Health

Summary

Mrs C complained that the board's decision to discharge her from the A&E department of the Royal Infirmary of Edinburgh was not reasonable.

Mrs C had accidentally swallowed her dental plate and was taken to A&E by ambulance. She complained that her plate caused her to choke and that she waited a long time in A&E before being sent for an x-ray. Although the x-ray did not identify her dental plate Mrs C said she knew it was still in her throat when she was discharged; around two weeks later, she started choking, coughed and dislodged it.

As part of our investigation, we took independent advice from two of our advisers (the first was an experienced ear, nose and throat specialist and the second was an A&E consultant). Our first adviser said the focus of staff in A&E appeared to have been on Mrs C's digestive system, as opposed to her throat (her chest was x-rayed and she was told to return if she developed abdominal pain). He explained that there were additional steps that could reasonably have been taken by A&E staff prior to Mrs C's discharge and our second adviser also said that A&E staff could reasonably have done more.

Our role was to consider whether the care and treatment Mrs C received in A&E was reasonable in the circumstances at the time. This meant we could not rely on hindsight and, as our first adviser pointed to some things that may not have been immediately apparent to a non-specialist, we took his relative expertise and experience into account (in addition to our second adviser's view). Taken as a whole, we were satisfied that the board's decision to discharge Mrs C had been unreasonable in the circumstances and we upheld her complaint. We made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• use this case as a learning point for staff at the next departmental meeting, in particular in relation to carrying out appropriate examinations and recording this in the medical records.

Summary

Mr C complained about the care and treatment he received from the board when he was admitted to prison. He said that he had consultations with two psychiatrists, but the consultations were too short for them to make reasonable decisions about his medical treatment. We found that there was evidence to show that the assessment completed by one of the psychiatrists was reasonable and that she was able to make decisions based on this. However, the evidence the board sent us had no record of the review by the second psychiatrist, so we were unable to say whether this review was reasonable, and we upheld this aspect of Mr C's complaint.

Mr C also complained that the board failed to prescribe a benzodiazepine class drug (drugs used to treat anxiety, insomnia, and a range of other conditions) that he had been receiving when he was admitted to prison. There was no evidence, however, that staff were made aware that he was receiving this medication at the time. It was also reasonable that they did not prescribe the drug when they were told about it, because there were other ways in which they could manage Mr C's symptoms. He also complained that the board had delayed in providing him with tablets that he had been prescribed to help him sleep, and that he had not received these on some of the dates the board recorded he had been given them. In addition, he complained that it was difficult to get the board's complaints forms. As we found no evidence to support these aspects of Mr C's complaint, we did not uphold them.

Finally, Mr C said that he had to wait some months for a mental health review. We upheld this aspect of his complaint, as we found that an appointment with the mental health team had been arranged, but was cancelled because he was at court that day. The appointment was not rearranged until Mr C complained about the delay more than three months later.

Recommendations

We recommended that the board:

• remind the psychiatrist of the need to ensure that appropriate records of consultations are kept in line with General Medical Council guidance;
• make prison healthcare staff aware of our finding that the delay in rearranging Mr C's appointment was unacceptable; and
• issue a written apology to Mr C.

Summary

Ms C complained about the care that her father (Mr A) received from the board. Mr A's optician referred him to the Princess Alexandra Eye Pavilion (the hospital) when he complained of failing sight in his left eye. He was referred to the stroke clinic to check for a possible mini-stroke, and was given medication to prevent blood clots. Ten days after his initial hospital referral, Mr A was referred by his optician again, having started to experience problems in his other eye. Upon examination, issues highlighted by the optician were not recorded by the hospital eye specialist and Mr A was advised to attend an appointment he already had scheduled around three weeks later. Mr A attended that appointment, but his vision had deteriorated further. Staff were concerned that Mr A might have giant cell arteritis (GCA: inflammation of the arteries, particularly around the temples) and prescribed steroids. A scan and biopsy (tissue sample) of an artery in his head were also ordered. The biopsy was inconclusive, and Mr A was continued on steroid treatment in line with a diagnosis of GCA.

