Health

Summary

Mr C had an accident at work and injured his shoulder. He was diagnosed with a sprain at A&E in Falkirk and District Royal Infirmary. No x-ray was taken and Mr C was told to see his GP if the pain continued. Mr C was referred to a specialist who suspected that he might have a rotator cuff tear (a tear to one of the tendons that stabilise the shoulder). The specialist arranged for a scan but no tear was found. Some time later, Mr C was referred to another specialist at Forth Valley Royal Hospital who carried out further tests and a second scan. Mr C was diagnosed with impingement syndrome, a condition where the bone and tendons of the shoulder rub together painfully. He was offered surgery and advised that this had a 60 to 70 percent chance of success. During the operation, the surgeon discovered that Mr C had an abnormality in his shoulder where pieces of bone had not fused together when he was a child. There was an unfused fragment of bone about three centimetres long, which the surgeon could not remove without causing damage. Mr C was advised that if his symptoms did not improve after the operation, he would require further surgery to fix the piece of bone using a screw. Although he was still in pain, Mr C decided not to go ahead with another operation. He then complained that an

x-ray or other imaging should have been carried out earlier as this would have highlighted the unfused fragment of bone. He was particularly concerned his surgery went ahead without this being done.

After taking independent advice from two of our medical advisers, we found that normal x-rays would not have shown the unfused piece of bone in Mr C's shoulder, as it would only have been visible on a special view x-ray that would not normally be requested. Although our accident and emergency adviser told us x-rays should have been taken after the accident and a review at the fracture clinic offered if Mr C's pain did not get better, our surgical specialist said that, even if it had been identified, an unfused piece of bone like that would not have been considered to be the cause of his pain and the treatment would have remained the same. This is because unfused fragments of bone in the shoulder do not usually cause any symptoms. Our surgical specialist also told us that

x-rays would not be carried out before such surgery and that scans are commonly used.

We found that Mr C's shoulder should have been x-rayed after his accident but there was no evidence that this would have resulted in an earlier diagnosis of the unfused piece of bone. We also considered it unlikely that an earlier diagnosis would have changed the treatment he received. Although we did not uphold his complaint, we made a recommendation.

Recommendations

We recommended that the board:

• take steps to ensure that A&E staff are made aware of our adviser's comments on x-rays and the offer of review at the fracture clinic in this case.

Summary

Mr C complained about the NHS health centre at his prison. He said that the health centre doctors did not provide adequate care and treatment when he sought medical attention for stomach, testicular and rectal (bowel) concerns.

We took independent advice from one of our medical advisers, who is a GP. We found that Mr C had been appropriately examined and assessed in respect of the rectal issues. However, we upheld that part of his complaint because, although Mr C had not been presenting with a clinical picture that suggested bowel cancer, he had visited the health centre several times on the same matter. National guidelines on the diagnosis and management of bowel cancer recommend that a specific blood sample is taken for all patients with persistent or recurring rectal bleeding (bleeding from the anus). That was not done in Mr C's case. Doing this would have better equipped the doctor to decide on the urgency of the referral that he made to the hospital. We also found that the referral letter to the hospital was not sent until two months after the doctor decided on a hospital referral. Although the clinical picture was not suggestive of bowel cancer, the part that rectal bleeding can play in bowel cancer makes that delay worrying. In due course, Mr C attended hospital and was discovered not to have cancer.

We did not uphold Mr C's complaints about the other issues as his medical records showed that the health centre had appropriately examined and assessed him in relation to these and we had no further concerns.

Recommendations

We recommended that the board:

• arrange for the prison health centre to audit a representative sample of their hospital referrals to ensure they are being sent in a timely manner;
• arrange for the prison health centre doctor to undertake a specific educational activity related to anaemia and bowel symptoms, for the purposes of Continuing Professional Development; and
• arrange for the prison health centre doctor to include the case in his annual appraisal.

Summary

Mr C, who is an independent advocate, complained on behalf of his client (Mrs A) that the board did not take reasonable steps to prevent Mrs A's husband (Mr A) from developing a pressure ulcer (bed sore) during his stay in Inverclyde Royal Hospital. Mr A had terminal cancer and was admitted to hospital for palliative care (care provided solely to prevent or relieve suffering). He was there for ten days, and was then discharged home with no mention of a pressure ulcer. Later on the day of his discharge from hospital, a district nurse examined Mr A and found that he had a pressure ulcer.

