Health

Summary

Mr C complained that prison healthcare staff behaved unreasonably towards him, after he complained about another matter regarding one of the staff. Mr C told us that he had a meeting with two nurses - one of them the person about whom he had complained - during which the nurses were confrontational and threatened him.

In general terms, it is not unusual for prison healthcare staff to visit complainants to discuss their complaint face-to-face at an early stage, to see if they can resolve the matter quickly. However, even at such an early stage, it is important to ensure that the complaint is dealt with impartially. This is in keeping with the NHS' Can I Help You? Guidance, and we agreed with the board’s comment in their response to Mr C’s complaint that the nurse he previously complained about should not have attended the meeting.

Where there are differing accounts of what was said or what happened in a particular situation, however, it can be difficult to prove what actually happened. In such cases, we primarily base our findings on written records. There was no audio recording of the meeting and, therefore, there was no way to determine what was said, or how people behaved. We could not resolve Mr C's complaint given these differing accounts. However, that did not mean we believed one account over another. As there was insufficient evidence to ascertain what was said, we did not uphold the complaint.

Summary

Mr C submitted a request to see a prison dentist, saying that he had severe dental pain. Seven days later, Mr C had not received an appointment and he complained to the board. The next day, Mr C had a triage appointment with a nurse, who arranged an urgent dental appointment three days later. At this appointment the dentist found that the nerve in Mr C's tooth had died, and root canal treatment was required.

The board did not uphold Mr C's complaint, as he had received an appointment by the time this was considered and they found the delay was reasonable for a 'routine referral'. Mr C was dissatisfied with this response, and complained to us about the delay in his dental treatment.

We asked the board why Mr C's referral was classified as 'routine', given that Mr C was not seen by any healthcare professional until his triage appointment a week later. They explained that requests for appointments were reviewed by healthcare staff, and any requests which were considered urgent were seen by a healthcare professional within 24 hours.

After taking independent advice from our dental adviser, we upheld Mr C's complaint. We found that the board did not follow their guidance on referrals, as Mr C's referral should have been classified as 'urgent' and he should have been seen within 24 hours. We also found that it was unreasonable for the board to classify the referral as routine without actually reviewing Mr C, given that the symptoms he described were in the 'urgent' category.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to properly classify his dental request and the delay in issuing him a dental appointment;
• review their procedures for classifying dental referrals, to ensure that all dental cases are reviewed by a healthcare professional within the time-frames required under the Prison Care Pathway guidance; and
• consider clarifying their guidance on the 'Urgent Care' pathway to make it clear that the 24 hour time-frame refers to the patient seeing a healthcare professional, rather than dental treatment being provided.

Summary

Mr C complained to us about the care and treatment he had received from his prison health centre in relation to pain in his wrist and jaw. Mr C had been prescribed tramadol (a strong painkiller) and the dosage had been gradually increased. He was then reviewed by a doctor, who considered that the tramadol he was receiving was inappropriate. The doctor recorded that the tramadol should be reduced and stopped and that it should be replaced by other painkillers. Mr C was unhappy with the decision to stop the tramadol. We took independent medical advice and found that the overall management of Mr C's pain had been reasonable. It had also been reasonable to reduce and then stop the tramadol and to try other medications to see if they addressed his pain. Consequently, we did not uphold this aspect of Mr C's complaint.

Mr C also complained about the board's handling of his complaint. However, we found that the board had adequately investigated and responded to the issues he had raised and we did not uphold Mr C's complaint about this.

Summary

Mr C had an elective arthroscopy procedure (a type of keyhole surgery) on his right knee at Forth Valley Royal Hospital. The surgery took longer than anticipated. Mr C was discharged home the following day but was readmitted with an infection in his knee several days later. He had to undergo two washouts of the knee (a technique that involves flushing the joint with fluid) and was prescribed antibiotics to treat the infection, although Mr C said that hospital staff did not give him several doses of the antibiotics. The board agreed that this had happened. Mr C then complained that the care and treatment he received during and after his knee surgery was unreasonable.

We took independent advice from a consultant in orthopaedic and trauma surgery, who explained that Mr C had suffered a severe complication of a joint infection after surgery, which is a recognised risk but is a rare complication. The adviser said that overall Mr C's care and treatment was appropriate and the failure to provide him with antibiotics on a number of occasions did not significantly alter the eventual outcome of the infection he acquired. Nevertheless, the adviser considered the failure to administer antibiotics was either due to failure by staff to be aware of the potential complications of this, or an indifference to 'getting it right' and was, therefore, a failing by the board in their duty of care to Mr C. We were, therefore, satisfied there was a failure in Mr C's care and treatment.

