Health

Summary

Mr C complained that the board’s prison health centre doctor unreasonably stopped his pain medication for a long-term knee injury, on the basis of alleged intelligence that Mr C misused another pain relief medication he had previously been prescribed. Mr C was concerned that the doctors at the health centre would not give him painkillers because of someone else’s say so, with no concrete proof or evidence and that in the meantime he had been left without effective medication.

We obtained independent medical advice on Mr C’s complaint from a GP. We also sought advice from the office of the Chief Medical Officer (CMO) on disclosure of information/confidentiality.

Our adviser noted that Mr C’s records indicated that the decision to stop his co-dydramol and not replace it with co-codamol was made, at least in part due to reported information regarding past drug misuse. However, our adviser explained that the pain guideline followed by the board suggested that there was no evidence for the continued prescribing of opioid based drugs such as tramadol, co-codamol and co-dydramol in patients with unexplained or persistent pain. Our adviser said it was, therefore, not unreasonable for the board to reduce and then stop Mr C’s tramadol or to stop his co-dydramol and not prescribe co-codamol in its place. Our adviser noted that the doctor prescribed appropriate alternative pain relief treatment for Mr C. We were satisfied that Mr C’s pain relief was appropriately managed by the doctor and the medication prescribed was appropriate for Mr C’s condition.

In terms of the disclosure of the information about past drug misuse, the doctor confirmed he did not disclose the information to Mr C at the time he made the decision to stop his opioid based medication. Based on the advice received from the office of the CMO, we were not critical of the prison health centre’s actions in this regard.

Summary

Mr C complained about the medication he was prescribed at Dumfries and Galloway Royal Infirmary. He said the side effects were not explained to him properly and that his medication had caused him to suffer problems with his lungs.

As part of our investigation, we took independent medical advice from one of our advisers. He explained that not discussing the medication’s side effects would have been unreasonable and that such discussions should ideally be noted in the medical records. Our adviser was unable to determine the extent of any such discussions from Mr C’s medical records and, although he accepted it was possible that it may have caused Mr C’s subsequent health problems, he said it was a low probability. However, he said the actual decision to have prescribed the medication was not, of itself, unreasonable.

In light of the advice we received, we could not absolutely say Mr C’s medication caused his health problems or the decision to have prescribed it was unreasonable and so we did not uphold his complaint. We did, however, have reservations about the extent of the discussions about its possible side effects and the extent of the assessment that was done for Mr C and so we made three recommendations.

Recommendations

We recommended that the board:

• remind clinical staff of the importance of accurate note keeping;
• remind staff to carry out and follow up on appropriate physical examinations for lung disease (particularly where symptoms such as lung crackles have been identified); and
• remind clinical staff of this medication’s side effects and the need to explain them to patients, particularly in light of patients’ presenting symptoms.

Summary

Mr C, a patient with long standing heart problems, complained that he was not provided with a cardiology service at Borders General Hospital for a period of nearly 18 months. We found that Mr C was not recalled for his routine six-monthly cardiology review appointment. The board said this was because, after Mr C declined surgery for an unrelated medical condition, surgeons did not let the cardiology department know that the surgery did not go ahead. We found that even after Mr C’s GP referred him again it took too long, and considerable effort on his part, to get another cardiology appointment. We asked the board to review the process by which patients are discharged from one service to another and back again. We asked them to build in safeguards to ensure the system was robust and, following review, that the process was shared and understood across specialist areas as well as within administration teams.

Mr C told us there was an unreasonable delay when a letter from the board took 49 days to reach him. The board acknowledged that there were problems with workload within the administration team and apologised for their failing. They acknowledged the delay was unacceptable. They also took steps to monitor workflow within the administration team. We found that these were reasonable actions.

We found some shortcomings in the handling of Mr C’s complaint. The initial response to Mr C’s complaint made no reference to key points he had raised. Nor did it refer to the difficulties he experienced when he contacted the board by phone. We found the board had apologised for the fact that a room used for the meeting caused Mr C distress in that it was very small and full of people when he arrived. The board acknowledged the agenda could have been better arranged. We found that the cumulative effect of these errors made Mr C feel that his complaints were not being taken seriously.

