Health

Summary

Miss C was concerned about a large lump in her mouth, and arranged an emergency dental appointment, where she was given antibiotics and advised to see her regular dentist. By the time Miss C saw her regular dentist a few days later her face was quite swollen. Miss C was advised by her regular dentist to have root canal treatment (RCT) on the infected tooth, noting that Miss C had started this treatment a year earlier but had cancelled the appointment to complete the treatment and not made another.

The dentist administered an anaesthetic to start the treatment, but this did not take effect, so asked Miss C to return the next day. When Miss C returned, the dentist administered the anaesthetic and started RCT. However, by the next day Miss C's face was extremely swollen and she was in considerable pain. She attended another emergency appointment and was immediately referred to hospital, where the tooth was removed and the abscess drained.

Miss C complained to us about the care and treatment she received. In particular, Miss C was concerned that the dentist did not take an x-ray, or attempt to remove the tooth or drain the abscess in her mouth.

After taking independent dental advice, we upheld Miss C's complaints. We found that the dentist should have attempted to drain the abscess, or referred Miss C on if she was not comfortable attempting this. We also found that the dentist should have taken an x-ray before starting RCT. Finally, we found that the dentist's record-keeping was not of a reasonable standard, as there was no proper description of the diagnosis or treatment plan.

Recommendations

We recommended that the dentist:

• issue a written apology to Miss C, acknowledging the failings our investigation found; and
• reflect on the findings of our investigation, as part of their on-going professional development.

Summary

Miss C was concerned about a large lump in her mouth, and made an emergency appointment at a dental practice. The dentist who carried out the emergency appointment examined Miss C, prescribed antibiotics and advised her to see her regular dentist. Following further visits to different dentists, Miss C was diagnosed with an abscess in her mouth, and a few days later she was referred to hospital, where the tooth was removed and the abscess drained.

Miss C complained to us about the care and treatment she received. In particular, Miss C was concerned that the dentist who she saw during the emergency appointment did not take an x-ray, or attempt to remove the tooth or drain the abscess in her mouth. In response to our enquiries the dentist said that Miss C had been undergoing root canal treatment to her tooth about a year previously, but had cancelled the appointment to complete the treatment and not made another. The dentist explained that, at the time of her appointment, it was not clear whether this tooth was the cause of the problem, as Miss C had multiple treatment needs.

After taking independent dental advice, we upheld Miss C's complaint. We found that, while the abscess was probably not swollen enough at that stage to drain it, the dentist should have taken an x-ray to establish which tooth was the source of the infection.

Recommendations

We recommended that the dentist:

• issue a written apology to Miss C, acknowledging the failings our investigation found; and
• reflect on the findings of our investigation, as part of their on-going professional development.

Summary

Miss C complained to us about her dental practice's handling of a complaint she made. She said that the practice's response to her complaint was inadequate, as it failed to address all the questions she had asked, and did not include comments from two of the three dentists she had complained about.

After investigating the matter, we upheld Miss C's complaint. We found that the staff member who dealt with Miss C's complaint had only sought comments from one of the dentists involved, and the other two had been given no opportunity to comment. The staff member also failed to check the response, to ensure that it addressed all of the relevant points of the complaint. While the dentist who did respond answered Miss C's questions relevant to the care he provided, and apologised appropriately for some aspects of treatment, the lack of coordination meant that the overall response was poor.

We also found that the complaints handling policy used by the practice appeared to be out of date and did not meet the Scottish Government's requirements for managing complaints about health services. This meant that the practice had failed to meet relevant requirements, such as including information in their acknowledgement letter about the complaints handling process and Miss C's right to bring her complaint to us. The policy also had incorrect information on where to direct customers if they remained dissatisfied, as it said that complaints could be directed to the board (instead of us).

Recommendations

We recommended that the practice:

• issue a written apology to Miss C, acknowledging the failings our investigation found;
• review staff training needs, to ensure complaints are appropriately coordinated and responded to; and
• review their complaints procedure to ensure that it reflects the requirements of the Scottish Government's 'Can I Help You?' guidance.

Summary

Mr C, an advocate, complained on behalf of Mrs A about the care and treatment of her late husband (Mr A). Mr C raised concerns that the board failed to appropriately manage Mr A's skin condition and that, as a result, he developed pressure ulcers. He submitted a photograph demonstrating that Mr A had a pressure ulcer on the day he was discharged from hospital to a care home, complaining that he should not have been discharged with his skin in such condition.

