Health

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.

Summary

Since 2010, Mrs C had been attending her medical practice complaining of stomach and breast pain. She said that she was incorrectly treated for thyroid problems and an ulcer and complained that the extent of her pain was never recognised and that she was not referred for tests. More recently Mrs C was diagnosed with a carcinoid tumour in her liver (a rare cancer). She felt that as a fit and healthy patient attending the doctor a lot, with symptoms that were not resolving, the practice should have sent her for tests and sought specialist help.

We took independent advice from one of our medical advisers and, after considering this, we did not uphold the complaint. Our investigation showed that over the period of time concerned, Mrs C was treated correctly in accordance with her symptoms. Amongst other things, she had symptoms suggestive of an underactive thyroid and an ulcer, for which she was treated appropriately. She also had a breast scan that showed a breast lump, but this was benign. It was only in late 2013 after an emergency admission to hospital and extensive investigations, including an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and a scan of her abdomen, that Mrs C was diagnosed with the tumour, which was noted to be extremely rare. Our adviser said that until then doctors had always provided reasonable diagnoses to explain Mrs C's symptoms.

Summary

Mrs C complained to us that the board had given her terminally ill child (child A) a large dose of a muscle relaxant before they were taken off a ventilator. Child A had been receiving a muscle relaxant to improve ventilation (breathing), but was approaching the end of life and care was being withdrawn. We took independent advice from one of our medical advisers, and found that it had been unnecessary to give Mrs C's child a large dose of relaxant immediately before being taken off the ventilator. Our adviser said that this might in fact have hastened child A's death by a short time. The board had also continued to give child A the muscle relaxant after they were taken off the ventilator. This was not in line with the relevant guidance, which said that this should not be done.

Mrs C also complained that staff did not discuss this with her. Although the large dose of muscle relaxant should not have been given, any significant changes that affect the care provided to a child should be discussed with the family/carers. There was a clear failure to do so in this case.

Mrs C made a further complaint that the consultant treating child A did not tell her about this, when she asked him several months later why her child had passed away so quickly. Our adviser found no evidence in the record of the meeting that the consultant told her about the large dose of muscle relaxant. It is imperative that parents are given full and complete information about the care and treatment provided to a child when they request this. There was no evidence that the consultant did so in this case. We upheld all of Mrs C's complaints.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for unnecessarily giving her child a muscle relaxant before they were taken off the ventilator and for continuing the muscle relaxant after ventilation had been withdrawn; and
• take steps to ensure that their guidance on end of life care for children reflects guidance on muscle relaxants from the Royal College of Paediatrics and Child Health.

Summary

Mr C complained that prison healthcare staff behaved unreasonably towards him, after he complained about another matter regarding one of the staff. Mr C told us that he had a meeting with two nurses - one of them the person about whom he had complained - during which the nurses were confrontational and threatened him.

In general terms, it is not unusual for prison healthcare staff to visit complainants to discuss their complaint face-to-face at an early stage, to see if they can resolve the matter quickly. However, even at such an early stage, it is important to ensure that the complaint is dealt with impartially. This is in keeping with the NHS' Can I Help You? Guidance, and we agreed with the board’s comment in their response to Mr C’s complaint that the nurse he previously complained about should not have attended the meeting.

Where there are differing accounts of what was said or what happened in a particular situation, however, it can be difficult to prove what actually happened. In such cases, we primarily base our findings on written records. There was no audio recording of the meeting and, therefore, there was no way to determine what was said, or how people behaved. We could not resolve Mr C's complaint given these differing accounts. However, that did not mean we believed one account over another. As there was insufficient evidence to ascertain what was said, we did not uphold the complaint.

Summary

Mr C submitted a request to see a prison dentist, saying that he had severe dental pain. Seven days later, Mr C had not received an appointment and he complained to the board. The next day, Mr C had a triage appointment with a nurse, who arranged an urgent dental appointment three days later. At this appointment the dentist found that the nerve in Mr C's tooth had died, and root canal treatment was required.

The board did not uphold Mr C's complaint, as he had received an appointment by the time this was considered and they found the delay was reasonable for a 'routine referral'. Mr C was dissatisfied with this response, and complained to us about the delay in his dental treatment.

We asked the board why Mr C's referral was classified as 'routine', given that Mr C was not seen by any healthcare professional until his triage appointment a week later. They explained that requests for appointments were reviewed by healthcare staff, and any requests which were considered urgent were seen by a healthcare professional within 24 hours.

