Health

Summary

When Mrs C joined the medical practice, she met the practice manager and expressed concerns about her experiences with her previous practices. In particular, Mrs C was concerned that the abbreviation 'DNR' was in her medical notes, as she believed that this related to a 'do not attempt cardiopulmonary resuscitation' order (a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). The practice manager told Mrs C that in her records DNR stood for 'diabetic nurse review', and followed this up with a letter explaining, amongst other things, that there was nothing anywhere in Mrs C's medical records about not attempting cardiopulmonary resuscitation. Mrs C acknowledged that she had spoken inappropriately to the practice manager in a phone conversation, although she had apologised for this afterwards. Following a consultation the next month, the practice then decided to warn Mrs C about her behaviour. Before they could do this, Mrs C wrote to them seeking clarification about issues arising from her clinical notes. The practice then wrote back saying there had been an irretrievable breakdown between her and the medical and management staff, and asked the health board to remove her from their list.

Mrs C complained about the way the practice responded to her complaint and the way they removed her from their list. We found that it would have been reasonable for them to have warned Mrs C before removing her, and that they did not explain why they did not do so. We upheld her complaint about this, and made recommendations. We also took independent advice from one of our medical advisers regarding the practice's explanations about the queries arising from Mrs C's medical notes. As we found that these were reasonable we did not uphold Mrs C's complaint about this.

Recommendations

We recommended that the practice:

• review their practice and processes in relation to removing patients, including training for staff where appropriate;
• review their practice and complaints processes, including training for staff where appropriate; and
• apologise to Mrs C for the failures this investigation identified.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) that his medical practice had failed to properly assess his symptoms and provide him with further tests to determine his increased risk of stroke. Mr A had attended the practice on a number of occasions with various symptoms. There was a history of heart and circulatory disease in his family and he was concerned that he had had a stroke.

We obtained independent medical advice on the complaint from one of our medical advisers. Although Mr A did subsequently have a stroke, the advice we received was that the symptoms with which he had presented to the practice did not suggest that he had suffered a stroke at that time. The adviser said that his symptoms were reasonably explained by other, more likely, diagnoses. Although we found that Mr A's concerns had not been fully addressed, the practice properly assessed the symptoms he presented with and arranged the appropriate tests. We found that they had acted reasonably and did not uphold this aspect of the complaint.

Mrs C told us that Mr A later did have a stroke and phoned the practice as soon as he realised what had happened. The practice recorded that he said that he was struggling to hold a cup in his left arm and was now having to drag his leg. They recorded that there was no mention of his arm being affected in the previous notes and that he might have suffered a stroke. They arranged an appointment for him later that day. However, Mr A instead went to hospital and was admitted to the stroke unit. We found that, based on the record of the phone discussion with Mr A, the correct course of action in line with relevant national guidance would have been for the practice to phone a blue light ambulance to take him to hospital. If the practice considered that there were good reasons for not doing so, at the very least, they should have recorded the reasons and arranged to examine Mr A immediately. The action they took was not appropriate and so we upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the practice:

• issue a written apology to Mr A for inappropriately telling him to attend an appointment later that day, when it was recorded that he had potentially suffered a stroke;
• make the GP that Mr A spoke to aware of our decision on this matter; and
• confirm that the matter will be discussed at the GP's next annual appraisal.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) about the care and treatment of his late mother (Mrs B). Mrs B was admitted to Glasgow Royal Infirmary with pain in her side and was found to have a kidney stone. She began taking medication to expel the stone and was discharged home for review in two weeks' time. When she attended for review, although she said she was still experiencing pain, an x-ray did not reveal any obvious stone. Arrangements were then made for a further examination and she was admitted to the New Victoria Hospital for surgery, following a discussion between Mrs B and the consultant in which Mrs B agreed to this. Mrs B was discharged the day after her surgery but later the same day she was admitted to hospital with pneumonia, moderate to severe hydronephrosis (where one or both kidneys become swollen or stretched as a result of a build up of urine) and multi-organ failure. She died a few days later in the intensive care unit.

Mr A was concerned about his mother's care. He questioned whether her previous medical history had been taken into account, whether she had been given the correct antibiotics and whether she should have been discharged the day after her operation.

In considering this complaint, we took independent advice from a consultant urological surgeon, who specialises in problems of the urinary system. We found that it had not been reasonable to operate on Mrs B and that this had not been in her best interest even though it was what she wanted. Our adviser said that best clinical practice would have been to keep her in hospital, offer her pain-killing medication and establish whether a stone was present as a possible cause of her pain. We noted that at the time of her discharge she had been well and the medication she was given was appropriate. However, Mrs B's medical notes were not clear about what was discussed with her before surgery and the risk (given her previous history) was not clear. We upheld the complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• make a formal apology to Mr A;
• ensure that the consultant urologist involved in Mrs B's surgery is made aware of the outcome of this complaint and that it is discussed at their next formal appraisal; and
• confirm to us that they are satisfied that consent forms and other clinical notes contain an appropriate level of detail.

