Health

Summary

Ms C complained about the care and treatment she received from her medical practice. She was unhappy they had not given her a clear diagnosis for her symptoms over an extended period of time, and felt they had delayed in telling her about the diagnoses they actually had made in this time.

As part of our investigation we took independent advice from one of our medical advisers, an experienced GP, who reviewed Ms C's medical records. He said the paperwork indicated that the practice had tried to address her concerns and their steps had been reasonable. Although he acknowledged they may not have explained Ms C's symptoms to her satisfaction, the evidence did not indicate they acted unreasonably. In addition, as most diagnoses were actually made by hospital doctors following referrals by the practice, our adviser explained that it would mainly have been for the hospital doctors to tell Ms C about her diagnoses. Our adviser said the records indicated that the practice had been reasonable in communicating any diagnoses they had actually made to Ms C.

Our role was to make a decision about the reasonableness of Ms C's care and treatment based on the available evidence. Some conditions are particularly difficult to diagnose and treat, and the absence of a clear diagnosis would not necessarily mean that the practice had acted unreasonably. Although we recognised how significant this matter was for Ms C, we did not uphold her complaints as we received clear advice that her care and treatment was of a reasonable standard.

Summary

Ms C complained that the board failed to diagnose and treat her in 2013, as well as failing to inform her about the steps they had taken during this time.

As part of our investigation we obtained independent advice from one of our medical advisers, who is an experienced doctor. He reviewed Ms C's medical records and explained that they indicated that throughout 2013 the board had made reasonable efforts to reach a diagnosis that explained Ms C's symptoms. He also said that the records indicated that the board had explained their findings to Ms C and that any diagnosis made – or not made – was reasonably communicated to her.

Although we recognised how strongly Ms C felt about this, our role was to consider whether the evidence indicated that her care and treatment fell below a reasonable standard. For example, although the board had not provided Ms C with a clear diagnosis this did not necessarily mean that they acted unreasonably. In light of the medical advice we received, we did not uphold her complaints as the evidence did not indicate that the board failed to diagnose and treat Ms C or to inform her about the steps they had taken.

Summary

Mr C was diagnosed with lung cancer that had spread to other areas of his body. The board advised Mr C that this was incurable and offered him palliative chemotherapy (treatment provided solely to prevent or relieve suffering). Mr C was told that this might prolong his life but that his survival was likely to be measured in months and was very unlikely to exceed a year or two. Mr C had chemotherapy and, nearly two years after the initial diagnosis, was advised that his cancer had gone into remission. This led Mr C to complain to the board about the original diagnosis and the information he was given about survival rates.

The board responded to Mr C's complaint and advised him that, for his type of lung cancer, he had had an unusually good response to the chemotherapy but there was no reason to doubt the original diagnosis. They also explained that due to the nature of his disease Mr C had been advised that survival rates often have a poor prognosis (forecast of the likely outcome of the condition) and outcome. They said that this is standard for patients in Mr C's situation and although his cancer was in remission, it did not mean that he had been cured.

When Mr C complained to us, he also complained about the board's response as they had used medical terminology, which he felt could have been better explained. After taking independent advice from one of our medical advisers, who is a consultant clinical oncologist (a doctor who specialises in treating patients who have cancer), we did not uphold Mr C's complaints about his original diagnosis or the information he was given on survival rates. Our adviser reviewed Mr C's medical records and said that there was no evidence that he was given an incorrect diagnosis. He also considered that the information that the board provided on survival rates was accurate and truthful. We found, however, that the board's response did use medical terminology that could have been explained more clearly, and as this was not in line with their policy on complaints handling, we upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for providing a response to Mr C's complaint that is not in line with their own policy; and
• take steps to ensure that staff who draft letters of response adhere to the policy on style.

Summary

Mr C broke his tibia (shin bone) while playing football and was admitted to Wishaw General Hospital. His injury was assessed and it was decided to move the bone into place before setting it with a full plaster cast. Mr C attended regularly at an out-patient clinic so that the healing process could be monitored. Over the following months the style of Mr C's cast was changed and he was given exercises to do. Mr C also attended at A&E on a number of occasions due to discomfort from his casts. Although there had been some signs of healing in the weeks following the injury, this did not progress and it was decided that surgery was necessary to fix the fracture using a nail.

