Health

Summary

Mrs C complained about the care and treatment provided to her daughter (Miss A) by the board's out-of-hours (OOH) service at St John's Hospital. Mrs C said that they failed to diagnose that Miss A had pneumonia (a lung infection) over the course of three visits. She told us that initially staff had failed to recognise that Miss A was seriously ill and she was sent home with misleading advice about how to care for Miss A. Mrs C also said that the doctor she saw on her final visit to the OOH service was dismissive of her concerns and her daughter had only been admitted to the children's ward because Mrs C had insisted that Miss A receive a second opinion.

Mrs C also complained that once on the children's ward, staffing levels were inadequate and this compromised the care provided to Miss A. Miss A's condition had continued to deteriorate and she was transferred to a children's hospital where she was treated as an in-patient for three weeks before she was discharged. Mrs C said Miss A had been traumatised by the experience and that she had required counselling to overcome her fear of hospitals and doctors.

We took independent advice from one of our medical advisers and a nursing adviser. The medical adviser said the medical records showed that the assessment Miss A received at each visit met national guidelines for the care of children with a fever. He said staff had recognised the severity of her condition and provided the appropriate treatment. There was no evidence to show that the doctor Mrs C complained about acted inappropriately. The nursing adviser said that the records for Miss A's stay in the children's ward were comprehensive, and provided a clear record of her care. We found no evidence that her care was substandard.

Summary

Mrs C took her young daughter (Miss A) to her medical practice as Miss A had a high temperature that would not come down, despite being given paracetamol. Mrs C said her daughter was shivering and was having difficulty catching her breath.

Mrs C said that at the appointment the GP described Miss A's condition as a chest infection and prescribed antibiotics. Miss A was later admitted to hospital suffering from pneumonia (a lung infection). Mrs C said that the GP should have told her that he suspected pneumonia, rather than describing her daughter's condition as a chest infection. She thought that her daughter should have been referred for further tests and investigations at the appointment, rather than being sent home with a prescription for antibiotics. Mrs C also said that the practice had failed to handle her complaint appropriately. She said that, at a meeting, the GP seemed more upset about her complaint than about Miss A's experience, which had left her traumatised with a fear of hospitals and doctors.

We took independent advice from one of our medical advisers. The adviser said that the evidence showed that the GP recorded a diagnosis of suspected pneumonia in his notes, and prescribed antibiotics for treatment at home, in line with national guidelines. He also said that there was no evidence that Miss A had not received an acceptable standard of care.

Our investigation also found that the practice carried out a thorough investigation into Mrs C's complaint. They provided an explanation for the remarks made by the GP at the meeting with Mrs C and where they identified learning points they took action to address them. We found that the practice had responded appropriately to Mrs C's complaint.

Summary

Ms C complained that the board had not followed the correct diagnostic and prescribing guidelines for her condition. She said that she was wrongly diagnosed with Graves' disease (a condition in which the body produces too much thyroid hormone) at St John's Hospital, and that what she was prescribed was harmful to her. Ms C was also unhappy that other clinicians were made aware of the diagnosis of her condition as being non-physical rather than physical, and said this had an adverse effect on her care and treatment. This diagnosis was retracted after Ms C complained, but she was unhappy that there was reference in her medical records to her complaint. She was also unhappy with the way her complaint was handled and said that the board had failed to carry out action they had agreed.

We took independent advice from one of our medical advisers, who is a consultant in endocrinology (a branch of medicine dealing with hormones). The adviser found no evidence that the board failed to follow the correct diagnostic and prescribing guidelines for Ms C's condition. He did say, however, that her disease was mild and was not the cause of her symptoms, and that the board should have looked more actively for other causes for Ms C's ill health. We found that Ms C had received attentive care and that the conventional guidelines (British Thyroid Association guidelines) were followed. We found no evidence that diagnosis of her condition as non-physical rather than physical had an adverse effect on treatment.

We were also satisfied that the board had responded to Ms C's concerns and had met with her to try to address her concerns. They had clearly explained that because the issues were about events from a number of years ago they were not going to investigate her complaint on a point by point basis. We were also satisfied that the board had done what they said they would, although we were concerned about the reference to the complaint in Ms C's medical records. Although we did not uphold her complaints, we made three recommendations to try to ensure good practice in future.

