Health

Summary

Mrs C complained on behalf of her mother (Mrs A) that staff at Inverclyde Royal Hospital provided inadequate care and treatment to her. Mrs C also complained that communication from hospital staff was not good enough. Mrs A had started taking antibiotics for a urinary tract infection two days before admission, and was admitted to the hospital with increasing confusion. Mrs C was particularly concerned about a fall her mother had in hospital, as well as treatment for Mrs A’s confusion.

We received Mrs A’s medical records from the board, and took independent advice from our nursing adviser. There was no dispute that Mrs A fell; what was disputed was the reason for the fall. In this case, we could not resolve the dispute given the differing accounts of what happened, although that did not mean we believed one version over another. In Mrs C’s view, the fall was not addressed properly. The medical records showed that Mrs A was assessed after the fall, and no major injuries were found. Our adviser’s view, which we accepted, was that the care provided to Mrs A was reasonable in the circumstances. Based on the available evidence, we concluded that hospital staff provided adequate care and treatment to Mrs A.

The board said they should have phoned Mrs C earlier to tell her about Mrs A’s fall, and they apologised for this and reminded staff of the importance of keeping patients and relatives informed. We found evidence in the medical records that staff spoke to Mrs C regularly during Mrs A’s stay in hospital, and that they were aware Mrs C was unhappy. Our adviser observed that staff could have tried to offer more support to Mrs C when she was visibly upset. However, we decided that, on balance, communication from hospital staff to Mrs C was adequate in the circumstances.

Although we did not uphold Mrs C’s complaints, we made recommendations to address specific concerns raised by our adviser.

Recommendations

We recommended that the Board:

• reflect on this case, as part of ongoing improvements, to ensure that an appropriately detailed approach is taken to care planning to help manage delirium; and
• reflect on this case, as part of ongoing improvements, to ensure that staff provide support to relatives of patients with delirium.

Summary

Mrs C complained to us on behalf of her husband (Mr C), following a consultation at the A&E department of the Royal Alexandra Hospital. Mr C went to A&E a few days after a fall, as he was suffering from back pain. He was examined by a consultant in emergency medicine, who concluded that the back pain was an exacerbation of a pre-existing problem. The consultant told Mr C to continue with pain relief and return if symptoms persisted or got worse. Mr C was eventually diagnosed with a fracture to one of his vertebrae.

We took independent advice from a consultant in emergency medicine, who considered the examination that Mr C had at his consultation to be reasonable, though he noted that it did not consider Mr C’s range of movement or any associated pain. Our adviser said that, when examining older people, doctors should have a low threshold for considering whether an x-ray is necessary, but that the decision should still be based on clinical judgement. However, he concluded that the decision not to x-ray Mr C had been reasonable in this case, given the findings of the consultant's examination.

The board apologised to Mr and Mrs C that an x-ray had not been requested, and said that they had raised this issue with staff, and reminded them of the need to particularly consider whether an x-ray is needed when an older person is examined.

On the basis of the advice we received, we considered that Mr C’s care and treatment had been reasonable. The board had already taken action, and there was nothing further we could achieve.

Summary

Ms C complained that, during a consultation at her medical practice, her GP asked her whether she was paranoid. She found this distressing and the GP's approach to be blunt and unprofessional. The GP had discussed referring her to the local community mental health team, but Ms C indicated that she did not want this. The police contacted her three days later and she was admitted to hospital under a compulsory treatment order (an order that allows professionals to treat a person's mental illness). Ms C then complained to us that her GP had referred her to psychiatric services against her wishes.

After taking independent advice from one of our medical advisers, we found that, although Ms C's GP had discussed a possible referral to psychiatric services, no referral was actually made and no confidential information was shared with the community mental health team.

Summary

Ms C was admitted to Leverndale Hospital under a compulsory treatment order (an order that allows professionals to treat a person's mental illness). She was assessed by a consultant psychiatrist as suffering from paranoid psychosis (a form of delusional disorder). Ms C disagreed with this assessment and was concerned that the psychiatrist had rushed to a judgement based on little evidence. She believed he was reluctant to be seen to disagree with one of his senior colleagues who had assessed Ms C at home before her admission. Ms C was also concerned that the psychiatrist's assessment was based, in part, on incorrect information the police gave him, which he failed to challenge. Ms C said that she later learned that the psychiatrist had intended to discharge her around 11 days earlier than he eventually did.

During our investigation, we took independent advice from one of our medical advisers, who is a psychiatric specialist. We accepted their advice that Ms C's assessment, diagnosis and treatment were all reasonable. We also found the timing of Ms C's discharge to be appropriate and that she was allowed out of hospital on a limited basis before this, in line with accepted practice. We found no evidence to suggest that an earlier discharge date had been considered.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), whose late brother died during an investigative procedure in Glasgow Royal Infirmary. The complaint was about the way the board investigated Mrs A's complaint about her brother's care and treatment.