Recommendations

We recommended that the board:

• review the process by which patients are discharged from one service to another and back again and ensure, following this review, that the process is shared and understood across specialist areas as well as within administration teams.

Summary

Mr C complained about the care and treatment that his late mother (Mrs A) received from her GP. Mrs A had attended her GP with symptoms of breathlessness and the GP arranged an x-ray, took a blood sample and prescribed antibiotics. The x-ray result was reported as normal. Mrs A died four days after the consultation from a pulmonary embolus (a clot in the blood vessel that transports blood from the heart to the lungs) caused by deep vein thrombosis. Mr C felt that the GP had taken insufficient note of his mother's breathlessness and should have taken urgent action to establish a further diagnosis as the x-ray had been reported as clear.

We took independent advice from a GP adviser and found that Mrs A's GP had acted reasonably by conducting appropriate investigations in order to establish a diagnosis and that there were no signs that Mrs A would suffer a pulmonary embolus a few days after the consultation. We also found that there was no delay by her GP in their consideration of the x-ray result. We did, however, note that the GP's record-keeping was not as thorough as it could have been and that the GP should reflect on this.

We did not uphold the complaint.

Summary

Ms C, who is an advice worker, complained that the care and treatment provided by the prison health centre to her client (Mr A) for pain in his arm was unreasonable. In particular, Mr A had been unhappy because a nurse had questioned why he was being prescribed a certain type of pain killer. Mr A felt the nurse did not have the authority to do that.

We reviewed Mr A's medical records which confirmed the nurse had concerns about Mr A receiving the pain killer whilst also being prescribed methadone. His medical record also confirmed the doctor was unsure what kind of pain Mr A was feeling and felt further investigation was needed. The doctor prescribed the pain killer for a two week period and also referred Mr A's case to neurology. We took independent medical advice from a GP adviser who confirmed that there was no issue with a clinician - either a doctor or nurse - clarifying why a patient was being prescribed certain medication. Our adviser also confirmed that Mr A's case was reviewed regularly by the doctor and proper steps were taken to explore the type of pain he was experiencing. In addition, our adviser said Mr A was prescribed an appropriate alternative pain killer. Because of this, we did not uphold the complaint.

Ms C also complained that the board's handling of Mr A's complaint was inappropriate. In particular, Mr A said that after he submitted his complaint form, he was called to a meeting with the doctor. He said that when he arrived in the doctor's room, the nurse who he had raised concerns about was there and she was holding his complaint form. Mr A said he understood his form would go to the board's complaints and feedback team. We reviewed the relevant Scottish Government guidance, Can I help you?, which outlines how health service providers should deal with complaints. In particular, it says that if a complaint is reasonably straight forward and non-complex it may be managed without the requirement for a detailed investigation. In Mr A's case, the prison health centre forwarded his complaint to the board's complaints and feedback team the day after the meeting took place and a written response was issued to him in line with the complaints procedure. We were satisfied that the handling of Mr A's complaint was appropriate and we did not uphold his complaint.

Summary

In January 2013, Mr A attended the medical practice as he had ongoing chest pain and a cough. A chest x-ray and blood tests were arranged and the results came back normal. However, as his pain was continuing he was given painkillers. In March 2013, Mr A attended the practice again because his symptoms were continuing and he was referred to hospital for a specialist opinion. Mr A was seen in hospital in May 2013 although, in the meantime, the practice prescribed him increasing painkillers and his tests were repeated but again with no result. After a difficult diagnosis pathway, Mr A was advised over the phone by his GP in September 2013 that he had cancer, and he died in May 2014.

Mr C complained to the practice on behalf of Mr A's widow (Mrs A) that it had taken the practice too long to refer Mr A for appropriate tests and opinion and that there was a lack of urgency to provide him with any meaningful treatment. He further complained that a GP within the practice told Mr A of his diagnosis over the phone, which he said was inappropriate and showed a lack of compassion.