We took independent advice from one of our medical advisers - a consultant ophthalmologist (a doctor who examines, diagnoses and treats diseases and injuries in and around the eye). Our adviser said that Mr A suffered from anterior ischaemic optic neuropathy (AION: loss of vision due to damage to the optic nerve through lack of blood supply). This can be either arteritic, or non-arteritic (either caused by inflammation of the artery walls or not), and there is no treatment for non-arteritic AION.

We found that Mr A did not display symptoms normally associated with GCA when he first attended the hospital, and that his referral to the stroke clinic was appropriate in the circumstances. When he returned to the hospital, he and his optician had clearly reported a deterioration in his condition, with new symptoms affecting his right eye. The eye specialist did not observe these, but we were critical that he did not seek a second, senior, opinion, given Mr A's recent history and the optician's comments. We took the view that this resulted in an unreasonable delay in Mr A receiving steroid treatment. Our adviser also said that GCA is normally diagnosed by biopsy, but in Mr A's case the sample was too small to provide a definitive diagnosis. It was, therefore, impossible to say whether or not he had GCA or non-arteritic AION. However, we took the view that had steroid treatment started sooner the sight in Mr A's right eye might have been preserved.

Recommendations

We recommended that the board:

• apologise to Mr A for the issues highlighted in our investigation;
• share our decision with the staff involved in Mr A's treatment; and
• conduct a review of Mr A's case with a view to identifying any points of learning.

Summary

Mr C suffered from ongoing problems urinating and tried to treat these himself, but this caused him further problems. He went to A&E at St John's Hospital and the urology department at the Western General Hospital several times. He was prescribed antibiotics for infection and given an appointment for a cystoscopy (an operation using a special telescope to examine the urethra - the tube that allows urine to pass out of the body - and bladder).

Mr C did not attend the appointment, as he said he did not receive the letter and did not know where to go. Another appointment was arranged, but Mr C developed another infection before this. He was prescribed more antibiotics, and although the operation could not be carried out, the surgeon met Mr C to discuss his condition and treatment. Another appointment was made for the cystoscopy, but Mr C was worried about the operation. He wrote to the surgeon about it, and they met again to discuss his concerns and his treatment plan, after which the operation went ahead with a different surgeon. Follow-up tests, however, showed that it was not successful and the new surgeon arranged for Mr C to have an urethrogram (an x-ray examination of the urethra). He planned to follow this up in his clinic, but Mr C was not given a follow-up appointment.

During this time, Mr C made several complaints about his treatment, in particular about medical staff being reluctant to give him ongoing antibiotics, which he thought he needed. He emailed the board's complaints team regularly about his complaints and ongoing health problems. While the board investigated and responded to several complaints, they eventually told him that the complaints team was not able to influence his medical treatment. They said that they would not respond to further complaints about antibiotics, but would investigate any new matters. However, when Mr C wrote to complain that he had not heard back since his urethrogram, the board told him that his complaint was closed and would not be investigated. Mr C asked his MSP to complain on his behalf, but the board told the MSP that the complaint was too old, as the events had happened over six months before. Mr C then complained to us about his medical treatment and the board's handling of his complaints.

We investigated Mr C's complaints and took independent medical advice on his case. As a result of our enquiries, the board acknowledged that he had not been given a follow-up appointment, and they arranged this as a matter of urgency. We upheld Mr C's complaint about treatment, as it was unreasonable that the board had at first failed to arrange this. We also found no evidence that Mr C was sent an appointment letter for his first surgery date, and we were critical of this. Finally we noted a lack of continuity in Mr C's care (with nine doctors involved over a six-month period). Although the first surgeon showed particular care in meeting twice with Mr C to explain his treatment, the lack of continuity meant that Mr C did not fully understand the treatment plan, or the importance of treating his underlying problems as well as taking antibiotics.