Recommendations

We recommended that the board:

• ensure that the medical advice we received in relation to this complaint is brought to the attention of the relevant clinicians;
• remind all staff that information about a patient's complaint should not be contained within medical records; and
• ensure that, in this case, the procedure for dealing with disagreements about entries on medical records has been followed.

Summary

Mrs C complained about the treatment that her son (child A) received from his dentist. She complained that the dentist failed to identify that her son was missing two lower premolar teeth. Mrs C said that this caused her son stress, led to a delay in diagnosis and impacted on the cost and the potential success of his future dental treatment. Child A had attended for a routine examination. A bitewing x-ray (a type of dental x-ray) was taken which showed spacing between his lower premolar and the first molar, but the dentist did nothing about this. Mrs C only found this out when her child attended another dentist several months later. He was referred for orthodontic assessment and it was identified that both his lower second premolars were congenitally absent (not present since birth).

We obtained independent advice from our dental adviser who explained that bitewing x-rays are normally taken to detect dental decay. Although this is the primary reason for using bitewing x-rays, they could be expected to show that the lower premolars were not developing. The adviser said that the dentist missed an opportunity for early diagnosis of the absence of the two lower second premolars and said that it would have been reasonable for the dentist to have investigated further at that time. The adviser also explained that there are guidelines on the use of x-rays in dental practice, which recommend that even in the event of a child being assessed as having a low risk of decay, bitewing

x-rays should be taken at intervals of 12 to 18 months whilst they have baby or milk teeth. We found that the dentist did not follow these guidelines in child A's case, so we made a recommendation about this.

Nevertheless, the adviser also said that an earlier referral to an orthodontist would not have achieved anything further, and that any delay in child A's treatment was marginal and would have made no difference to possible treatment. Given this, although on balance we upheld Mrs C's complaint, we did not consider that the treatment her son received impacted on the cost and potential treatment success for him.

Recommendations

We recommended that the dentist:

• reflects on our adviser's findings in terms of future dental practice and in particular takes into account the relevant European guidelines in relation to the frequency of taking bitewing x-rays.

Summary

Miss C had major surgery on her bowel, and complained to us about the treatment she received after the surgery, which she thought was inadequate, and about the handling of her out-patient appointments.

During our investigation, we took independent advice from a consultant general and colorectal surgeon, following which we did not uphold Miss C's complaint. The adviser said that, although Miss C had not been seen personally by the doctor who carried out the surgery, she was seen in his clinic by his representative. The adviser was satisfied that the action taken was consistent with good practice. He also said that Miss C's medical records confirmed that the doctor offered reasonable treatment following the surgery and discussed the treatment options open to Miss C, including further surgery. It was unfortunate that some of Miss C's out-patient appointments were rescheduled and that this added to her concern about the level of aftercare she was receiving, but we noted that the board had already apologised to her for this.

Summary

Mrs C complained that the board failed to provide her with appropriate treatment after her GP referred her to a cardiologist because of her worsening shortness of breath and pitting ankle oedema (where areas of skin temporarily hold the imprint of a finger when pressed). We obtained medical advice on the complaint from one of our medical advisers, who is an experienced cardiologist. We found that it was reasonable for the cardiologist to repeat an echocardiogram (an ultrasound scan of the heart) that her GP had already carried out. The adviser said that if an abnormality is found in a test requested by a GP, then most hospital-based cardiologists would repeat the echocardiogram, so that not only can the hospital-based doctor review the images him or herself, but is also aware of the experience and training of the technician making the recording.

The adviser said that although Mrs C had two leaking heart valves, they were unlikely to affect her health in the future and did not account for her current symptoms. He also agreed with the board that it would not be appropriate for Mrs C to have heart bypass surgery. That said, the adviser said that it was not reasonable for the cardiologist to increase Mrs C's dose of ramipril (medication used to prevent high blood pressure and heart failure) based on a single blood pressure reading. The cardiologist had not taken account of the commonplace observation that when any patient meets a new doctor, particularly in a hospital setting, their blood pressure is elevated. It was also unclear why the cardiologist prescribed bisoprolol (a beta blocker used to slow down the activity of the heart), as the results of relevant tests that the cardiologist had requested were not available at that point.