Mrs A complained to the board in July 2012 and two weeks later she and a friend met with members of the clinical, nursing and complaints team staff to discuss her concerns. Mrs A expected to receive a copy of the meeting notes shortly afterwards, but this did not happen. She chased this up over the next few weeks but did not receive the notes until October that year.

When Mrs A reviewed them, she found several inaccuracies and omissions according to her recollection of the meeting and sent the board a list of these in early November. She asked them for a final written response, so that she could escalate her complaint to us if necessary. This did not happen, although she had several more contacts from the board. Mrs C eventually complained to us in October 2013. The board eventually, and only after our intervention, provided an amended copy of the notes. Mrs A still thought that there were inaccuracies and omissions, and was confused by conflicting information about the board's process for investigating significant clinical incidents and how they are reported on the NHS system (known as Datix).

In response to our enquiries, the board said that the complaint file was closed in error after the meeting, so no automatic reminders were sent to the complaints team or the clinical staff involved in the complaint about the outstanding meeting notes.

Our investigation found that the board had not complied with the timescales in their own complaints handling procedure. We were concerned at the time taken, firstly to produce the meeting notes, and then to correct them. We were particularly concerned that we had to intervene before the amended notes were issued. It was also of concern to us that when Mrs A contacted senior members of staff because she had not received any response from the complaints team, they did nothing to progress this or assist Mrs A. We noted that the members of the clinical team that Mrs A contacted did not respond to her because they assumed the complaints team would do so.

Recommendations

We recommended that the Board:

• issue a written apology for failing to notify Mrs A of her right to complain to this office and the inconsistent explanations she received about the significant clinical incidents policy;
• take steps to review their procedures for preparing and issuing notes of complaints meetings to ensure they are issued to complainants as soon as possible after the meeting and that they address any concerns about accuracy appropriately at the time; and
• review the current Datix form and consider how best to reflect the outcomes for incidents which, following initial review, do not escalate to full investigation.

Summary

Ms C and her partner (Mr C) complained to us about the failures in communication from staff at Aberdeen Maternity Hospital following the death of their baby. The failures included a lack of postnatal checks; being given a damaged keepsake memory box; a failure to inform their GP of the circumstances; appointment letters for baby checks sent following the baby's death; and delayed contact by the community obstetric team.

The board had apologised to Ms C and Mr C and had taken action in an effort to prevent a repeat occurrence happening to another family. We gave the case considerable consideration and upheld the complaint. However, we were satisfied that as the board had apologised and had taken appropriate action following the complaint by amending procedures, no additional recommendations were required.

Summary

Mr C, who is a prisoner, complained that the prison health centre had unreasonably failed to explain why his complaints were being managed in line with NHS Scotland's policy for dealing with habitual and vexatious complaints. In response to our enquiries, the board confirmed that the prison health centre inappropriately applied the incorrect version of a national policy and said that the decision to manage his complaints in line with that policy had now been revoked.

In addition, Mr C said the board failed to respond appropriately to his complaint about the decision to manage his complaints in line with the policy. In response to our enquiry, the board said that they were not in a position to confirm that the steps taken by the prison health centre in responding to Mr C's complaint were appropriate, given that the prison health centre had implemented the incorrect policy.

In light of the information available, we upheld Mr C's complaints.

Recommendations

We recommended that the Board:

• take steps to ensure staff within the prison health centre are fully aware of the correct complaints policy and its procedures.

Summary

Miss C was unhappy with the care and treatment she received during her pregnancy. She complained there was a failure to provide her with appropriate clinical treatment for an ovarian cyst (a fluid-filled sac) and to provide her with appropriate nursing care during her labour. When Miss C was about 18 weeks pregnant she had experienced severe abdominal pain. She had a consultation with an out-of-hours GP, who referred her to her own GP. She was later admitted to Forth Valley Royal Hospital with a suspected torsion (where the weight of the cyst causes the whole ovary to twist, cutting off the blood supply). A laparotomy (an open operation on the abdomen) was carried out. However, when the surgery was performed, no cyst was present (it appeared to have resolved on its own) and no other reason for Miss C’s pain was identified. Miss C was later prescribed antibiotics because the surgical wound was leaking. She considered the operation unnecessary and that it could have been avoided if she had been given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) before surgery. She was also upset about the scar left by the operation, which she felt could have been avoided if she had been scanned or given a laparoscopy (keyhole surgery) instead of the laparotomy.

We took independent advice from a GP adviser, a midwifery adviser and an obstetrics adviser (a specialist in pregnancy, childbirth etc). The GP adviser said that it was reasonable for the out-of-hours GP to refer Miss C to her own GP. The obstetrics adviser said that, while performing the operation laparoscopically might have improved Miss C’s experience, the decisions to perform a laparotomy and to do so without a further ultrasound were reasonable. We found that the care and treatment provided to Miss C was reasonable in the circumstances known to the medical staff at the time.

