Health

Summary

Mrs C went to her medical practice with a thickened and discoloured toenail. The GP suspected a fungal nail infection and sent clippings for testing but the results were negative. The practice took no follow-up action until, after seeing a private podiatrist (foot specialist), Mrs C went back to her GP almost a year later. At the recommendation of the podiatrist, the GP made an urgent referral to a dermatologist (skin specialist). Mrs C was diagnosed with a malignant melanoma (a type of skin cancer) and her toe was later amputated. She complained that the practice unreasonably failed to refer her for further diagnostic tests. She also complained that the practice did not respond appropriately to her complaint about this.

Mrs C had complained by phone to the practice manager. During the call she said that she did not want to speak to the GP. Despite this, the GP called Mrs C a few minutes later. Mrs C spoke to the manager again the following day, who confirmed that she had passed Mrs C's message to the GP but that he had phoned her anyway, thinking that it would be of help. Mrs C then complained in writing and the GP responded but Mrs C did not receive the letter. About four months later, she chased up the response and was provided with a copy.

Our investigation, which included taking independent advice from a medical adviser, found that the cancer was very rare and difficult to diagnose, and that national guidelines confirmed this. The adviser commented that in general practice it is usual for patients who are having investigations to be told to return for review when the results are available. The GP had noted on Mrs C's record 'RV [review] with results' when the nail clippings were sent for investigation. Mrs C did not return for review but our adviser said that as the results were normal, no further investigation was required at this time. When Mrs C did return, having been reviewed by a podiatrist, the GP then took appropriate and timely action to follow the podiatrist's recommendations.

Mrs C was concerned that when discussing the negative fungal infection results with her, the GP did not advise her to make an appointment with the in-house podiatrist. The GP said that he was certain that he had advised Mrs C to do so, but conceded that he had not documented this. We were unable to determine which version of events was correct, but overall our adviser was of the view that the care and treatment provided to Mrs C was reasonable.

On the handling of Mrs C's complaint, our view was that in view of Mrs C's specific request not to speak to the GP, it was inappropriate for him to call her. While early and direct discussion of a complaint can bring about a speedy resolution, in this case contact was not helpful. However, we did consider that it was reasonable for the GP to have written the response letter to Mrs C. This contained the GP's personal apologies for the experience Mrs C had been through and also his explanations of why he had not thought the condition in her toe was serious at the outset.

We noted during our investigation that the practice's complaints literature was out of date, but that the timescales for both the previous and current NHS guidance on complaints handling had been met. Also, Mrs C was given the correct information about the next stage of the complaints process at the correct time. Although we did not uphold this complaint, we brought this to the attention of the practice.

Summary

Mr C complained that the board had failed to carry out an appropriate investigation into his concerns about his daughter (Miss A)'s treatment in Stobhill Hospital. His concerns included a lack of information from staff about matters affecting Miss A; inappropriate behaviour and actions of staff; and staff not displaying their name badges.

We found that the board had treated Mr C's concerns seriously, had made appropriate and detailed investigations into them and had provided him with a reasonable response. The board explained that at times staff name badges may not be visible and that they had reminded staff of their responsibilities in that regard.

Summary

Mrs C complained that a consultant at Forth Valley Royal Hospital dismissed an urgent referral from her GP for suspected lung cancer and failed to follow up the suspicion of lung cancer. Mrs C said that the consultant failed to take account of her medical history or a recent x-ray and that, as a result, diagnosis of and treatment for lung cancer were delayed.

Mrs C's GP referred her to the respiratory unit because she had a longstanding persistent cough. The consultant there reviewed the referral letter, and as he thought it unlikely that she had lung cancer he decided not to see her at his clinic. He suggested that she first stop taking medication that was known to cause coughs, to see whether this was the cause of her symptoms. After taking independent advice from one of our medical advisers, although we found it acceptable for referrals to be screened in this way we found that the consultant overlooked information in the referral about Mrs C's recent x-ray. Whilst we were satisfied that the advice to alter Mrs C's medication would have been the same had the information about the x-ray been taken into account, we upheld the complaint about the consultant's actions and criticised the board, as this was a key item of information and it was clearly overlooked.

We did not uphold the complaint about delay as we were satisfied that although there was some delay in diagnosis, this was not unreasonable in the circumstances. We did, however, uphold Mrs C's complaint about the board's complaints handling as we found that their investigation and response were not thorough enough.