We also found failings in the board's communication. The cardiologist should have explained the alterations to Mrs C's drug therapy to her and should have met her to explain why she required indefinite treatment with warfarin (a medicine that stops blood from clotting). The cardiologist also delayed in informing both Mrs C and her GP of test results. In view of these failings, we upheld Mrs C's complaint. However, we noted that the board had since addressed many of the communication failures, and had apologised to Mrs C for the poor communication when they later met her.

Mrs C also complained to us about the board's handling of her complaint. They had asked the cardiologist for comments on the complaint. The response was dismissive and failed to demonstrate that the cardiologist had reflected on the complaint and considered if any lessons could be learned. The board's response to Mrs C simply set out the cardiologist's views. There were also problems with the arrangements for a meeting that the board set up to discuss Mrs C's complaints with her. In view of all of this, we also upheld this aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• make the cardiologist aware of our findings;
• confirm that the case will be discussed at the cardiologist's next annual appraisal; and
• issue a written apology to Mrs C for the poor handling of her complaint.

Summary

Mrs C complained to us about the care and treatment provided to her late father (Mr A) before his death. Mr A had been admitted to Wishaw General Hospital with mobility problems. He was known to have a number of medical conditions, including cancer and cirrhosis (scarring of the liver due to liver disease). He was diabetic and had right pleural effusion (a collection of fluid between the lung and chest wall). He was initially given diuretics (substances that increase urine excretion) for the plural effusion, but it was then agreed with the family that these would be stopped. Mr A was then transferred to a hospice. His condition improved and he was discharged home. However, several weeks later, he was readmitted to the hospital. He stayed there for two weeks before being transferred to an NHS long-term care facility in a care home. Mr A died in the care home a month later. Mrs C complained about Mr A's clinical treatment in the hospital and the care home. Although we cannot normally look at complaints about care homes, we were able to investigate in this case, as Mr A was in an NHS long-term care facility.

We took independent advice from one of our medical advisers. We found that Mr C had received reasonable treatment for MRSA (meticillin-resistant staphylococcus aureus, a bacterial infection that is resistant to a number of widely used antibiotics) in the hospital and that communication with him and his family there was reasonable. We also found that there had been regular consideration of Mr A's symptoms in the care home and there were appropriate responses, in terms of treatment and communication with the family. It had also been reasonable for staff in the care home to withdraw Mr A's insulin. However, we found that a decision was made in the hospital that the fluid in Mr A's chest was related to his cirrhosis. This was done without more consideration of contrary evidence that this could have been a pleural effusion related to his cancer. There was no evidence that the doctor who prescribed the diuretics for this had considered the pleural effusion in sufficient detail. (There was, however, no suggestion that Mr A's health was unduly affected by this treatment.) This was a balanced decision, but in view of this specific failing and taking into account that the pleural effusion was the main abnormality on admission, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that staff had failed to respect the wishes of Mr A and his family that diuretic medication and morphine were not to be administered. Mrs C had sent the board an email requesting this whilst he was in the hospital. Her request was shared with medical staff and after this Mr A was not given these again in hospital. However, when he was admitted to the care home staff started to give him morphine again. Although we found that it had been reasonable to provide Mr A with small doses of morphine to manage his pain, in view of the request in the email, this should have been discussed and agreed with the family. This did not happen, because hospital staff did not communicate that request to the care home. In view of this communication failure, which occurred at a difficult time for the family and was about an issue they had already raised, we upheld this complaint.

Mrs C also complained about the nursing care provided to Mr A in the hospital and the care home. However, we found that this had been reasonable.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings identified in relation to the diagnosis of the cause of Mr A's pleural effusion and for the failure to communicate to the care home the family's request that Mr A was not to be given diuretics or morphine; and
• make the staff involved in Mr A's care and treatment aware of our decision.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Ms A) about her care and treatment. Ms A's GP referred her to Raigmore Hospital because she had been experiencing backache, painful urination and pain in her thighs, and she was admitted as an emergency. She was treated for a urinary tract infection and, as she also had back pain, arrangements were made for her to have an x-ray after she was discharged. Less than a month later, Ms A was seen in hospital again but when she was examined, no pulse could be found in either of her legs below her knee. She was started immediately on aspirin and a statin (a drug to reduce cholesterol in the blood) and an MR angiogram (magnetic resonance angiogram, a type of imaging) was carried out. Subsequently, Ms A was admitted to hospital where she underwent a femoral distal bypass (an operation to bypass the blocked part of an artery, carried out when a patient is threatened with amputation). This was re-done on two further occasions and the possibility of amputation of one of Ms A's legs was discussed.