We took independent advice from one of our GP advisers and we found that while Mr A was treated reasonably and appropriately and that efforts were made to treat his pain, he was not referred to hospital in line with national guidelines for suspected cancer. His referral should have been urgent rather than routine. Because of this, there was a delay in him being seen in hospital and a delay in his treatment being started. While it was confirmed that Mr A had been told of his diagnosis over the phone, this was for the best of intentions in order to explain his increasingly strong painkillers. Nevertheless, this should not have happened and arrangements should have been made for a house call or for Mr A to attend the practice. In light of the advice we received, we upheld Mr C's complaint.

Recommendations

We recommended that the practice:

• make a formal apology to Mrs A for this failure;
• ensure that all medical staff familiarise themselves with the national referral guidelines for suspected lung cancer; and
• ensure that the GP reflects on the distress caused and he ensures that the matter is raised at his next formal appraisal. He should advise us that he has done so.

Summary

Mrs C complained on behalf of her client (Mrs A) who was unhappy with the care and treatment she received from her GP practice in relation to a finger injury.

After injuring her finger, Mrs A attended the hospital minor injuries and illnesses unit, but she was discharged. A week later, she attended the practice as she was still unable to bend her finger. The GP examined her finger and prescribed antibiotics. Mrs A returned a week later and a different GP prescribed different antibiotics. Mrs A returned again another week later, and at this appointment she mentioned that soon after the first injury, she had had a second injury which stretched her finger. The third GP then considered that Mrs A might have an injury to her flexor tendon (the tendon that connects the muscles in the forearm to the bones in the finger), and referred her to the orthopaedic clinic as a routine referral. After further investigations, Mrs A was diagnosed with an incomplete tear of the flexor tendon.

After taking independent medical advice from a GP adviser, we upheld the complaint. We found that, although the first two GPs did not know about the second injury, in view of Mrs A's symptoms they should still have considered the possibility of a flexor tendon injury and referred her for specialist assessment. Although the third GP acted appropriately in referring Mrs A to orthopaedics, this should have been an urgent referral, rather than routine. We were concerned that the GPs' failures to refer Mrs A appropriately led to a delay of over three weeks in her treatment, which our adviser said was significant as flexor tendon injuries are normally treated within a few days.

Recommendations

We recommended that the practice:

• issue a written apology to Mrs A for the failings our investigation found; and
• draw our findings to the attention of the GPs involved, for reflection as part of their annual appraisal.

Summary

Mrs C complained on behalf of her client (Mrs A) about the board's care and treatment of Mrs A's finger injury.

Mrs A attended the minor injuries and illnesses unit with an injury to her finger, but she was discharged as the nurse considered it a superficial wound. However, after some weeks, Mrs A's GP referred her to the orthopaedic unit, as she still could not bend her finger. After further investigation she was diagnosed with an incomplete tear of the flexor tendon (the tendon that connects the arm muscles to the bones in the finger). Mrs A was referred for physiotherapy, but this did not help, and the orthopaedic surgeon offered Mrs A surgery to try and improve the movement in her finger. Mrs A agreed, but the surgery was delayed four months while waiting on an echocardiogram (a scan of the heart), which Mrs A had been referred to by the general medical clinic (for an unrelated issue). Mrs C complained about the care and treatment and the delay in Mrs A's surgery, as well as about the board's response to her complaint to them.

After taking advice from an orthopaedic surgeon and a general medical consultant, we upheld Mrs C's complaints. We found that the first assessment of the wound at the minor injuries and illnesses unit was inadequate, and may have missed an opportunity to diagnose Mrs A's injury earlier, although the later care and treatment by orthopaedics was reasonable. We also found that the delay in surgery was unreasonable, as the adviser said this scan should have been completed within weeks, rather than months (in this case it was delayed because the referral was missed). We also found that the board's response to Mrs C's complaint was inadequate, as they did not acknowledge failings which they were aware of at the time, and they did not explain the delay in Mrs A's surgery.

Recommendations

We recommended that the board:

• remind staff in the minor injuries and illnesses unit of the 'Tayside Hand Unit – Trauma Referral Guidelines' (in particular the guidance on assessment of wounds on page 7);
• consider options for improving the tracking of similar referrals in the general medical clinic;
• bring our findings to the attention of relevant staff for reflection and learning;
• issue a sincere written apology to Mrs A, acknowledging the failings our investigation found; and
• remind relevant staff of the need to ensure complaints are fully investigated in line with the complaints procedure and the responses provide full explanations of the matters raised.

