Health

Summary

Mrs C complained on behalf of her late husband (Mr C) that there was an unreasonable delay in taking him from their home to an ambulance. Mrs C said that the ambulance crew spent too long trying to get her husband to respond to them and should have taken him to the ambulance and conveyed him to hospital straight away. Mrs C also raised concerns that the crew were unable to insert an intravenous line (a plastic tube introduced with a metal needle into a vein to allow the delivery of medications to assist resuscitation).

We took independent advice from one of our medical advisers, who is a GP. The adviser said that the time taken at the scene (22 minutes) was not excessive. They explained that as Mr C had 'shut down' (when a patient is in the extremes of a medical crisis and their peripheral veins collapse) it would have been very difficult for the paramedic to have inserted an intravenous line. This was not unusual and in itself did not make the paramedic's actions unreasonable. The adviser explained that, when the insertion of an intravenous line fails, it is reasonable to use an intraosseous needle (a large bore needle pushed into the bone marrow of the shin to allow the introduction of drugs and fluids to assist resuscitation). However, in this case the crew attending Mr C did not have access to such a needle and the adviser said that even had one been available and the conditions appropriate, its use would have been unlikely to have changed the outcome for Mr C.

The evidence suggested that the ambulance crew acted appropriately and in accordance with their organisation's and national guidelines in their treatment of Mr C. However, we were concerned that the service told us that use of intraosseous needles was not their custom and practice, given that national guidelines on resuscitation say that if intravenous access cannot be established within the first two minutes of resuscitation, consideration should be given to intraosseous access.

Recommendations

We recommended that the Scottish Ambulance Service:

• consider reviewing the use of intraosseous needles to take account of national guidance in this area.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mrs A), about the care and treatment provided to Mrs A's son (Mr A). He was admitted to the Western General Hospital after feeling unwell for a few weeks. He was extremely tired, with bleeding gums and a sore throat, and had noticed lumps in his armpits, neck and groin. The next day, after bone marrow tests, Mr A was diagnosed with an acute form of leukaemia (cancer of the white blood cells). Treatment was immediately started and at first he appeared to be responding well but his temperature suddenly rose and tests revealed that he had a fungal blood infection. Despite treatment, including being transferred to the intensive care unit, Mr A's condition got worse and he died shortly afterwards.

Mrs A complained about the circumstances of her son's death saying that he had not been cared for or treated properly, and she questioned how his condition could have declined so rapidly. She was of the view that the doctors attending him did not have sufficient expertise or seniority and had not explored all possible options, including a bone marrow transplant, for him.

We took independent advice on this complaint from a consultant haematologist (a specialist concerned with the study of blood and blood-related disorders), after which we did not uphold Mrs A's complaints. Our investigation found that Mr A was treated on a protocol that was appropriate for his disease and which would have been used at any similar treatment centre in the UK. His treatment had to be intensive, and involved substantial doses of a drug that, while being an excellent killer of malignant cells, caused significant immunosuppression (reduced efficiency of the immune system). Our adviser said that, unfortunately, Mr A got the fungal infection at a time when his blood count was extremely low (because of disease and chemotherapy) and when his resistance to fighting infection was at its poorest.

Although Mrs A thought that a bone marrow transplant was not considered, our investigation confirmed that tissue typing, which is the first step in the process, had begun. However, this could not be fully implemented until such time as Mr A was in remission and had been cleared of all signs of the disease. We also confirmed that all the staff involved had been of appropriate seniority and expertise. Mr A's death was sudden and unexpected and although Mrs A complained that her family had not been kept fully informed of his condition or the risks of his treatment, we did not find this to be the case.

Summary

Mr C complained to the board that they had not treated him fairly when they were considering the discharge arrangements for his mother (Mrs A) from hospital. He believed that they had unprofessionally accused him of acting inappropriately towards other patients before the accusations had been investigated; that they had unreasonably reported to the police that he had been acting in an inappropriate manner; and that they had inappropriately instructed him to refrain from contacting other patients and visitors and restricted his contact with his mother.

We took independent advice on this complaint from one of our medical advisers. We found that the staff had a duty of care towards their patients and that there were adult protection issues to consider. Their actions were appropriate in order to discharge their duties and obligations.

Summary

Mr C's wife (Mrs C) suffered from severe liver disease, and was admitted to, and discharged from, the Royal Infirmary of Edinburgh three times in a three-month period. Shortly after her last discharge, Mrs C was admitted to the Western General Hospital, where she passed away about a week later. Mr C complained to us about a number of aspects of his late wife's nursing and medical care in the first hospital. He said that the multiple discharges showed that doctors were not really interested in getting to the bottom of what was going on, they just wanted to get Mrs C a little better and send her home. He also complained about medical care during the first few days of Mrs C's admission to the second hospital, when he said she was moved to a side room where he believed she was forgotten about.

