Health

Summary

After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures.

We took independent advice from one of our medical advisers. He said that while the initial examination of Miss A was of a reasonable standard, a second more comprehensive examination should have identified the need for an x-ray of the spine. The adviser also said there was no record of Miss A's mobility having been assessed and that, as she was suffering pain in her abdomen, she should have been assessed for liver damage, given the speed at which the vehicle was travelling immediately before the crash.

In light of this advice we upheld Mr C's complaints, as we concluded that the board had failed to adequately assess and treat Miss A and had unreasonably failed to arrange for x-rays or scans to be taken of her spine.

Recommendations

We recommended that the Board:

• apologise for the failings identified in the care provided; and
• provide evidence that they have addressed the failings our investigation identified with the doctor responsible, through the staff appraisal process.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice over a three-year period before she died in 2012. Mrs A had a complex medical history with many severe and debilitating conditions, which had been present for a number of years. Mr C raised a number of issues about the care and treatment provided for his late mother's conditions, including the treatment she received for leg ulcers, chronic kidney disease (CKD) and epilepsy, dietary issues, and nursing infection control methods. Mr C also complained that the GP had not communicated adequately with him and/or Mrs A.

Our investigation, which included taking independent advice from one of our medical advisers, found that the care and treatment provided to Mrs A was reasonable, appropriate and timely. The adviser reviewed Mrs A's medical records and found no evidence (other than one lapse in monitoring kidney function) that her care and treatment was deficient. National guidance on the management of CKD says that kidney function should be monitored at least every three months, and there was at one point a gap of six rather than three months in testing Mrs A's kidney function. There was no explanation for this gap but the adviser said that it had no detrimental effect on Mrs A's overall condition.

We did, however, identify failings in communication and upheld Mr C's complaint about that. We found that some of the written communications from the GP to other healthcare professionals contained subjective comments about Mrs A and her lifestyle. After Mr C complained to the practice, the GP acknowledged that the comments were not appropriate and apologised to Mr C for the distress this had caused him. The adviser agreed that the comments were not appropriate and said that they had detracted from the GP's otherwise professional approach to Mrs A's care. The adviser was also concerned that at times the GP appeared to make unilateral decisions about Mrs A's care without discussing them with her and/or Mr C.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on their practice in relation to communication and discusses any learning points at their next appraisal.

Summary

Mrs C complained about the medical care and treatment the medical practice gave to her late husband (Mr C). In particular, she was unhappy that he was not referred to hospital earlier.

During our investigation, we obtained independent advice from one of our medical advisers, who is a GP. We found that for the most part the treatment provided to Mr C was reasonable and appropriate. The adviser said that, although some GPs might have considered referring him to hospital earlier, the practice had acted within national guidelines and it was not unreasonable that Mr C was not referred earlier than he was. The medical records showed that the practice had been attentive and had managed Mr C's care as best they could.

We were, however, concerned that there was no evidence in the records that the practice had recognised and considered Mr and Mrs C's distress when deciding how best to progress his care. We were also concerned that there was no evidence to support the practice's position that Mr C was involved in the decision-making process. As a result we made a number of recommendations to further improve practice.

Recommendations

We recommended that the practice:

• provide us with evidence demonstrating how the practice involve the patient in the decision-making process; and
• consider this case to see if any further lessons can be learned, and bring the concerns raised by our investigation to the attention of the staff involved.

Summary

Ms C complained that a consultation that her late husband (Mr A) had at his medical practice was unreasonable, and was unhappy with their handling of her subsequent complaint. Mr A had been suffering from a cough and loss of appetite, and was due to see his GP but as his condition had worsened he arranged an earlier emergency appointment. The GP examined him and diagnosed pneumonia. He prescribed an antibiotic (a drug used to fight bacterial infections), took blood samples for testing, completed a referral form for Mr A to take to his local hospital for a chest x-ray later that day and planned to review Mr A again in one week, or earlier if his condition deteriorated. Mr A returned home, and, sadly, his teenage son found him dead there some three hours later. Ms C complained to the practice in July and September 2013 and the GP responded in July and October 2013. Ms C was dissatisfied with the responses and asked us to look at her complaint.

Our investigation, which included taking independent advice from one of our medical advisers, found that there were some failings in the GP's actions and his recording of the consultation and we upheld this part of Ms C's complaint. The adviser said that although the GP had noted some observations, other key observations (such as blood pressure, temperature, and respiratory rate) were not recorded. The adviser said that, although there was no indication that Mr A needed to be immediately admitted to hospital, the lack of these recordings were of concern where a patient had been diagnosed with pneumonia.