Summary

Mr C complained on behalf of Mrs A, the widow of Mr A. Following a referral by his GP, Mr A was seen in Ninewells Hospital for advice and investigation in May 2013. He was given a computerised tomography (CT) scan (which uses

x-rays and a computer to create detailed images of the inside of the body) which showed an abnormality on one of his ribs which was suspected to be sinister. In July 2013, a biopsy was attempted but this failed because it was too uncomfortable for Mr A. The following month, a further CT scan was taken as was a biopsy under general anaesthetic. The results confirmed that Mr A had cancer. Mr A had further investigations the following month and a treatment plan for him was discussed by a multi-disciplinary team. Mr A was advised of his diagnosis and plan in October 2013. Regrettably, Mr A's condition continued to deteriorate and he died in May 2014.

Mr C questioned why early tests and investigations given to Mr A failed to show evidence of his illness and said that there had been delays in providing him with treatment. Mr C said that as a consequence, Mr A had lost time with his family. Mr C also complained that there had been delay in issuing correspondence to Mr A. On behalf of the hospital, the board said that it had been very difficult to diagnose Mr A's illness and that while tests showed that something was wrong, this could have been for a number of reasons; there had been a delay in getting biopsy results but this had been unavoidable. Similarly, they said that there had been a delay in sending out letters because of administrative problems but that this had not affected Mr A's treatment overall.

We took independent advice from a consultant clinical oncologist and found that it had been very difficult to diagnose Mr A's cancer and to establish information by biopsy to determine the type of treatment he needed. This was not unreasonable in the circumstances. However, it had not been reasonable not to have treated Mr A as a suspected case of cancer from the outset and thus provide him with this care and treatment at an earlier date. Because of this delay and confusion in correspondence sent to Mr A, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• provide a formal apology to Mrs A;
• provide a formal apology for the delays in correspondence;
• inform us of the outcome of their administrative review and the steps taken to avoid a similar situation; and
• ensure that the advice provided for this complaint is brought to the attention of those clinicians involved in the case.

Summary

Mr C complained about care and treatment provided to his daughter (Miss A) at Perth Royal Infirmary when she attended the eye clinic there. Mr C believed that her condition was misdiagnosed, and that the treatment prescribed may have aggravated her condition and led to her sudden death.

Mr C told us that Miss A was being treated by her GP for acute conjunctivitis. The common treatment is with antibiotic (drugs to fight infection) drops or ointment and in some cases also steroid (drugs to fight inflammation) drops or ointment. The GP prescribed an antibiotic only. When her condition worsened, Miss A went back to the GP and was referred urgently to the eye clinic. Miss A attended the clinic the following day and a specialist doctor there diagnosed marginal keratitis (MK - an eye condition), with a possible allergic reaction to the antibiotic prescribed by the GP. The specialist changed the antibiotic, added a steroid and arranged a follow-up appointment for a week later. Three days later, however, Miss A died suddenly. Mr C told us that he disagreed with the stated cause of her death. He was of the view that she had in fact been suffering from a more serious infective eye condition and that the treatment provided was not only wrong, but contributed to her death by increasing pressure and inflammation in the brain.

Our investigation included taking independent advice from one of our medical advisers, who was of the view that appropriate examinations and investigations were carried out and that Miss A had been correctly diagnosed with, and treated for, MK. The adviser said that although the two conditions have similar symptoms, sufferers of the more serious condition also experience other symptoms, which Miss A did not have. The adviser was, therefore, of the view that Miss A's diagnosis, care and treatment were reasonable, appropriate and timely and there was no evidence that these contributed to her sudden death.

Amendment to summary text

When it was originally published on 20 May 2015, the first sentence of the second paragraph read: Miss A was being treated by her GP for marginal keratitis (MK- an eye condition).

This has been amended to read: Mr C told us that Miss A was being treated by her GP for acute conjunctivitis.

The reference to ‘MK’ in the fifth line of the second paragraph has been amended to read marginal keratitis (MK – an eye condition).

4 June 2015