After taking independent nursing and medical advice, we did not uphold Mr C's complaints. Our nursing adviser considered that the overall nursing care in the Royal Infirmary of Edinburgh was reasonable, and found no evidence of the specific issues Mr C raised. Our medical adviser said that Mrs C's medical care was also reasonable, and explained that her experience of multiple admissions to hospital was typical for a person in her condition. The medical adviser also found evidence that Mrs C was regularly reviewed and received reasonable care during her first few days at the Western General Hospital. As during our investigation we noted that the board had not responded to Mr C's complaints properly, we drew this to their attention.

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) by the board's out-of-hours (OOH) service at St John's Hospital. Mrs C said that they failed to diagnose that Miss A had pneumonia (a lung infection) over the course of three visits. She told us that initially staff had failed to recognise that Miss A was seriously ill and she was sent home with misleading advice about how to care for Miss A. Mrs C also said that the doctor she saw on her final visit to the OOH service was dismissive of her concerns and her daughter had only been admitted to the children's ward because Mrs C had insisted that Miss A receive a second opinion.

Mrs C also complained that once on the children's ward, staffing levels were inadequate and this compromised the care provided to Miss A. Miss A's condition had continued to deteriorate and she was transferred to a children's hospital where she was treated as an in-patient for three weeks before she was discharged. Mrs C said Miss A had been traumatised by the experience and that she had required counselling to overcome her fear of hospitals and doctors.

We took independent advice from one of our medical advisers and a nursing adviser. The medical adviser said the medical records showed that the assessment Miss A received at each visit met national guidelines for the care of children with a fever. He said staff had recognised the severity of her condition and provided the appropriate treatment. There was no evidence to show that the doctor Mrs C complained about acted inappropriately. The nursing adviser said that the records for Miss A's stay in the children's ward were comprehensive, and provided a clear record of her care. We found no evidence that her care was substandard.

Summary

Mrs C took her young daughter (Miss A) to her medical practice as Miss A had a high temperature that would not come down, despite being given paracetamol. Mrs C said her daughter was shivering and was having difficulty catching her breath.

Mrs C said that at the appointment the GP described Miss A's condition as a chest infection and prescribed antibiotics. Miss A was later admitted to hospital suffering from pneumonia (a lung infection). Mrs C said that the GP should have told her that he suspected pneumonia, rather than describing her daughter's condition as a chest infection. She thought that her daughter should have been referred for further tests and investigations at the appointment, rather than being sent home with a prescription for antibiotics. Mrs C also said that the practice had failed to handle her complaint appropriately. She said that, at a meeting, the GP seemed more upset about her complaint than about Miss A's experience, which had left her traumatised with a fear of hospitals and doctors.

We took independent advice from one of our medical advisers. The adviser said that the evidence showed that the GP recorded a diagnosis of suspected pneumonia in his notes, and prescribed antibiotics for treatment at home, in line with national guidelines. He also said that there was no evidence that Miss A had not received an acceptable standard of care.

Our investigation also found that the practice carried out a thorough investigation into Mrs C's complaint. They provided an explanation for the remarks made by the GP at the meeting with Mrs C and where they identified learning points they took action to address them. We found that the practice had responded appropriately to Mrs C's complaint.

Summary

Ms C complained that the board had not followed the correct diagnostic and prescribing guidelines for her condition. She said that she was wrongly diagnosed with Graves' disease (a condition in which the body produces too much thyroid hormone) at St John's Hospital, and that what she was prescribed was harmful to her. Ms C was also unhappy that other clinicians were made aware of the diagnosis of her condition as being non-physical rather than physical, and said this had an adverse effect on her care and treatment. This diagnosis was retracted after Ms C complained, but she was unhappy that there was reference in her medical records to her complaint. She was also unhappy with the way her complaint was handled and said that the board had failed to carry out action they had agreed.

We took independent advice from one of our medical advisers, who is a consultant in endocrinology (a branch of medicine dealing with hormones). The adviser found no evidence that the board failed to follow the correct diagnostic and prescribing guidelines for Ms C's condition. He did say, however, that her disease was mild and was not the cause of her symptoms, and that the board should have looked more actively for other causes for Ms C's ill health. We found that Ms C had received attentive care and that the conventional guidelines (British Thyroid Association guidelines) were followed. We found no evidence that diagnosis of her condition as non-physical rather than physical had an adverse effect on treatment.

We were also satisfied that the board had responded to Ms C's concerns and had met with her to try to address her concerns. They had clearly explained that because the issues were about events from a number of years ago they were not going to investigate her complaint on a point by point basis. We were also satisfied that the board had done what they said they would, although we were concerned about the reference to the complaint in Ms C's medical records. Although we did not uphold her complaints, we made three recommendations to try to ensure good practice in future.

Recommendations

We recommended that the board:

• ensure that the medical advice we received in relation to this complaint is brought to the attention of the relevant clinicians;
• remind all staff that information about a patient's complaint should not be contained within medical records; and
• ensure that, in this case, the procedure for dealing with disagreements about entries on medical records has been followed.

