Health

Summary

Mrs C complained on behalf of her late mother (Mrs A) about the care and treatment Mrs A received at Monklands Hospital. She had fractured her neck and was admitted to hospital for conservative management (medical treatment avoiding radical therapeutic measures or operations).

Mrs A had a history of chronic obstructive pulmonary disease (a type of lung disease) and was treated for a chest infection whilst in hospital. She was also found to have fractured ribs. Mrs A's chest condition deteriorated and an x-ray revealed a haemothorax (blood in the cavity surrounding the lung). A chest drain was inserted to drain the fluid, and she was transferred to the High Dependency Unit for several days then transferred back to the ward when her condition stabilised. However, a few days later she suffered a rapid deterioration and died.

We took independent advice on this case from one of our medical advisers who found that the decision to transfer Mrs A back to the ward was reasonable given that her breathing rate, oxygen levels, blood pressure, and heart rate were all stable and met the board's transfer criteria in this respect. We also took independent advice from our nursing adviser, and noted that the board had acknowledged that there was delay in a drip being reconnected due to the cannula (intravenous tube) becoming dislodged and that a dose of antibiotics was missed. They provided refresher training for the ward staff, and a member of the nursing staff had apologised to the family. We found this reasonable and our nursing adviser considered that this was not a significant failing that affected the overall outcome for Mrs A.

Although we noted that the board had arranged for staff to have refresher training in relation to chest drains, neither of our advisers identified any evidence of failings with the management of the chest drain. In relation to Mrs C's concerns about staffing on the ward, we found that some of the shifts had lower numbers than planned, but that bank staff and overtime were used to address this, which was reasonable. On balance, we concluded that the medical and nursing care was reasonable.

Summary

Mrs C complained about the treatment she had received from her GP when she reported a lump in her breast. Mrs C attended the medical practice twice before being referred to the breast clinic where she was later diagnosed with breast cancer.

Mrs C said that she should have been referred to the breast clinic sooner and was concerned about the GP's attitude. Mrs C also said that when she was referred, the referral should have been classed as urgent rather than routine.

During our investigation we asked for independent advice from one of our GP advisers. Our adviser found that the GP had conducted a thorough examination of Mrs C and gave her appropriate advice regarding monitoring the lump. The adviser said that it was hard to judge the attitude of the GP through the medical notes, however, based on the record of Mrs C's condition at the time of the referral, and relevant National Institute for Health and Care Excellence (NICE) guidance, a routine referral was appropriate. We did not uphold Mrs C's complaints.

Summary

Ms C, who is an advocate, complained to us on behalf of her client (Mr A) that the board's response to his complaint was inadequate.

Mr A had complained to the board about the conduct of a nurse. The board investigated Mr A's complaint and, in their written response, acknowledged that his experience was distressing and they apologised. The board explained to Mr A that their investigation had been conducted in line with their Management of Employee Conduct Policy, and that they were unable to share any actions arising from the investigation due to the confidentiality of employee matters. In a further letter to Mr A, the board confirmed that he would not be notified of the outcome of any internal board process.

We concluded that it was reasonable in the circumstances that the board did not tell Mr A whether his complaint was or was not upheld. This was because the standard complaints procedure, under which Mr A submitted his complaint to the board, was superseded by the Management of Employee Conduct Policy due to the nature of the allegations made in Mr A's complaint. This was why the board decided they could not tell Mr A whether his complaint about the nurse had or had not been upheld, as to have done so would breach employee confidentiality. Although we thought that they could have explained the sequence of events more clearly, we considered that the board's response to Mr A's complaint provided relevant information that they were able to share with him in the circumstances, and we did not uphold the complaint.

Summary

Ms C had been living abroad but returned to Scotland, although she still had connections overseas. She was experiencing difficult personal circumstances and she was referred for psychiatric review. She received mental health care but complained that her treatment was inadequate and that the board failed to provide appropriate support. In particular, Ms C complained that after a referral to psychological services, it took too long for her to be seen; that although she was frequently suicidal, she was not admitted to hospital; and that there was a general failure to respond to her needs which contributed to her acute mental distress. She said as a consequence, this led to her child being taken into care.

We took independent advice from one of our advisers who specialises in mental health. We found that Ms C's initial assessment and plan were appropriate and a psychiatric review took place on schedule. At times of crisis, there was a good response with reasonable follow-up arrangements being put in place. However, although it was not considered that Ms C required compulsory treatment, her management was complicated by her continuing treatment overseas and her travel between the two countries and, at various times, she declined psychiatric appointments.

However, we found there was an extended delay before Ms C was seen by psychological services and so we upheld her complaint about this. The board had already apologised to Ms C for the delay, so we did not make a recommendation about this, but we did make two other recommendations.

Recommendations

We recommended that the board:

• confirm to us the actions they have taken to resolve the delay identified; and
• confirm to us that they are satisfied that they can meet reasonable waiting times for psychological services.

