Health

Summary

Mrs C complained that her physiotherapist had not referred her for an MRI scan (a scan used to diagnose conditions that affect organs, tissue and bone). As the physiotherapist had not done this, Mrs C arranged one privately, which did not reveal any abnormalities. Mrs C then sought to recover the cost of her private MRI scan from the board.

As part of our investigation we took independent advice from one of our medical advisers. She said the physiotherapist's decision to refer Mrs C to the pain clinic and not for an MRI scan was reasonable. This was because the notes did not indicate that Mrs C's condition required a referral for an MRI scan, in line with the relevant guidance. Although we took Mrs C's concerns into account, our role was to determine the reasonableness of the care and treatment she received. In light of the clear advice we received that the board had acted reasonably and in line with the appropriate guidance, we did not uphold Mrs C's first complaint.

Mrs C was also unhappy at the time the board took to respond to her complaint. Mrs C had contacted them over a period of months and the paperwork showed they had failed to meet their timescales or keep her updated. We upheld this complaint and made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in responding to her complaint; and
• review their handling of Mrs C's complaint and feed back to relevant staff to prevent this from happening in future.

Summary

Miss C, who is an advocate, complained on behalf of her client (Mrs A) about the nursing and medical care provided to Mrs A's late husband (Mr A) at Dumfries and Galloway Royal Infirmary after he was admitted for a below-knee amputation. Mrs A was concerned that staff had not been monitoring Mr A's urine output or identified that fluid had been building up in his lungs. Mrs A felt that this caused Mr A to suffer a heart attack. After Mr A was discharged from hospital, Miss C complained to the board, however, there was a significant delay in the response being provided, by which time Mr A had died suddenly.

We took independent advice from two medical advisers, one a nurse and the other a consultant nephrologist (specialising in kidneys). We found that Mr A had a medical history of diabetes with multiple complications that had caused kidney damage in the past. Given this history, the medical complications he suffered (including a deterioration in kidney function, fluid collecting in the lungs, and a heart attack) were not unexpected. We did not find that the complications were a result of poor care and treatment, and so we did not uphold the complaint about medical care. However, there was no clear evidence to show that Mr A had been advised about the possible risk of cardiac problems given his medical history and we drew this to the board's attention. We also found that the nursing staff had not properly completed the fluid balance charts on a number of occasions, albeit the medical staff had carried out daily examinations for signs of fluid accumulation and managed the fluids and Mr A's medication appropriately. Therefore, we upheld Miss C's complaint about the nursing care Mr A received. We could not say for certain what had actually caused the heart attack but we made recommendations to address the failings in record-keeping.

In relation to complaints handling, the board accepted that they had delayed unreasonably in responding to the complaint. We were critical that there was a 13 week delay and made a number of recommendations to address the matter.

Recommendations

We recommended that the board:

• carry out an audit of patient medical records for the wards involved to ensure that fluid balance charts are being accurately completed;
• review their complaints procedure with a view to ensuring measures are in place to update complainants regularly in line with the guidance in the event that the 20 working day timescale cannot be met;
• remind all relevant staff dealing with complaints of the importance of updating complaints with the reason for any delays and their entitlement to contact us if the delay exceeds 20 days;
• apologise to Mrs A for the failings identified in the nursing care provided and complaints handling;
• take steps to ensure that the target timescale for dealing with complaints is met wherever possible; and
• ensure the nursing staff involved in Mr A's care are made aware of the importance of adequately assessing, monitoring and recording fluid balance.

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.

Summary

Ms C was admitted to Borders General Hospital (hospital 1), then Knoll Hospital (hospital 2) after being involved in an accident. She was given pain relief at the scene of the accident and taken to hospital 1. On arrival, there was a mix-up over patient details and Ms C told us that on that day and the following day, staff tried to give her medication meant for another patient. Ms C told us that this took some time to resolve and, as a result, she said she was not given pain medication in a timely manner or when requested. She also believed she was given an overdose of morphine, which affected her ability to pass urine. She alerted nursing staff who then identified a urine retention issue. Ms C was transferred to hospital 2 the following month. She said that nursing staff there were institutionalised in their attitudes and treated her as if she was an elderly patient. Ms C discharged herself five days later.

