Ms C complained that staff at Borders General Hospital failed to diagnose and treat her ankle injury. During the course of our investigation, Ms C decided that she no longer wished to pursue her complaint with us, and so we closed the file and took no further action.
Ms C, an advocate, complained to the board on behalf of her client (Mrs A) about the care she received at A&E at Borders General Hospital after she had fallen at home. Mrs A had fractured a bone in her arm and was discharged home the same day. The following day, she returned to the hospital in significant pain and further tests showed that she had fractured her kneecap and had bone cancer. Ms C also complained about a delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy.
We took independent medical advice from a consultant in emergency medicine who considered that Mrs A did not receive a reasonable standard of treatment when she initially attended A&E. There was insufficient evidence to show that the emergency doctor had carried out a thorough examination of Mrs A's joints below the fracture or her lower limbs despite ambulance staff having documented bruising to the right knee. We also took independent medical advice from an orthopaedic consultant who considered that the one day delay in identifying the fractured kneecap was unlikely to have impacted on Mrs A's overall outcome. However, we also found that Mrs A's significant pain level was not reassessed prior to being sent home and had it remained high, then she may have required intravenous morphine and admission to hospital. There was also no evidence to show that any assessment had been carried out of how she might manage at home and who was able to care for her if required.
In considering Ms C's complaint about the delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy, our orthopaedic adviser told us the eight week delay in Mrs A being reviewed was unlikely to have had a detrimental effect on the healing of her arm fracture. However, given she was to be reviewed within three weeks we found the delay in this case to be unreasonable.
We upheld all of Ms C's complaints, although we noted that the board had apologised to Mrs A that the pain relief they gave her was inadequate and acknowledged that a mistake had been made in her not being referred to the orthopaedic clinic and physiotherapy for further review. They also arranged for the hospital's discharge procedure to be reviewed with a view to making improvements in order to prevent the matter recurring. However, we made recommendations which related to the treatment of Mrs A when she initially attended the A&E department.
We recommended that the board:
Mr C complained because he said an addictions caseworker inappropriately shared information about him at an integrated case management (ICM) meeting. The board told Mr C that he had consented to information about him to be shared because he had signed a consent form. Mr C disputed that he had given consent.
We obtained a copy of the information sharing protocol (ISP) agreement drawn up between the Scottish Prison Service and the NHS. That document was prepared to support the regular sharing of personal information for patients who are in prison with a view to supporting their care and case management in prisons and their transition in and out of prison. The ISP confirms that the information being shared will be used to facilitate operational prison management, including ICM, and the ongoing management and review of a prisoner's health and social care. It confirms the information that can be shared includes clinical information and also states that, for the purposes of the protocol and the processes described in it, no consent will be required from service users. We also obtained a copy of the consent form Mr C signed which confirmed that he consented to participating in the ICM process and understood what the process involved and how the information gathered would be used and stored.
In light of the information available, we concluded that the caseworker shared information about Mr C in line with the ISP. In addition, Mr C signed a consent form. Therefore, we did not uphold the complaint.
Ms C complained that her dentist had failed to fit temporary crowns properly. As a result they had become detached shortly after fitting. Ms C said when she returned to the dental practice, she was made to wait for an hour, before being told to go home and come in later that day. When she attended again, she felt the dentist was unprofessional and unreasonable as she asked Ms C to leave the surgery and refused to provide her with the impressions that had been taken of her teeth.
We took independent advice from one of our dental advisers on the treatment provided to Ms C. We found that the treatment provided was well documented and complied with the appropriate national guidance. Our investigation found there was no evidence that Ms C had received inappropriate or unreasonable dental care.
Mrs C suffered a fall when she was on holiday and attended Arran War Memorial Hospital on two occasions over a four day period. The doctors who examined Mrs C on both occasions thought that she had suffered a musculoskeletal injury to her chest and that she had possibly broken a couple of ribs. They prescribed painkillers which did not resolve the pain. Mrs C then returned to her home area where it was found that she had suffered a punctured lung. Mrs C believed that the punctured lung should have been identified by staff at the hospital prior to her having to travel back home. We took independent medical advice which showed that the doctors who treated Mrs C at the hospital provided her with appropriate treatment (painkillers and advised to rest). There was no indication at that time that Mrs C had suffered a punctured lung and there was no requirement to carry out an x-ray. We did not uphold the complaint.
Mrs C complained about her discharge from a private hospital, which she had been admitted to for NHS-funded hip replacement surgery. She felt she was not fit to be sent home as she had severe diarrhoea, which she blamed on being given too many laxatives on the day of discharge. She needed to be admitted to hospital a few days later, where she remained for over four weeks. The board said that she had not been given any laxatives on the day of discharge and they considered that she had been fit to go home.
We took independent advice from one of our medical advisers and he said there was no evidence of Mrs C having been given laxatives on the day of her discharge. However, he did not consider that her bowel symptoms had been properly investigated and treated prior to sending her home. He said there seemed to have been undue focus placed on meeting the planned discharge date rather than ensuring Mrs C was fit to go home. As such, Mrs C required prompt readmission to have her bowel symptoms addressed. The adviser also noted that the records from Mrs C's admission lacked the detail that could reasonably have been expected. We accepted this advice and upheld the complaint.