We noted that a senior charge nurse had apologised to Mr C for the failure to give him antibiotics and that other nursing staff had been spoken to, to ensure that this was addressed. However, we thought that the board should apologise to Mr C as well. The adviser had further commented that although the board's explanation about the duration of Mr C's surgery was reasonable, the operation notes did not mention any particular problems or difficulties. We would have expected the reasons for the length of Mr C's surgery to have been noted, and we made a recommendation about this as well.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to administer antibiotics;
• provide us with evidence of the action they have taken to address the failure to administer antibiotics; and
• ensure that our adviser's comments in relation to the operation notes are brought to the attention of the relevant staff.

Summary

Mrs C complained about the standard of medical care she received when she reported a cough to the medical practice. She said that she reported a persistent cough on two occasions but was not referred for a chest x-ray. At a third consultation, seven months after Mrs C first reported her cough, a locum GP referred her for a chest x-ray and, after further tests, Mrs C was diagnosed with lung cancer.

We took independent medical advice from one of our GP advisers. We found that the practice missed two opportunities to arrange for Mrs C to have a chest x-ray as part of their routine investigations into a persistent cough. We found that the practice failed to reasonably follow the national referral guidance for suspected cancer which all GPs should be aware of and which clarify the significance of a cough in the diagnosis of lung cancer and state that a time-frame of three weeks should be considered a persistent cough.

When Mrs C first reported the cough it had been present for eight weeks, and when she next mentioned the cough it had been present for 13 weeks. The criteria for referral for suspected cancer had been met on both occasions. We found that Mrs C should have been sent for a chest x-ray earlier than she was, so we upheld her complaint, and made a number of recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C and her family for the distress caused by the late arrangement of investigations into the cause of her cough;
• notify the board's clinical support group and ask them to consider whether to undertake a random review of patient consultation records for quality assurance purposes; and
• carry out a reflective significant event analysis with support from the board's clinical support group and provide us with a copy.

Summary

Mrs C complained that her physiotherapist had not referred her for an MRI scan (a scan used to diagnose conditions that affect organs, tissue and bone). As the physiotherapist had not done this, Mrs C arranged one privately, which did not reveal any abnormalities. Mrs C then sought to recover the cost of her private MRI scan from the board.

As part of our investigation we took independent advice from one of our medical advisers. She said the physiotherapist's decision to refer Mrs C to the pain clinic and not for an MRI scan was reasonable. This was because the notes did not indicate that Mrs C's condition required a referral for an MRI scan, in line with the relevant guidance. Although we took Mrs C's concerns into account, our role was to determine the reasonableness of the care and treatment she received. In light of the clear advice we received that the board had acted reasonably and in line with the appropriate guidance, we did not uphold Mrs C's first complaint.

Mrs C was also unhappy at the time the board took to respond to her complaint. Mrs C had contacted them over a period of months and the paperwork showed they had failed to meet their timescales or keep her updated. We upheld this complaint and made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the delay in responding to her complaint; and
• review their handling of Mrs C's complaint and feed back to relevant staff to prevent this from happening in future.

Summary

Miss C, who is an advocate, complained on behalf of her client (Mrs A) about the nursing and medical care provided to Mrs A's late husband (Mr A) at Dumfries and Galloway Royal Infirmary after he was admitted for a below-knee amputation. Mrs A was concerned that staff had not been monitoring Mr A's urine output or identified that fluid had been building up in his lungs. Mrs A felt that this caused Mr A to suffer a heart attack. After Mr A was discharged from hospital, Miss C complained to the board, however, there was a significant delay in the response being provided, by which time Mr A had died suddenly.

We took independent advice from two medical advisers, one a nurse and the other a consultant nephrologist (specialising in kidneys). We found that Mr A had a medical history of diabetes with multiple complications that had caused kidney damage in the past. Given this history, the medical complications he suffered (including a deterioration in kidney function, fluid collecting in the lungs, and a heart attack) were not unexpected. We did not find that the complications were a result of poor care and treatment, and so we did not uphold the complaint about medical care. However, there was no clear evidence to show that Mr A had been advised about the possible risk of cardiac problems given his medical history and we drew this to the board's attention. We also found that the nursing staff had not properly completed the fluid balance charts on a number of occasions, albeit the medical staff had carried out daily examinations for signs of fluid accumulation and managed the fluids and Mr A's medication appropriately. Therefore, we upheld Miss C's complaint about the nursing care Mr A received. We could not say for certain what had actually caused the heart attack but we made recommendations to address the failings in record-keeping.

In relation to complaints handling, the board accepted that they had delayed unreasonably in responding to the complaint. We were critical that there was a 13 week delay and made a number of recommendations to address the matter.

Recommendations

We recommended that the board:

• carry out an audit of patient medical records for the wards involved to ensure that fluid balance charts are being accurately completed;
• review their complaints procedure with a view to ensuring measures are in place to update complainants regularly in line with the guidance in the event that the 20 working day timescale cannot be met;
• remind all relevant staff dealing with complaints of the importance of updating complaints with the reason for any delays and their entitlement to contact us if the delay exceeds 20 days;
• apologise to Mrs A for the failings identified in the nursing care provided and complaints handling;
• take steps to ensure that the target timescale for dealing with complaints is met wherever possible; and
• ensure the nursing staff involved in Mr A's care are made aware of the importance of adequately assessing, monitoring and recording fluid balance.