We took independent advice on this case from our nursing adviser, who said that pain charts were not fully utilised at hospital 1 to manage Ms C's pain. Although pain was recorded there was no record of any action taken. In addition, Ms C was known to the pain team but they were not alerted until four days after her admission. We also found that although Ms C was already known to have chronic pain, she was not assessed for this in a proactive manner, and that in this instance care was not reasonable. Moreover, we were concerned that her patient details were incorrect. This was rectified and did not result in any medication errors, but could potentially have had more serious consequences. We were satisfied that the nursing care in relation to urine monitoring and that provided by staff at hospital 2 including their attitude was reasonable, and were satisfied Ms C was not given an overdose of morphine. However, in light of the failings identified, we upheld the complaint.

Recommendations

We recommended that the board:

• review how pain is assessed and monitored in Borders General Hospital and how instruments such as early warning system charts are used;
• inform us of the steps taken to ensure patient details are correct; and
• apologise for the failures this investigation identified.

Summary

Mr C complained about care and treatment provided to his late mother (Mrs A) by the board. Mrs A attended the A&E department at University Hospital Ayr and was admitted to the hospital, where she was diagnosed with a urinary tract infection. Mrs A had a number of longstanding conditions including spinal curvature and lymphoma (a type of cancer). An x-ray was taken which showed a large abnormality at the top of the right lung. This was reviewed by a doctor who considered the progression of Mrs A's lymphoma as a possible diagnosis. After being advised that Mrs A's x-ray showed deterioration, Mr C and his family decided to take her home and she was discharged the following day. The doctor's reading of the x-ray was incorrect as the abnormality was caused by Mrs A's head resting against her chest. The family were advised of this after her discharge and she was readmitted two days after returning home. Mrs A died several weeks later.

Mr C complained that Mrs A had not been given appropriate medication for her infection due to the misdiagnosis and that this had hastened her death. Mr C also complained that the response to his complaint was inadequate.

After taking independent advice from our medical adviser, we found that there had been a major error in the doctor's interpretation of the x-ray and that Mr C and his family should not have been advised that there was a deterioration in her condition. Although we did not find any evidence that Mrs A had been given inappropriate medication or that the incident had hastened her death, we upheld Mr C's complaints due to the significance of the error in reading the x-ray. We also found that the board's investigation of Mr C's complaints did not fully address the doctor's error and that the responses provided were inconsistent. We upheld both Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• make staff aware of our adviser's comments on the incorrect diagnosis and determine if there are lessons that can be learned from this incident;
• remind staff of the importance of keeping accurate contemporary records in line with the relevant General Medical Council guidance;
• provide a copy of our decision to the doctor to ensure he is fully aware of the outcome of this investigation and allow any learning points to be discussed at his next appraisal; and
• carry out a review to determine if the doctor's misinterpretation of the x-ray was an isolated incident and provide appropriate training if required.

Summary

Mrs C complained about the medical care her late mother (Mrs A) received at University Hospital Ayr. Mrs A had suffered from diabetes for over 40 years. She was admitted to the hospital and diagnosed with diabetic ketoacidosis (a condition where consistently high blood sugar levels can result in severe insulin deficiency). Mrs C said that Mrs A did not receive appropriate medical treatment, was discharged home on too high a dosage of insulin, and that her blood sugar was not monitored at home. Mrs A's condition deteriorated at home and she was re-admitted to the hospital five days later having collapsed. She went into a coma and died around four weeks later.

We did not identify any failings in the medical treatment of Mrs A. There was evidence to show that she was given appropriate treatment in the form of intravenous fluids and insulin. We noted that Mrs A had a history of poor diabetic control. However, the insulin dosages were appropriate and, after she returned home, the specialist diabetic nurse had contacted Mrs A to monitor her condition and make changes in her prescription.