After taking independent advice from our dental adviser, we upheld Mr C's complaint. We found that the board did not follow their guidance on referrals, as Mr C's referral should have been classified as 'urgent' and he should have been seen within 24 hours. We also found that it was unreasonable for the board to classify the referral as routine without actually reviewing Mr C, given that the symptoms he described were in the 'urgent' category.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to properly classify his dental request and the delay in issuing him a dental appointment;
• review their procedures for classifying dental referrals, to ensure that all dental cases are reviewed by a healthcare professional within the time-frames required under the Prison Care Pathway guidance; and
• consider clarifying their guidance on the 'Urgent Care' pathway to make it clear that the 24 hour time-frame refers to the patient seeing a healthcare professional, rather than dental treatment being provided.

Summary

Mr C complained to us about the care and treatment he had received from his prison health centre in relation to pain in his wrist and jaw. Mr C had been prescribed tramadol (a strong painkiller) and the dosage had been gradually increased. He was then reviewed by a doctor, who considered that the tramadol he was receiving was inappropriate. The doctor recorded that the tramadol should be reduced and stopped and that it should be replaced by other painkillers. Mr C was unhappy with the decision to stop the tramadol. We took independent medical advice and found that the overall management of Mr C's pain had been reasonable. It had also been reasonable to reduce and then stop the tramadol and to try other medications to see if they addressed his pain. Consequently, we did not uphold this aspect of Mr C's complaint.

Mr C also complained about the board's handling of his complaint. However, we found that the board had adequately investigated and responded to the issues he had raised and we did not uphold Mr C's complaint about this.

Summary

Mr C had an elective arthroscopy procedure (a type of keyhole surgery) on his right knee at Forth Valley Royal Hospital. The surgery took longer than anticipated. Mr C was discharged home the following day but was readmitted with an infection in his knee several days later. He had to undergo two washouts of the knee (a technique that involves flushing the joint with fluid) and was prescribed antibiotics to treat the infection, although Mr C said that hospital staff did not give him several doses of the antibiotics. The board agreed that this had happened. Mr C then complained that the care and treatment he received during and after his knee surgery was unreasonable.

We took independent advice from a consultant in orthopaedic and trauma surgery, who explained that Mr C had suffered a severe complication of a joint infection after surgery, which is a recognised risk but is a rare complication. The adviser said that overall Mr C's care and treatment was appropriate and the failure to provide him with antibiotics on a number of occasions did not significantly alter the eventual outcome of the infection he acquired. Nevertheless, the adviser considered the failure to administer antibiotics was either due to failure by staff to be aware of the potential complications of this, or an indifference to 'getting it right' and was, therefore, a failing by the board in their duty of care to Mr C. We were, therefore, satisfied there was a failure in Mr C's care and treatment.

We noted that a senior charge nurse had apologised to Mr C for the failure to give him antibiotics and that other nursing staff had been spoken to, to ensure that this was addressed. However, we thought that the board should apologise to Mr C as well. The adviser had further commented that although the board's explanation about the duration of Mr C's surgery was reasonable, the operation notes did not mention any particular problems or difficulties. We would have expected the reasons for the length of Mr C's surgery to have been noted, and we made a recommendation about this as well.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to administer antibiotics;
• provide us with evidence of the action they have taken to address the failure to administer antibiotics; and
• ensure that our adviser's comments in relation to the operation notes are brought to the attention of the relevant staff.

Summary

Mrs C complained about the standard of medical care she received when she reported a cough to the medical practice. She said that she reported a persistent cough on two occasions but was not referred for a chest x-ray. At a third consultation, seven months after Mrs C first reported her cough, a locum GP referred her for a chest x-ray and, after further tests, Mrs C was diagnosed with lung cancer.

We took independent medical advice from one of our GP advisers. We found that the practice missed two opportunities to arrange for Mrs C to have a chest x-ray as part of their routine investigations into a persistent cough. We found that the practice failed to reasonably follow the national referral guidance for suspected cancer which all GPs should be aware of and which clarify the significance of a cough in the diagnosis of lung cancer and state that a time-frame of three weeks should be considered a persistent cough.

When Mrs C first reported the cough it had been present for eight weeks, and when she next mentioned the cough it had been present for 13 weeks. The criteria for referral for suspected cancer had been met on both occasions. We found that Mrs C should have been sent for a chest x-ray earlier than she was, so we upheld her complaint, and made a number of recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C and her family for the distress caused by the late arrangement of investigations into the cause of her cough;
• notify the board's clinical support group and ask them to consider whether to undertake a random review of patient consultation records for quality assurance purposes; and
• carry out a reflective significant event analysis with support from the board's clinical support group and provide us with a copy.