Mr C complained that his fracture should have been nailed immediately after the accident. After taking independent advice on this case from one of our medical advisers, we did not uphold Mr C's complaint. Our adviser said that the treatment that Mr C had received was reasonable in the circumstances and fell within the range of normal practice for the management of this type of fracture. The adviser considered that the casts and exercises that Mr C had been given were appropriate for the management of his injury.

Summary

Mrs C complained on behalf of her late mother (Mrs A) that the board did not adequately assess and monitor Mrs A's nutritional needs following her emergency admission to Hairmyres Hospital. From what Mrs C told us, it was clear that this had been an upsetting experience for her and her family.

We looked at information provided by Mrs C and the board, and we took independent advice from one of our medical advisers. We found that the board's assessment and monitoring of Mrs A's nutritional needs was adequate. Specifically, we found that the board carried out the relevant assessments (including nutritional assessments), that she was seen regularly and that the nursing assessment and monitoring was clear and comprehensive. We also found that Mrs A was given an immediate referral to the dietician. We were satisfied that Mrs A was able to give consent and that her wishes were respected in that a nasogastric tube (a tube that is passed through the nose into the stomach) was not inserted until she gave consent. We did not uphold Mrs C's complaint.

Summary

Mrs C's late mother (Mrs A) had a fall in the care home where she lived. The next morning a carer accompanied her to A&E at Monklands Hospital. A doctor examined Mrs A, but considered that she only had bruising and did not arrange an x-ray. The doctor discharged Mrs A back to the care home.

The next morning, care home staff remained very concerned about Mrs A, and she returned to A&E, accompanied by another carer, who was told to specifically ask that Mrs A be given an x-ray. Mrs C said that A&E staff were very reluctant to x-ray Mrs A and, when the carer asked them to call the care home unit manager to discuss this, they told the manager that Mrs A had already been x-rayed on the previous day. However, after checking the records A&E staff acknowledged that this had not happened. Another doctor examined Mrs A and arranged an x-ray, which showed Mrs A had a fractured collarbone.

Mrs C phoned the hospital to complain about her mother's treatment, but staff told her she had to put her complaint in writing, and that Mrs A had to give written consent to the complaint being made. Mrs C wrote and complained, but the board did not receive this until Mrs C also sent the letter to her MSP, who forwarded it to them (some three weeks later). Mrs C complained about the delay in x-raying Mrs A, the failure to give Mrs A any pain relief on her first visit to A&E and the attitude of the staff member when she phoned to complain. The board apologised for the failure to correctly diagnose Mrs A's fracture on her first visit. The board said that, given Mrs A's age and frailty, she should have been given an x-ray, and the doctor involved had accepted this as a learning point for the future. The Board also apologised for the mistaken assumption staff made during Mrs A's second visit to A&E that she had already been x-rayed, and for the attitude of the staff member when Mrs C phoned to complain.

Mrs C was not satisfied with the board's response, and complained to us about Mrs A’s care and treatment, as well as the handling of her complaint. After taking independent medical advice, we upheld Mrs C's complaints. We found that the doctor on the first visit to A&E should have arranged for an x-ray. However, we noted that the board had already acknowledged and dealt with this. We found no evidence that staff were unreasonably reluctant to x-ray Mrs A when she returned to A&E. We did not criticise staff for not providing pain relief during Mrs A’s first visit to A&E, because we found that they had checked that she had already taken pain relief. However, we found that staff had failed to follow their complaints handling policy by not accepting Mrs C's complaint verbally and by not handling it within the required time-frames.

Recommendations

We recommended that the board:

• remind A&E triage staff at Monklands Hospital of the importance of fully reassessing any patient who returns to A&E, including taking a new set of observations, to ensure that nothing has been missed or overlooked;
• apologise to Mrs C for the failings our investigation found; and
• review their processes for accepting and processing verbal complaints (including obtaining consent, where required, where a complaint is made verbally on behalf of someone else); and tracking expected complaints time-frames (including updating complainants where anticipated time-frames will not be met).

Summary

Mr C complained about the care and treatment provided to his father (Mr A) by the board.

