Health

Summary

Mr C complained about the care and treatment his late brother (Mr A) received from the medical practice. Mr A had been suffering from a cough, shortness of breath and chest pain and died of a pulmonary thromboembolism (a blood clot which forms at one point in the circulation, becomes detached and lodges at another point) in April 2014. Mr C said that he believed the practice had contributed to the death of his brother.

Mr C complained that Mr A's GP did not treat his condition as worsening on his last visit to the practice. He also said that the day before Mr A's death, a receptionist had not allowed Mr A to speak to, or see, a GP when he called the practice to get the results of tests.

Mr C complained to the practice but was unhappy with the response he received. He said that there were several things which he felt were inaccurate or incorrect in their response. Mr C questioned why the GP had not considered or recognised that Mr A's condition was worsening and disputed the practice's version of what was said during the phone call with the receptionist.

We took independent advice from one of our medical advisers, who is a GP. We found that the medical records depicted a series of events consistent with a chest infection with some additional signs which needed further investigation and that the appropriate tests had been arranged, so we did not uphold Mr C's complaint about his brother's treatment.

However, our adviser also said that the role of reception staff is to facilitate communication between a patient and a GP, and, therefore, they should not be making a decision that a patient who has specifically asked to speak to a GP should not have this option. Our adviser said the information should be passed to the GP who has clinical knowledge and responsibility for patient care to make the decision as to how to proceed. On this basis, we upheld the complaint about the care given to Mr A by the practice.

Recommendations

We recommended that the practice:

• carry out a significant event analysis paying particular attention to their system of contacting an on-call doctor;
• ensure GPs involved in Mr A's care discuss this complaint at their next appraisal;
• apologise to Mr C for the failings identified;
• establish, using the practice's appointment system, which receptionist spoke to Mr A on the date in question;
• review the details of the GP's complaint response in relation to the information received from reception staff, and write to Mr C to explain the findings;
• review and revise where appropriate the practice system for passing requests by patients to speak to a doctor; and
• consider enhanced staff training for the receptionists in terms of their interactions with patients and practice guidelines on responding to patients who request to speak to a doctor.

Summary

Mr C complained that the care and treatment of his wife (Mrs C) had been unreasonable, in particular in relation to managing Mrs C's stiffness and contractures (rigidity in a joint that cannot be overcome, leaving the limb in a fixed position). Mrs C, who suffered from dementia, was initially cared for at home under the care of a speciality doctor in old age psychiatry and her GP. However, when there was a marked deterioration in her mobility and rigidity in her limbs, she was admitted to Victoria Hospital. A month later, she was transferred to Queen Margaret Hospital. During this time, as Mrs C was becoming increasingly agitated and upset, she was prescribed increasing doses of an antipsychotic drug (a medicine used to treat mental health conditions). Mr C complained that this resulted in his wife's physical condition deteriorating and her body becoming more rigid.

We took independent medical advice from two of our advisers - consultants in old age psychiatry and in geriatrics - and we found that while it was known that the drug prescribed to Mrs C might have side effects causing muscle contractures, in Mrs C's case it was initially prescribed to her in a low dose to reduce her agitation. This had been fully discussed with Mr C. We also found that the clinical staff involved considered the benefits of using the drug against the possible side effects, and concluded that the benefits outweighed the possibility of any side effects. It was also known that many patients with end-stage dementia went on to develop contractures. While Mrs C was given increasing doses of the drug, the matter had always been discussed with Mr C and clinicians followed good practice by continually monitoring Mrs C. We did not uphold Mr C's complaint.

Summary

Mrs C complained about the treatment that her late mother (Mrs A) received from her medical practice between September and November 2012. Mrs A was eventually diagnosed with lung cancer and Mrs C said that the family had made repeated requests for a chest x-ray but these were ignored. The family believed that an earlier x-ray might have allowed Mrs A's cancer to be diagnosed sooner. They were also concerned that the practice failed to follow up blood test results as they should have done and which again they thought would have led to an earlier diagnosis.

