Health

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) by a medical practice. Miss A has a long-term health condition and needs multivitamins daily. Mrs C said that, on more than one occasion, GPs at the practice wrongly prescribed a multivitamin containing a high dose of vitamin A, which was potentially toxic to Miss A. Mrs C said that she and the dietician noticed the error, not the GPs, and she complained to the board, who responded on behalf of the practice. Mrs C was not satisfied with the board's response.

After taking independent advice from one of our medical advisers, we were satisfied that the practice took Mrs C's complaint seriously, conducted a full and honest investigation, including a significant event analysis, and proposed reasonable actions to prevent a similar situation in the future. There had clearly been a mis-prescription of Miss A's multivitamins which affected a period of roughly six months, which the practice accepted. We found that this was caused by poor communication between the practice and other healthcare staff involved in Miss A's care. We also found that the practice operated two different methods of prescription, which meant that a GP dealing with Miss A for the first time could easily miss details of previous prescriptions which had not been entered on the practice system. We were also critical that, when it was established early on that Miss A's prescribed multivitamin was not listed on that system, no action was taken to have the system updated or to forewarn other GPs in the practice. We upheld Mrs C's complaint and made recommendations to address the failings identified.

Mrs C also complained about the handling of her complaint, but we found that it was investigated thoroughly and that the board’s response was reasonable.

Recommendations

We recommended that the practice:

• apologise to Mr and Mrs C for the poor handling of Miss A's multivitamin prescription; and
• provide us with evidence of the procedural changes that have been implemented following the significant event analysis.

Summary

Mrs C complained about the care that her mother (Mrs A) received in Borders General Hospital. Mrs A had a collapse/fall while she was alone at home and was taken to A&E. As Mrs A had a pacemaker and had a number of issues with her heart while she was at the hospital, she was transferred to another hospital in a different NHS board area for specialist investigations (the second hospital). Tests there showed that there were no abnormalities with Mrs A's pacemaker. She was scheduled for transfer back to Borders General Hospital but an outbreak there of norovirus (winter vomiting bug) prevented this. The second hospita carried out further tests, and Mrs A was diagnosed with pulmonary emboli (blockages in the blood vessels that carry blood from the heart to the lungs, usually caused by blood clots). She was prescribed warfarin (a medicine that prevents blood clotting) to treat this and a few days later was transferred back to Borders General Hospital. The medical transfer documentation did not include information about the new diagnosis and treatment, although the nursing transfer document specifically identified them. When Mrs A was readmitted to Borders General Hospital, staff only considered the medical transfer documents, and missed the pulmonary emboli diagnosis.

Mrs C had been concerned about her mother's ability to cope at home, but as Mrs A was considered to be medically fit to return there, she was discharged two days after she went back to Borders General Hospital. She became increasingly breathless, however, and was readmitted two days later where the pulmonary emboli diagnosis was picked up and treated.

Mrs C complained to the board about the care Mrs A received. The board apologised for the errors in communication between Borders General Hospital and the second hospital. They also advised that steps would be taken to ensure that the issue was followed up with the second hospital and that doctors would now check both medical and nursing transfer documents when admitting patients.

After taking independent advice from one of our medical advisers who is a consultant physician, we upheld Mrs C's complaint. The adviser considered that the failure to identify Mrs A's diagnosis of pulmonary emboli from the nursing transfer document was unreasonable and that insufficient effort was made to assess her before she was discharged. We were also critical that there appeared to have been a delay in the board carrying out the actions advised in their response to Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise for the standard of care and treatment provided to Mrs A during the period relating to the complaint;
• take steps to ensure that actions agreed following a complaint investigation are followed up promptly;
• consider the adviser's comments about taking the views of family members into account and determine whether there are lessons that can be learned; and
• make medical staff involved in Mrs A's care aware of the adviser's concerns regarding the decision to discharge, including the lack of documentation, to ensure that a similar situation does not occur in future.

Summary

Mrs C complained that the board failed to diagnose her with rheumatoid arthritis while she was under their care. Although she had a number of appointments in just over a year, Although she had a number of appointments in just over a year, Mrs C was only diagnosed with this after she moved out of Scotland.. She said that this was despite the fact that there had been sufficient indicators present to have confirmed this. She said that, as a consequence, she was not properly treated and that she had subsequently lost her independence.