Mr A, who had a previous medical history which included Type II Diabetes, was admitted to Wishaw General Hospital as a day-patient for a gastroscopy (internal inspection of the stomach by way of a tube fitted with a camera). On admission Mr A's blood glucose level (a measure of how the body is able to process sugars in food and drink) was very low and staff gave him medication to increase it. Two subsequent readings were also low and Mr A was given a further dose of medication, followed by insulin (a drug used by diabetics to help them process sugars) delivered intravenously (directly into the vein). His blood glucose level eventually reached a reading considered to be within an acceptable range and the procedure went ahead. Following the procedure, Mr A was discharged home.

Three days after his discharge, Mr A collapsed at home and his blood glucose level was again very low. Mr A was taken by ambulance to Monklands Hospital where he was admitted to the Emergency Receiving Unit and in the early hours of the next day, which was a Friday, transferred to a ward. He then underwent some tests and investigations and his family were told that the team caring for Mr A were considering operating on him for abdominal problems. Later that day, the family were told that the surgeon was not going to operate as he did not work weekends; they were told that the surgeon would review Mr A again on the Monday and decide if he would operate. Over the weekend Mr A's condition deteriorated and his family found it difficult to obtain information from staff about Mr A's condition and treatment. Mr A died on the Monday morning without having had surgery.

Our investigation included taking independent advice from two of our advisers, a consultant geriatrician (specialising in the care of older people), and a nurse. In relation to Mr A's first admission to hospital, we found that although the board had stated in their responses to Mr C and to us that their guidelines on diabetic patients undergoing surgical procedures had been followed, this was not evidenced in Mr A's medical notes. We also found that despite the guideline stating that a patient's blood glucose level should be checked one or two times an hour, only one reading was taken after the procedure and before Mr A was discharged.

We also found that although Mr A had been advised to speak to his GP about his low blood glucose level, no advice on how to manage his condition for the rest of the day, or who to contact for advice, was given. We also found that although the Board's guideline gave advice on how to treat patients before a surgical procedure, it did not give guidance on how to treat patients after a procedure. Mr A was also not given anything to eat or drink before he was discharged to ensure that he was able to eat and drink normally, which is recommended by the Diabetes Association (a UK-wide organisation who provide advice to patients and carers and are often involved in preparing NHS guidance). Both advisers agreed that Mr A should have been kept in hospital until his blood glucose level stabilised and he was able to eat and drink normally.

In relation to the second admission to hospital, we found no evidence to link Mr A's earlier discharge from Wishaw General Hospital directly with his subsequent collapse and death. Our geriatrician adviser said that the assessment, investigation and treatment of Mr A's condition was reasonable and that contrary to what the family were apparently told, surgical intervention, although an option considered by the team, was never thought to be realistic. This was because it had been clear to the team caring for Mr A at an early stage that he was very frail and surgery would have been likely to cause his deterioration and death. However, we found that the team failed to convey this information to the family. Our nursing adviser also agreed that communication was poor and that there was only one record in the nursing notes that a staff nurse intended to speak with Mr A's daughter when she came to visit the day before Mr A died, but there was no record of this discussion ever having taken place.

We were also critical of the Board's response to Mr C's complaint. Although the board offered apologies for failings identified during the internal investigation, it was done in such a way as to devalue the apology.

Recommendations

We recommended that the board:

• review their guideline on diabetic patients undergoing elective procedures to ensure that it provides appropriate support and guidance to staff in both pre-operative and post-operative situations;
• ensure that staff involved in this complaint are made aware of the findings of our investigation;
• ensure that staff involved in this complaint are reminded of the importance of accurate and appropriate record-keeping;
• remind staff involved in this complaint about the importance of good communication with patients and their loved ones, in particular where the prognosis is poor;
• ensure that staff involved in complaints handling are made aware of the importance of making appropriate apologies for failings identified during internal investigations; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the care and treatment provided to her late father (Mr A) while he was in hospital. She was also unhappy with the board's response to her complaint.

During our investigation, we took independent medical advice from a geriatrician (a doctor specialising in medical care for the elderly). The advice we received was that, while several aspects of Mr A's care were good, and there was no evidence of major system failure or any actions that directly and adversely affected his physical health, in other areas his care fell below the level that he could have reasonably expected to receive. This included a failure to act on the findings of an x-ray and to provide further follow-up and monitoring, as well as a lack of communication with Mr A and his family while he was in hospital. We were concerned that these failings would have added to the distress that Mr A and his family were experiencing. We were, however, aware that the board had already taken action as a result of his case, in relation to improving communication with patients and their relatives, and were carrying out work around patient experience. The board had also apologised for the lack of communication and had carried out a debrief with staff. We were also concerned that there was a lack of communication with Mrs C while they were considering her complaint, and that the board had at first failed to fully respond to the issues she raised.

