alert would have been sent to GPs and OOH services to increase vigilance for the condition.

We, therefore, concluded that in light of the symptoms Mr C presented with at the time, he was provided with a reasonable diagnosis.

Summary

Mr C complained to us that the board had refused to investigate his complaint about his late partner (Ms A)'s medical treatment at Dunoon Hospital. The board had refused to respond to the complaint as Mr C was not Ms A's next of kin, and to have access to her medical records they would have to have permission from her next of kin.

We found that the board had given Mr C's request for information about Ms A's clinical treatment careful consideration, and had consulted senior staff before reaching a final decision that they were not in a position to respond to the complaint. The board had also suggested that Mr C should contact Ms A's next of kin to ask for permission to release the information from Ms A's medical records, and that he had chosen not to do so. We were satisfied that the board had considered the matter carefully and we found no reason to question their actions.

Summary

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn.

We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment.

Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Recommendations

We recommended that the board:

• make a formal apology for their delay and for any further distress caused; and
• remind those staff involved in responding to complaints (including any clinical staff) of the necessity of providing timely replies and demonstrate to us how this was done.

Summary

Ms C complained on behalf of her client (Mr A) who suffers from a delusional disorder (a mental health disorder where sufferers hold irrational beliefs). Mr A went to A&E in Lorn and Islands Hospital as he wanted them to check a mark on his leg. Staff were concerned about his mental wellbeing and spoke to the duty psychiatrist at another hospital who decided that he should be transferred and admitted there. In the event that Mr A was unwilling to go, it was agreed that his admission be facilitated with the use of an Emergency Detention Certificate (EDC). Documentation had to be completed for this and, before arrangements could be made for transfer, Mr A left Lorn and Islands Hospital. He was later brought back, handcuffed, by the police, sedated and transferred.

Ms C complained that Mr A was not adequately assessed at A&E. She also said that staff did not follow the correct process/procedures in relation to the EDC and there was unreasonable delay in transferring Mr A between hospitals. She subsequently complained of the delay in responding to her complaint about this.

We took independent medical advice from one of our psychiatric advisers. We found that, while it had been reasonable to prioritise Mr A's mental health over his concerns about his leg, the board had not first tried to establish whether he was a risk to others or himself, nor attempted to discuss his condition with his usual psychiatrist and review his records before deciding that he needed to be tranquilised. They also failed to follow the correct procedures (in terms of assessment and proper completion of the appropriate forms) for issuing an EDC. This led to Mr A being sedated against his will. Furthermore, the board delayed in dealing with Ms C's complaints. We, therefore, upheld these complaints.

Ms C had also complained that the board delayed in transferring Mr A between hospitals, but we did not find evidence to confirm this, and did not uphold her complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the shortcomings in assessing him;
• ensure that the circumstances of the complaint are brought to the attention of the on-call psychiatrist and ensure that it is considered at his next formal appraisal;
• make a formal apology to Mr A for failing to follow correct procedures;
• review the training given to medical staff working in A&E to ensure that they understand what is required before detaining people under an EDC and how to complete the appropriate paperwork;
• should formally apologise to Ms C and Mr A for their failure to respond in a timely manner; and
• should emphasise to the staff involved in this complaint the importance of responding to complaints in accordance with the board's stated response times.

Summary

Mrs C, who is an advocate, complained to us that her client (Mr A) had suffered depression as a result of the community mental health team stopping his anti-psychotic medication. We sought independent advice from one of our medical advisers who told us that Mr A's medication had been stopped in line with national guidelines. The adviser also said that research has shown that there was no recorded evidence that such action can cause depression.

Summary

Mr C was transferred between prisons and, as is routine for new arrivals, had a GP appointment at his new prison's health centre the day after he arrived. The GP decided to reduce and later stop Mr C's headache medication. This was because in the first prison Mr C had been found to have less of the medication in his possession than he should have had, and so he was in breach of prison protocol about this.

Two days after his GP appointment, Mr C was found to be concealing his medication in his mouth, rather than swallowing it. This was also in breach of a protocol, which said that if a prisoner was found to be concealing medication that they were being given on a supervised basis (as in Mr C's case), the clinical need for it would be reassessed. On reassessment, it was decided to stop the medication with immediate effect. The medical records indicated that Mr C was offered an alternative but declined. Mr C complained that the decisions to reduce his medication on arrival at the new prison and to stop his medication after reassessment were both unreasonable.

We took independent advice from one of our medical advisers and found that on both occasions medical staff acted appropriately. The medication in question was one which is often abused in a prison environment (for example, by prisoners selling it to other prisoners). Drug security in prison is very important and the NHS have to have firm policies for such security and follow them.

Summary

Miss C told us she was not treated with reasonable courtesy during a breast screening appointment. She said she did not receive adequate information before, during, or after the appointment and was unprepared for her experience which she found both distressing and painful. Miss C said she told staff that she was afraid of hospitals, needles and the sight of blood. She complained in particular about her x-ray guided biopsy (where a special machine uses x-rays to help guide the radiologist to the site of an abnormal growth to take a tissue sample). She said she did not know what was involved with this procedure, or about the side effects or aftercare. She said she did not get the chance to ask questions or speak to anybody about it. Miss C told us the treatment room was full of people and that no introductions were made. Her treatment lasted more than four hours, although her appointment letter said that the appointment might take up to three hours.

