Health

Summary

Mr C complained on behalf of his wife (Mrs C) about the care and treatment she received at the Princess Alexandra Eye Pavilion. Mr C said that mistakes were made during an operation, and that his wife was left virtually blind in her left eye. Mr C also complained about the board's response when his wife complained about this.

During our investigation, we took independent medical advice from an experienced cataract surgeon. The advice we received was that the care and treatment Mrs C received was appropriate and that no mistakes were made during the surgery. Mrs C had, however, suffered two rare complications. While the advice we received was that, in general, both complications were handled well, there was a small error in relation to the first one, in that the vitrector (a machine used in eye surgery) used as a result of the complication was not tested before it was used on Mrs C's eye, and was not working. Our adviser said that this was unlikely to have had a material impact on the outcome and was not the cause of the second complication, but we were concerned that the machine was not fully tested before it was used. We were satisfied that there was no evidence that work continued on Mrs C's eye after it was discovered that the machine was not working.

We did, however, find that the complications that arose in Mrs C's case were not discussed with her before the surgery and were not included in the information leaflets that she was given. In addition, we were concerned that Mrs C was not given enough time to make a considered decision about the surgery. We were also concerned about the handling of Mrs C's complaint - in particular that the response she received to her representations contained unnecessary, confusing details and did not meet her needs.

Recommendations

We recommended that the board:

• ensure that the relevant staff members are made aware of our adviser's view that it is wise, where a vitrector has been set up, that the flow of fluid through the vitrector is checked and that a check is carried out to ensure the guillotine cutter is working before it is used;
• consider the process for informed consent for cataract surgery to ensure that it complies with guidance about informed consent, in particular, in relation to the information provided about serious or frequently occurring risks;
• draw to the attention of relevant staff our adviser's comments that where potentially serious complications have occurred it would be wise to make a note in the medical records of the discussions held with patient/relatives;
• apologise to Mrs C for the handling of her representations; and
• ensure that their written responses to complaints meet the needs of the patient in relation to tone and language etc.

Summary

Mr C complained to us about the care and treatment his mother (Mrs A) received from the medical practice after a GP visited Mrs A's home as she had abdominal pain. Mr C told us that the GP examined his mother, gave her a injection for pain and called an ambulance. He said that the GP spent approximately 15 minutes with his mother before leaving. Mr C said that the ambulance arrived two and a half hours later and during this time his mother's pain worsened. He said that the ambulance crew expressed shock at Mrs A's condition and gave her more pain medication before taking her to hospital. When he went to the practice to complain, he felt that the GP was aggressive towards him. He also said that he asked for information on making a complaint and was told there were no specific forms and that each practice is different.

The practice said that they provided proper care and treatment. The GP said that as Mrs A had family support and her condition was not considered life threatening, it was appropriate to leave and return to other patients at the surgery. The practice said that Mrs A's family did not call them to say that she was worse. They apologised for confusion about the complaints form and explained that although they do not have such forms they do have a procedure, and complaints can be made in writing. They said that they were not aggressive towards Mr C – they in fact felt that he had been aggressive towards them, and they had sent him a formal warning.

We took independent advice from one of our GP advisers, who said that the GP provided reasonable care. Our adviser was of the view that the pain relief given and the decision to request an ambulance within a two hour window were reasonable. The Scottish Ambulance Service provided evidence during our investigation that their crew that day had no recollection of criticising the GP and or of expressing shock at Mrs A's condition. We did not uphold this complaint.

We did uphold Mr C's complaint about the practice's complaints handling. Although they responded to his complaint well, he had asked for complaints handling information and been told there was none. They should have referred to the NHS Scotland 'Can I help you?' guidance and provided information on the process they would use to deal with his complaint.

Recommendations

We recommended that the practice:

• ensure that all practice staff are aware of the NHS Scotland 'Can I help you?' guidance and ensure that the practice leaflets on the complaints handling process, detailed on the practice website, are available to patients and staff.

Summary

Mr C was treated for appendicitis at Monklands Hospital. As part of his treatment, he was given antibiotics, including gentamicin, intravenously (directly into a vein) for ten days. During and after this treatment, Mr C experienced symptoms of dizziness and difficulty with his balance. He saw an ear, nose and throat consultant, who diagnosed him with permanent damage to his hearing and balance, possibly as a result of gentamicin poisoning. Mr C complained that the decision to administer gentamicin was inappropriate, and that he was not told of the side effects or asked for his consent before the drug was administered.

