Health

Summary

Ms C complained that her dentist failed to examine her or treat her reasonably or appropriately. She said that it was only shortly afterwards, when she changed to a new dentist, that she learned the extent of her problems, which she said the first dentist had allowed to develop.

We took independent advice from a senior dental practitioner and we found that as the appointment concerned had been on an emergency basis, Ms C had been given immediate treatment on the particular problem she presented with. The appointment was not routine, and so the dentist had not been expected to make a full examination of Ms C's mouth. We found the treatment he gave her had been appropriate in the circumstances.

Summary

Mr C complained about the nursing care and treatment provided to his late wife (Mrs C) and also complained that when her condition deteriorated she was not transferred to the Intensive Treatment Unit (ITU). Mrs C had a previous medical history which included Type II diabetes, heart disease, and kidney problems and she had been progressively unwell several months before she was admitted to Forth Valley Royal Hospital. At that time she was complaining of a six-week history of breathlessness, an unproductive cough, reduced exercise tolerance, and increasing leg oedema (swelling due to fluid retention). Mrs C was treated with drugs to fight infection and to reduce fluid retention but her condition failed to respond and she died around four weeks after being admitted.

We took independent medical advice from one of the Ombudsman's nursing advisers and a consultant who specialises in care of the elderly. We found that although the nursing treatment was reasonable, appropriate and timely, there were some failings in the nursing care provided including failure to appropriately supervise Mrs C when she was self-administering her insulin (a drug used to treat diabetes); to deal appropriately with urine samples; and to communicate the seriousness of Mrs C's condition to Mr C and members of the family. These failings had already been acknowledged and apologised for by the board in their responses to Mr C's complaint to them, and an action plan had been implemented to address the issues, including ongoing staff education. Therefore, although on balance we upheld this aspect of Mr C's complaint, we did not make any recommendations as we considered that appropriate action had already been taken by the board.

On the medical treatment provided to Mrs C, our consultant adviser said that Mrs C received appropriate assessments, investigations, specialist reviews and modifications of treatment where required. On the specific issue of transfer to the ITU, we found that when Mrs C's condition deteriorated, she had been appropriately reviewed and her treatment was modified accordingly. She was then reviewed shortly after by an ITU consultant. By the time of the ITU review, Mrs C's condition had improved and then remained clinically stable, although she was still very unwell, for the next few days. The decision was taken that admission to the ITU would be unlikely to achieve any further improvement in Mrs C's condition and we considered that this was a reasonable decision, so we did not uphold this aspect of Mr C's complaint.

Summary

Mr C complained because he felt a nurse had inappropriately disclosed his medical information at a meeting with prison staff. He also complained about the way the board handled his complaints.

In response to our enquiries, the board confirmed the nurse discussed issues in relation to Mr C at the meeting but she did not disclose any medical information. They also confirmed that Mr C had given instructions to the board that his information should not be shared but those instructions were given after the meeting in question had taken place. The board provided a copy of a patient registration form that Mr C signed when he was received into the prison healthcare system which advised him that the NHS may need to share information about his health and medication with people outside the NHS, such as prison staff. In light of this, we did not uphold his complaint about this.

However, in looking at the board's handling of Mr C's complaints, the evidence available confirmed that they did not respond to some of them and for those they did respond to, they could have provided a fuller reply. We upheld this part of Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for not responding fully to his complaint; and
• advise us of the steps that have been taken to improve the handling of healthcare complaints from prisoners.

Summary

Mrs C was admitted to Forth Valley Royal Hospital suffering from shortness of breath and oedema (swelling) caused by fluid retention due to her chronic (long-term) congestive heart failure. She also suffered from kidney disease and insulin-dependent diabetes. Despite treatment, Mrs C died some two weeks later, and her husband (Mr C) then complained about her care and treatment. As he held power of attorney (PoA - a legal document appointing someone to act or make decisions for another person) for Mrs C, Mr C said it was inappropriate for staff to speak to his wife alone about her condition and treatment, and he complained that he and his family were not kept informed about her care and treatment.