Recommendations

We recommended that the board:

• apologise for the failings identified in this investigation;
• ensure that the findings of our investigation be included in consultant appraisals in relation to the specific incidents referred to in our report;
• apologise for the failings identified in the handling of the complaint; and
• ensure that complaint responses adequately and fully address the issues raised in a complaint.

Summary

Mrs C complained on behalf of her son (Mr A) that the board failed to provide him with an earlier diagnosis of Asperger's syndrome. She said that for many years he had been under the care of mental health services in both England and Scotland. In 2010 he saw a consultant psychiatrist in New Craigs Hospital, and continued to see him until early 2011. During this time, Mr A was not considered to show signs of mental illness, although he spent time in hospital for assessment. He was encouraged to become more active and independent, establish proper sleep hygiene and reduce his medication.

Mr A requested a second opinion and was moved to the care of another consultant psychiatrist. No formal diagnosis was made and, again, Mr A was encouraged to develop independent structures in his life. While he appeared content with this, Mr A also mentioned the possibility of Asperger's. He was referred to a consultant neuropsychologist for review and was diagnosed with Asperger's later that year.

Mrs C complained that it took too long to provide this diagnosis and that meanwhile her son had been treated incorrectly, which was very traumatic for him. She also complained that his medication was withdrawn too quickly and without proper support.

We took independent advice from one of our medical advisers, who is a mental health specialist. Our investigation found that this kind of diagnosis was very difficult to make, particularly where the condition was mild and where the spectrum for the diagnosis overlapped with the general population. We noted that there was no specific treatment for such a diagnosis. We found that Mr A was treated reasonably and appropriately during his treatment, and that referrals were made in a timely way. Although an earlier diagnosis was not made, this did not have an adverse effect on his management and treatment. There was no evidence that Mr A's medication was unreasonably withdrawn or that he was not given appropriate support, and we did not uphold Mrs C's complaint, although we made a related recommendation.

Recommendations

We recommended that the board:

• give consideration to setting up a specific team to ensure multi-disciplinary assessment as per the recommendation of the national Strategy for Autism in Scotland.

Summary

Mr C's late father (Mr A) attended the medical practice and was seen by a GP who said that he had flu. He went back two days later because he had got worse, and was prescribed antibiotics. The GP told Mr A that if he did not improve he wanted to see him again and would arrange a chest x-ray. Mr A was also told that he not to go back to work.

The following day Mr C's brother visited Mr A and, given his condition, took him to the A&E department of the local hospital. He was admitted and a significant infection or inflammation was diagnosed, the cause of which was unclear at that stage. Later test results suggested that Mr A had bacterial endocarditis (an infection affecting the tissues that line the inside of the heart chambers). Mr A was in hospital for five weeks and was diagnosed with heart valve leakage, which needed surgery. Mr A was then transferred to another hospital where he died shortly after. Mr C felt that the GP's treatment of his father was unreasonable and might have contributed to his death.

We took independent advice from one of our medical advisers, who said that bacterial endocarditis is extremely rare, and most GPs will not diagnose it during their working lives. Accordingly, our adviser would not have expected the GP to diagnose this. They said that that the role of a GP in a patient with a flu-like illness is to take sufficient history and carry out a sufficient examination to exclude the likelihood of a cause other than a viral respiratory tract infection.

We found that there were clear failings in how the GP recorded his consultations with Mr A, which made it impossible to say that the clinical history taken and the examination of Mr A were sufficient. While the GP said he had examined Mr A, the evidence from the medical records did not establish this. Our adviser said that the GP's actions did not meet the standards of good medical practice, in accordance with General Medical Council (GMC) guidance, so we upheld Mr C's complaint about the care and treatment his father received from the practice. We were, however, unable to say whether the GP's actions possibly contributed to Mr A's death.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C and his family for the failings identified;
• ensure that the GP reflects on his assessment of patients presenting with flu-like illness; and
• ensure that the GP reflects on his clinical record-keeping and improves the information recorded so that it meets the standards of good medical practice in accordance with GMC guidance.