We took independent advice on this case from one of our medical advisers. Our adviser said that the practice had not failed to follow up on blood tests arranged by the hospital. However, he considered that the practice did not take reasonable steps in light of the results of blood tests they themselves organised. The adviser said that there were repeated and high levels of inflammatory markers shown on blood tests in late October 2012. These should have created a higher degree of suspicion, and led to consideration of a referral rather than just arranging repeat tests. The test results should have been considered in the context of an unwell adult and consideration given to referral for other possible conditions, although he also said that it was unlikely this would have led to an earlier diagnosis. The adviser also thought that Mrs A should have been referred for an x-ray in early November, when swollen lymph glands were noted.

We concluded that, whilst Mrs A's care was reasonable up to the end of October 2012, and that earlier diagnosis was unlikely in her case, on balance there were failings by the practice from early November 2012 onwards.

Recommendations

We recommended that the practice:

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

Summary

Mrs C's father (Mr A) had suffered from a painful degenerative condition that caused his spinal cord to become compressed. An operation was carried out and, after a difficult recovery, Mr A was pain free for a number of months. He then began to have new pain in his shoulder and went to his GP as he was worried that this could have been a recurrence of the condition. Mr A's GP considered that he did not have any new symptoms that indicated his spinal cord was compressed. Mr A had a number of consultations over the following months where the GP adjusted his pain relief medication. He also attended hospital appointments which clinicians reported to the GP; none of them considered that he was suffering from spinal cord compression. Mr A was subsequently seen at home by the GP as he was in too much pain to visit the surgery. The GP made a referral for a scan which was carried out a few days later. The scan showed a narrowing of the spinal canal and an urgent referral was made.

Mrs C complained that the GP repeatedly failed to diagnose her father's condition, delayed referring him for a scan and had not assisted him in obtaining medical equipment to help him manage at home. The practice responded saying that the GP had acted appropriately.

After taking independent advice from one of our medical advisers, we found that the GP had provided Mr A with reasonable care and treatment. Our adviser explained that there was no evidence that Mr A was suffering from new spinal cord compression and so there was nothing to suggest that a scan should have been carried out earlier. In relation to obtaining medical equipment for use at home, our adviser said that the occupational therapy department would deal with this rather than the GP. As the GP had advised Mrs C's family to contact the occupational therapy department, we considered that this had been handled reasonably.

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) by a medical practice. Miss A has a long-term health condition and needs multivitamins daily. Mrs C said that, on more than one occasion, GPs at the practice wrongly prescribed a multivitamin containing a high dose of vitamin A, which was potentially toxic to Miss A. Mrs C said that she and the dietician noticed the error, not the GPs, and she complained to the board, who responded on behalf of the practice. Mrs C was not satisfied with the board's response.

After taking independent advice from one of our medical advisers, we were satisfied that the practice took Mrs C's complaint seriously, conducted a full and honest investigation, including a significant event analysis, and proposed reasonable actions to prevent a similar situation in the future. There had clearly been a mis-prescription of Miss A's multivitamins which affected a period of roughly six months, which the practice accepted. We found that this was caused by poor communication between the practice and other healthcare staff involved in Miss A's care. We also found that the practice operated two different methods of prescription, which meant that a GP dealing with Miss A for the first time could easily miss details of previous prescriptions which had not been entered on the practice system. We were also critical that, when it was established early on that Miss A's prescribed multivitamin was not listed on that system, no action was taken to have the system updated or to forewarn other GPs in the practice. We upheld Mrs C's complaint and made recommendations to address the failings identified.

Mrs C also complained about the handling of her complaint, but we found that it was investigated thoroughly and that the board’s response was reasonable.

