Health

Summary

Mrs C complained on behalf of her daughter (Ms A) that a medical practice would not register Ms A because she did not attend a new patient medical consultation. Mrs C also complained that the practice manager did not return Ms A's phone calls when she was trying to explain why she missed the consultation.

We found that the practice's policy at the time was to refuse registration to people who failed to attend for a new patient medical consultation. However, two months later, the health board wrote to all practices in their area to clarify the regulations for registration. In their letter to us, the practice acknowledged that their policy and their actions were incorrect when they did not register Ms A. The regulations for registration, set out in The National Health Service (General Medical Services Contracts) Regulations 2004, say that new patients shall be invited to a consultation, but do not say that attendance is mandatory. The regulations also say that registration could only be refused on reasonable grounds, which did not appear to include failure to attend a new patient medical consultation.

The practice also explained that the practice manager did not return Ms A's phone calls because there was a breakdown in communication. They said they would apologise to Ms A, and explained to us what they had done to address all these failures, including carrying out a significant event analysis to understand what had gone wrong and how they could improve.

Recommendations

We recommended that the practice:

• apologise to Ms A in writing for their failure to register her as a patient;
• offer Ms A the opportunity to register, if she wishes to do so; and
• provide us with a copy of their significant event analysis and the review of their complaints handling processes.

Summary

Mr C, who is an advocate, complained on behalf of his client (Mr A). Mr A had raised concerns about changes to his anti-depressant medication. He said that one doctor told him the medication he was taking was illegal and switched him to another medication. He complained that he experienced adverse side effects from the medication he was switched to and he did not believe it to be suitable for someone of his age. He noted that, when he later brought his concerns to the attention of another doctor, he was switched back to his original medication and told that the drug was not illegal.

The medical practice said that Mr A was not told his original medication was illegal. They explained that the dose had previously been reduced following a licence change, which set a lower maximum dose for elderly patients. We took independent advice on this complaint from one of our GP advisers, who confirmed that the changes to Mr A's medication were reasonable and in line with acceptable clinical practice. We were advised that the decision to restart Mr A on his original medication was appropriate in light of his symptoms at the time, and was not an indication that the initial switch was unreasonable.

Mr C also complained that the records of Mr A's consultations with the practice did not accurately reflect what was discussed. As we were not party to the consultations, we could not say exactly what was discussed. The adviser reviewed the records and considered them to be clear and of a reasonable standard.

In the circumstances, we did not uphold either complaint.

Summary

Mrs C wrote to the board on a number of occasions seeking clarification and information about a wide range of issues arising from her medical records. Mrs C said that the board failed to carry out a full investigation of her records and, as a result, she had become very anxious about any future care she may need.

After taking independent advice from one of our medical advisers, we found that the board's explanations were reasonable. There was no evidence of Mrs C having a significant diagnosis or condition that the board failed to disclose, or that they failed to address a significant medical issue. We found that they had carried out a full investigation into her complaint.

Summary

Mrs C said that when she was a patient at the practice, the acronym DNR appeared in her medical records. She said she was told by a medical professional this meant 'do not resuscitate'. She was extremely upset about this and wrote to the practice asking for an explanation. The practice said that the acronym referred to 'diabetic nurse review' and that they used the abbreviation DNAR for 'do not attempt resuscitation', rather than DNR. Mrs C complained that this explanation did not make sense in the context of her medical records.

After taking independent advice from one of our medical advisers, we found that the practice's explanation was accurate and that they had responded to Mrs C's complaint in a reasonable way.

Summary

Mrs C wrote to the practice to complain about her medical records. She thought there were a number of inconsistencies between the two copies of the records she had, which she said showed that her notes appeared to have been rewritten or that information had been re-entered by the practice at some point. Mrs C also referred to the coded acronym 'DNR' which she believed related to not resuscitating her and meant that she had at some point been identified for palliative care (care provided solely to prevent or relieve suffering). The practice responded explaining that Mrs C's medical notes had not been altered and a resuscitation-related code had never been entered into her records.