Summary

Mr C complained that a dentist had failed to provide him with an acceptable level of treatment, including root canal treatment, which meant he had to have a significant amount of additional treatment.

In considering Mr C's complaint, we took independent advice from one of our advisers, who is a dentist. Although a drill had broken whilst inside Mr C's tooth during root canal treatment, our adviser said that this is a well-recognised complication of the treatment and is a fairly common occurrence. Mr C was concerned that part of the drill remained in his tooth, but there was no evidence of this in an x-ray taken after the treatment. Mr C had also been sprayed with water during the treatment, but the practice had already written to him to apologise for this. We found that it was reasonable for the dentist to try to repair a fractured filling rather than removing and replacing the whole filling, and that it was reasonable to prescribe Mr C with an antibiotic. In addition, we found that there was no requirement for the practice to offer Mr C an emergency appointment when a temporary filling fell out. Overall, we found that that the dental treatment provided to Mr C was reasonable.

Summary

Mr C complained about poor pain management and lack of information following hernia repair surgery (a procedure to address a bulge or protrusion of an organ through the structure or muscle that usually contains it) at Gartnavel General Hospital. Mr C said that he suffered severe pain because he was not given patient-controlled analgesia (PCA) morphine following the surgery, despite the anaesthetist having discussed his pain management and agreeing to the PCA at Mr C's pre-operation assessment.

Mr C was taken back to theatre the following morning to find out the reasons for his worsening pain, but no complications were found, and his surgery was considered successful. He suffered breathing difficulties which resulted in him being transferred to the high dependency unit (HDU) and then to an intensive treatment unit in a different hospital where he recovered several weeks later. Mr C also said that the cause of his severe pain and respiratory failure was not fully explained to him.

In responding to the complaint, the board said the anaesthetist discussed with Mr C that he would be assessed after the operation to see if a PCA was necessary. However, they also said that the respiratory failure following surgery was precipitated by poor pain control and that earlier establishment of PCA might have altered the sequence of events, although they could not be certain of this. As a consequence, Mr C was advised that in the event of future surgery, PCA and HDU care would be arranged for him because he would have a high risk of respiratory failure again.

We took independent advice on this case from one of our medical advisers, after which we upheld the complaint. Our adviser said that it was reasonable for the anaesthetist to say that the PCA would be put in place after Mr C's operation, if it was needed. However, we were critical that the PCA had not been written up on Mr C's drug chart before he was transferred from the theatre to the ward, so that it would be available if necessary. This was especially important as the record of Mr C's surgery indicated that he had undergone a long and difficult procedure, and it was highly likely that strong analgesia would have been necessary later in the evening. We considered that it was likely that a PCA would have avoided the subsequent problems with his pain relief.

Recommendations

We recommended that the board:

• share our findings with relevant medical staff involved in Mr C's pain management at the hospital in order to ensure lessons are learned;
• apologise to Mr C for the failings our investigation identified; and
• ensure that the medical staff involved in Mr C's care at the hospital record information discussed with patients and their families in line with General Medical Council guidance.

Summary

Mr C complained that after he was sent to prison there was a delay in the prison health centre prescribing medication that he had been taking in the community. In particular, Mr C was concerned that he had not received a blood thinning drug for deep vein thrombosis (a blood clot in a vein) and diazepam for anxiety. In responding to his complaint, the board acknowledged and apologised that there had been a delay and partially upheld his complaint. However, they did not agree that he should have been prescribed diazepam. The health centre prescribed him a different drug that also treats anxiety and which he had been taking in the community.

After taking independent advice from our GP adviser, we found it reasonable for the health centre not to have prescribed diazepam, as it is not used to treat anxiety long term, and we noted that he was prescribed an appropriate medication that he had already been receiving. However, we noted a delay of six days before he was given this and that this may have caused him some side effects. We also found that there was an unreasonable delay of five days before Mr C received his blood thinning medication. Our adviser said that this is a potentially life-saving drug that can wear off after 24 hours. We found that both the locum (temporary) doctor who reviewed Mr C shortly after his admission to prison and the on-call doctor who saw him several days later had failed to access Mr C's emergency care summary (ECS - an electronic system for checking information about a person's health in an out-of-hours care environment), and we upheld his complaints.

During our investigation, the board carried out a further review and accepted that there were failings in the doctors promptly accessing the ECS to confirm Mr C's medication on admission. Because of this, the board drafted written guidance on the process to be followed when obtaining and maintaining an accurate list of a patient's medication on admission to prison, through their transfer and at the time of discharge.

Recommendations

We recommended that the board:

• confirm to us when the draft medicines reconciliation guidance has been implemented; and
• confirm the steps they have taken to ensure all relevant clinicians working for the health centre have knowledge of and access to the emergency care summary.