We investigated Mr C's complaint and took independent advice from a consultant in general medicine. We did not uphold Mr C's complaints, as we found that gentamicin was the appropriate treatment for his symptoms and condition at the time. We also found that there was no requirement to explain the side effects or seek Mr C's consent before administering gentamicin, given that the side effects are extremely rare. However, we found that the board failed to monitor Mr C for signs of gentamicin poisoning, and failed to consider referral to an audiologist, as required by their guidance. Although we did not uphold his complaint, we made recommendations about this.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings our investigation found; and
• remind relevant staff of the gentamicin guidance in relation to monitoring for ototoxicity (ear poisoning) and considering audiology assessment where gentamicin is administered for more than seven days.

Summary

Mrs C complained about the care and treatment that her late husband (Mr C) received at Wishaw General Hospital. Mr C had advanced cancer and was admitted to the hospital because he was vomiting blood. He was in the hospital for about a week before being transferred to a hospice, where he died shortly after. Mrs C complained that the hospital did not adequately assess and treat her husband's bladder and bowel problems and failed to take adequate precautions to prevent him from falling out of bed. She also complained that neither she nor Mr C had been involved in discussions about the withdrawal of his medical treatment and his future management plans.

We took independent medical advice from an experienced hospital doctor, who reviewed Mr C's records. Our adviser said that although it was clear that Mr C was most unwell when he was admitted, there were a number of steps the hospital should have taken sooner. Viewed as a whole, he said that Mr C's care fell below a reasonable standard and we upheld this complaint.

We also took independent advice from our nursing adviser, who said that a falls assessment was completed when Mr C was admitted. This indicated that he was not at risk of falling and, in her view, there was no reason for the hospital to have suspected he might do so. Our adviser said the hospital's assessment was reasonable and the board had acted reasonably, based on the information available at the time. In her view, Mr C's fall could not have been avoided, and we did not uphold this complaint.

In terms of Mrs C's complaint about the lack of discussions, our medical adviser pointed to an apparent lack of clarity around the approach being taken with Mr C's care. He was moved to the hospital's high dependency unit for treatment – despite the notes indicating he would not be moved – but it was then decided to move him onto palliative care (care provided solely to prevent or relieve suffering). Our adviser said that this decision was appropriate but should have been discussed sooner than it was. We took the view that the evidence showed a lack of certainty over the direction of Mr C's care and that his family were given mixed messages. We considered this unreasonable and upheld this complaint.

Recommendations

We recommended that the board:

• discuss this case at the next departmental meeting to ensure early recognition of kidney dysfunction and infection, so appropriate steps are taken in such cases;
• ensure that the failings in care and treatment identified are fed back to the relevant staff;
• provide us with a copy of their local action plan for the relevant Scottish Government guidance and confirm the steps in place in acute wards to support patients and families receiving end of life care including staff communication;
• use this case in Mr C's consultant's appraisal with reflection on the issues identified, including the decision on when to move to palliative care, communication and consultant supervision; and
• apologise to Mrs C for the failings we identified.

Summary

Mr C complained that the board failed to diagnose his condition properly when he attended an out-of-hours (OOH) service at Raigmore Hospital. Mr C was diagnosed with a viral infection, and he was discharged. A few days later, however, he became very unwell and was admitted to hospital where he was later diagnosed with legionnaires' disease.

Mr C said that the OOH service should have considered this as a possible diagnosis, particularly as he had mentioned recent travel abroad. We took independent advice from one of our medical advisers, who is a GP. The adviser said that the examination of Mr C was thorough and well recorded. The adviser also reviewed the Health Protection Scotland (a government body that monitors infectious and environmental hazards) website, and noted that at the time of Mr C's admittance there were no notifications of increased incidents of legionella (the bacteria that causes legionnaires' disease) in the location Mr C had visited. Therefore, no alert would have been sent to GPs and OOH services to increase vigilance for the condition.

We, therefore, concluded that in light of the symptoms Mr C presented with at the time, he was provided with a reasonable diagnosis.

Summary

Mr C complained to us that the board had refused to investigate his complaint about his late partner (Ms A)'s medical treatment at Dunoon Hospital. The board had refused to respond to the complaint as Mr C was not Ms A's next of kin, and to have access to her medical records they would have to have permission from her next of kin.

We found that the board had given Mr C's request for information about Ms A's clinical treatment careful consideration, and had consulted senior staff before reaching a final decision that they were not in a position to respond to the complaint. The board had also suggested that Mr C should contact Ms A's next of kin to ask for permission to release the information from Ms A's medical records, and that he had chosen not to do so. We were satisfied that the board had considered the matter carefully and we found no reason to question their actions.

Summary

Ms C complained that, during her pregnancy, the board failed to give her reasonable care and treatment and that there was a failure to diagnose placental insufficiency (a complication in pregnancy where the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus), or that her baby was too small. Ms C's baby was stillborn.