Recommendations

We recommended that the practice:

• apologise to Mr and Mrs C for the poor handling of Miss A's multivitamin prescription; and
• provide us with evidence of the procedural changes that have been implemented following the significant event analysis.

Summary

Mrs C complained about the care that her mother (Mrs A) received in Borders General Hospital. Mrs A had a collapse/fall while she was alone at home and was taken to A&E. As Mrs A had a pacemaker and had a number of issues with her heart while she was at the hospital, she was transferred to another hospital in a different NHS board area for specialist investigations (the second hospital). Tests there showed that there were no abnormalities with Mrs A's pacemaker. She was scheduled for transfer back to Borders General Hospital but an outbreak there of norovirus (winter vomiting bug) prevented this. The second hospita carried out further tests, and Mrs A was diagnosed with pulmonary emboli (blockages in the blood vessels that carry blood from the heart to the lungs, usually caused by blood clots). She was prescribed warfarin (a medicine that prevents blood clotting) to treat this and a few days later was transferred back to Borders General Hospital. The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them. When Mrs A was readmitted to Borders General Hospital, staff only considered the medical transfer documents, and missed the pulmonary emboli diagnosis.

Mrs C had been concerned about her mother's ability to cope at home, but as Mrs A was considered to be medically fit to return there, she was discharged two days after she went back to Borders General Hospital. She became increasingly breathless, however, and was readmitted two days later where the pulmonary emboli diagnosis was picked up and treated.

Mrs C complained to the board about the care Mrs A received. The board apologised for the errors in communication between Borders General Hospital and the second hospital. They also advised that steps would be taken to ensure that the issue was followed up with the second hospital and that doctors would now check both medical and nursing transfer documents when admitting patients.

After taking independent advice from one of our medical advisers who is a consultant physician, we upheld Mrs C's complaint. The adviser considered that the failure to identify Mrs A's diagnosis of pulmonary emboli from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged. We were also critical that there appeared to have been a delay in the board carrying out the actions advised in their response to Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the standard of care and treatment provided to Mrs A during the period relating to the complaint;
• take steps to ensure that actions agreed following a complaint investigation are followed up promptly;
• consider the adviser's comments about taking the views of family members into account and determine whether there are lessons that can be learned; and
• make medical staff involved in Mrs A's care aware of the adviser's concerns regarding the decision to discharge, including the lack of documentation, to ensure that a similar situation does not occur in future.

Summary

Mrs C complained that the board failed to diagnose her with rheumatoid arthritis while she was under their care. Although she had a number of appointments in just over a year, Although she had a number of appointments in just over a year, Mrs C was only diagnosed with this after she moved out of Scotland.. She said that this was despite the fact that there had been sufficient indicators present to have confirmed this. She said that, as a consequence, she was not properly treated and that she had subsequently lost her independence.

We investigated the complaint and took independent advice from a consultant rheumatologist. Our adviser said that diagnosing rheumatoid arthritis is neither straightforward nor easy and other conditions can mimic its presentation. Accordingly, great care has to be taken in making a diagnosis, and also in prescribing appropriate drugs, some of which have significant side-effects. We found that in the time period about which Mrs C was concerned, and faced with a complicated picture, clinicians responsible for her care had carefully monitored her, formed appropriate working diagnoses and treated her appropriately. At about the same time as Mrs C moved, the evidence about her condition became much clearer and the findings and updated treatment were summarised to her new clinician when her treatment recommenced.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the care and treatment given to Mrs A's late husband (Mr A) before he died. Mr A had bowel cancer and his prognosis (the forecast of the likely outcome of his condition) was not good. He was discharged home from hospital into the care of his GP and the district nursing service. After being at home for a short while, Mr A died. Mrs A complained about the various agencies involved in her husband's care and was particularly unhappy because she considered that district nurses had failed to properly care for her husband in the final weeks and days of his life and that levels of support, communication and standards of care had been poor. In responding to her complaint, the board agreed that there were failures in the support and care offered to Mr and Mrs A, and apologised for this, but Mrs A remained concerned that lessons had not been learned nor had procedures been put in place to prevent this happening again. She also complained about the way in which her complaint had been handled.