Summary

Mrs C complained that a GP at her medical practice failed to deal with her mental health problems in an appropriate manner. She said that over a two-year period they failed to provide her with a reasonable service for her mental health problems and refer her for specialist support. Mrs C said she asked the GP to refer her to a psychiatrist on a number of occasions and that her counsellor had also made a request for this on her behalf, but no referral was made. Mrs C also complained about how the GP handled the reduction of her sleep medication.

We took independent advice from one of our medical advisers, who is also a GP. We found no evidence that the GP failed to consider Mrs C's requests for referral for specialist support, or failed to refer Mrs C to a psychiatrist in response to her counsellor's request. However, the evidence showed that the practice were copied into a letter from a consultant psychiatrist to Mrs C's counsellor indicating that an appointment would be arranged for Mrs C in the 'near future'. Our adviser said that as the GP continued to see Mrs C for over a year after the letter was sent, and as Mrs C was still having mental health problems and no appointment with the psychiatrist had been forthcoming, it would have been reasonable for the GP to have enquired about this. Our adviser also expressed some concerns about the tone and content of the GP's letter in response to Mrs C's complaint. We were particularly concerned that they referred to Mrs C in the letter as 'patient', which was inappropriate. We were also concerned that the GP took nearly two months to respond to the complaint and that no updates appeared to be sent to her during this time.

On the matter of the sleep medication, it was clear that the guidance in this area was that such medication should be for short-term use and that the doctor was correct to explore the reduction in Mrs C's dosage.

On balance, however, we upheld Mrs C's complaint as we concluded that the GP failed to deal with her mental health problems in an appropriate manner.

Recommendations

We recommended that the practice:

• feed back the failings identified to the GP to ensure that a similar situation does not happen in future; and
• provide Mrs C with a written apology for the failings identified.

Summary

Mr C complained that his medical practice had failed to appropriately assess and diagnose the cause of pain and swelling in his leg. Mr C saw three GPs at the practice and was diagnosed with a Baker's cyst (a fluid-filled swelling that develops at the back of the knee and is caused by a problem with the knee joint or the tissue behind it). However, he subsequently had a pulmonary embolism (a blockage, usually a blood clot, in the pulmonary artery, which is the blood vessel that carries blood from the heart to the lungs). Mr C considered that the pain in his leg had in fact been a blood clot that had travelled up his veins and caused the pulmonary embolism.

We took independent advice on Mr C's complaint from one of our medical advisers. We found that the GPs who saw Mr C had carried out the correct investigations and had provided him with a reasonable standard of care in relation to the pain and swelling in his leg. Based on the investigations, it had been reasonable to assume that the swelling was a Baker's cyst. The GPs had also considered alternative diagnoses. We found that the pulmonary embolism could not have been foreseen and we did not uphold this aspect of Mr C's complaint.

Mr C also complained that the results of a specialised blood test he had to try to detect pieces of blood clot in his bloodstream were inaccurate. The blood test had been negative. However, there was no clear evidence that Mr C had a blood clot at that time. We found that there was no evidence that the test results were inaccurate and we did not uphold this aspect of his complaint.

Summary

Mr C had tests and investigations at Aberdeen Royal Infirmary over three years to try to identify the cause of his abdominal pain. He complained that these were not carried out in an appropriate manner, which meant he had unnecessary procedures and treatment. Mr C felt that there was a delay in him having an endoscopy (a procedure using a camera to look at the stomach) and that he should have been tested sooner for helicobacter pylori (bacteria that can cause inflammation in the lining of the stomach). He was also concerned that he was given unnecessary medication.

We obtained advice from a gastroenterologist (a specialist in the treatment of conditions affecting the liver, intestine and pancreas) and a surgeon in relation to the tests and surgical procedures. Both advisers said that these were reasonable given Mr C's ongoing symptoms and the results of the various tests. There was no indication that any of the tests should have been done sooner. It was also reasonable that Mr C was prescribed medication to see if it helped his symptoms, as there was an indication of an abnormality with his pancreatic duct (which connects the pancreas - a gland behind the stomach - with the intestine).

We concluded that Mr C received extensive assessments, investigations and treatment for his abdominal pain, and that the gastroenterology and surgical care he received was reasonable and appropriate.

Summary

Ms C complained that staff at the prison health centre had taken away her TENS machine (a form of pain relief that delivers small electrical pulses to the body via electrodes placed on the skin) that she had been using to manage pain. She also complained that she had not been told why the machine was removed.

We took independent advice from one of our medical advisers, who specialises in mental health nursing. We found that staff had removed the machine and offered alternative pain relief to Ms C. Our adviser said that staff had acted correctly in removing the machine as they had concerns for Ms C's safety. We were also satisfied that the board had explained the reason for the removal to her, and we did not uphold her complaints.