We took independent advice on this complaint from one of our medical advisers, who is an experienced GP. We found evidence that staff checked she was available to stay for the biopsy, but not that they explained in any detail what it would entail or how long it would take. We found confused and conflicting evidence about who was present during the procedure, and it was clear that people in the room were not introduced to Miss C as they should have been. The board had already apologised for the distress Miss C experienced on the day of her appointment. They acknowledged the importance of giving information, obtaining consent and introducing members of staff. We found that Miss C was given only limited information in advance, which did not meet her needs. Although she could have taken a more cautious approach to giving consent for the procedure, it was the board's responsibility to tell her what the biopsy involved and what degree of discomfort she might experience afterwards. They should also have offered her the opportunity to ask any questions before asking for consent.

Although we upheld Miss C's complaint and made recommendations, we commended the board for meeting with her to hear from her first-hand, and noted that the tone and content of their correspondence showed that they wanted to learn from her poor experience and were willing to improve.

Recommendations

We recommended that the board:

• offer an additional apology in light of the failings identified;
• carry out a review of the information and communication needs of patients attending Assessment Clinics, particularly those attending on recall, to ensure that at each stage patients can make informed and supported choices prior to giving their consent; and
• remind staff with responsibility for handling complaints of the correct procedures to follow.

Summary

Mr C's son (Master A) was diagnosed with epilepsy in 2013, and was being treated by a consultant neurologist from another NHS board. In January 2014 Master A was having significant episodes, and Mr C's GP contacted hospitals in both NHS boards for advice. The GP received some conflicting advice as, because of his age, Master A was regarded by some services as an adult and by others as a child. The Southern General Hospital said that they dealt with adults and advised the GP to contact the board's children's hospital, but the GP did not do so as they understood that the children's hospital only dealt with younger patients. The board's response to Mr C's complaint indicated that had the GP contacted that hospital, Master A would have been seen there. However, he was not taken to hospital at that time.

Master A's condition did not improve and four days later Mr C took him to A&E at the Southern General Hospital. Master A was assessed and examined, and diagnosed with hyperventilation (abnormally fast breathing), but was not found to have had a seizure. He was discharged without treatment and was told to go to his GP and his consultant neurologist for follow-up (he already had an appointment scheduled with the consultant). Mr C was not satisfied with this and complained to the board about a lack of neurology service. He was dissatisfied with their responses and with the time taken to investigate his concerns.

Our investigation included taking independent medical advice from one of our advisers, who is an A&E consultant. We found that staff assessed and examined Master A appropriately, and that their decisions about discharging him were clinically reasonable. It did take some time for the board to respond to the complaints, but these were complex and involved consulting staff from various departments. For the most part Mr C was kept informed of the progress of the investigation and the timescales set out in NHS Scotland guidance on complaints handling were met. On one occasion this did not happen and we brought this to the board's attention, but we did not uphold Mr C's complaints.

Summary

Mr C said that when he arrived in prison he was in a poor state of mental health, and he complained about the time it took to see a doctor and a psychiatrist. He was also unhappy that he was refused specific medication for his attention deficit hyperactivity disorder (ADHD) and said that he got no benefit from the medication that was prescribed.

We took independent medical advice from two advisers, one a GP and the other a mental health specialist. We found that Mr C was seen by an experienced doctor the day after he arrived in the prison, and a reasonable assessment of his physical and mental state was made. In addition, there was no indication that Mr C needed to urgently see a psychiatrist. We also found that, given his medical history, the medication he was prescribed for agitation and ADHD was appropriate, and in line with national guidance.

Summary

Mrs C complained about the care and treatment she received in the Royal Alexandra Hospital. She had been transferred there from a community hospital in another board's area after injuring her upper back and neck.

We obtained independent advice on the complaint from one of our medical advisers, after which we upheld both of Mrs C's complaints. We found that although Mrs C was triaged (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are) within ten minutes of arriving in the hospital, there was some confusion about whether the orthopaedics team (who deal with conditions involving the musculoskeletal system) were told that she had been transferred there. She was not seen by a doctor from that team until nearly four hours after her arrival. During this time, staff in A&E failed to escalate the matter to ensure that she was seen by a clinician, and failed to record her neurological status. After Mrs C was eventually seen by the orthopaedics team, there was then a further 45-minute delay before she was reviewed by a more senior doctor and an additional delay in obtaining a CT scan (a scan that uses a computer to produce an image of the body).

We also found that, although it had been reasonable for staff to carry out a rectal examination (a physical examination during which a doctor or nurse inserts a finger into the rectum/back passage) to assess the extent of Mrs C's spinal injury, this was not adequately explained to her. The overall quality of the medical notes was good, but there was a failure in relation to the prescription of morphine in the drug chart. There was also a delay in arranging an ambulance for Mrs C when it was decided that she should be transferred to the national spinal injuries unit.

Mrs C also complained about the board's handling of her complaint. We found that their investigation into the problems in her care was inadequate. There was no in-depth review of the communication failures that caused the delay in her being reviewed by the orthopaedics team, and formal statements had not been taken from the key members of staff involved in her care and treatment to establish their views directly. As a result of all of this, opportunities both to identify a possible cause of the poor experience she had and to learn and rectify behaviours and improve care for the next patient were lost. In addition, the board delayed in responding to the complaint.

Recommendations

We recommended that the board:

• carry out an significant clinical incident review regarding the care and treatment provided to Mrs C;
• remind staff in the orthopaedics team to clearly explain the need for a rectal examination to patients before it is carried out;
• provide evidence that they have taken steps to try to prevent the recurrence of the problems that occurred in relation to the handling of Mrs C's complaint; and
• issue a written apology to Mrs C for the failings identified during our investigation.