We took independent advice from one of our nursing advisers. She was critical that a specific care plan for the management of Mr A's skin, which was identified as being at high risk of pressure ulcers, was not begun until his skin showed signs of deterioration. She told us that the photograph from the time of discharge showed a small yet established pressure ulcer. Whilst this would not have provided grounds for keeping Mr A in hospital, she highlighted that sufficient information on the care of his skin should have been passed to the care home to allow them to carry this on.

We concluded that the board had not consistently followed their pressure ulcer prevention policy and we upheld the complaint. We were concerned that, in responding to the complaint, the board maintained that Mr A's skin was intact at the time of discharge when the records did not demonstrate this clearly and the photographic evidence suggested otherwise. That said, we welcomed the comprehensive remedial actions the board had already taken further to the complaint. However, we recommended that they take additional action to ensure that sufficient information is passed on at the time of discharge. We also recommended that they apologise to Mrs A for the failings we identified.

Recommendations

We recommended that the board:

• remind staff of the importance of providing sufficient information on handover to ensure continuity of care; and
• apologise to Mrs A for the failings this investigation has identified.

Summary

Mr C complained to us about the care and treatment his father (Mr A) received at the Southern General Hospital. Mr A was admitted to hospital following a failed catheter change with a medical history including angina, heart attack and chronic kidney disease. A urinary tract infection was suspected and Mr A's kidneys were also found to be working abnormally. Treatment with intravenous (IV) fluids (administered directly into the veins) and antibiotics was started. Due to Mr A's cardiac history, he was prescribed IV fluids at a reduced rate. Mr A became breathless and was treated for fluid overload. Mr A's condition deteriorated and after some delay he was transferred to the Coronary Care Unit (CCU). Mr A died some weeks later.

Mr C complained about Mr A's fluid intake and that there was an unreasonable delay in transferring him to the CCU. The board advised that both Mr A's heart and kidney conditions had been considered but that it can be difficult to balance treatment in these situations. They provided an apology that no parameters or guidance had been given around oral fluid intake. In relation to delay, the board advised that there had been a breakdown in communication between staff. They assured Mr C that their processes had been reviewed to ensure that this would not happen in future.

After taking independent advice from one of our medical advisers, who is a consultant physician, we found that Mr A's treatment in relation to fluids was consistent with established good practice and we did not uphold this part of the complaint. However, the second element of Mr C's complaint was upheld as our adviser was critical of the delays in referring Mr A to the CCU and we found that this should have taken place at an earlier stage than the board identified.

Recommendations

We recommended that the board:

• make staff aware of the need to consider whether parameters and guidance for oral fluid intake may be required in specific cases;
• apologise to Mr C for the delay in referring Mr A for a cardiology assessment;
• draw the findings of this investigation to the attention of appropriate staff; and
• provide full details of their referral escalation process and confirm how awareness of this has been raised with staff.

Summary

Miss C attended an emergency dental appointment, as she was concerned about a large lump in her mouth that had become extremely painful and caused her face to swell. The swelling had been developing for a week, and had worsened despite receiving antibiotics and starting root canal treatment with her regular dentist.

The dentist at the emergency appointment immediately referred Miss C to hospital, and gave her a letter of referral to take with her. Miss C asked where exactly she should go, and the dentist told her to go to A&E, as they would transfer her to the right unit. However, when she got to A&E, staff told Miss C she was given the wrong advice and the dentist should have phoned the maxillofacial unit (a unit specialising in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) and sent her there directly. At the unit, Miss C had an infected tooth removed and the abscess in her mouth was drained. While she was there, hospital staff called the practice to advise them of the correct referral process for that unit.

Miss C complained about the care and treatment she had received. In particular, Miss C was concerned that the dentist had not taken an x-ray, or tried to drain the abscess or remove the tooth themselves. She said that staff at the hospital told her this was a simple procedure, and the dentist could have phoned the hospital and received advice over the phone about this. The dentist explained that in Miss C's condition he thought it was appropriate to refer her for hospital treatment immediately. He apologised for not knowing the correct referral process for the unit, and explained that dentists at the practice had now been made aware of this. Miss C was not satisfied with the dentist's response, and brought her complaint to our office.