Mrs C complained to us that the practice unreasonably failed to respond to her complaint about information held in her medical notes, particularly the use of the abbreviation DNR. After taking independent advice from one of our medical advisers on the clinical aspects of Mrs C's complaint, we found that the practice's explanations were reasonable. We also found no evidence that Mrs C's medical notes were purposely altered, and we did not uphold Mrs C's complaint.

Summary

When Mrs C joined the medical practice, she met the practice manager and expressed concerns about her experiences with her previous practices. In particular, Mrs C was concerned that the abbreviation 'DNR' was in her medical notes, as she believed that this related to a 'do not attempt cardiopulmonary resuscitation' order (a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). The practice manager told Mrs C that in her records DNR stood for 'diabetic nurse review', and followed this up with a letter explaining, amongst other things, that there was nothing anywhere in Mrs C's medical records about not attempting cardiopulmonary resuscitation. Mrs C acknowledged that she had spoken inappropriately to the practice manager in a phone conversation, although she had apologised for this afterwards. Following a consultation the next month, the practice then decided to warn Mrs C about her behaviour. Before they could do this, Mrs C wrote to them seeking clarification about issues arising from her clinical notes. The practice then wrote back saying there had been an irretrievable breakdown between her and the medical and management staff, and asked the health board to remove her from their list.

Mrs C complained about the way the practice responded to her complaint and the way they removed her from their list. We found that it would have been reasonable for them to have warned Mrs C before removing her, and that they did not explain why they did not do so. We upheld her complaint about this, and made recommendations. We also took independent advice from one of our medical advisers regarding the practice's explanations about the queries arising from Mrs C's medical notes. As we found that these were reasonable we did not uphold Mrs C's complaint about this.

Recommendations

We recommended that the practice:

• review their practice and processes in relation to removing patients, including training for staff where appropriate;
• review their practice and complaints processes, including training for staff where appropriate; and
• apologise to Mrs C for the failures this investigation identified.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) that his medical practice had failed to properly assess his symptoms and provide him with further tests to determine his increased risk of stroke. Mr A had attended the practice on a number of occasions with various symptoms. There was a history of heart and circulatory disease in his family and he was concerned that he had had a stroke.

We obtained independent medical advice on the complaint from one of our medical advisers. Although Mr A did subsequently have a stroke, the advice we received was that the symptoms with which he had presented to the practice did not suggest that he had suffered a stroke at that time. The adviser said that his symptoms were reasonably explained by other, more likely, diagnoses. Although we found that Mr A's concerns had not been fully addressed, the practice properly assessed the symptoms he presented with and arranged the appropriate tests. We found that they had acted reasonably and did not uphold this aspect of the complaint.

Mrs C told us that Mr A later did have a stroke and phoned the practice as soon as he realised what had happened. The practice recorded that he said that he was struggling to hold a cup in his left arm and was now having to drag his leg. They recorded that there was no mention of his arm being affected in the previous notes and that he might have suffered a stroke. They arranged an appointment for him later that day. However, Mr A instead went to hospital and was admitted to the stroke unit. We found that, based on the record of the phone discussion with Mr A, the correct course of action in line with relevant national guidance would have been for the practice to phone a blue light ambulance to take him to hospital. If the practice considered that there were good reasons for not doing so, at the very least, they should have recorded the reasons and arranged to examine Mr A immediately. The action they took was not appropriate and so we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology to Mr A for inappropriately telling him to attend an appointment later that day, when it was recorded that he had potentially suffered a stroke;
• make the GP that Mr A spoke to aware of our decision on this matter; and
• confirm that the matter will be discussed at the GP's next annual appraisal.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) about the care and treatment of his late mother (Mrs B). Mrs B was admitted to Glasgow Royal Infirmary with pain in her side and was found to have a kidney stone. She began taking medication to expel the stone and was discharged home for review in two weeks' time. When she attended for review, although she said she was still experiencing pain, an x-ray did not reveal any obvious stone. Arrangements were then made for a further examination and she was admitted to the New Victoria Hospital for surgery, following a discussion between Mrs B and the consultant in which Mrs B agreed to this. Mrs B was discharged the day after her surgery but later the same day she was admitted to hospital with pneumonia, moderate to severe hydronephrosis (where one or both kidneys become swollen or stretched as a result of a build up of urine) and multi-organ failure. She died a few days later in the intensive care unit.

