Health

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.

Summary

Mr C complained about Stobhill Hospital's administrative arrangements of his wife (Mrs C)'s treatment. During the course of our investigation, Mr C withdrew his complaint.

Summary

Mrs C was unhappy with the care and treatment provided to her late mother (Mrs A) when she was admitted to Glasgow Royal Infirmary to repair her broken hip. She complained about failure to manage Mrs A's diabetes, poor wound management, and failure to take appropriate action when Mrs A's condition deteriorated. Mrs A had fallen at home, and had surgery to repair her hip the following day. She developed an infection and had two more surgical procedures, including removal of a hip implant that had been inserted during the first operation. Her condition deteriorated, however, and just over a month after going into hospital she was admitted to the intensive care unit (ICU) where she died three days later.

Our investigation included taking independent advice from two of our medical advisers, a consultant orthopaedic surgeon and a consultant in critical care. We found that Mrs A's condition had been appropriately monitored and managed with specialist advice being taken from the diabetic and ICU teams when necessary. Mrs A's diabetes was known to be unstable before she went into hospital and it was difficult to control while she was there. The advisers said that this would have made her prone to infection, and that in turn, infection could have made her diabetes more difficult to control. They were satisfied that appropriate action was taken to monitor and address this, including asking the diabetes specialist nurse and a specialist registrar to review Mrs A several times.

The advisers were satisfied that the care and treatment of Mrs A's wound infection was reasonable. There were no clear indications of infection until almost two weeks after the operation and until then appropriate action was taken to investigate and address the symptoms that Mrs A was displaying. When her condition deteriorated further, the advisers said that Mrs A was appropriately reviewed by the ICU team and then transferred to the ICU. Our investigation found that, overall, the care and treatment provided to Mrs A was reasonable, appropriate, timely and in line with standard practice and national guidance.

Summary

Ms C complained that the board had not funded a place for her at a charitable health support organisation. The board fund a limited amount of places, but individuals can also choose to pay for the service themselves. Ms C said that she thought she had been referred for a funded place, but when she became aware that she had not been, she paid for the service herself and asked the board to refund her. The board said that they would not refund her as she did not meet the criteria for funding and that this had been made clear to her.

We found evidence that Ms C had been told she would not meet the criteria and that she had decided to arrange a place herself. We, therefore, found that Ms C was informed that no place had been booked for her and did not uphold the complaint.

Summary

Mrs C complained about the care and treatment she received at Aberdeen Royal Infirmary for autoimmune haemolytic anaemia (AHA - a blood disorder). Mrs C's medical history included high blood pressure for which she had been prescribed simvastatin (used to treat high cholesterol, which can cause high blood pressure). When Mrs C was diagnosed with AHA, she was treated by the haematology team (specialists in blood disorders). She was prescribed steroids (a group of drugs used to treat various conditions) to stabilise her haemoglobin levels (a measure of the red blood cells in the blood). This is the accepted first-line treatment for AHA. The accepted second-line treatment is removal of the spleen (an organ which helps to fight infection) and this was recommended to Mrs C. She agreed to this reluctantly, as she thought that the simvastatin tablets were causing the AHA symptoms.

Our investigation included taking independent advice from one of our medical advisers, who is a consultant haematologist (blood specialist). The adviser found no evidence that the simvastatin tablets were linked to the AHA, although some of their common side effects are similar to AHA symptoms. The adviser said it was reasonable that doctors did not tell Mrs C to stop taking the simvastatin before her spleen was removed. Although Mrs C felt that her condition was unchanged after the operation, our adviser noted that doctors were then able to reduce her steroid dosage to zero.

We did, however, find problems in communication between the medical team and Mrs C, and in the taking of her consent for the operation. She had reluctantly agreed to the operation and signed a consent form. However, as she was sure the simvastatin was the cause of her symptoms, she then tried to discuss this with hospital doctors. She felt that she was being ignored, and spoke to her GP who contacted the hospital to say that Mrs C had changed her mind about the operation. However, when she next went to the clinic, the hospital doctor that Mrs C's GP had spoken to told her that she had to have the operation which then went ahead. Our adviser was concerned that although the consent form would still have been legally valid, doctors did not revisit the issue of consent in the light of Mrs C's concerns. We were also unable to find a record in Mrs C's notes of the discussions about the pros and cons of the operation.

Recommendations

We recommended that the board:

• ensure that all the staff involved in this complaint are reminded of the importance of patients giving a fully informed consent to any procedure or treatment, and that appropriate records are kept of any discussions;
• bring this decision to the notice of the staff involved so that they may reflect on the failings identified in relation to Mrs C's treatment; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer and received chemotherapy (a treatment where medicine is used to kill cancer cells). Mrs C said that he attended the medical practice regularly over the two years leading up to his diagnosis, during which time his health deteriorated. Mrs C believed that his symptoms were indicative of cancer and that he should have been investigated for this sooner. She also complained that the GP made a routine - instead of an emergency - referral for a colonoscopy and gastroscopy (a fibre-optic telescope looking into both the upper and lower parts of the bowel). After Mr A was diagnosed with bowel cancer, he attended the practice with a sore leg. His wife contacted the oncology department (who specialise in treating patients who have cancer) at the local hospital (the first hospital), who arranged a scan that showed that he had a blood clot in his leg and lung, and the following year his health began to deteriorate significantly.