We took independent medical advice from a consultant obstetrician, who told us that while ultrasound (a scan that uses sound waves to create images of organs and structures inside the body) provided the best estimate of fetal size, unfortunately it was not always accurate. Other tests (including measurements of the abdomen and blood flow in the umbilical artery) did not always pick up that a baby was small. Scans and other tests were also used to detect problems with the placenta but again were not foolproof. In Ms C's case, as she had already had two healthy births and had no apparent risk factors, all appropriate and reasonable steps were taken to properly monitor her pregnancy. While our adviser noted that with earlier delivery the baby would likely have survived, there was no indication for her to have been delivered earlier. Based on the evidence, we did not uphold Ms C's complaints about her care and treatment.

Ms C also complained about the way her complaint was handled. We upheld this complaint, as we found that there had been numerous delays, and that these had added to her distress.

Recommendations

We recommended that the board:

• make a formal apology for their delay and for any further distress caused; and
• remind those staff involved in responding to complaints (including any clinical staff) of the necessity of providing timely replies and demonstrate to us how this was done.

Summary

Ms C complained on behalf of her client (Mr A) who suffers from a delusional disorder (a mental health disorder where sufferers hold irrational beliefs). Mr A went to A&E in Lorn and Islands Hospital as he wanted them to check a mark on his leg. Staff were concerned about his mental wellbeing and spoke to the duty psychiatrist at another hospital who decided that he should be transferred and admitted there. In the event that Mr A was unwilling to go, it was agreed that his admission be facilitated with the use of an Emergency Detention Certificate (EDC). Documentation had to be completed for this and, before arrangements could be made for transfer, Mr A left Lorn and Islands Hospital. He was later brought back, handcuffed, by the police, sedated and transferred.

Ms C complained that Mr A was not adequately assessed at A&E. She also said that staff did not follow the correct process/procedures in relation to the EDC and there was unreasonable delay in transferring Mr A between hospitals. She subsequently complained of the delay in responding to her complaint about this.

We took independent medical advice from one of our psychiatric advisers. We found that, while it had been reasonable to prioritise Mr A's mental health over his concerns about his leg, the board had not first tried to establish whether he was a risk to others or himself, nor attempted to discuss his condition with his usual psychiatrist and review his records before deciding that he needed to be tranquilised. They also failed to follow the correct procedures (in terms of assessment and proper completion of the appropriate forms) for issuing an EDC. This led to Mr A being sedated against his will. Furthermore, the board delayed in dealing with Ms C's complaints. We, therefore, upheld these complaints.

Ms C had also complained that the board delayed in transferring Mr A between hospitals, but we did not find evidence to confirm this, and did not uphold her complaint.

Recommendations

We recommended that the board:

• apologise to Mr A for the shortcomings in assessing him;
• ensure that the circumstances of the complaint are brought to the attention of the on-call psychiatrist and ensure that it is considered at his next formal appraisal;
• make a formal apology to Mr A for failing to follow correct procedures;
• review the training given to medical staff working in A&E to ensure that they understand what is required before detaining people under an EDC and how to complete the appropriate paperwork;
• should formally apologise to Ms C and Mr A for their failure to respond in a timely manner; and
• should emphasise to the staff involved in this complaint the importance of responding to complaints in accordance with the board's stated response times.

Summary

Mrs C, who is an advocate, complained to us that her client (Mr A) had suffered depression as a result of the community mental health team stopping his anti-psychotic medication. We sought independent advice from one of our medical advisers who told us that Mr A's medication had been stopped in line with national guidelines. The adviser also said that research has shown that there was no recorded evidence that such action can cause depression.

Summary

Mr C was transferred between prisons and, as is routine for new arrivals, had a GP appointment at his new prison's health centre the day after he arrived. The GP decided to reduce and later stop Mr C's headache medication. This was because in the first prison Mr C had been found to have less of the medication in his possession than he should have had, and so he was in breach of prison protocol about this.

Two days after his GP appointment, Mr C was found to be concealing his medication in his mouth, rather than swallowing it. This was also in breach of a protocol, which said that if a prisoner was found to be concealing medication that they were being given on a supervised basis (as in Mr C's case), the clinical need for it would be reassessed. On reassessment, it was decided to stop the medication with immediate effect. The medical records indicated that Mr C was offered an alternative but declined. Mr C complained that the decisions to reduce his medication on arrival at the new prison and to stop his medication after reassessment were both unreasonable.

We took independent advice from one of our medical advisers and found that on both occasions medical staff acted appropriately. The medication in question was one which is often abused in a prison environment (for example, by prisoners selling it to other prisoners). Drug security in prison is very important and the NHS have to have firm policies for such security and follow them.