Summary

Miss C said that when her late mother (Mrs A) was admitted to University Hospital Crosshouse, she lay on a hospital trolley for over eight hours until she was admitted to a ward, which led to great pain and distress. She also complained that staff failed to properly assess Mrs A's capacity to make decisions and failed to consult Miss C in a reasonable way, given that she had welfare power of attorney (a legal document appointing someone to act or make decisions for another person) for her mother. Mrs A underwent several medical interventions, and Miss C said medical staff failed to properly obtain consent for these procedures. She also said that communication about these interventions was not reasonable, and that she and Mrs A were not told of the results of an electrocardiogram (a test that records the electrical activity of the heart) within a reasonable time.

Miss C also complained about the nursing treatment provided, including a lack of care and attention when Mrs A was waiting to be admitted to a ward and length of time left on a trolley, failure to treat Mrs A with respect and dignity in relation to her mobility problems and incontinence including failure to move Mrs A in a reasonable way, and failures in communication particularly around discharge. Miss C said Mrs A could not tolerate the physical, mental, psychological and emotional pain and abuse she was subjected to, and wanted her taken home. Medical advice, however, was that Mrs A should not be discharged and should receive further treatment in hospital, but after further discussion nursing staff arranged a patient transport ambulance.

We took independent advice from two advisers. Our medical adviser said that was no evidence Mrs A had impaired capacity and, in fact, there was evidence in the medical notes that Mrs A gave verbal consent for the medical interventions. Given the evidence that Mrs A had capacity to understand what was happening, Miss C was unable to invoke the welfare power of attorney and we found that the actions of the healthcare professionals in this respect were reasonable. There was also clear evidence that communication by clinical staff was reasonable, including the time taken to tell Miss C and Mrs A the results of the electrocardiogram. However, we upheld the complaint about Mrs A's care and treatment as our nursing adviser said that while the majority of nursing care was also reasonable, the length of time Mrs A waited before she was admitted to the ward from the emergency department was not. We made no recommendations, as the board had already acknowledged that this was not acceptable and had taken appropriate steps to address this.

Summary

Mr C complained on behalf of his late wife (Mrs C) about the care and treatment she received in University Hospital Ayr when she was admitted there apparently suffering from epileptic seizures. He complained that staff had not taken reasonable account of Mrs C's stress and anxiety when she was first admitted to hospital, and that she had not received adequate care and treatment on the ward.

We took independent advice from two of our advisers - a nursing adviser and a neurology adviser (a specialist in the science of the nerves and the nervous system, and of the diseases affecting them). Our neurology adviser said that Mrs C was suffering from a complex, unusual condition, which the neurologist involved in her care did not diagnose at first. Mrs C's initial diagnosis was incorrect, but had been difficult due to her unusual condition and existing medical conditions. Nursing advice indicated that staff noted Mrs C's anxiety, and took appropriate action to try and alleviate this, although Mrs C should have been given the option of treatment for nicotine withdrawal when she was first admitted. We concluded that, overall, the care and treatment she received was reasonable, and that staff responded to her situation appropriately.

Mrs C was later transferred to Girvan Community Hospital. Mr C complained that, while she was there, Mrs C's medication was altered without his knowledge, leading him to continue to give her particular medication while she was at home at weekends, although she was no longer taking it in hospital. During this period, Mr and Mrs C felt that the medication had a positive effect on her and, when it became apparent that the hospital had stopped it, they asked for it to be reinstated. This request was declined, and Mr C was unhappy about this.

Our adviser noted that the medication was no longer clinically necessary, given Mrs C's second diagnosis, and on this basis it was reasonable to withdraw it. However, he said that it would have been appropriate for staff to have given greater consideration to reinstating the medication when Mrs C clearly indicated that was what she wanted. He was also critical of the lack of evidence of any discussion with Mr and Mrs C before or after the withdrawal of the medication.