We took independent advice on this case from our nursing adviser, an experienced registered nurse. Our investigation confirmed that the board had admitted that there were shortcomings in Mr A's care, and we found that they took too long to deal with her complaint. We, therefore, upheld the complaint, while noting that the board had put processes in place to address the problems with Mr A's care and had apologised sincerely to Mrs A for the failings. As our investigation also found that the board had taken Mrs A's concerns most seriously and that the processes put in place provided a good response to them, we did not find it necessary to make any recommendations.

Summary

Mrs C had suffered from knee pain for a number of years. She was diagnosed with degenerative changes in her knee and a meniscal tear (a tear in the pad which provides shock absorption and other functions in the knee). She also had a meniscal cyst (a cyst often found in the presence of a meniscal tear and which can cause pain and discomfort). Following an initial course of physiotherapy, Mrs C had surgery at Perth Royal Infirmary to treat her meniscal tear and decompress the cyst. Although she experienced some initial improvement, her knee pain returned. She had further physiotherapy and a second operation. However, again her pain returned and in fact became worse. She complained that the board did not adequately treat her knee problems or provide appropriate follow-up care.

We took independent advice from one of our medical advisers, who explained that meniscal cysts can return and knee pain can persist following surgery. We were satisfied that this was explained to Mrs C before her first operation. We could find no mention of the cyst in the notes for the first operation. Whilst this could have indicated that the cyst could not be found, or that it was treated successfully, the absence of records meant we had to conclude that the cyst was not treated during the first procedure. That said, we found that it was treated appropriately during the second procedure and overall, we were satisfied that Mrs C was discharged and re-referred to the orthopaedic department appropriately as required when her knee pain flared up. We were also satisfied that physiotherapy was used appropriately. We did not uphold Mrs C's complaint, but we did ask the board to apologise to Mrs C in relation to the uncertainty surrounding her first operation.

Recommendations

We recommended that the board:

• apologise to Mrs C for the uncertainty surrounding her initial operation.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Perth Royal Infirmary and Ninewells Hospital. In particular, he said there was a protracted period of complacency by the staff involved in his daughter's care. At the time Mr C complained to us, Ms A had been experiencing severe and debilitating pain for over 18 months. A number of diagnoses had been suggested, and while treatments were ongoing, no single definitive cause had been found for her pain and other related symptoms. Mr C said that the medical team had ruled out endometriosis (a condition where cells similar to those that line the womb lie outside it) without adequate investigation or involving a colorectal surgeon.

In response to the complaint, the board apologised for the delays and the lack of communication between departments. They explained the reasons for and outcomes of the various tests that had been arranged, along with organising further clinical review for Ms A.

We took independent advice from three specialist clinical advisers - a gynaecologist, a gastroenterologist (a specialist in the treatment of conditions affecting the liver, intestine and pancreas) and a radiologist (a specialist in the analysis of images of the body). The radiologist said that a scan had been incorrectly interpreted, as he considered it did not show evidence of endometriosis. However, he did not consider this to be a major error of judgement requiring further action. In addition, whilst we identified that there was some confusion over referrals and some delays in arranging treatment, our advisers said that the tests and treatments offered were all appropriate in light of what was known at the time. On balance, we did not uphold Mr C's complaint as we found that although there were some errors in Ms A's care, no department had acted unreasonably and there were no serious failings. However, we did make a number of recommendations to the board.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• ensure that the radiologist responsible for reporting the scan is made aware of the views of our radiology adviser on the interpretation of that scan and given an opportunity to reflect on this; and
• reflect on the potential role of multi-disciplinary team meetings in complex cases such as Ms A's and consider how this might be embedded into clinical practice, and advise us of the outcome of their consideration.