Health

Summary

Mr C complained that he was not properly assessed by his prison health centre after he submitted an emergency nurse triage form saying that he was unfit to work because he was suffering from leg cramps, a black toe and being unable to sleep. A meeting was held with Mr C to discuss his concerns and the board told him that there was no record of the health centre having received a triage form from him on the date in question. However, they said he had submitted a triage form (assessment form) four days before the date he referred to in his complaint and was seen by a nurse who assessed him and then arranged a consultation with the doctor at Mr C's request. The board concluded that the clinical team had dealt with Mr C appropriately.

We could not find clear evidence that Mr C submitted a triage form on the date he said he did. However, we noted that he had done so four days before, for the same problems, and that the triage nurse did not consider that he was unfit for work at that time. We considered it unlikely that the problems he raised would have prevented him from working then. The nurse should have documented her judgement that Mr C was fit for work and we drew this to the board's attention. They confirmed they would take steps to highlight to staff the importance of accurate record-keeping. We did not, however, consider this to be a significant failing and we were satisfied that the board were taking reasonable action to ensure the matter does not happen again. We concluded that Mr C was reasonably assessed.

Summary

Ms C’s daughter (Miss A) broke her leg and was admitted to Forth Valley Royal Hospital. Her leg was put in plaster and managed conservatively (without surgery). In the three months after her accident, Miss A was provided with a number of plaster casts but continued to experience pain and discomfort.

Miss A went abroad and, while she was there, had to seek medical attention as she continued to suffer pain in her leg. After seeing an orthopaedic surgeon there, she was admitted to hospital for surgery. Ms C said that doctors there told her that, without this, there would have been long term complications. She complained that her daughter did not receive appropriate treatment for her broken leg from Forth Valley Royal Hospital and had not given informed consent for the conservative treatment she received there.

We obtained independent medical advice from an experienced consultant in trauma and orthopaedic surgery. We found that there would be variations in approach about the treatment of this type of injury, and differing views between countries, between different hospitals in the same country and between individual surgeons in the same orthopaedic unit. Our adviser said that both conservative management and surgery are well supported managements for this type of injury and both are considered to be appropriate treatment. Once the decision was made to manage Miss A’s injury in plaster, the care and treatment she received was correct and plaster casts were left on for the appropriate length of time before they were removed. We also found that Miss A was able to give informed consent for her treatment.

On one occasion, there was a failure to carry out an x-ray after Miss A’s plaster was changed. The board had acknowledged this and had already apologised. Our adviser considered that they had taken appropriate action and did not identify any other failings in Miss A’s treatment. The adviser also said that Miss A’s medical records did not support the criticism of her treatment that the doctors abroad appeared to have made.

Summary

Mr C complained about the care and treatment his late brother (Mr A) received from the medical practice. Mr A had been suffering from a cough, shortness of breath and chest pain and died of a pulmonary thromboembolism (a blood clot which forms at one point in the circulation, becomes detached and lodges at another point) in April 2014. Mr C said that he believed the practice had contributed to the death of his brother.

Mr C complained that Mr A's GP did not treat his condition as worsening on his last visit to the practice. He also said that the day before Mr A's death, a receptionist had not allowed Mr A to speak to, or see, a GP when he called the practice to get the results of tests.

Mr C complained to the practice but was unhappy with the response he received. He said that there were several things which he felt were inaccurate or incorrect in their response. Mr C questioned why the GP had not considered or recognised that Mr A's condition was worsening and disputed the practice's version of what was said during the phone call with the receptionist.

We took independent advice from one of our medical advisers, who is a GP. We found that the medical records depicted a series of events consistent with a chest infection with some additional signs which needed further investigation and that the appropriate tests had been arranged, so we did not uphold Mr C's complaint about his brother's treatment.

However, our adviser also said that the role of reception staff is to facilitate communication between a patient and a GP, and, therefore, they should not be making a decision that a patient who has specifically asked to speak to a GP should not have this option. Our adviser said the information should be passed to the GP who has clinical knowledge and responsibility for patient care to make the decision as to how to proceed. On this basis, we upheld the complaint about the care given to Mr A by the practice.

Recommendations

We recommended that the practice:

• carry out a significant event analysis paying particular attention to their system of contacting an on-call doctor;
• ensure GPs involved in Mr A's care discuss this complaint at their next appraisal;
• apologise to Mr C for the failings identified;
• establish, using the practice's appointment system, which receptionist spoke to Mr A on the date in question;
• review the details of the GP's complaint response in relation to the information received from reception staff, and write to Mr C to explain the findings;
• review and revise where appropriate the practice system for passing requests by patients to speak to a doctor; and
• consider enhanced staff training for the receptionists in terms of their interactions with patients and practice guidelines on responding to patients who request to speak to a doctor.