Recommendations

We recommended that the board:

• remind staff of the importance of discussing nicotine withdrawal and any available treatment options at the time of admission and as appropriate thereafter;
• remind staff of the importance of discussing changes in medication with patients and their relatives, and documenting these discussions;
• take steps to ensure that Girvan Community Hospital provide up to date information to carers in relation to medication when patients are allowed home during an admission to hospital; and
• apologise to Mr C for their failure to discuss medication with him, to respond appropriately when Mrs C indicated her desire for the medication to be reinstated, and for the distress this caused Mr and Mrs C and their family.

Summary

Ms C complained to us on behalf of her relative (Ms A) in relation to the care and treatment of Ms A's late baby (Baby A). Baby A was born at University Hospital Crosshouse following a normal delivery, and was assessed at birth to be fit and well. Around three hours after birth, the baby's temperature was taken using an adult thermometer, as no paediatric thermometer could be found. As the temperature was found to be low, Baby A was placed under an overhead heater, and was monitored carefully. After half an hour a paediatric thermometer was used to take Baby A's temperature, which had returned to normal levels. A paediatrician reviewed Baby A an hour later, and assessed Baby A as fit for transfer to the maternity ward. Following another 20 hours of monitoring, mother and baby were assessed as fit for discharge.

Two weeks later, Baby A took severely ill and was taken to A&E. Baby A was treated by a team from the intensive care team from the nearest children's hospital, and was immediately transferred there. Baby A died four days later, from late onset Group B streptococcal septicaemia (a bacterial infection of the blood), which developed into meningitis (an infection of the lining of the brain).

Our adviser found that the monitoring of Baby A's temperature in the first 24 hours of life was appropriate. He also noted that, while one temperature reading was not taken appropriately, this was rectified soon after, and subsequent readings were appropriately timed and were taken with the right equipment. The adviser considered the standard of care to be good, and did not raise any concerns about the management of Baby A's temperature. He also clarified that concerns about Baby A's temperature in the first day of life did not have any impact on the subsequent infection. On the basis of this advice, and as the board met with the requirements of the guidance on the management of infection in new-born babies, we did not uphold this complaint.

Summary

Miss C complained there was an avoidable delay before her hip replacement surgery was carried out. We took independent advice from one of our medical advisers, who explained that total hip replacements are best avoided in younger patients until all other possibilities have been considered. This is because such replacements have a limited time span and in younger patients they wear out and loosen earlier due to physical activities. In such cases the patient might need at least one further surgery, if not two. As Miss C was a younger patient, the delay before surgery was appropriate as it was important to explore all other non-surgical options before operating. We also found that Miss C asked to delay the surgery further, for personal reasons, and so not all of the delay was caused by the surgeon.

Miss C had replacement surgery on both hips. While the right hip surgery was successful, Miss C experienced pain after the surgery on her left hip and needed another operation. She complained that there was a failure to take timely action or arrange appropriate investigations to try to diagnose the cause of her pain. Our adviser said, however, that the investigations carried out on this were reasonable and appropriate. In particular, after unsuccessful surgery there may be complications with a further operation, and the adviser said that it was reasonable to wait and see if a patient's symptoms settled down (which in many cases they do) before taking further action.

Although we did not uphold Miss C's complaint, our adviser noted that the cause of Miss C's pain and her dissatisfaction with the surgery on her left hip was likely a direct consequence of the hip replacement socket being badly positioned. Our adviser said that in this respect her care and treatment fell below an acceptable standard, and we made recommendations about this.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to ensure that her left hip replacement operation was undertaken to a reasonable standard of care; and
• carry out an internal audit of any known or reported complications of the doctor's surgery and a review of all postoperative x-rays of the hip replacements performed by them over a twelve month period; report to us the findings of the audit and in the event that this shows that Miss C's case was not an isolated incident inform us of the action they intend taking to address this; and raise the findings of our investigation with the doctor for reflection.