Mr A was concerned about his mother's care. He questioned whether her previous medical history had been taken into account, whether she had been given the correct antibiotics and whether she should have been discharged the day after her operation.

In considering this complaint, we took independent advice from a consultant urological surgeon, who specialises in problems of the urinary system. We found that it had not been reasonable to operate on Mrs B and that this had not been in her best interest even though it was what she wanted. Our adviser said that best clinical practice would have been to keep her in hospital, offer her pain-killing medication and establish whether a stone was present as a possible cause of her pain. We noted that at the time of her discharge she had been well and the medication she was given was appropriate. However, Mrs B's medical notes were not clear about what was discussed with her before surgery and the risk (given her previous history) was not clear. We upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• make a formal apology to Mr A;
• ensure that the consultant urologist involved in Mrs B's surgery is made aware of the outcome of this complaint and that it is discussed at their next formal appraisal; and
• confirm to us that they are satisfied that consent forms and other clinical notes contain an appropriate level of detail.

Summary

Mr C complained that a dentist had failed to provide him with an acceptable level of treatment, including root canal treatment, which meant he had to have a significant amount of additional treatment.

In considering Mr C's complaint, we took independent advice from one of our advisers, who is a dentist. Although a drill had broken whilst inside Mr C's tooth during root canal treatment, our adviser said that this is a well-recognised complication of the treatment and is a fairly common occurrence. Mr C was concerned that part of the drill remained in his tooth, but there was no evidence of this in an x-ray taken after the treatment. Mr C had also been sprayed with water during the treatment, but the practice had already written to him to apologise for this. We found that it was reasonable for the dentist to try to repair a fractured filling rather than removing and replacing the whole filling, and that it was reasonable to prescribe Mr C with an antibiotic. In addition, we found that there was no requirement for the practice to offer Mr C an emergency appointment when a temporary filling fell out. Overall, we found that that the dental treatment provided to Mr C was reasonable.

Summary

Mr C complained about poor pain management and lack of information following hernia repair surgery (a procedure to address a bulge or protrusion of an organ through the structure or muscle that usually contains it) at Gartnavel General Hospital. Mr C said that he suffered severe pain because he was not given patient-controlled analgesia (PCA) morphine following the surgery, despite the anaesthetist having discussed his pain management and agreeing to the PCA at Mr C's pre-operation assessment.

Mr C was taken back to theatre the following morning to find out the reasons for his worsening pain, but no complications were found, and his surgery was considered successful. He suffered breathing difficulties which resulted in him being transferred to the high dependency unit (HDU) and then to an intensive treatment unit in a different hospital where he recovered several weeks later. Mr C also said that the cause of his severe pain and respiratory failure was not fully explained to him.

In responding to the complaint, the board said the anaesthetist discussed with Mr C that he would be assessed after the operation to see if a PCA was necessary. However, they also said that the respiratory failure following surgery was precipitated by poor pain control and that earlier establishment of PCA might have altered the sequence of events, although they could not be certain of this. As a consequence, Mr C was advised that in the event of future surgery, PCA and HDU care would be arranged for him because he would have a high risk of respiratory failure again.

We took independent advice on this case from one of our medical advisers, after which we upheld the complaint. Our adviser said that it was reasonable for the anaesthetist to say that the PCA would be put in place after Mr C's operation, if it was needed. However, we were critical that the PCA had not been written up on Mr C's drug chart before he was transferred from the theatre to the ward, so that it would be available if necessary. This was especially important as the record of Mr C's surgery indicated that he had undergone a long and difficult procedure, and it was highly likely that strong analgesia would have been necessary later in the evening. We considered that it was likely that a PCA would have avoided the subsequent problems with his pain relief.

Recommendations

We recommended that the board:

• share our findings with relevant medical staff involved in Mr C's pain management at the hospital in order to ensure lessons are learned;
• apologise to Mr C for the failings our investigation identified; and
• ensure that the medical staff involved in Mr C's care at the hospital record information discussed with patients and their families in line with General Medical Council guidance.