We also upheld Mr C's complaints about the board's complaints handling, as they did not correctly follow their complaints handling policy or their unacceptable actions policy. In particular, the board should have tried to clarify Mr C's complaints earlier, and should have told him as soon as they had concerns about the amount of contact he was having with them. We also found that they should have investigated his last complaint about the lack of follow-up appointment, as it raised a new issue that had occurred within the last six months and had not previously been investigated.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failings our investigation found, and provide a reassurance that his future requests for medical care will be treated with respect;
• review the processes for arranging urology appointments at the Western General Hospital, to ensure there are clear records of when an appointment is required and when an appointment letter (or replacement letter) has been sent;
• consider identifying a single clinician to maintain continuity of care in cases where the patient may benefit from this;
• remind complaints handling staff of the requirements of the complaints policy in relation to clarifying complaints at the outset and the time-frames for acknowledging and responding to complaints;
• identify and address any training needs for complaints handling staff in relation to supporting vulnerable complainants (including responding appropriately to comments relating to self-harm); and
• review complaints handling processes and procedures to ensure they comply with the unacceptable actions policy.

Summary

Miss C attended the A&E department at Hairmyres Hospital with abdominal (stomach) pain. After examination in A&E, she was transferred to one of the wards. She complained about her treatment in both A&E and on the ward, in particular that a doctor wrongly decided she was an abuser of alcohol which had an impact on the treatment she was given.

We took independent advice from one of our medical advisers. Our investigation found that the doctor had formed the conclusion about the alcohol use from a 13-year-old entry in Miss C's medical records, which referred to one episode of alcohol abuse at that time. We did not consider it was appropriate to make the assumption he made from that entry and concluded the doctor should have made more of an effort to find out the current facts. As we otherwise found Miss C's care and treatment to be appropriate, we did not uphold the complaint but we made two recommendations.

Recommendations

We recommended that the board:

• add a note to Miss C's medical records to show the context in which they made their remarks about previous alcohol excess and about a treatment plan; and
• ensure that the doctor discusses the complaint with his education supervisor as part of his training record.

Summary

Mr C had concerns that action was not being taken to prevent patients, visitors and staff from smoking at entrances to buildings at Monklands Hospital. He tried to report the matter via the contact number displayed on the 'no smoking' signs but no such number existed. When Mr C spoke to staff about the matter they seemed resigned to the fact that smoking outside the premises was an ongoing problem that happened all the time. He complained to the board but their response did not address all the issues he raised, and he brought the matter to us. We upheld his complaint, as we found that the board's response lacked detail and did not address a number of Mr C’s questions.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings which have been identified as a result of our investigation; and
• review their original response and provide Mr C with a further response which addresses the specific concerns which were raised.

Summary

Mrs C was unhappy with a phone consultation she had with an out-of-hours GP. Specifically, Mrs C complained that the GP failed to visit her at home or arrange a visit by another GP, and that the GP terminated the phone consultation and gave an inaccurate account of the phone consultation. In addition, Mrs C complained about the board's handling of her complaint.

We looked at Mrs C's medical records, and took independent advice from one of our medical advisers. We concluded that the service Mrs C received was below a standard that could have been reasonably expected. We found that the GP should have agreed an outcome of the consultation with Mrs C and communicated this to her; in particular, that Mrs C should have been referred for a home visit as she felt unable to travel to the local hospital. In terms of how the board dealt with Mrs C's complaint, we found that their initial responses were in line with their process, and that it was reasonable of them to offer an opportunity to meet with staff to discuss the complaint. However, a delay in concluding the complaint was unreasonable, and it was only after Mrs C had prompted the board that a promised update was provided. We upheld these aspects of Mrs C's complaint. However, given the actions already taken by the board to resolve these matters, we did not make any recommendations.

In relation to Mrs C's complaints about what happened during the phone consultation, we found that there was no audio recording of the call. Where there are differing accounts of what was said or what happened in a particular situation, it can be difficult to prove what actually happened. In such cases, we primarily base our findings on written records. As there was no audio recording in this case, there was no way to determine what was said, or how the call was ended. Even then, it would have been difficult to ascertain exactly what caused the call to end. We could not resolve these aspects of Mrs C's complaint given the differing accounts. However, that did not mean we believed one account over another. Given there was insufficient evidence to allow us to reach a finding, we did not uphold these aspects of Mrs C's complaint.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Ms A) about the actions of a health visitor in relation to a burn to Ms A's child's arm. The burn was treated at the time by the child's grandmother, who is a healthcare professional. Some weeks later, the child's GP noticed the burn during a routine visit, and asked the health visitor to visit Ms A. During the visit, Ms A explained that the burn had been caused by an accident with a pair of hair straighteners: she had left the hair straighteners on, thinking they were out of reach of the child, but the child had pulled on the cord, causing the straighteners to fall onto the child's arm. The health visitor was not satisfied with this description and, after consulting with the child's GP, the child protection adviser and the duty social worker, she submitted a Notification of Concern to social work.