The adviser also noted that guidance on the management of lower respiratory tract infections (SIGN 59), issued by the Scottish Intercollegiate Guidance Network (SIGN) recommended that two different, but complementary, types of antibiotic should be prescribed for patients with suspected pneumonia. SIGN 59 also recommended review in 48 hours rather than the one week planned by the GP. Overall, the adviser was of the view that immediate hospitalisation might not have changed the outcome for Mr A. He said that bronchopneumonia (acute inflammation of the lungs) - which was identified as the cause of Mr A's death - can progress rapidly and aggressively. Because of the failings in the records of the consultation, however, it was impossible to say this for certain. We noted that the practice had conducted a significant events analysis (a process of examining what happened and identifying what, if anything, went wrong and what, if any, remedial action is needed). The adviser said that this had picked up some, but not all, of the learning points from this complaint.

Our investigation found that the practice acknowledged and responded to Ms C's complaint within the timescales in their complaints process, which mirrored the national guidance on complaints handling. The first acknowledgement was incorrectly dated but the practice manager had apologised for this in a later letter. Although we appreciated that Ms C was not happy with the practice's handling of her complaint, we considered that the timescales had been met and all the issues she raised were addressed - albeit not to her satisfaction. Because of this we did not uphold this part of her complaint.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on his practice in relation to these events, in particular in relation to SIGN 59 and clinical note-taking, and discusses any learning points at his next appraisal;
• review their procedure for conducting a significant event analysis to ensure that all learning points are recorded and addressed; and
• issue a written apology for the failings our investigation identified.

Summary

Miss C complained about her care and treatment when she was admitted to St John's Hospital for planned surgery. In particular, Miss C said that she had left hospital with an open wound, and was given inadequate post-discharge advice and care. She also complained about the care and treatment she received after being re-admitted nine days later with a severe wound infection, and said that her wound packing had been removed on the ward without adequate pain relief, and that packing was left in it.

During our investigation, we took independent advice from two of our advisers, one who is a specialist gynaecology consultant and another who is a plastic surgery consultant. The gynaecology adviser said that the operation appeared to have been straightforward but that Miss C was at high risk of infection. He found no evidence that prophylactic antibiotics (drugs that treat bacterial infection, given in advance of a procedure to reduce the risk of infection) had been given to Miss C during surgery, although he accepted that there might have been a reason for not doing so. He also said that she should have been given antibiotic therapy on discharge. However, he said that there was no evidence that she was discharged with an open wound.

After Miss C returned to hospital she had a further surgical procedure. The plastic surgery adviser was satisfied that the initial assessment and surgery were carried out to a high standard. He also indicated that it was routine practice to remove the wound packing on the ward, but noted that Miss C had not been given any additional pain relief for this procedure which can be traumatic and that this should have been considered. He also advised that it was unlikely that the full extent of Miss C's wound was observed during the procedure and that it was likely some of the large gauze swabs used as packing were left in the wound. We were critical of these apparent failures by the board.

We found nothing in Miss C's clinical records to indicate that at her pre-operative assessment she was given the information the board said she should have. There was also nothing to indicate whether it had been explained to Miss C that she was responsible for passing a discharge letter to her GP. We noted, however, that the board said they had already taken steps to remind staff of the importance of providing appropriate information and advice.

Recommendations

We recommended that the Board:

• apologise to Miss C for the inadequate care and treatment we identified, that she was not given adequate information about post-operative care at her pre-operative assessment, and that it was not properly explained to her that she was responsible for passing on the discharge letter to her GP;
• make relevant staff members aware of our adviser's comments and give them an opportunity to reflect on these for their future practice - in particular in relation to consideration of the use of prophylactic antibiotics both during surgery and prior to discharge, and the issue of pain relief and wound observation at dressing change; and
• provide us with evidence of the steps taken to remind staff of the importance of providing appropriate information and advice as stated in the board's response to Miss C's complaint.

Summary

Mrs C complained that her medical practice had not provided her with reasonable care and treatment. Mrs C had suffered from cancer before so, when she noticed swelling on her leg and groin, she suspected it had returned and went to the practice immediately. During the following months she went there a number of times and various tests were arranged. When the practice then referred her to hospital, cancer was diagnosed. Mrs C did not feel that the care she received from the practice was appropriate.

We took independent advice from one of our advisers, who is an experienced GP, who reviewed Mrs C's medical records and explained that they showed that the practice had been alert to the possibility of cancer throughout Mrs C's consultations and had arranged appropriate tests and investigations. The adviser also said that the practice made reasonable referrals, on the basis of the information available at the time, and had considered the whole picture of Mrs C’s symptoms.

Although we recognised that this was a most significant and distressing matter for Mrs C, our role was to consider whether, based on the evidence available to the practice at the time and without hindsight, they had provided her with reasonable care and treatment. The advice we received was clear - that the practice had investigated and referred Mrs C appropriately - and on this basis we did not uphold her complaint.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mr A) about a failure by staff at Monklands Hospital to properly assess and diagnose him after he attended the A&E department on two separate occasions. Mr A was initially diagnosed with a possible faint or seizure, with anxiety as the possible cause. He was discharged home and a referral made for him to attend a seizure clinic. Mr A then went to see his GP who referred him back to hospital, where he was admitted to intensive care and diagnosed with TB meningitis (an infection of the tissues covering the brain and spinal cord). Mr C had a very slow recovery and has been left with long term debility.

