Health

Summary

Mrs C complained about the care and treatment provided to her stepfather (Mr A) during his admissions to Gartnavel General Hospital and the Western Infirmary, Glasgow. She was unhappy about the standard of nursing care and the medical treatment Mr A received. Mrs C said there were delays in admitting Mr A and, once admitted, he was not properly cared for and nursing staff did not take his disabilities into consideration. Mr A was discharged from his first admission with a diagnosis of cancer, which proved to be incorrect, and there was a substantial delay in providing the correct diagnosis. The family said that this diagnosis came too late, as Mr A passed away some weeks later. Another of the board's departments then contacted them, offering assistance with Mr A's proposed discharge home, which added to their distress.

We took independent advice on this case from a nursing adviser and a medical adviser. We found the board had already acknowledged and apologised for a significant number of failings in Mr A's nursing care, and had provided evidence of what they had done to stop this happening again. Our nursing adviser said that Mr A's care was clearly substandard, but the board had demonstrated they had taken this seriously and had responded by taking proportionate and reasonable steps. Our medical adviser said that although Mr A's cancer diagnosis was not unreasonable, the delay in providing a conclusive diagnosis breached Scottish Government targets and that the board had not addressed this. We concluded that Mr A had experienced failings in nursing care, and in communication with the family, but that the board had taken reasonable steps to address these issues. They had not, however, identified that there was a failure to provide a follow-up appointment for Mr A following the cancer diagnosis.

Recommendations

We recommended that the board:

• provide evidence they have taken steps to identify the cause of the delay following Mr A's referral;
• provide evidence they have taken steps to ensure the delay experienced by Mr A when waiting for a follow-up appointment could not reoccur;
• provide evidence that they have taken action to ensure community-based staff are informed timeously of a patient's death; and
• apologise in a simple unqualified way for the failings our investigation identified, and the distress experienced by Mr A's family.

Summary

Mr C's wife (Mrs C) had an operation at Gartnavel General Hospital to treat a bunion on her foot, which involved inserting metalwork. Afterwards, she was in pain and could only mobilise with difficulty. The wound was slow to heal and six weeks after the operation she was admitted to a hospital in another board area with a severe infection, which was treated with intravenous antibiotics. At her next review, Mrs C's foot was still swollen and she had pain over her ankle and tenderness in her shin. The metalwork was removed the following month. However, at a subsequent review, she had pain in her heel and a magnetic resonance imaging scan (MRI: a scan used to diagnose health conditions that affect organs, tissue and bone) then showed that she had a tendon condition. Mrs C was reviewed again 14 weeks later, but decided not to have a further operation in light of the terminology the consultant used at that review.

Mr C complained about the care and treatment provided to his wife. He said that her tendon was damaged during the operation, causing pain in her ankle outside the site of injury and that she should not have been discharged so quickly. He also said that her infection was not treated reasonably and that the metalwork should have been removed sooner. Finally, Mr C complained that the injured tendon was not investigated appropriately or within a reasonable time and that there was an unreasonable delay between the scan and the subsequent consultation.

We took independent advice from one of our medical advisers, who said there was no evidence that Mrs C's tendon was injured during surgery. She had a wound that was slow to heal and was complicated by infection, but this was treated appropriately and effectively and the metalwork was removed within a reasonable time. In relation to Mrs C's final consultation, we were unable to reconcile the differing accounts about communication. However, we found that the advice given about the condition and treatment options was reasonable. Having said that, the delay between the MRI and subsequent consultation was unreasonable. Although this had no impact on the outcome for Mrs C, we found that the delay caused her additional uncertainty while she was dealing with a painful condition.

Recommendations

We recommended that the board:

• bring the failings in record-keeping to the attention of the relevant healthcare professional; and
• inform us of the steps taken to ensure there is no recurrence of the delay between the MRI scan and follow-up consultation.

Summary

Miss A was unhappy with the advice she had received on the management of her hypothyroidism (where the thyroid gland produces too little thyroid hormone) with regards to conception and pregnancy. Mrs C, who complained on behalf of Miss A, added that Miss A had complained that she was never offered a face-to-face appointment with a GP at the medical practice and that she had been added to the thyroid follow up register without her knowledge.

We took independent medical advice from our GP adviser. We found that the practice were reasonable in adding Miss A's name to the thyroid follow up register as this is a way to ensure that the patient has annual blood tests to manage the condition. In addition, the practice had responded by apologising and said that this was simply an administrative tool and they had not anticipated it causing any concern. Our adviser told us that there are no guidelines dictating any treatment prior to pregnancy with regards to hypothyroidism, only about actions that should be taken after the woman becomes pregnant. In addition, we found that, given the nature of the consultations, it was reasonable to offer phone appointments. We found that the practice had given a reasonable standard of care.

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.