We investigated the complaint and took independent advice from a consultant rheumatologist. Our adviser said that diagnosing rheumatoid arthritis is neither straightforward nor easy and other conditions can mimic its presentation. Accordingly, great care has to be taken in making a diagnosis, and also in prescribing appropriate drugs, some of which have significant side-effects. We found that in the time period about which Mrs C was concerned, and faced with a complicated picture, clinicians responsible for her care had carefully monitored her, formed appropriate working diagnoses and treated her appropriately. At about the same time as Mrs C moved, the evidence about her condition became much clearer and the findings and updated treatment were summarised to her new clinician when her treatment recommenced.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about the care and treatment given to Mrs A's late husband (Mr A) before he died. Mr A had bowel cancer and his prognosis (the forecast of the likely outcome of his condition) was not good. He was discharged home from hospital into the care of his GP and the district nursing service. After being at home for a short while, Mr A died. Mrs A complained about the various agencies involved in her husband's care and was particularly unhappy because she considered that district nurses had failed to properly care for her husband in the final weeks and days of his life and that levels of support, communication and standards of care had been poor. In responding to her complaint, the board agreed that there were failures in the support and care offered to Mr and Mrs A, and apologised for this, but Mrs A remained concerned that lessons had not been learned nor had procedures been put in place to prevent this happening again. She also complained about the way in which her complaint had been handled.

We took independent advice on this case from our nursing adviser, an experienced registered nurse. Our investigation confirmed that the board had admitted that there were shortcomings in Mr A's care, and we found that they took too long to deal with her complaint. We, therefore, upheld the complaint, while noting that the board had put processes in place to address the problems with Mr A's care and had apologised sincerely to Mrs A for the failings. As our investigation also found that the board had taken Mrs A's concerns most seriously and that the processes put in place provided a good response to them, we did not find it necessary to make any recommendations.

Summary

Mrs C had suffered from knee pain for a number of years. She was diagnosed with degenerative changes in her knee and a meniscal tear (a tear in the pad which provides shock absorption and other functions in the knee). She also had a meniscal cyst (a cyst often found in the presence of a meniscal tear and which can cause pain and discomfort). Following an initial course of physiotherapy, Mrs C had surgery at Perth Royal Infirmary to treat her meniscal tear and decompress the cyst. Although she experienced some initial improvement, her knee pain returned. She had further physiotherapy and a second operation. However, again her pain returned and in fact became worse. She complained that the board did not adequately treat her knee problems or provide appropriate follow-up care.

We took independent advice from one of our medical advisers, who explained that meniscal cysts can return and knee pain can persist following surgery. We were satisfied that this was explained to Mrs C before her first operation. We could find no mention of the cyst in the notes for the first operation. Whilst this could have indicated that the cyst could not be found, or that it was treated successfully, the absence of records meant we had to conclude that the cyst was not treated during the first procedure. That said, we found that it was treated appropriately during the second procedure and overall, we were satisfied that Mrs C was discharged and re-referred to the orthopaedic department appropriately as required when her knee pain flared up. We were also satisfied that physiotherapy was used appropriately. We did not uphold Mrs C's complaint, but we did ask the board to apologise to Mrs C in relation to the uncertainty surrounding her first operation.

Recommendations

We recommended that the board:

• apologise to Mrs C for the uncertainty surrounding her initial operation.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received at Perth Royal Infirmary and Ninewells Hospital. In particular, he said there was a protracted period of complacency by the staff involved in his daughter's care. At the time Mr C complained to us, Ms A had been experiencing severe and debilitating pain for over 18 months. A number of diagnoses had been suggested, and while treatments were ongoing, no single definitive cause had been found for her pain and other related symptoms. Mr C said that the medical team had ruled out endometriosis (a condition where cells similar to those that line the womb lie outside it) without adequate investigation or involving a colorectal surgeon.

In response to the complaint, the board apologised for the delays and the lack of communication between departments. They explained the reasons for and outcomes of the various tests that had been arranged, along with organising further clinical review for Ms A.

We took independent advice from three specialist clinical advisers - a gynaecologist, a gastroenterologist (a specialist in the treatment of conditions affecting the liver, intestine and pancreas) and a radiologist (a specialist in the analysis of images of the body). The radiologist said that a scan had been incorrectly interpreted, as he considered it did not show evidence of endometriosis. However, he did not consider this to be a major error of judgement requiring further action. In addition, whilst we identified that there was some confusion over referrals and some delays in arranging treatment, our advisers said that the tests and treatments offered were all appropriate in light of what was known at the time. On balance, we did not uphold Mr C's complaint as we found that although there were some errors in Ms A's care, no department had acted unreasonably and there were no serious failings. However, we did make a number of recommendations to the board.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• ensure that the radiologist responsible for reporting the scan is made aware of the views of our radiology adviser on the interpretation of that scan and given an opportunity to reflect on this; and
• reflect on the potential role of multi-disciplinary team meetings in complex cases such as Ms A's and consider how this might be embedded into clinical practice, and advise us of the outcome of their consideration.

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.