Health

Summary

Mr C complained that after he was sent to prison there was a delay in the prison health centre prescribing medication that he had been taking in the community. In particular, Mr C was concerned that he had not received a blood thinning drug for deep vein thrombosis (a blood clot in a vein) and diazepam for anxiety. In responding to his complaint, the board acknowledged and apologised that there had been a delay and partially upheld his complaint. However, they did not agree that he should have been prescribed diazepam. The health centre prescribed him a different drug that also treats anxiety and which he had been taking in the community.

After taking independent advice from our GP adviser, we found it reasonable for the health centre not to have prescribed diazepam, as it is not used to treat anxiety long term, and we noted that he was prescribed an appropriate medication that he had already been receiving. However, we noted a delay of six days before he was given this and that this may have caused him some side effects. We also found that there was an unreasonable delay of five days before Mr C received his blood thinning medication. Our adviser said that this is a potentially life-saving drug that can wear off after 24 hours. We found that both the locum (temporary) doctor who reviewed Mr C shortly after his admission to prison and the on-call doctor who saw him several days later had failed to access Mr C's emergency care summary (ECS - an electronic system for checking information about a person's health in an out-of-hours care environment), and we upheld his complaints.

During our investigation, the board carried out a further review and accepted that there were failings in the doctors promptly accessing the ECS to confirm Mr C's medication on admission. Because of this, the board drafted written guidance on the process to be followed when obtaining and maintaining an accurate list of a patient's medication on admission to prison, through their transfer and at the time of discharge.

Recommendations

We recommended that the board:

• confirm to us when the draft medicines reconciliation guidance has been implemented; and
• confirm the steps they have taken to ensure all relevant clinicians working for the health centre have knowledge of and access to the emergency care summary.

Summary

Mrs C complained that a GP at her medical practice failed to deal with her mental health problems in an appropriate manner. She said that over a two-year period they failed to provide her with a reasonable service for her mental health problems and refer her for specialist support. Mrs C said she asked the GP to refer her to a psychiatrist on a number of occasions and that her counsellor had also made a request for this on her behalf, but no referral was made. Mrs C also complained about how the GP handled the reduction of her sleep medication.

We took independent advice from one of our medical advisers, who is also a GP. We found no evidence that the GP failed to consider Mrs C's requests for referral for specialist support, or failed to refer Mrs C to a psychiatrist in response to her counsellor's request. However, the evidence showed that the practice were copied into a letter from a consultant psychiatrist to Mrs C's counsellor indicating that an appointment would be arranged for Mrs C in the 'near future'. Our adviser said that as the GP continued to see Mrs C for over a year after the letter was sent, and as Mrs C was still having mental health problems and no appointment with the psychiatrist had been forthcoming, it would have been reasonable for the GP to have enquired about this. Our adviser also expressed some concerns about the tone and content of the GP's letter in response to Mrs C's complaint. We were particularly concerned that they referred to Mrs C in the letter as 'patient', which was inappropriate. We were also concerned that the GP took nearly two months to respond to the complaint and that no updates appeared to be sent to her during this time.

On the matter of the sleep medication, it was clear that the guidance in this area was that such medication should be for short-term use and that the doctor was correct to explore the reduction in Mrs C's dosage.

On balance, however, we upheld Mrs C's complaint as we concluded that the GP failed to deal with her mental health problems in an appropriate manner.

Recommendations

We recommended that the practice:

• feed back the failings identified to the GP to ensure that a similar situation does not happen in future; and
• provide Mrs C with a written apology for the failings identified.

Summary

Mr C complained that his medical practice had failed to appropriately assess and diagnose the cause of pain and swelling in his leg. Mr C saw three GPs at the practice and was diagnosed with a Baker's cyst (a fluid-filled swelling that develops at the back of the knee and is caused by a problem with the knee joint or the tissue behind it). However, he subsequently had a pulmonary embolism (a blockage, usually a blood clot, in the pulmonary artery, which is the blood vessel that carries blood from the heart to the lungs). Mr C considered that the pain in his leg had in fact been a blood clot that had travelled up his veins and caused the pulmonary embolism.