Mrs C said that there was a failure by healthcare professionals in the community to provide a discussed and implemented care plan about support throughout Mr A's illness and end of life care. Mr A wanted to receive end of life care at home but at no time was he consulted about his wishes or preferred place to die. He had a number of admissions to hospital due to blood clots and his deteriorating condition. In the last month of his life, it was noted in the GP records that chemotherapy treatment had stopped due to progression of the disease. During his last admission to the first hospital, Mrs C said a doctor told them surgical intervention was not possible and the aim was to get Mr A's pain under control and discharge him home. However, Mr A's wife received a phone call several days later saying that her husband would be transferred to a second hospital where he would be under the care of his GP practice. Mr A remained unresponsive for several days, and his GP said Mr A was dying, but did not tell the family that he had decided that Mr A should no longer be given oral medication. Several days later, the family became distressed at Mr A's condition, and his GP told the family it was difficult to say how much longer he had to live. Mr A died shortly after.

Mrs C complained that the practice failed to refer Mr A to a specialist consultant within a reasonable time, failed to diagnose the blood clots he developed and that the communication and support was not reasonable. In relation to her complaint about the care provided by GPs when Mr A was a patient at the second hospital, Mrs C said she had concerns about prescription of medication and that Mr A was unresponsive for an unreasonable length of time.

After taking independent advice from one of our medical advisers, we found it was unlikely that Mr A would have had bowel cancer symptoms until around 18 months before his diagnosis, and there was no evidence that his medical problems were not reasonably assessed and dealt with. However, the medical adviser said that Mr A should have been referred urgently to hospital at one point in light of his warning symptoms and we upheld this complaint. We found that the practice's management of Mr A in relation to his blood clots was reasonable. We upheld the complaint about end of life care, as our adviser said that while it was not the sole responsibility of the GP to have such discussions with patients, they should ensure it was done within a reasonable time. In this case, the practice's failure to coordinate an appropriate end of life care plan compounded Mr A's and his family's distress at what was happening.

Our adviser said that there was a shared responsibility between the practice and the consultant oncologist (a doctor who specialises in treating patients who have cancer) to ensure that Mr A and his wife understood why chemotherapy was stopped. While we found that communication was on the whole reasonable, particularly in relation to stopping all medication and likely timescale of death, the failing around the decision to stop chemotherapy was significant because it meant that later discussions about treatment involved palliative care (care solely to prevent suffering), and we upheld this complaint.

Finally, we did not uphold Mrs C's complaint that medical staff at the second hospital (which was provided by GPs from the practice) failed to provide Mr A with appropriate medical care, as we found that the care and treatment provided in relation to pain relief was reasonable.

Recommendations

We recommended that the practice:

• review their process for referrals where referral symptoms are present in light of the medical adviser's comments;
• bring the failures this investigation identified to attention of the relevant staff; and
• apologise for the failures this investigation identified.

Summary

Ms C complained about her dentist. In particular, she said that his care and treatment had been unreasonable and inappropriate and that this caused her pain and upset. Ms C also said that the dentist had delayed in making a referral for her to a dental clinic and that when she attended the clinic, the referral was unnecessary. She further said that unsuccessful work had been carried out on one of her teeth which then had to be extracted at her own expense.

We took independent advice from a senior dental practitioner and our investigation showed that when Ms C first saw the dentist it was for an emergency appointment. She was immediately given appropriate treatment. She attended again and after an x-ray, treatment options were discussed and Ms C made decisions about her preferred treatment. Later, because a problem with one of her teeth was not settling, it was agreed with Ms C that she should be seen at a dental clinic and a referral was immediately made. However, the dental clinic had problems with their email and it was not received. As soon as this was discovered, the dentist made a further referral and Ms C was seen. Although she complained about her treatment it was established that it had been reasonable and appropriate in the circumstances.

Summary

Ms C complained that her dentist failed to examine her or treat her reasonably or appropriately. She said that it was only shortly afterwards, when she changed to a new dentist, that she learned the extent of her problems, which she said the first dentist had allowed to develop.

We took independent advice from a senior dental practitioner and we found that as the appointment concerned had been on an emergency basis, Ms C had been given immediate treatment on the particular problem she presented with. The appointment was not routine, and so the dentist had not been expected to make a full examination of Ms C's mouth. We found the treatment he gave her had been appropriate in the circumstances.