Recommendations

We recommended that the board:

• apologise for failing to note that Mrs C had had a clear chest x-ray;
• draw our findings to the consultant's attention; and
• review their complaints handling procedures to ensure that detailed, impartial, investigations are carried out into issues raised by patients.

ummary

Mr C complained to us about the care and treatment given to his late wife (Mrs C). Mrs C had been diagnosed with emphysema (a lung disease) and fibrosis (scarring of the lungs) some years ago. When she attended her medical practice in 2013 complaining of a cough, she was initially treated with antibiotics but after attending again a few weeks later she was referred for a chest x-ray. This showed little change from an x-ray taken a few years before.

A few months later, Mrs C returned to the practice and was referred again for an x-ray. This showed signs of infection and she was given more antibiotics. After at first feeling a little better, Mrs C began to experience shortness of breath and a cough and was referred urgently to the respiratory team at the local hospital. She was then given an x-ray which showed that she had a tumour. Mrs C's condition deteriorated and she died a few months later, around seven months after initially attending the practice about her cough.

Mr C complained that the care and treatment given to Mrs C by the practice was unreasonable. He was particularly concerned at the length of time it took for Mrs C to receive a scan and, therefore, the time taken to provide a diagnosis. He also said time was spent on treating her for a chest infection rather than diagnosing her condition.

We took independent advice on this complaint from one of our medical advisers, who is a GP. We found that Mrs C's case was unusual in that she had an x-ray that showed no signs of cancer only four months before having another which showed she had a fairly advanced cancer. The tumour was particularly aggressive and fast growing, and Mrs C was frail and had other illnesses. We did not find the the way in which the practice cared for and treated Mrs C unreasonable.

Summary

Mrs C complained that when she was admitted to Aberdeen Royal Infirmary staff did not take account of her specific condition when treating her, did not appropriately access her medical notes, and did not keep accurate and secure test results.

Mrs C suffers from a chronic condition which can cause an imbalance in blood chemistry, particularly sodium and potassium. She had also just had a bout of gastroenteritis (vomiting and diarrhoea) and had been prescribed dioralyte (a medication used to replace fluids and regulate blood chemistry after diarrhoea) by a locum (temporary) GP. When she saw her own GP after she had been ill for six days, she was referred to the hospital, and was admitted. Mrs C was given a saline drip (to prevent dehydration) and kept in overnight then discharged the following day. Since then Mrs C has suffered ongoing symptoms of tiredness, weakness and an inability to tolerate any foods containing sodium or potassium, which she attributes to the treatment she received.

Mrs C said that when she tried to tell medical staff that the combination of treatment she had received from the locum GP and the hospital would have a negative effect on her, they dismissed her views and began writing in the medical records of another patient with a similar surname to hers. Mrs C also said that a person wearing a white coat told her that they had amended her blood test results to read as normal to prevent her getting treatment.

Our investigation included taking independent advice from one of our medical advisers, who said that the medical records showed that Mrs C's treatment was reasonable, appropriate and would have been very unlikely to have caused the symptoms she described. We were also satisfied that there was no evidence of any gaps, inaccuracies or tampering with Mrs C's medical records or blood test results. We asked the board what they had done to investigate Mrs C's concerns about her medical records and blood test results, and were satisfied that they had carried out extensive and appropriate investigations and found no evidence to support her concerns.

Summary

Mr C complained about a number of aspects of the care and treatment the practice provided for his late mother (Mrs A). This included that there was a delay of six weeks in the practice referring Mrs A to a specialist, after a doctor at the practice told Mr C at a home visit that this would be done. Mr C also complained that when another doctor at the practice saw Mrs A at home on a later date, he failed to arrange for her to be admitted to hospital and made an inappropriate reference to her condition. Mr C said the practice failed to take his mother's deteriorating condition seriously and provide her with appropriate care and treatment.

After obtaining independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaints. Our adviser said that he would have expected the first GP to have set a time to see Mrs A to go over blood test results and to review her condition. This did not happen. The referral, which was eventually made more than six weeks after the home visit, appeared to have been prompted by Mr C and was made to a psychiatrist for the elderly, rather than a consultant geriatrician. It appeared that the practice might have taken some reassurance from tests that had suggested there was no sinister cause for Mrs A's long-term problems. The adviser said, however, that as Mrs A had red flag (warning) symptoms that could suggest underlying cancer and as some time had passed since the tests were carried out, a referral to a consultant geriatrician should have been made.