After taking independent dental advice, we did not uphold Miss C's complaint. We found that the dentist had acted correctly in referring her immediately to hospital, and it would not have been appropriate for the dentist to take an x-ray or attempt treatment himself (even with advice from the hospital). Although the dentist should ideally have referred Miss C directly to the specialist unit, we found that the important thing was for her to be transferred to hospital as soon as possible, so it was not unreasonable to tell her to go to A&E.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Miss A) that the board failed to carry out her hysterectomy at Glasgow Royal Infirmary to an appropriate standard. She said this caused significant and irreparable damage to Miss A's bladder and ureter. Ms C said the surgeon who performed the operation unreasonably failed to identify the damage and remedy this during the operation. She said that as a result, repairs which might have prevented exacerbation of the damage were not carried out.

We obtained independent medical advice from a consultant in obstetrics and gynaecology. Our adviser explained that Miss A experienced an uncommon but recognised complication of hysterectomy. She said that injuries to the bladder and ureter could occur during surgery or it was possible for injuries as a result of surgery to be delayed. Our adviser said it was unlikely that the damage in Miss A's case occurred due to cutting or tearing during surgery and it was more likely to have been caused by compromised blood supply resulting in tissue/cells dying and a fistula (an abnormal passageway between two organs) forming after the surgery was complete. As such, the surgeon could not have reasonably been expected to rectify damage which was not immediately visible at the end of surgery and would only have become apparent some days later.

There was evidence that Miss A was made aware that damage to the bladder and ureter were recognised complications of the surgery she consented to receive. Our adviser said the records showed that the surgeon demonstrated a reasonable level of care during the surgery to avoid these complications and there was no evidence that Miss A's hysterectomy was performed unreasonably.

Summary

Mr C said the board unreasonably failed to provide the correct care and treatment on two occasions when he attended Stobhill Hospital with an ankle injury. He said that a piece of bone below his ankle bone should have been recognised and he should have been referred to a consultant orthopaedic surgeon much sooner. Mr C also said that during his first attendance, the board failed to tell him that he had a piece of bone below his ankle bone.

We obtained independent advice on the complaint from an emergency medicine consultant. The adviser said that the examination and investigation Mr C received at the hospital, leading to the conclusion of a soft tissue injury, was reasonable on both occasions. He said there were no failings by the board in Mr C's management, as on both occasions his x-rays were reported as normal by the radiology department, this was reported back to Mr C's GP and he did not need to be recalled. The adviser said that if Mr C had ongoing problems with his ankle the appropriate action would have been review by his GP and referral to the orthopaedic service.

Mr C's medical records did not indicate that the emergency nurse practitioner who saw him on his first attendance advised him about the piece of bone. However, the adviser said there were no failings by the board in the management of Mr C's case and the conclusion that he had a soft tissue injury was reasonable. Therefore, on balance, we did not find it unreasonable that the board did not tell Mr C about the piece of bone.

Summary

Mr C complained about the treatment he had received from the board for problems he had with his nose and breathing. Mr C had two operations on his nose, but this did not resolve the problems. We took independent advice from one of our medical advisers, who is an experienced ear, nose and throat surgeon. We found that it had been reasonable to carry out the operations on Mr C's nose. He had also been given appropriate information about the procedures before they were carried out. The operations had been carried out appropriately, but the symptoms Mr C complained of were rarely completely resolved by the surgery. It was also reasonable that the board had decided that that no further surgical options were possible. We found that the board had provided a reasonable standard of medical treatment to Mr C and we did not uphold his complaint.

Summary

Mrs C complained about the care and treatment her late husband (Mr C) received from the practice in the final months of his life. Mr C died after a period of illness and Mrs C felt he did not get the level of care he required as his health deteriorated. In particular, she raised concerns that her requests for GPs to attend were ignored despite Mr C having been very ill and in a lot of pain. Mrs C was also unhappy that the practice recorded the cause of Mr C's death as dementia, as she considered that he had shown signs of many other illnesses.

We took independent advice from one of our GP advisers. Our adviser considered that the practice provided a reasonable standard of care and treatment to Mr C. She said there was a good level of multi-disciplinary involvement, particularly in the last 24 days of his life when he had multiple visits from a range of clinicians. She also considered that the recorded cause of death was appropriate, advising that Mr C's deterioration was consistent with the decline exhibited by patients with dementia. She acknowledged that Mr C had other illnesses that could potentially have been listed in part 2 of the death certificate. However, she explained that this part should not be used to list all conditions present at death but rather only those felt to have directly contributed to the death. She noted that this was a matter of clinical judgement and considered that the practice acted reasonably, and in line with national guidance, in this instance. We accepted the advice we received and did not uphold these complaints.