We took independent advice from our nursing adviser, who said that the board had not thoroughly assessed Mr A during his admission and so had not recognised his increased risk of developing a pressure ulcer. If this had been done then Mr A's condition would have been more regularly assessed. The adviser was critical that staff relied on the assessments made when he was admitted, and said they had not exercised good clinical judgement. The adviser also said that the record-keeping was poor. In light of these failings, we upheld the complaint. As, however, the board had already taken positive steps to stop this happening again, we made only one recommendation.

Recommendations

We recommended that the board:

• provide Mrs A with information about steps taken to address the shortcomings identified.

Summary

Ms C, an advice worker, had written to her client (Mr A)'s medical practice to seek clarification about whether a request that Mr A made to his GP for a referral had been carried out. She received no response. After two follow-up letters were also ignored and two months had gone by, Ms C complained to us.

The practice told us that they did not consider that entering into correspondence with Ms C would serve any practical purpose as the issues Mr A was concerned about had been dealt with some years previously. We decided, however, that the practice should have explained this to Ms C. We, therefore, upheld her complaint that the practice did not reasonably respond to her correspondence.

Recommendations

We recommended that the practice:

• apologise to Ms C and Mr A for the failure to reply to correspondence; and
• review their communication policies to ensure that they clearly advise correspondents when a decision is taken that correspondence will not be responded to, and explain the reasons for that decision.

Summary

Mr C complained that his medication was stopped after a spot check of his cell revealed a discrepancy in the medication he should have had in his possession. The check showed that capsules had been emptied and, as a result, the prison health centre stopped the medication. Mr C complained, saying that his cellmate had told a prison officer that it was he, the cellmate, who had taken the contents of the capsules. Mr C could not see why he was being punished for something that someone else had done without his knowledge.

We took independent advice on this case from two of our medical advisers, one of whom is a GP and the other is a nurse. Our investigation confirmed that the cellmate had told a prison officer that he had taken the medication. However, the medication in question, gabapentin, is one that is prone to misuse in prisons. Drug security in prison is particularly important, and as someone - regardless of who - had tampered with the medication, the NHS policy is to stop supplying the medication. Mr C had signed a medication contract in the prison, confirming that he was aware that medication would be stopped if there was any discrepancy and that it was his responsibility to keep any of his medications safely.

We, therefore, considered the health centre had acted appropriately in stopping the medication when the discrepancy was discovered and we did not uphold Mr C's complaint.

Summary

Mr C complained on behalf of his wife (Mrs C) who suffers from various life-limiting medical conditions, including Raynaud's Disease (a condition where the blood supply to the extremities is severely restricted, causing pain and ulcers). Mrs C receives regular infusions of a drug to help with this condition, and Mr C complained about the way this treatment was administered during one period of time. He also complained about the way the board handled his complaints about this.

Mrs C is admitted to Ninewells Hospital every three months to have a series of seven-hour infusions over a five-day period. Normally 17 hours of rest are allowed between infusions. However, the board's protocol for the treatments says that they can be given with a minimum of 12 hours between them. During one admission Mrs C's treatment was compressed according to this protocol, to allow her to be discharged from hospital earlier. Mrs C developed severe headache, nausea and vomiting, and asked that this should not happen again. Despite this, she felt that her treatment was compressed on her next admission.

Our investigation included taking independent advice from a medical adviser with experience in treating patients with Raynaud's Disease. The adviser said that there are no national guidelines on administering this treatment, but that the board's protocol was in line with normal NHS practice to give infusions over a six to eight hour period across three to seven days. The adviser reviewed Mrs C's treatment and found that the infusion was given after less than a 12 hour break only once - when one was given after 11 hours. However, the adviser was of the view that this was still within normal NHS practice. They also said that staff took appropriate action to address the side effects Mrs C suffered, and noted that headache, nausea and vomiting were common side effects. After considering this advice, we did not uphold Mr C's complaint about treatment as we were satisfied that, overall, this was reasonable. We also noted that Mrs C now has a patient-held treatment plan confirming that no compression will take place in future.