The second doctor accepted that, at the later home visit, he had referred to Mrs A inappropriately. In our view, the term he used was insensitive and would likely have added to the distress Mr C was experiencing at that time. Having correctly decided not to admit Mrs A to hospital, it then appeared that this doctor failed to assess Mrs A's social situation at the visit, although we accepted that, overall, the practice acted reasonably in trying to get social work involved in her case.

Recommendations

We recommended that the practice:

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

Summary

Mr C said that he had been suffering pain from his rib cage for a number of years and believed he had a displaced rib. He complained that the board delayed in providing him with treatment or a firm diagnosis. He wanted to be referred to a chiropractor (a practitioner who uses their hands to treat disorders of the bones, muscles and joints) and was unhappy that the board declined to provide this.

After taking independent advice from one of our medical advisers, and considering Mr C's medical records, our investigation found that while the treatment given to Mr C took place over a considerable period of time, there were no periods of unreasonable delay. The x-rays carried out were appropriate and timely. Although Mr C wanted to be referred to a chiropractor, our adviser said that physiotherapy was an acceptable, reasonable alternative, and the board had provided this.

Summary

Mrs C's son (Mr A) sustained a head injury while playing sport. He attended A&E at Perth Royal Infirmary where he was examined and discharged. He was later found to have suffered a fracture to his neck which required surgery to correct. Mrs C complained that her son was not properly assessed in A&E and should have been sent for medical imaging. The board stated that they had followed established guidance on the decision-making process regarding medical imaging and that on the information available at the time regarding Mr A’s symptoms there was no reason to perform any medical imaging.

We took independent medical advice on this complaint from one advisers, who told us that Mr A's assessment in A&E was thorough and adhered to the relevant guidance. The adviser also said when Mr A was examined there was no obvious reason to refer Mr A for imaging. We considered Mr A’s treatment to have been reasonable and did not uphold the complaint.

Summary

Mrs C complained about the treatment she received as an out-patient at Perth Royal Infirmary. She was being treated for a bladder complaint and was prescribed a drug (trospium chloride) as part of her treatment. Shortly after this she had a relapse of a previous mental health problem, and she attributed this to being prescribed the drug.

Our investigation included taking independent advice from one of our medical advisers, who was of the view that the choice of drug was reasonable for a patient in Mrs C's age group, and with her medical history and medical condition. The adviser said that this type of drug was less, rather than more, likely to cause a worsening of a patient's mental health, that it was an appropriate choice of therapy and that Mrs C's reaction was very unusual.

The outcome Mrs C was seeking was to have her medical notes annotated with a warning not to prescribe this drug to her in the future and the board had told us during the investigation that they had already put notes in the relevant records. We asked the board to confirm in writing to Mrs C, and to us, that this had been done.

Summary

Mr C had an accident at work and was taken to Perth Royal Infirmary A&E, where his back and neck were examined and x-rayed. No bony injuries were identified and Mr C was discharged. He said that he told hospital staff that his arms and shoulders were extremely painful and heavy, but the only test that they carried out was that he was asked to squeeze the doctor's fingers. Mr C continued to have pain in his shoulders and arms and his GP referred him for an MRI scan (magnetic resonance imaging - used to diagnose health conditions affecting organs, tissue and bone). This showed that he had torn the rotator cuffs (the muscles around the shoulder joint) in both shoulders. Mr C continued to have shoulder problems, and complained that the A&E examination was inadequate and did not properly assess the extent of his injuries.

After taking independent advice from one of our medical advisers, we found that Mr C was examined in line with good practice. The range of movement in his arms and shoulders was checked and the finger squeezing test was carried out to check for nerve damage (which might have indicated a neck injury). The examination indicated that Mr C had soft tissue injuries, which would not show up on an x-ray. We did not uphold his complaint,as we found the decision to allow his injuries time to settle, with pain medication, to be appropriate. However, we noted a delay to Mr C's MRI scan and diagnosis when his pain did not resolve and made a recommendation related to this.

Recommendations

We recommended that the Board:

• share our decision with the staff involved in Mr C's treatment and diagnosis with a view to identifying any points of learning that may be used to improve the treatment of future patients; and
• remind their A&E staff of the importance of inviting patients to return to hospital or their GP should their symptoms persist, and of documenting the advice given to patients discharged from their care.