Summary

Mr C complained to us about the care and treatment he had received from a dentist. He had attended the dentist for emergency treatment, who had extracted a badly broken tooth. Mr C was given an antibiotic and advised to return to the surgery for a more detailed examination to be carried out to assess what other dental treatment was required.

Mr C returned to the dentist two days later and complained of pain and swelling. He said that he had been unable to eat. It was noted that a small swelling was present at the border of the lower jaw and there was pus discharging from the area where the tooth had been extracted. The dentist diagnosed a dry socket (an infected wound at the site of an extraction) and Mr C was prescribed another antibiotic and an antiseptic mouthwash. A dressing was not applied, as this was too uncomfortable for him.

Mr C attended his GP on the following day, as he was still in some pain. He was then admitted to hospital later that day with a submandibular (inside the lower jaw) abscess, which was spreading into the tissue spaces. This was leading to extensive swelling, which was threatening his breathing. He was also suffering from a fever. Mr C was admitted in order that the hospital could drain the infected fluid from the abscess.

There was nothing to indicate the presence of the abscess when Mr C had the tooth extracted on his first visit to the dentist. However, when Mr C attended again two days later, the dentist noted unusual symptoms, including a spreading infection, that did not fit the normal pattern. The development of an abscess of the type Mr C experienced following dental extraction is a very rare occurrence. After taking independent advice from our dental adviser, we found that that the dentist should have arranged an urgent referral to the local maxillofacial surgery department (the specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) when Mr C had returned complaining of pain and swelling, but had failed to do so. In view of this, we found that the dentist did not provide reasonable care and treatment on that occasion and upheld the complaint.

Recommendations

We recommended that the dentist:

• issue a written apology to Mr C for the failings identified.

Summary

Mr A was admitted to the Royal Northern Infirmary for rehabilitation. He was suffering from lung cancer as well as recuperating from a stroke and a broken arm. He had a stoma bag (a surgically made pouch on the outside of the body) as a result of an earlier ileostomy (a surgical procedure on the small intestine). It was hoped that he would be able to recover some of his mobility whilst in hospital, but Mr A became unwell after a few days and was transferred to another hospital, where he later died as a result of a blocked bowel. His daughter (Ms C) complained to us about the care and treatment her father received at the Royal Northern Infirmary towards the end of his life.

We took independent advice on Mr A's care from our nursing adviser. We found that as a result of Ms C's complaint, a significant event review was carried out which included several recommendations and actions to be taken. While we found that there were issues about the lack of end of life care and poor communication with Ms C and the rest of the family, we found that the pain assessment, nursing and stoma care Mr A received was reasonable. We, therefore, did not uphold Ms C's complaint about her father's care and treatment.

Ms C also complained that the board failed to deal with her complaint according to their policies and procedures. As we found that there were considerable delays in responding, we upheld this complaint.

Summary

Mr C complained that the board had failed to provide his partner (Mr A) with appropriate and timely treatment for a needlestick injury (when the skin is accidentally pierced by a needle), when he attended the A&E department at the Southern General Hospital. He said that Mr A had to wait for two and a half hours to see a doctor and that other people who arrived after him were seen before him. Mr C complained that they refused to give Mr A post exposure prophylaxis (PEP - short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure), despite the fact that the needle had been discarded close to the home of an HIV positive drug user. He also said that Mr A was not offered a polymerase chain reaction (PCR) test (a test that can be used to identify HIV) which can be done around ten days after the exposure.

After obtaining independent advice from our medical adviser, we found that the care and treatment provided to Mr A had been reasonable, appropriate and in keeping with standard care. Patients with a community-acquired needlestick injury are not treated as a priority when they attend A&E. It was not unreasonable that some patients with other conditions who arrived after Mr A were assessed before him. The board had acted in line with their guidelines in relation to providing PEP and it was not given because any benefit would have been outweighed by the risk of side effects. It was also appropriate that a PCR test was not used, as another test was available. In view of all of this, we did not uphold the complaint.

Summary

Mr C complained that staff at the Royal Alexandra Hospital, Paisley failed to adequately assess his symptoms following a jarring injury to his neck from a fall in his garden. Mr C raised a number of concerns, including that the doctor who saw him failed to take adequate account of his dystonia (a movement disorder that causes muscle spasms and contractions), failed to arrange an x-ray and failed to ensure he had adequate pain relief. Mr C said it was later identified that his neck was fractured, but said that by then it was too late for it to be treated.

We took independent medical advice from a consultant in emergency medicine. The board indicated that the doctor's assessment of Mr C was appropriate. However, as the board could not locate Mr C's medical records, we could not clearly determine that this was the case. We were very critical of the board's management of Mr C's records.