We took independent advice on Mr C's complaint from one of our medical advisers. We found that the GPs who saw Mr C had carried out the correct investigations and had provided him with a reasonable standard of care in relation to the pain and swelling in his leg. Based on the investigations, it had been reasonable to assume that the swelling was a Baker's cyst. The GPs had also considered alternative diagnoses. We found that the pulmonary embolism could not have been foreseen and we did not uphold this aspect of Mr C's complaint.

Mr C also complained that the results of a specialised blood test he had to try to detect pieces of blood clot in his bloodstream were inaccurate. The blood test had been negative. However, there was no clear evidence that Mr C had a blood clot at that time. We found that there was no evidence that the test results were inaccurate and we did not uphold this aspect of his complaint.

Summary

Mr C had tests and investigations at Aberdeen Royal Infirmary over three years to try to identify the cause of his abdominal pain. He complained that these were not carried out in an appropriate manner, which meant he had unnecessary procedures and treatment. Mr C felt that there was a delay in him having an endoscopy (a procedure using a camera to look at the stomach) and that he should have been tested sooner for helicobacter pylori (bacteria that can cause inflammation in the lining of the stomach). He was also concerned that he was given unnecessary medication.

We obtained advice from a gastroenterologist (a specialist in the treatment of conditions affecting the liver, intestine and pancreas) and a surgeon in relation to the tests and surgical procedures. Both advisers said that these were reasonable given Mr C's ongoing symptoms and the results of the various tests. There was no indication that any of the tests should have been done sooner. It was also reasonable that Mr C was prescribed medication to see if it helped his symptoms, as there was an indication of an abnormality with his pancreatic duct (which connects the pancreas - a gland behind the stomach - with the intestine).

We concluded that Mr C received extensive assessments, investigations and treatment for his abdominal pain, and that the gastroenterology and surgical care he received was reasonable and appropriate.

Summary

Ms C complained that staff at the prison health centre had taken away her TENS machine (a form of pain relief that delivers small electrical pulses to the body via electrodes placed on the skin) that she had been using to manage pain. She also complained that she had not been told why the machine was removed.

We took independent advice from one of our medical advisers, who specialises in mental health nursing. We found that staff had removed the machine and offered alternative pain relief to Ms C. Our adviser said that staff had acted correctly in removing the machine as they had concerns for Ms C's safety. We were also satisfied that the board had explained the reason for the removal to her, and we did not uphold her complaints.

Summary

Mr C complained that he did not get adequate care and treatment at his prison's health centre for nerve pain resulting from a finger injury. He also questioned the adequacy of his medical records, as the board's response to his complaint included an incorrect date for his injury.

We looked at Mr C's medical records, and took independent advice from one of our medical advisers. We found it was appropriate for prison health centre staff to try different treatments, with a view to finding one that would provide Mr C with good pain relief. We also found that, while there was one minor error in a date in Mr C's medical records, this did not impact on the care and treatment provided to him, and the correct date was included elsewhere in the records.

Summary

Mrs C was suffering from pain in her thigh some time after having a hip replacement, and her GP referred her for an x-ray. The report of the x-ray noted that there was no abnormality, but that there were also no previous images available for comparison as Mrs C's earlier x-rays were taken in another NHS board area. Mrs C was later seen by a private doctor who considered that the x-ray did show an abnormality that needed investigation. Further x-rays showed a problem with the replacement hip and a possible fracture, and Mrs C needed two more operations to fix this.

She complained that the board had failed to identify the abnormality in her

x-ray. The board took the view that the x-ray did show a subtle abnormality, but that without previous images to compare this to, it was difficult to tell if it was significant. They explained that a new system had since been introduced which made it easier to view x-rays taken elsewhere in Scotland.

After taking independent advice from one of our medical advisers, who is a consultant in radiology, we upheld Mrs C's complaint. The adviser reviewed Mrs C's x-ray and took the view that whilst the abnormality was relatively subtle, it was visible and could have been considered potentially significant for Mrs C. The adviser explained that it would have been appropriate to refer Mrs C for further investigations on the basis of the x-ray.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure to identify and report the abnormality in her x-ray; and
• provide a copy of our decision letter to the reporting doctor to allow him to reflect on Mrs C's case and discuss any learning points at his next appraisal.