After taking independent advice from a medical adviser, we identified that there were shortcomings with the observations carried out on Mr A during both hospital visits. The board acknowledged that it was unacceptable that staff did not take Mr A's temperature during his first visit or repeat his observations when it was noted that his blood pressure and heart rate were raised. However, although we were critical of these omissions we did not consider that they were significant failings overall, nor were they likely to have led to an earlier diagnosis or different outcome. Our adviser said that TB meningitis is a very rare condition, and it was not unreasonable of the medical staff to attribute Mr A's symptoms to more common conditions such as anxiety and epilepsy. We concluded that the actions taken by staff were reasonable and in accordance with national guidelines. The board also showed us evidence that they have reviewed the observations procedure in the A&E department and made changes to ensure that the failings do not recur.

Recommendations

We recommended that the Board:

• apologise to Mr A for the failings in relation to his observations when he attended the hospital on two separate occasions.

Summary

Mrs C complained that communication from staff and the care provided to her husband (Mr C) in Caithness General Hospital were inadequate. Mr C had been taken to A&E after collapsing, and although Mrs C thought he had symptoms of a stroke, he was discharged. The board said that this was because Mr C did not want to stay in hospital overnight. He suffered a significant stroke shortly afterwards. Mrs C also complained about the nursing care after her husband was admitted to hospital, saying that when visiting him the next day she found him in a side room, lying on a mattress on the floor. She was distressed that Mr C's dignity was compromised, as he was not wearing pyjama bottoms.

After taking independent advice from one of our medical advisers and our nursing adviser, we upheld all Mrs C's complaints. We found that the junior doctor and the consultant physician involved did not give enough consideration to Mr C's diagnosis, particularly to the likelihood that he had suffered a minor stroke. Had they done so, it might have led them to have assessed the risk of this happening again and provided treatment if appropriate. However, our medical adviser pointed out that the outcome for Mr C might not have been different even had he been admitted to hospital at the start.

Although both the nursing staff and the doctors had indicated in the clinical records that Mr C did not want to stay overnight, there was no clear written information to show that they had recommended that he should be admitted before having an urgent scan in the morning. As the doctors had not indicated what they thought was wrong with Mr C, he would not have been aware of any potential risks in being discharged. We considered that the communication with Mr and Mrs C fell below a reasonable standard. We also found that the nursing staff should have told Mrs C before she visited that they were nursing Mr C on a mattress on the floor, to reduce the likelihood of him falling out of bed. The board had acknowledged that his care in terms of his dignity was unreasonable and had taken steps to address this with relevant nursing staff.

Recommendations

We recommended that the Board:

• draw to the attention of the junior doctor and the consultant physician our findings in relation to the lack of consideration given to Mr C's initial diagnosis;
• draw to the attention of the junior doctor and the consultant physician the importance of ensuring that communication about likely diagnosis is clearly explained to patients and their families where appropriate; and
• apologise to Mr and Mrs C for the failings we identified in Mr C's care.

Summary

Miss C has suffered from acne for a number of years. She complained to us that the medical practice had failed to offer appropriate support and treatment for her condition. She had asked to be referred to an endocrinologist (a specialist in a branch of medicine dealing with hormones) but the practice had refused and offered to refer her to a psychologist. We reviewed Miss C's medical records and found that over a prolonged period the practice had carried out appropriate assessments and had sought specialist opinions in an effort to manage her condition.

Summary

Ms C, who suffers from mild cerebral palsy and epilepsy, complained that when she attended the Western Infirmary Glasgow following a fall, staff failed to take her concerns seriously and discharged her without taking an x-ray of her left knee. Ms C says she was told to carry out exercises, which she did, but the pain worsened and she returned to the hospital three days later to be told, following an x-ray, that her left knee had suffered a fracture.

In response to Ms C's complaint, the board apologised for the delay in the diagnosis of a left knee fracture and told Ms C that the member of staff involved had been asked to reflect on her practice and attitude. We contacted the board and were told that they had upheld Ms C's complaint that staff had not carried out an x-ray when Ms C first attended the hospital and that advice should had been sought from a senior member of the medical staff. The board also said that the member of staff involved did not follow recognised protocol and that all staff are required to have an up-to-date Knowledge and Skills Framework and a Personal Development Plan, both of which are used to ensure that staff are kept up to date in their clinical practice. We found that the board's response to Ms C was lacking in specific detail and did not make clear that her complaint had been upheld. The board's response also failed to include information about what action had been taken to prevent a repeat occurrence.

Recommendations

We recommended that the Board:

• apologise to Ms C for failing to make clear that her complaint was upheld and that appropriate action had been taken to help prevent a similar situation occurring in future.