Summary

Mrs C complained about the treatment that her son (child A) received from his dentist. She complained that the dentist failed to identify that her son was missing two lower premolar teeth. Mrs C said that this caused her son stress, led to a delay in diagnosis and impacted on the cost and the potential success of his future dental treatment. Child A had attended for a routine examination. A bitewing x-ray (a type of dental x-ray) was taken which showed spacing between his lower premolar and the first molar, but the dentist did nothing about this. Mrs C only found this out when her child attended another dentist several months later. He was referred for orthodontic assessment and it was identified that both his lower second premolars were congenitally absent (not present since birth).

We obtained independent advice from our dental adviser who explained that bitewing x-rays are normally taken to detect dental decay. Although this is the primary reason for using bitewing x-rays, they could be expected to show that the lower premolars were not developing. The adviser said that the dentist missed an opportunity for early diagnosis of the absence of the two lower second premolars and said that it would have been reasonable for the dentist to have investigated further at that time. The adviser also explained that there are guidelines on the use of x-rays in dental practice, which recommend that even in the event of a child being assessed as having a low risk of decay, bitewing

x-rays should be taken at intervals of 12 to 18 months whilst they have baby or milk teeth. We found that the dentist did not follow these guidelines in child A's case, so we made a recommendation about this.

Nevertheless, the adviser also said that an earlier referral to an orthodontist would not have achieved anything further, and that any delay in child A's treatment was marginal and would have made no difference to possible treatment. Given this, although on balance we upheld Mrs C's complaint, we did not consider that the treatment her son received impacted on the cost and potential treatment success for him.

Recommendations

We recommended that the dentist:

• reflects on our adviser's findings in terms of future dental practice and in particular takes into account the relevant European guidelines in relation to the frequency of taking bitewing x-rays.

Summary

Miss C had major surgery on her bowel, and complained to us about the treatment she received after the surgery, which she thought was inadequate, and about the handling of her out-patient appointments.

During our investigation, we took independent advice from a consultant general and colorectal surgeon, following which we did not uphold Miss C's complaint. The adviser said that, although Miss C had not been seen personally by the doctor who carried out the surgery, she was seen in his clinic by his representative. The adviser was satisfied that the action taken was consistent with good practice. He also said that Miss C's medical records confirmed that the doctor offered reasonable treatment following the surgery and discussed the treatment options open to Miss C, including further surgery. It was unfortunate that some of Miss C's out-patient appointments were rescheduled and that this added to her concern about the level of aftercare she was receiving, but we noted that the board had already apologised to her for this.

Summary

Mrs C complained that the board failed to provide her with appropriate treatment after her GP referred her to a cardiologist because of her worsening shortness of breath and pitting ankle oedema (where areas of skin temporarily hold the imprint of a finger when pressed). We obtained medical advice on the complaint from one of our medical advisers, who is an experienced cardiologist. We found that it was reasonable for the cardiologist to repeat an echocardiogram (an ultrasound scan of the heart) that her GP had already carried out. The adviser said that if an abnormality is found in a test requested by a GP, then most hospital-based cardiologists would repeat the echocardiogram, so that not only can the hospital-based doctor review the images him or herself, but is also aware of the experience and training of the technician making the recording.

The adviser said that although Mrs C had two leaking heart valves, they were unlikely to affect her health in the future and did not account for her current symptoms. He also agreed with the board that it would not be appropriate for Mrs C to have heart bypass surgery. That said, the adviser said that it was not reasonable for the cardiologist to increase Mrs C's dose of ramipril (medication used to prevent high blood pressure and heart failure) based on a single blood pressure reading. The cardiologist had not taken account of the commonplace observation that when any patient meets a new doctor, particularly in a hospital setting, their blood pressure is elevated. It was also unclear why the cardiologist prescribed bisoprolol (a beta blocker used to slow down the activity of the heart), as the results of relevant tests that the cardiologist had requested were not available at that point.

We also found failings in the board's communication. The cardiologist should have explained the alterations to Mrs C's drug therapy to her and should have met her to explain why she required indefinite treatment with warfarin (a medicine that stops blood from clotting). The cardiologist also delayed in informing both Mrs C and her GP of test results. In view of these failings, we upheld Mrs C's complaint. However, we noted that the board had since addressed many of the communication failures, and had apologised to Mrs C for the poor communication when they later met her.

Mrs C also complained to us about the board's handling of her complaint. They had asked the cardiologist for comments on the complaint. The response was dismissive and failed to demonstrate that the cardiologist had reflected on the complaint and considered if any lessons could be learned. The board's response to Mrs C simply set out the cardiologist's views. There were also problems with the arrangements for a meeting that the board set up to discuss Mrs C's complaints with her. In view of all of this, we also upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• make the cardiologist aware of our findings;
• confirm that the case will be discussed at the cardiologist's next annual appraisal; and
• issue a written apology to Mrs C for the poor handling of her complaint.