We did, however, uphold his complaint about the board's complaints handling, as there were unacceptable delays in their responses. Our investigation found that Mr C complained in August, September, and November 2012, and again in May 2013. The board responded by arranging a meeting in June 2013 and sending a written response two weeks after the meeting. Mr C then made a further complaint about that response, to which the board replied two months later. The board said that Mr C several times added new complaints before previous complaints had been responded to, which caused part of the delay as the response due dates were amended. However, they also acknowledged that there were some avoidable delays due to staff error and staff shortages and that it would have been better to have dealt with each complaint separately. They explained that they had since made changes in their complaints department to address the issues identified.

Recommendations

We recommended that the board:

• issue a written apology for the unacceptable delays that occurred in dealing with Mr C's complaints; and
• provide us with evidence of the improvements that have taken place within the complaints department since Mr C's complaint and evidence of the progress of any ongoing work to improve complaints handling.

Summary

Ms C complained on behalf of her daughter (Ms A) about the care and treatment she received at the Western Infirmary for appendicitis. She complained that her daughter was not fully diagnosed soon enough, as there was a delay to her initial scan, and she was not monitored appropriately. She also said that a delay in operating to remove Ms A's appendix caused a rapid deterioration in her condition and a more complex operation. Ms A was operated on some 24 hours after she was admitted to hospital. Ms C also complained about the board's handling of her complaint.

The board had accepted that there was poor communication in relation to some elements of Ms A's care, and that the family were misled in relation to when the operation might take place. They apologised for the distress this caused.

After taking independent advice from two of our advisers - a consultant surgeon and a nursing adviser - we upheld both complaints. The surgical adviser was satisfied that Ms A's treatment was reasonable, and that the operation took place within a reasonable timeframe. However, the nursing adviser was concerned that Ms A was not monitored frequently enough, given that the reason for admitting her to hospital was to keep her under close observation. We were also critical of the communication between ward staff and Ms C. She was given inaccurate information on at least three occasions, increasing the family's distress.

We found that the board had delayed in responding to Ms C's complaint, and did not act on assurances they had given during that process. The board explained to us, however, what they had since done to ensure that this did not happen again, so we made no recommendation about this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• reflect on the failures in communication that our investigation identified, and consider how communication with patients and their families could be improved to ensure information is as accurate as possible; and
• ensure that nursing staff within the surgical unit are aware of the importance of carrying out vital signs observations as part of their role in the assessment and monitoring of surgical patients.

Summary

Mrs C's late father (Mr A) had a rare type of lung cancer and was admitted regularly to the Victoria Infirmary for problems related to this, particularly chest infections. In early 2013, he was admitted there and started on antibiotics to cover the possibility of another chest infection. A few days later, a doctor described him as being frail and it became apparent, as Mr A deteriorated further, that he was at the end of his life. He received palliative care (care provided solely to prevent or relieve suffering), and he was reviewed by several doctors and prescribed pain relief for agitation. Mr A died two weeks after being admitted to hospital.

Mrs C complained about the end of life care her father received, saying that he was not given reasonable pain relief or antibiotic treatment and that there was a lack of senior clinical input. She also said that nursing staff failed to assess his pain and keep comprehensive records. Mrs C said that her father was screaming out in pain during the latter stages of his illness, and she was extremely concerned that staff failed to respond to this appropriately.

We took independent medical advice on the case from two of our medical advisers, one of whom is a doctor specialising in care for the elderly, and the other a nurse, after which we did not uphold Mrs C's complaint. We found that we were unable to reconcile the different accounts of the level of pain that Mr A experienced, and the advice we received was that Mr A had symptoms of breathlessness, anxiety and agitation, which were treated adequately. There was no evidence in the medical records or statements from staff of Mr A screaming in pain. We noted that a delay in providing antibiotics and failure by senior staff to review Mr A had been raised with the staff concerned, but our medical adviser (a doctor specialising in care for the elderly) said that these did not affect what happened or the management of Mr A's condition. Our nursing adviser also noted a lack of documentation in relation to pain assessment and end of life care, and we made a recommendation about this. However, again these did not impact on the care Mr A received, which she said was of a reasonable standard.