We recommended that the board:
Mr C complained about the care and treatment his late wife (Mrs C) received at University Hospital Ayr. Mr C was concerned that mistakes had been made when his wife had attended A&E. In particular, he told us about his concerns in relation to the insertion of chest drains, the removal of oxygen and the loss of four pints (units) of blood. Mr C was also concerned about the standard of communication with him and his family and that, as a result of information given directly to his wife, she lost any fight for life.
During our investigation, we took independent advice from a consultant in respiratory medicine. The complaint was investigated and showed that the treatment given to Mrs C was reasonable and appropriate. While she had in total three chest drains inserted these were necessary according to the circumstances and as part of her symptoms. We found no evidence in Mrs C's medical records that she had lost four units of blood nor was there evidence that oxygen was removed. The advice we received was that the medical records demonstrated that Mrs C was closely monitored even a few hours before she passed away and that she was given the maximum treatment necessary. There was no evidence of service failure on the part of the board and we did not uphold the complaint that the treatment given to her was unreasonable.
The board accepted that there had been some failings in communication and while they met with Mr C and his son as a result of these failings we were concerned that there was no written record of the meeting. The board also explained that a medical decision was taken not to resuscitate Mrs C and this was discussed with her. While the advice we received was that it would be good practice to document that this would be discussed with the family when they were available, our adviser also said that Mrs C's critical condition and poor prognosis, including that she was too unwell to be considered transfer to the intensive care unit or for resuscitation, was communicated to Mr C and his family reasonably well.
We recommended that the board:
Mrs C complained about the treatment her late father (Mr A) received from the board. Mr A had died soon after being diagnosed with cancer and Mrs C felt his treatment had been unreasonably delayed (she was aware that her father was very unwell but felt things could have been handled better, including providing end of life care sooner). Although the board had acknowledged certain delays to Mrs C and said they would recruit additional staff, she remained dissatisfied and brought her complaint to us.
We considered whether Mr A's treatment at University Hospital Ayr was reasonable in the circumstances at the time. We took independent medical advice which confirmed that Mr A's cancer had been a very rare and complex kind. Our adviser, having reviewed the records, also said that Mr A's initial treatment pathway had been reasonable and confirmed that Mr A had not fallen between the cracks of different clinical disciplines (Mrs C had been concerned about this). However, our adviser said the delay for a subsequent investigation that was needed for Mr A's diagnosis and treatment was unreasonable and also that end of life care should have been discussed sooner than it was.
We found the evidence indicated that Mr A's condition was complex and that his initial care was reasonable. However, we considered the delay to his subsequent investigation to have been unreasonable as was the delay in discussing end of life care. We upheld Mrs C's complaint and made three recommendations.
We recommended that the board:
Ms C complained about the care and treatment that her late brother (Mr A) received during two admissions to University Hospital Ayr. She felt he was inappropriately discharged on the first occasion and that the board had not communicated adequately or provided appropriate treatment during his second admission. During that admission, Mr A died and, although Ms C explained that her family were aware that he had been most unwell, she felt the board's care was unreasonable.
As part of our investigation we took independent advice from one of our medical advisers. He explained that Mr A had been suffering from serious liver disease and the outlook for him was poor. However, it was unclear from the medical records why a proposed course of treatment during his first admission was not administered. The notes said Mr A would be given medication if a particular test result was above a certain level, which it was. On balance, therefore, we upheld Ms C's first complaint and made two recommendations.
In terms of Mr A's second admission, our adviser explained that in such situations it is difficult to decide when it is appropriate to move to palliative care (care to prevent or relieve suffering only). However, staff had acted in line with appropriate guidance. Although we recognised the significance of this for Mr A's family, we found no evidence that Mr A's care was unreasonable or of an unreasonable delay in moving to palliative care. The evidence about communication was limited, but our adviser said that the records pointed to conversations with Mr A's family that reflected his condition at those times. Although we took Ms C's concerns into account we did not find that the evidence, viewed as a whole, indicated that the board failed to communicate adequately. We did not uphold these complaints.
We recommended that the board:
Mr C complained about the care and treatment provided to his mother-in-law (Mrs A) in Crosshouse Hospital before her death. Mrs A had dementia and had contracted clostridium difficile (C diff - a common healthcare-associated infection), which caused severe diarrhoea. Mr C complained that staff had failed to maintain Mrs A's personal hygiene. He said that they had not changed her often enough and that her hands were covered in her own faeces.
We took independent advice from our nursing adviser. The combination of Mrs A's dementia and severe diarrhoea had caused problems for staff and distress for her family. However, we found that staff had carried out frequent checks on Mrs A and had taken reasonable steps to maintain her personal hygiene. We did not uphold this aspect of Mr C's complaint.
Mr C also complained that staff failed to ensure that Mrs A's food or fluid was provided at the appropriate consistency. We found there had been problems with fluid consistency, and that there was delay in prescribing a dietary supplement. In view of these failings, we upheld this aspect of Mr C's complaint. However, the board sent us an action plan showing that refresher training on the provision of thickened fluids had been provided to staff. They had also apologised to Mr C for the shortcomings in Mrs A's care.
Finally, Mr C complained that staff failed to make adequate arrangements for Mrs A's discharge. We found that there should have been a multi-disciplinary meeting with social work and the family invited to attend before Mrs A was discharged, but that staff had failed to arrange this. In view of this, we also upheld this aspect of Mr C's complaint.
We recommended that the board: