Health

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.

Summary

Mrs C complained that when her father (Mr A) attended the out-of-hours (OOH) service with abdominal (stomach) pain, he was seen by a GP who failed to take into account his previous medical history and diagnosed Mr A as suffering from indigestion. Mr A felt the same for the next two days and then suddenly deteriorated and an ambulance was called. He was admitted to hospital with a diagnosis of septicemia (blood poisoning) and pneumonia. Mr A died two weeks later.

The board maintained that the GP from the OOH service carried out an appropriate assessment. We took independent advice from one of our medical advisers, and we found that the OOH service GP had put himself in a position where he was aware of Mr A's medical history, that appropriate assessment and treatment were provided for the symptoms which were reported, and that there was no evidence that a hospital admission was required at that time.

Summary

Mrs C complained to us on behalf of her grandson (Mr A) about Mr A's medical practice. Mrs C did not feel that the practice had taken the appropriate steps to diagnose her grandson's illness. Mr A had attended the practice for consultations for about two months saying that, among other things, he had difficulty swallowing and a feeling of a blockage in his throat. Over the course of these consultations, blood tests were taken and Mr A was treated for anaemia. His symptoms did not improve and the practice referred him to a stomach specialist who found nothing and asked him to return two weeks later.

However, Mr A went to A&E and was admitted to hospital, where an underlying heart condition that would require surgery was diagnosed. While awaiting this surgery, Mr A suffered a stroke. Mrs C said that if the heart condition had been identified more promptly, then Mr A might not have had the stroke.

Although we understood this had been very difficult for Mrs C and Mr A, our role was to consider whether the steps the practice took were reasonable in the circumstances at the time. As part of our investigation, our GP medical adviser reviewed the medical notes and provided us with independent advice. Although he acknowledged how significant Mr A’s stroke had been, he explained that the symptoms had not suggested the underlying heart condition that Mr A actually had (which was a very rare condition in otherwise healthy individuals). The adviser also noted that the practice had listened to Mr A’s heart when he attended there, and this would have reduced any suspicion of Mr A’s underlying condition being heart-related. In light of this advice we did not uphold Mrs C’s complaint.

Summary

Miss C complained about a dentist. The dental practice acknowledged her complaint and told her they intended to respond within 21 days. On the 21st day they wrote to her saying that they needed more time to reach a decision, and would respond within around two weeks. They provided a final response around two weeks later. Miss C complained that the time taken by the practice to respond had been unreasonable. Our investigation found that the practice's complaints procedure said they would seek to respond within ten working days and would give reasons for any requirement to extend this. As the practice had not given Miss C such reasons we upheld the complaint.

Recommendations

We recommended that the practice:

• apologise to Miss C that they did not give her reasons for the delay in responding to her complaint; and
• review their complaints procedure in line with NHS Scotland's Can I Help You? guidance.

Summary

Mrs C complained that she had been refused cosmetic surgery based on an incorrect mental health diagnosis. She also said that the investigation into her complaint was not thorough.

In our investigation, we considered the information provided by Mrs C and the board, along with her medical records, as well as obtaining independent advice from one of our medical advisers. The board said that they had not diagnosed a condition but, rather, had used a particular condition to explain Mrs C's symptoms. Our adviser recognised this but, as the symptoms were used as the reason to refuse surgery, took the view that the diagnosis was implicit. Our adviser also said that the diagnosis was clinically disputable, and so we upheld Mrs C's complaint about this.

We found that the board dealt with her complaint in line with normal procedures, but our adviser pointed out that during their investigation they had not picked up that there had been a significant misinterpretation of the government guidelines about such treatment (the adult exceptional aesthetic referral protocol). We were concerned that they did not identify this, and we also upheld this complaint.

Recommendations

We recommended that the board:

• make a full written apology to Mrs C for the shortcomings we found in relation to her diagnosis; and
• remind relevant staff of the importance of ensuring that reasoning and decision-making in relation to cosmetic surgery is in line with the guidance and exclusion criteria set out in the updated adult exceptional aesthetic referral protocol.

Summary

Ms C had surgery on her foot to treat bunions at Ninewells Hospital. She complained that the operation did not relieve her pain and discomfort, but made it worse, and so the operation was unsuccessful. After treatment, other possible surgical options were discussed with her, but Ms C was anxious about having further surgery without assurances that she would be properly assessed and treated in future. She was particularly concerned that no x-rays were taken before or after her operation.

During our investigation, the board were unable to explain why they took no

x-rays before surgery. We took independent advice from one of our medical advisers, who said that although it was not mandatory, it was normal practice to take x-rays. Because they were not taken, the adviser was not able to say with certainty whether the procedure Ms C had was appropriate. We were also critical of the board for not properly recording Ms C's consent for the surgery. The procedure carried out was different from that to which she consented and we were concerned that Ms C might not have been properly advised of the procedures involved in this or the potential for failure.

Recommendations

We recommended that the board:

• apologise to Ms C for the failures to x-ray her or record her consent as part of the initial assessment of her suitability for surgery; and
• consider whether there are wider implications for the failings identified in this case, and advise us of the actions taken to address this recommendation and any outcomes.

Summary

Mr C complained on behalf of his wife (Mrs C) that the Scottish Ambulance Service did not adequately demonstrate that they had taken remedial action in response to his complaint. Mr C told us that his wife was visited at home by her GP, who thought she might have had a stroke. Mr C said that at 11:45, the GP called for an ambulance to arrive within four hours, but that Mrs C had to wait for seven and a half hours before an ambulance arrived. Mr C said he was satisfied that the service had investigated his complaint but, given the seriousness of his wife's condition, he wanted an assurance that the service's procedures and attitudes had changed for the better.

We looked at the information provided by Mr C and the service, and took independent advice from one of our medical advisers. We found that the service had taken the remedial action that they outlined in their response to Mr C's complaint. They had reviewed Mrs C's case, including the phone calls made and the relevant electronic records, as well as speaking to the supervisor involved and taking follow-up action with them. We were satisfied that the information in the service's response was reasonable and that they had done what they said they would.

Summary

Mr C, who is a doctor, complained on behalf of his friend (Mr A). Mr A had phoned Mr C because he had pain in his chest and arm. Mr C was concerned that his friend was having a heart attack, so he phoned for an ambulance. The crew assessed Mr A, including carrying out an electrocardiograph (ECG - a test that records the electrical activity of the heart). They found no indicators of a heart attack, and Mr A decided not to go to hospital. When Mr C heard this, he was very concerned and phoned for another ambulance. At this point his call was transferred to NHS 24, who went on to speak to Mr A before sending another ambulance. Mr A was taken to hospital and was found to have had a heart attack. Mr C then complained that the first crew did not assess Mr A properly and take him to hospital.

The Scottish Ambulance Service said that Mr A had not been taken to hospital in the first ambulance at his own request. However, they also noted that the crew did not make sufficiently thorough records of the tests they carried out and their visit.

We sought independent advice from a paramedic, who said that the first call was taken and prioritised appropriately, and that the service appropriately sent an emergency ambulance. He also considered that, given the finding of the tests when they assessed Mr A, it was reasonable for the crew's assessment to override Mr C's phone assessment. Mr C's second phone call was also appropriately handled, given the evidence available. We did not uphold the complaint, as although we found that the first crew were not told that a doctor had assessed Mr A by phone, and did not keep sufficient records of their interaction with Mr A, we were satisfied that they appropriately assessed his condition. We also noted that the service had reminded ambulance crews that they should make sure they evidence all of their clinical actions, particularly where a patient is not being taken to hospital.