Ms C complained that the health visitor acted inappropriately by insisting that social work take action, despite being advised by the child protection adviser and the duty social worker that the child was not at risk. Ms C raised concerns that the health visitor failed to assess the situation appropriately and did not obtain additional information from the previous health visitor or the child's medical practice; that the description of the burn given to social work by the health visitor was inaccurate; and that the health visitor acted unreasonably by failing to inform Ms A before making the referral.

We investigated Ms C's complaint and took independent nursing advice from one of our advisers. We found that the health visitor had followed the appropriate procedures in making the referral to social work, including by appropriately discussing her concerns with the child's GP, the child protection adviser and the duty social worker. Although the health visitor did not follow the advice provided by the duty social worker that a referral was not necessary, we accepted that the decision whether to make the referral was a matter for the health visitor's professional judgment, and we were not critical of this. We also found that the description of the burn which the health visitor gave social work was reasonable in the circumstances. However, we found that the health visitor failed to comply with the relevant policy by not discussing her decision to share information with social work with Ms A, before making the referral. On balance, we upheld Ms C's complaint.

Recommendations

We recommended that the board:

• issue a written apology to Ms A for the failings our investigation found;
• review their guidance on child protection referrals, including both internal and national guidance, to ensure that there are clear and consistent steps for healthcare professionals to follow when considering a child protection concern; and
• raise the findings of our investigation with the health visitor for reflection.

Summary

Mrs C complained on behalf of her late mother (Mrs A) about the care and treatment Mrs A received at Monklands Hospital. She had fractured her neck and was admitted to hospital for conservative management (medical treatment avoiding radical therapeutic measures or operations).

Mrs A had a history of chronic obstructive pulmonary disease (a type of lung disease) and was treated for a chest infection whilst in hospital. She was also found to have fractured ribs. Mrs A's chest condition deteriorated and an x-ray revealed a haemothorax (blood in the cavity surrounding the lung). A chest drain was inserted to drain the fluid, and she was transferred to the High Dependency Unit for several days then transferred back to the ward when her condition stabilised. However, a few days later she suffered a rapid deterioration and died.

We took independent advice on this case from one of our medical advisers who found that the decision to transfer Mrs A back to the ward was reasonable given that her breathing rate, oxygen levels, blood pressure, and heart rate were all stable and met the board's transfer criteria in this respect. We also took independent advice from our nursing adviser, and noted that the board had acknowledged that there was delay in a drip being reconnected due to the cannula (intravenous tube) becoming dislodged and that a dose of antibiotics was missed. They provided refresher training for the ward staff, and a member of the nursing staff had apologised to the family. We found this reasonable and our nursing adviser considered that this was not a significant failing that affected the overall outcome for Mrs A.

Although we noted that the board had arranged for staff to have refresher training in relation to chest drains, neither of our advisers identified any evidence of failings with the management of the chest drain. In relation to Mrs C's concerns about staffing on the ward, we found that some of the shifts had lower numbers than planned, but that bank staff and overtime were used to address this, which was reasonable. On balance, we concluded that the medical and nursing care was reasonable.

Summary

Mrs C complained about the treatment she had received from her GP when she reported a lump in her breast. Mrs C attended the medical practice twice before being referred to the breast clinic where she was later diagnosed with breast cancer.

Mrs C said that she should have been referred to the breast clinic sooner and was concerned about the GP's attitude. Mrs C also said that when she was referred, the referral should have been classed as urgent rather than routine.

During our investigation we asked for independent advice from one of our GP advisers. Our adviser found that the GP had conducted a thorough examination of Mrs C and gave her appropriate advice regarding monitoring the lump. The adviser said that it was hard to judge the attitude of the GP through the medical notes, however, based on the record of Mrs C's condition at the time of the referral, and relevant National Institute for Health and Care Excellence (NICE) guidance, a routine referral was appropriate. We did not uphold Mrs C's complaints.