We took independent advice on Mr C's complaint from two of our advisers, a doctor and a nurse, and we also reviewed the relevant legislation and medical guidance. Mr C was concerned that one of the drugs (furosemide) that his wife was prescribed for fluid retention was making her worse and contributing to the worsening of her kidney disease. National guidance says that this is the recommended first-line treatment, but that it can cause kidney damage and needs to be carefully monitored. We found that it was monitored and that when Mrs C's kidney function continued to deteriorate the drug was stopped. Mr C also had concerns that Mrs C's diabetes was not being appropriately managed but this was not supported by the evidence in the medical and nursing notes, and there was evidence of regular reviews by a diabetic nurse specialist and a dietician. We were, therefore, satisfied that the care and treatment provided to Mrs C was reasonable, appropriate and timely.

In relation to the PoA and general communication issues, the PoA clearly stated that it was to be invoked only if Mrs C lacked capacity - this is in line with the relevant legislation (the Adults with Incapacity (Scotland) Act 2000). Guidance issued by the General Medical Council (GMC) and Nursing and Midwifery Council (NMC) (the governing bodies for doctors and nurses respectively) says that a patient should be deemed to have capacity to make decisions about their care unless it can be demonstrated that they do not. There was ample evidence within Mrs C's notes that staff considered her to have capacity, so we took the view that it was reasonable and appropriate for staff to discuss care and treatment with Mrs C herself and to act upon her wishes. We also found evidence of numerous discussions between medical and nursing staff with members of the family, including Mr C. In light of this, we did not uphold Mr C's complaint.

Summary

Mr C complained that he was not properly assessed by his prison health centre after he submitted an emergency nurse triage form saying that he was unfit to work because he was suffering from leg cramps, a black toe and being unable to sleep. A meeting was held with Mr C to discuss his concerns and the board told him that there was no record of the health centre having received a triage form from him on the date in question. However, they said he had submitted a triage form (assessment form) four days before the date he referred to in his complaint and was seen by a nurse who assessed him and then arranged a consultation with the doctor at Mr C's request. The board concluded that the clinical team had dealt with Mr C appropriately.

We could not find clear evidence that Mr C submitted a triage form on the date he said he did. However, we noted that he had done so four days before, for the same problems, and that the triage nurse did not consider that he was unfit for work at that time. We considered it unlikely that the problems he raised would have prevented him from working then. The nurse should have documented her judgement that Mr C was fit for work and we drew this to the board's attention. They confirmed they would take steps to highlight to staff the importance of accurate record-keeping. We did not, however, consider this to be a significant failing and we were satisfied that the board were taking reasonable action to ensure the matter does not happen again. We concluded that Mr C was reasonably assessed.

Summary

Ms C’s daughter (Miss A) broke her leg and was admitted to Forth Valley Royal Hospital. Her leg was put in plaster and managed conservatively (without surgery). In the three months after her accident, Miss A was provided with a number of plaster casts but continued to experience pain and discomfort.

Miss A went abroad and, while she was there, had to seek medical attention as she continued to suffer pain in her leg. After seeing an orthopaedic surgeon there, she was admitted to hospital for surgery. Ms C said that doctors there told her that, without this, there would have been long term complications. She complained that her daughter did not receive appropriate treatment for her broken leg from Forth Valley Royal Hospital and had not given informed consent for the conservative treatment she received there.

We obtained independent medical advice from an experienced consultant in trauma and orthopaedic surgery. We found that there would be variations in approach about the treatment of this type of injury, and differing views between countries, between different hospitals in the same country and between individual surgeons in the same orthopaedic unit. Our adviser said that both conservative management and surgery are well supported managements for this type of injury and both are considered to be appropriate treatment. Once the decision was made to manage Miss A’s injury in plaster, the care and treatment she received was correct and plaster casts were left on for the appropriate length of time before they were removed. We also found that Miss A was able to give informed consent for her treatment.

On one occasion, there was a failure to carry out an x-ray after Miss A’s plaster was changed. The board had acknowledged this and had already apologised. Our adviser considered that they had taken appropriate action and did not identify any other failings in Miss A’s treatment. The adviser also said that Miss A’s medical records did not support the criticism of her treatment that the doctors abroad appeared to have made.

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.