Summary

Mrs C complained about a number of aspects of the care and treatment she received in A&E at Dumfries and Galloway Royal Infirmary. These included concerns about the examinations and investigations carried out and whether doctors should have identified that she had a pulmonary embolism or embolus (a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream), which was discovered when she attended hospital again ten days later.

We obtained independent medical advice on the case from a consultant in general medicine. Our adviser explained that the level of investigation during Mrs C's attendance at A&E was not sufficiently detailed to justify the exclusion of the diagnosis of pulmonary embolus and that in this regard, Mrs C's care fell below the level that she could have expected.

The adviser said it was not possible to say that Mrs C's pulmonary embolus would definitely have been diagnosed if more care had been taken during her attendance at hospital. However, he said it was much more likely to have been diagnosed if doctors had carried out a sufficiently detailed assessment and investigation. The adviser also explained that, overall, he considered it likely that Mrs C's pulmonary embolus was present when she first went to A&E, and should have been considered as a diagnosis at that time.

Recommendations

We recommended that the board:

• feed back the failings identified to the staff involved and ask them to complete reflective commentaries for their educational/appraisal portfolios; and
• provide Mrs C with a written apology for failing to perform an adequate assessment of her in A&E.

Summary

Ms C was admitted to Borders General Hospital (hospital 1), then Knoll Hospital (hospital 2) after being involved in an accident. She was given pain relief at the scene of the accident and taken to hospital 1. On arrival, there was a mix-up over patient details and Ms C told us that on that day and the following day, staff tried to give her medication meant for another patient. Ms C told us that this took some time to resolve and, as a result, she said she was not given pain medication in a timely manner or when requested. She also believed she was given an overdose of morphine, which affected her ability to pass urine. She alerted nursing staff who then identified a urine retention issue. Ms C was transferred to hospital 2 the following month. She said that nursing staff there were institutionalised in their attitudes and treated her as if she was an elderly patient. Ms C discharged herself five days later.

We took independent advice on this case from our nursing adviser, who said that pain charts were not fully utilised at hospital 1 to manage Ms C's pain. Although pain was recorded there was no record of any action taken. In addition, Ms C was known to the pain team but they were not alerted until four days after her admission. We also found that although Ms C was already known to have chronic pain, she was not assessed for this in a proactive manner, and that in this instance care was not reasonable. Moreover, we were concerned that her patient details were incorrect. This was rectified and did not result in any medication errors, but could potentially have had more serious consequences. We were satisfied that the nursing care in relation to urine monitoring and that provided by staff at hospital 2 including their attitude was reasonable, and were satisfied Ms C was not given an overdose of morphine. However, in light of the failings identified, we upheld the complaint.

Recommendations

We recommended that the board:

• review how pain is assessed and monitored in Borders General Hospital and how instruments such as early warning system charts are used;
• inform us of the steps taken to ensure patient details are correct; and
• apologise for the failures this investigation identified.

Summary

Mr C complained about care and treatment provided to his late mother (Mrs A) by the board. Mrs A attended the A&E department at University Hospital Ayr and was admitted to the hospital, where she was diagnosed with a urinary tract infection. Mrs A had a number of longstanding conditions including spinal curvature and lymphoma (a type of cancer). An x-ray was taken which showed a large abnormality at the top of the right lung. This was reviewed by a doctor who considered the progression of Mrs A's lymphoma as a possible diagnosis. After being advised that Mrs A's x-ray showed deterioration, Mr C and his family decided to take her home and she was discharged the following day. The doctor's reading of the x-ray was incorrect as the abnormality was caused by Mrs A's head resting against her chest. The family were advised of this after her discharge and she was readmitted two days after returning home. Mrs A died several weeks later.

Mr C complained that Mrs A had not been given appropriate medication for her infection due to the misdiagnosis and that this had hastened her death. Mr C also complained that the response to his complaint was inadequate.

After taking independent advice from our medical adviser, we found that there had been a major error in the doctor's interpretation of the x-ray and that Mr C and his family should not have been advised that there was a deterioration in her condition. Although we did not find any evidence that Mrs A had been given inappropriate medication or that the incident had hastened her death, we upheld Mr C's complaints due to the significance of the error in reading the x-ray. We also found that the board's investigation of Mr C's complaints did not fully address the doctor's error and that the responses provided were inconsistent. We upheld both Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• make staff aware of our adviser's comments on the incorrect diagnosis and determine if there are lessons that can be learned from this incident;
• remind staff of the importance of keeping accurate contemporary records in line with the relevant General Medical Council guidance;
• provide a copy of our decision to the doctor to ensure he is fully aware of the outcome of this investigation and allow any learning points to be discussed at his next appraisal; and
• carry out a review to determine if the doctor's misinterpretation of the x-ray was an isolated incident and provide appropriate training if required.