Summary

Mr C complained that the care and treatment of his wife (Mrs C) had been unreasonable, in particular in relation to managing Mrs C's stiffness and contractures (rigidity in a joint that cannot be overcome, leaving the limb in a fixed position). Mrs C, who suffered from dementia, was initially cared for at home under the care of a speciality doctor in old age psychiatry and her GP. However, when there was a marked deterioration in her mobility and rigidity in her limbs, she was admitted to Victoria Hospital. A month later, she was transferred to Queen Margaret Hospital. During this time, as Mrs C was becoming increasingly agitated and upset, she was prescribed increasing doses of an antipsychotic drug (a medicine used to treat mental health conditions). Mr C complained that this resulted in his wife's physical condition deteriorating and her body becoming more rigid.

We took independent medical advice from two of our advisers - consultants in old age psychiatry and in geriatrics - and we found that while it was known that the drug prescribed to Mrs C might have side effects causing muscle contractures, in Mrs C's case it was initially prescribed to her in a low dose to reduce her agitation. This had been fully discussed with Mr C. We also found that the clinical staff involved considered the benefits of using the drug against the possible side effects, and concluded that the benefits outweighed the possibility of any side effects. It was also known that many patients with end-stage dementia went on to develop contractures. While Mrs C was given increasing doses of the drug, the matter had always been discussed with Mr C and clinicians followed good practice by continually monitoring Mrs C. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the treatment that her late mother (Mrs A) received from her medical practice between September and November 2012. Mrs A was eventually diagnosed with lung cancer and Mrs C said that the family had made repeated requests for a chest x-ray but these were ignored. The family believed that an earlier x-ray might have allowed Mrs A's cancer to be diagnosed sooner. They were also concerned that the practice failed to follow up blood test results as they should have done and which again they thought would have led to an earlier diagnosis.

We took independent advice on this case from one of our medical advisers. Our adviser said that the practice had not failed to follow up on blood tests arranged by the hospital. However, he considered that the practice did not take reasonable steps in light of the results of blood tests they themselves organised. The adviser said that there were repeated and high levels of inflammatory markers shown on blood tests in late October 2012. These should have created a higher degree of suspicion, and led to consideration of a referral rather than just arranging repeat tests. The test results should have been considered in the context of an unwell adult and consideration given to referral for other possible conditions, although he also said that it was unlikely this would have led to an earlier diagnosis. The adviser also thought that Mrs A should have been referred for an x-ray in early November, when swollen lymph glands were noted.

We concluded that, whilst Mrs A's care was reasonable up to the end of October 2012, and that earlier diagnosis was unlikely in her case, on balance there were failings by the practice from early November 2012 onwards.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failings identified; and
• review our adviser's comments on this complaint, reflect on the decision-making processes used by GPs individually and collectively in assessing Mrs A in early November, and provide us with evidence of this reflection having taken place and its outcome.

Summary

Mrs C's father (Mr A) had suffered from a painful degenerative condition that caused his spinal cord to become compressed. An operation was carried out and, after a difficult recovery, Mr A was pain free for a number of months. He then began to have new pain in his shoulder and went to his GP as he was worried that this could have been a recurrence of the condition. Mr A's GP considered that he did not have any new symptoms that indicated his spinal cord was compressed. Mr A had a number of consultations over the following months where the GP adjusted his pain relief medication. He also attended hospital appointments which clinicians reported to the GP; none of them considered that he was suffering from spinal cord compression. Mr A was subsequently seen at home by the GP as he was in too much pain to visit the surgery. The GP made a referral for a scan which was carried out a few days later. The scan showed a narrowing of the spinal canal and an urgent referral was made.

Mrs C complained that the GP repeatedly failed to diagnose her father's condition, delayed referring him for a scan and had not assisted him in obtaining medical equipment to help him manage at home. The practice responded saying that the GP had acted appropriately.

After taking independent advice from one of our medical advisers, we found that the GP had provided Mr A with reasonable care and treatment. Our adviser explained that there was no evidence that Mr A was suffering from new spinal cord compression and so there was nothing to suggest that a scan should have been carried out earlier. In relation to obtaining medical equipment for use at home, our adviser said that the occupational therapy department would deal with this rather than the GP. As the GP had advised Mrs C's family to contact the occupational therapy department, we considered that this had been handled reasonably.

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) by a medical practice. Miss A has a long-term health condition and needs multivitamins daily. Mrs C said that, on more than one occasion, GPs at the practice wrongly prescribed a multivitamin containing a high dose of vitamin A, which was potentially toxic to Miss A. Mrs C said that she and the dietician noticed the error, not the GPs, and she complained to the board, who responded on behalf of the practice. Mrs C was not satisfied with the board's response.

After taking independent advice from one of our medical advisers, we were satisfied that the practice took Mrs C's complaint seriously, conducted a full and honest investigation, including a significant event analysis, and proposed reasonable actions to prevent a similar situation in the future. There had clearly been a mis-prescription of Miss A's multivitamins which affected a period of roughly six months, which the practice accepted. We found that this was caused by poor communication between the practice and other healthcare staff involved in Miss A's care. We also found that the practice operated two different methods of prescription, which meant that a GP dealing with Miss A for the first time could easily miss details of previous prescriptions which had not been entered on the practice system. We were also critical that, when it was established early on that Miss A's prescribed multivitamin was not listed on that system, no action was taken to have the system updated or to forewarn other GPs in the practice. We upheld Mrs C's complaint and made recommendations to address the failings identified.