Recommendations

We recommended that the board:

• ensure the failures in record-keeping, in particular completion of SEWS (Scottish early warning system - a set of patient observations) are raised with relevant staff.

Summary

Mrs C attended A&E at Monklands Hospital in the early hours of the morning with her daughter (Miss A), who was given a liquid steroid to treat croup (an infection of the voice box and windpipe) before being discharged. Later that same day, and after speaking with NHS 24, Mrs C returned to A&E because she felt that Miss A's condition had not improved. Mrs C said she was advised that an out-of-hours (OOH) appointment had been booked for her daughter that evening but that she did not know about it. A nurse examined Miss A, and after a discussion with the duty consultant, advised Mrs C that she could take her daughter home. The following day, Mrs C visited her doctor for an unrelated issue and whilst there, the doctor examined Miss A and confirmed there was a slight wheeze so prescribed steroids. Because of this, Mrs C complained that the care and treatment provided to her daughter in A&E was unreasonable.

The board told Mrs C that because Miss A was well and had a normal set of observations, the duty consultant felt it would be best if she was allowed to attend her booked OOH appointment. They said this was because it was unlikely that she would be seen by an A&E doctor earlier than the time of the scheduled appointment later that evening. However, when we examined the evidence, we identified that the scheduled appointment had already been cancelled because Miss A was seen in A&E. When we asked the board about this, they told us that the appointment with the OOH service would have been cancelled when Mrs C arrived at reception in the A&E department. The board said the receptionists for both services sat side by side and would have liaised with each other about this.

We took independent advice from one of our medical advisers, but he said he was unable to say whether the care and treatment provided to Miss A by the A&E department was reasonable, given that the duty consultant made an incorrect assumption that her OOH appointment was still booked for later in the evening that day. We found that the consultant appeared to have taken the decision to allow Miss A to leave A&E on the basis of inaccurate information and because of that, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure our investigation identified; and
• take steps to review what happened in Mrs C's case and ensure appropriate measures are in place to prevent the same thing from happening again.

Summary

Mrs C complained about the care and treatment of her late husband (Mr C). Mr C was diagnosed with lung cancer and over a five-month period had six appointments with five different consultants. At most of the appointments, which were at both the Beatson Cancer Centre and Royal Alexandra Hospital, Mr and Mrs C had to wait around one and a half hours beyond the appointment time, which was extremely stressful for them. Mr and Mrs C also attended one of the appointments expecting to receive the results of a scan. However, this was not available until 17 days after it was taken, when Mr C began to develop increasing weakness in his legs. He was admitted to hospital the following day and developed complete paralysis of his legs and lack of sensation up to his abdomen. The cancer was found to have spread to his spine, leading to spinal cord compression, and Mr C died shortly after. Mrs C complained that if the results of the scan been available earlier, there might have been a better outcome for her husband, had treatment been administered sooner.

After taking independent advice on Mr C's case from two of our medical advisers, we found that there was a delay in making the scan available, and that the radiologist failed to flag the risk of spinal cord compression when reporting the scan. While there was only a slight possibility that earlier information would have meant that the outcome would have been different for Mr C, these failings led to a significant personal injustice as the delay caused a great deal of distress and there was a missed potential opportunity to diagnose and treat Mr C's spinal compression earlier. We also found an error in the reporting of a previous scan, which might have affected treatment decisions relating to Mr C's pain. Finally, in relation to Mrs C's complaint about the board's appointment handling, we found that there was a lack of continuity of care because of poor record-keeping and the involvement of multiple consultants. This adversely affected the information available to the consultant at each appointment, potentially impacted on Mr C's care and was particularly distressing for both Mr and Mrs C, given the ongoing situation.

Recommendations

We recommended that the board:

• take account of our medical adviser's comments about reviewing report turnaround times and reporting radiology errors, and provide us with evidence on how they intend to avoid a recurrence;
• provide evidence that multi-disciplinary team meetings play a role in the management of patients with lung cancer, in line with the relevant guidelines;
• raise the failures our investigation identified with relevant staff, and ensure it forms part of their annual appraisal;
• provide us with evidence on how they intend to avoid a recurrence of the failures that our investigation identified in the complaint about appointment handling; and
• apologise to Mrs C for the failures our investigation identified.