Our adviser said that in general Mr C's dystonia would have played no part in his assessment and the determination of the treatment he required. However, he said that the doctor who saw Mr C should have considered the impact of his dystonia on his ability to swallow when determining appropriate pain relief. In the absence of a pain score, it was difficult to determine exactly what level of pain relief should have been provided. However, the board acknowledged that their understanding of the medication available to Mr C at home was incorrect and it would appear that Mr C was, therefore, sent home without adequate pain relief.

Further, given Mr C's swallowing problems caused by his dystonia, our adviser said that he would have expected senior involvement in deciding if Mr C should have been admitted for pain relief and we were critical of the board for failing to arrange this.

In terms of the need for an x-ray, the adviser was clear that, given the absence of any direct blow to Mr C's head, an x-ray was not indicated.

Recommendations

We recommended that the board:

• review their practice on the storage of patients' medical records to ensure that records are stored securely in future.

Summary

Mrs C had a history of abdominal (stomach) pain, for which no specific cause had been found. In June 2010, she and her husband (Mr C) went for fertility treatment, and a scan revealed a large endometriotic cyst (a blood-filled sac) on Mrs C's ovary. This was removed and Mr and Mrs C were referred for fertility treatment. At that point, Mrs C's levels of AMH (a hormone that gives an estimate of the capacity of the ovary to provide egg cells capable of fertilisation) were within normal range. Some time after this, a scan showed another large cyst - this was removed and Mrs C was given treatment to reduce the chances of this happening again.

Mr and Mrs C were seen again in July 2012 before starting fertility treatment at Glasgow Royal Infirmary, at which time Mrs C's AMH level had decreased to a 'less than a normal' range. The first cycle of treatment was unsuccessful and the fertility unit recommended a different procedure for the next cycle. Before this could happen, however, the board closed the unit because of poor fertilisation rates (possibly related to contamination from nearby building works). The board wrote to Mrs C explaining this and offering the couple a complimentary treatment cycle.

Mr and Mrs C complained about Mrs C's care and treatment, saying that the cysts were not diagnosed quickly enough and that she should have had regular scans after the first operation. They also said that the board did not provide a reasonable standard of care and fertility treatment, that their communication about the problems was inadequate and their guidance to affected patients confusing. Mr and Mrs C thought they should be offered a third fully funded cycle of treatment.

After taking independent advice on this complaint from two advisers - one a surgeon (adviser 1) and the other a specialist in assisted conception treatment (adviser 2) - we did not uphold Mr and Mrs C's complaints. Adviser 1 said that the board reasonably investigated and treated Mrs C's earlier abdominal symptoms and found no evidence that the cysts were related to these. Adviser 2 also said that care and treatment in relation to the cysts was reasonable, and that Mrs C's decreased AMH levels were likely to have been due to the second operation, rather than any delay in identifying the second cyst.

The board had acknowledged the problems in relation to assisted conception, and had taken steps to address them. Adviser 2 said that it was probable that the first cycle failed because of the environmental contamination, and that the board's offer of one further complimentary cycle was reasonable. They did not think that there was a failure in care and treatment by the board, who were dealing with a complex and fast-changing situation, and we found that the board's communication was reasonable in the circumstances. We were also satisfied that their guidance for affected patients was intended to ensure that no-one was at a disadvantage, so that each couple received two fully funded NHS cycles of treatment.

Summary

Mr C complained about the care and treatment given to his father (Mr A). He said that the board failed to admit Mr A to hospital on two occasions, did not provide him with appropriate medication and infection control measures, and did not communicate appropriately with Mr A's family.

During our investigation, we took independent medical advice from an emergency medicine consultant, a consultant physician and a consultant microbiologist. The advice we received was that the decisions not to admit Mr A to hospital were reasonable, and that Mr A received appropriate medication on both occasions. However, we were concerned that on the first occasion the commencement of antibiotics (drugs to treat bacterial infection) was poorly managed, although we also noted that the board apologised and took action to address this. Our emergency medicine adviser said that there were no failings that would have impacted on the outcome, but commented on the board's action in relation to screening Mr A for sepsis (blood infection) and we made a recommendation about this.

We found that the antibiotics given to Mr A before he was admitted to hospital were appropriate. He also received appropriate antibiotic therapy when he was admitted and this was revised appropriately during his stay in hospital. Our consultant physician adviser said that the decision not to isolate Mr A when he was first admitted was reasonable and that he was later treated with appropriate infection control measures.

We were concerned that there were failures in communication with Mr A and his family, although we were aware that the board had accepted that in several areas communication had not been as they would have expected, and had apologised for this. We also noted that they had taken action to improve communication between medical staff and between hospital staff and relatives. We did not, therefore, find it necessary to make recommendations about this.

Recommendations

We recommended that the board:

• ensure that relevant staff members are made aware of our adviser's comments in relation to sepsis screening and given the opportunity to reflect on these for future practice.