Ms C complained about the care and treatment Ms A received on her first admission to hospital and said that she had not been properly examined and appropriate tests had not been carried out. She also said that an inaccurate diagnosis was made and Ms A was discharged without appropriate follow-up arrangements. Ms A thought that if she had been kept in hospital for tests, the outcome might have been different.

We took independent medical advice from a consultant surgeon as part of our investigation. We found that when Ms A was first admitted to hospital she showed no signs of peripheral vascular disease (a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles) and she did not report any pain in her legs or discolouration in her feet. Accordingly, her treatment had been appropriate. Similarly, before she was sent home, she had been assessed as fit for discharge. It was quite appropriate for further tests, including an x-ray, to be arranged for her as an out-patient. It was only later, after it was found that there were no pulses in her lower legs and further tests were done that the extent of Ms A's problem was revealed.

Summary

Mrs C complained on behalf of her mother (Mrs A) that the care and treatment of her grandmother (Mrs B), had been unreasonable. Mrs C and Mrs A felt that it was not appropriate to put the Liverpool Care Pathway (LCP - an end of life care planning system) in place in view of the state of Mrs B's health, and said that the family were not told that it was in force.

We investigated the complaint and took independent advice from an experienced registered nurse. The investigation showed that when Mrs B arrived in hospital with her son (Mr B) who was her next of kin, she had an ischaemic leg (where the blood supply to the leg is poor, causing the tissue to die). Her condition was so poor that amputation was discussed. Mrs B, who had capacity to make her own decisions, said that she did not wish an amputation even though she was aware that her decision would lead to her death. She said that she wanted to be kept comfortable and out of pain. Immediate steps were taken to do this and the LCP was initiated.

We found that the board had acted in accordance with Mrs B's wishes, which was appropriate. Mr B, as next of kin, was involved in the discussions and, although Mrs A believed that matters should have been put on hold until she arrived and they could be discussed with her, this was not reasonable or appropriate in the circumstances.

Summary

Mr C's father (Mr A) suffered from Parkinson's disease and was admitted to a care home, where he lived for the last few years of his life. A few years after Mr A's death, Mr C applied to the board for a retrospective award of funding for Mr A's care. In response to Mr C's application, the multi-disciplinary team involved in Mr A's care retrospectively undertook an assessment of his needs, and the board declined Mr C's application. Mr C appealed this decision. The appeal was considered first by the clinical director, who recommended granting the application. However, the appeal was decided by the medical director, who personally reviewed Mr A's records and chose not to accept the clinical director's recommendation, instead declining Mr C's application.

Mr C complained that the board's assessment of his application was unreasonable. He raised concerns that the multi-disciplinary team's assessment was unreasonable, that the board did not refer to relevant medical records, and that they did not take account of the fact that the decision not to transfer Mr A to a hospital was made on social, rather than medical, grounds. Mr C also said that the medical director gave no reasons for not accepting the clinical director's recommendation.

After taking independent advice on this complaint from one of our medical advisers, we did not uphold Mr C's complaint. The medical adviser said that the multi-disciplinary team's retrospective assessment of Mr A's needs was reasonable in the circumstances. There was no evidence that the medical records that Mr C thought had been overlooked existed, so we found that the board had not overlooked evidence in this regard. We also found that the medical director had taken account of the argument that the decision not to transfer Mr A to a hospital was based on social, not medical, grounds but had nevertheless decided not to uphold the appeal. Finally, we found that the medical director's decision not to accept the clinical director's recommendation was reasonable and that the reasons for this were set out in the decision letter. Although Mr C did not agree with the board's conclusions, we were satisfied that the assessment was conducted reasonably and in line with relevant guidance.