Summary

Mrs A registered with the medical practice when she moved into a care home. She had several ongoing medical conditions and was seen by GPs from the practice on a number of occasions. A number of months after moving into the care home, Mrs A became quiet and was not drinking enough fluids. Staff contacted the practice and were advised to keep her under close observation. A call back was arranged for a short time later at which time the care home staff reported that Mrs A was much better and was drinking fluids. As they also advised the practice that Mrs A had very strong, foul smelling urine, an antibiotic was prescribed to treat any underlying infection. Later that night, however, Mrs A's condition deteriorated and she was admitted to hospital later that night. She died some days later.

Mrs A's daughter (Mrs C) complained that the GPs had not provided Mrs A with appropriate medical care while she was resident at the care home. In considering this complaint, we took independent advice from one of our medical advisers, who is a GP. Having reviewed Mrs A's medical records, our adviser said that she had received reasonable care and treatment from the practice. The GPs had reviewed and amended her medication, referred her to specialists in old age psychiatry and speech and language therapy, and responded to requests for advice from the care home staff as well as monitoring her general health. We did not uphold this complaint.

However, Mrs C also complained that the practice took too long to respond to her complaint. We reviewed their complaints handling procedure and agreed that the complaint had not been dealt with within their published timescales. We also noted that their complaints handling procedure had not been updated to reflect the introduction of new legislation, so we upheld this complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to respond to her complaint in a timely manner; and
• update their complaints handling procedure.

Summary

Mr C visited his dentist because he had toothache. The dentist found an abscess that was discharging pus from the gumline of the third and fourth teeth on the lower right side of Mr C's mouth. As Mr C was already taking a course of antibiotics prescribed by his GP, the dentist said that he should let the inflammation settle before returning to have the teeth extracted. Mr C returned and his teeth were extracted but the pain and swelling continued. He went for an emergency appointment, and the abscess was found on the first lower right tooth. Mr C was referred to local maxillofacial surgeons (specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) who provided intravenous antibiotics before removing all his lower teeth.

Mr C complained that his dentist did not provide reasonable treatment during the first consultation. He said he was not already taking antibiotics and that these were prescribed when he found it necessary to visit his GP having been unable to secure an emergency appointment with his dentist.

We found clear evidence that the antibiotics were prescribed before Mr C visited his dentist. Based on the information available at that time, we were satisfied that the dentist could not provide any immediate treatment, and we did not uphold this complaint. We were, however, critical that the dentist did not take additional x-rays to identify the true location of Mr C's abscess. The failure to do so delayed treatment by around two weeks and so we upheld the complaint that the care and treatment was unreasonable. However, we were satisfied that the two teeth that were extracted had to come out in any case. We found no evidence to suggest that emergency appointments were requested and refused and did not uphold that complaint.

Recommendations

We recommended that the dentist:

• apologise to Mr C for the delay to the treatment of his abscess; and
• take note of the adviser's comments regarding the need for additional x-rays with a view to identifying any points of learning for future treatment.

Summary

Mrs C raised a number of concerns about the care and treatment that her late mother (Mrs A) received at the Victoria Hospital during two separate admissions. Mrs A was taken to hospital with symptoms suggestive of a stroke. Tests showed that she had a lung tumour, and a biopsy (tissue sample) was taken several days later. She was discharged, but was readmitted four days later having suffered a major stroke. Mrs A died three months later.

We took independent advice on this case from our nursing adviser and one of our medical advisers, who is a GP. The GP adviser identified that a number of aspects of Mrs A's medical care fell below a reasonable standard. At the time of the first admission, more consideration could have been given to the stroke diagnosis and treatment, and there was an unreasonable delay in the lung biopsy being processed although we took the view that the board had since taken reasonable steps to address this. In respect of the second admission, the GP adviser said there was a lack of communication between specialist stroke staff and the family. We also found that, although Mrs A's medication was managed well on a daily basis, there was a need for more strategic consideration of this. There was delay in providing medication to address Mrs A's high calcium levels and her low mood. In addition, medication for nausea was stopped, and there was no reason for this given in the medical records. Our GP adviser was also critical that there were a number of undated entries in relation to blood results.

We noted that the board had acknowledged Mrs C's concerns that Mrs A's dignity was compromised and that on one occasion she was not properly clothed, and our nursing adviser was satisfied with the measures the board took to address this. In relation to the management of incontinence, pain levels, involvement from speech and language therapy and dieticians, along with Mrs A's care planning and rehabilitation work, there was evidence in the medical records to support that the overall nursing care was of an acceptable standard.

Recommendations

We recommended that the board:

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