In relation to Miss C’s complaint about nursing care during her labour, our midwifery adviser said that the midwifery care Miss C received during and following the birth of her baby was appropriate and in line with relevant guidance. Miss C was unhappy with the conditions in the room where she gave birth but, although we considered these to be less than ideal, we did not consider that they amounted to unreasonable care.

Although we did not uphold Miss C’s complaints we noted that the board intended to review the management of her care to allow any learning to be identified and ensure improvement and development if required, and so we made a relevant recommendation.

Recommendations

We recommended that the Board:

• provide us with evidence of the review of the management of Miss C's care carried out at their clinical review group meeting.

Summary

Mr C complained about the treatment and support that his late son (Mr A) received from the board. Mr A had been suffering from low mood and agitation for about two months. He tried to take an overdose, but was stopped by his family. Following a call to the local out-of-hours service, he went to Forth Valley Royal Hospital for a review by their mental health unit. After what Mr C considered to be a very brief assessment, Mr A was discharged home, with phone numbers for three support organisations should he become upset again. Mr A went to his GP two days later saying that he was still depressed and that he had considered taking his own life. His GP referred him back to the mental health unit, where another assessment was carried out and Mr A was discharged home again. He took his own life a few days later. Mr C complained that the mental health unit failed to act on the concerns raised by his son's GP or to properly assess the severity of his condition. He felt that, had they done so, Mr A might have been admitted to the hospital as an in-patient and might have been treated.

After taking independent advice on this complaint from one of our medical advisers, who is a consultant forensic psychiatrist, we did not uphold Mr C's complaints. The adviser said that there was clear evidence that the mental health unit had acknowledged the concerns raised by Mr A's GP. The assessments that were carried out were thorough and followed accepted practice. We accepted his advice that, based on the information available to staff at both consultations, there was no cause for Mr A to be admitted as an in-patient. The adviser said that, in the circumstances, it was reasonable for Mr A to be discharged home with advice as to who to contact should he need support. He noted that Mr A was receiving medication from his GP and had reported benefitting from the support numbers he had been given.

Summary

Mr C was referred to Dumfries and Galloway Royal Infirmary. After tests and surgery, it was confirmed that he had prostate cancer, and he was started on hormone therapy. Mr C later had a scan of his abdomen and pelvis, and it was thought that the cancer was spreading and that he might also have Crohn's disease (a long-term condition that causes inflammation of the lining of the digestive system). In the meantime, Mr C was required to have a bone scan.

Mr C complained that in carrying out his surgery, the board did not follow his wishes about the use of anaesthetic, and did not tell him about the use of hormone therapy, that he might have Crohn's disease or that he needed a bone scan. He also complained about the delay in arranging a colonoscopy (examination of the bowel with a camera on a flexible tube) and in receiving radiotherapy.

We obtained independent advice on the complaint from one of our medical advisers, who is a consultant urological surgeon (a specialist in problems of the urinary and male reproductive systems). We took all relevant information into account, including the complaints correspondence and Mr C's medical records.

Our investigation found that, in accordance with his wishes, Mr C had a spinal anaesthetic when he had surgery. However, in association with this, he had been given some sedation to relieve anxiety. Although Mr C said that he had been explicit about the use of sedation, there was nothing in his notes to confirm this and we did not uphold this complaint. Mr C also said that there was a delay in providing him with a colonoscopy and the evidence showed that after a scan (made as a result of an urgent referral and which suggested possible Crohn's disease) it was ten weeks before a request for a colonoscopy was made. It took a further month for this to be carried out and it was only then, when a diagnosis was confirmed, that radiotherapy could be considered. Mr C's complaint about delay was, therefore, upheld. Furthermore, we found nothing to show that hormone therapy had been discussed with him, or that he had been told that he could have Crohn's disease. We upheld his complaints about this as well as about general communication during his treatment. We also found that the board did not deal with his complaints within a reasonable timescale.

Recommendations

We recommended that the Board:

• apologise to Mr C for their failure to discuss his medication with him properly;
• ensure that relevant staff are made aware of the findings of this complaint and if necessary undertake relevant training;
• emphasise to relevant staff the importance of completing timely and appropriately detailed medical records;
• specifically apologise for their failure to discuss the possibility of Crohn's disease;
• ensure that relevant staff are reminded of their responsibility to keep patients appropriately informed of their medical condition;
• apologise for the delay in sending a response to the complaint.
• share my comments with the clinicians involved, including those involved in multi-disciplinary team meetings, to ensure that CT scan results are considered and acted upon promptly; and
• provide a written explanation about the two different decisions taken in relation to radiotherapy treatment.