Mrs C also complained about the handling of her complaint, but we found that it was investigated thoroughly and that the board’s response was reasonable.

Recommendations

We recommended that the practice:

• apologise to Mr and Mrs C for the poor handling of Miss A's multivitamin prescription; and
• provide us with evidence of the procedural changes that have been implemented following the significant event analysis.

Summary

Mrs C complained about the care that her mother (Mrs A) received in Borders General Hospital. Mrs A had a collapse/fall while she was alone at home and was taken to A&E. As Mrs A had a pacemaker and had a number of issues with her heart while she was at the hospital, she was transferred to another hospital in a different NHS board area for specialist investigations (the second hospital). Tests there showed that there were no abnormalities with Mrs A's pacemaker. She was scheduled for transfer back to Borders General Hospital but an outbreak there of norovirus (winter vomiting bug) prevented this. The second hospita carried out further tests, and Mrs A was diagnosed with pulmonary emboli (blockages in the blood vessels that carry blood from the heart to the lungs, usually caused by blood clots). She was prescribed warfarin (a medicine that prevents blood clotting) to treat this and a few days later was transferred back to Borders General Hospital. The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them. When Mrs A was readmitted to Borders General Hospital, staff only considered the medical transfer documents, and missed the pulmonary emboli diagnosis.

Mrs C had been concerned about her mother's ability to cope at home, but as Mrs A was considered to be medically fit to return there, she was discharged two days after she went back to Borders General Hospital. She became increasingly breathless, however, and was readmitted two days later where the pulmonary emboli diagnosis was picked up and treated.

Mrs C complained to the board about the care Mrs A received. The board apologised for the errors in communication between Borders General Hospital and the second hospital. They also advised that steps would be taken to ensure that the issue was followed up with the second hospital and that doctors would now check both medical and nursing transfer documents when admitting patients.

After taking independent advice from one of our medical advisers who is a consultant physician, we upheld Mrs C's complaint. The adviser considered that the failure to identify Mrs A's diagnosis of pulmonary emboli from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged. We were also critical that there appeared to have been a delay in the board carrying out the actions advised in their response to Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the standard of care and treatment provided to Mrs A during the period relating to the complaint;
• take steps to ensure that actions agreed following a complaint investigation are followed up promptly;
• consider the adviser's comments about taking the views of family members into account and determine whether there are lessons that can be learned; and
• make medical staff involved in Mrs A's care aware of the adviser's concerns regarding the decision to discharge, including the lack of documentation, to ensure that a similar situation does not occur in future.

Summary

Mrs C complained that the board failed to diagnose her with rheumatoid arthritis while she was under their care. Although she had a number of appointments in just over a year, Although she had a number of appointments in just over a year, Mrs C was only diagnosed with this after she moved out of Scotland.. She said that this was despite the fact that there had been sufficient indicators present to have confirmed this. She said that, as a consequence, she was not properly treated and that she had subsequently lost her independence.

We investigated the complaint and took independent advice from a consultant rheumatologist. Our adviser said that diagnosing rheumatoid arthritis is neither straightforward nor easy and other conditions can mimic its presentation. Accordingly, great care has to be taken in making a diagnosis, and also in prescribing appropriate drugs, some of which have significant side-effects. We found that in the time period about which Mrs C was concerned, and faced with a complicated picture, clinicians responsible for her care had carefully monitored her, formed appropriate working diagnoses and treated her appropriately. At about the same time as Mrs C moved, the evidence about her condition became much clearer and the findings and updated treatment were summarised to her new clinician when her treatment recommenced.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the care and treatment given to Mrs A's late husband (Mr A) before he died. Mr A had bowel cancer and his prognosis (the forecast of the likely outcome of his condition) was not good. He was discharged home from hospital into the care of his GP and the district nursing service. After being at home for a short while, Mr A died. Mrs A complained about the various agencies involved in her husband's care and was particularly unhappy because she considered that district nurses had failed to properly care for her husband in the final weeks and days of his life and that levels of support, communication and standards of care had been poor. In responding to her complaint, the board agreed that there were failures in the support and care offered to Mr and Mrs A, and apologised for this, but Mrs A remained concerned that lessons had not been learned nor had procedures been put in place to prevent this happening again. She also complained about the way in which her complaint had been handled.

We took independent advice on this case from our nursing adviser, an experienced registered nurse. Our investigation confirmed that the board had admitted that there were shortcomings in Mr A's care, and we found that they took too long to deal with her complaint. We, therefore, upheld the complaint, while noting that the board had put processes in place to address the problems with Mr A's care and had apologised sincerely to Mrs A for the failings. As our investigation also found that the board had taken Mrs A's concerns most seriously and that the processes put in place provided a good response to them, we did not find it necessary to make any recommendations.