Health

Summary

As part of a research project, Mrs C had a knee replacement at Glasgow Royal Infirmary. The operation, which was robot-assisted, replaced only the part of her knee which was damaged. As this type of surgery is carried out on a smaller area than traditional knee replacement operations, recovery should be faster. However, after the surgery, Mrs C complained about the care and treatment she received. She questioned whether she had been fit for discharge and about the number of cancelled clinic appointments after the operation. She said that nerve endings were damaged during the operation, which had hindered her recovery. She also told us that she was in pain and had to give up her job.

During our investigation, we obtained independent advice from a medical adviser, who is a consultant in orthopaedic and trauma surgery. We also considered all the available documentation and Mrs C's relevant medical records. Having done so, we did not uphold Mrs C's complaint.

Our adviser said that the operation was carried out appropriately and the knee implant was well positioned. Before the operation, appropriate investigations were made, and appropriate information and consent were given. Later, Mrs C was properly assessed before she was discharged from hospital. The adviser said, however, that there is a known outcome of this operation for some patients, who will be left with worse pain than before. Mrs C fell into this category, and despite things going well, she was one of a small number of patients left with residual pain. While it was noted that two of Mrs C's follow-up appointments were cancelled, another was arranged and we found no evidence that this delay affected the outcome of her treatment.

Summary

Mr C complained that the medical practice did not provide his late wife (Mrs C) with appropriate diagnosis, care and treatment over a four-year period. Mrs C suffered from haemochromatosis (a condition where the body absorbs an excessive amount of iron which is then deposited in organs, mainly the liver) and had cirrhosis of the liver as a result. She also had diabetes and other health conditions. Mr C said that the practice demonstrated a lack of personal interest and care, and had not communicated with his wife. Mr C said that they were never told about the seriousness of her state of health, and that she had a life threatening condition. Mrs C died in 2012, and Mr C also said that no-one from the practice contacted him after her death.

We took independent advice on the complaint from one of our advisers, who is a GP. The adviser said that most of Mrs C's care and treatment was reasonable and appropriate. However, the adviser identified a number of failings in relation to her care and treatment in 2011. The practice had not recorded Mrs C's diabetes diagnosis on her medical summary and so she was not entered on their diabetic recall register to attend for an annual review. The adviser said, however, that this failure was unlikely to have resulted in Mrs C coming to any significant harm. The practice told us that they had reviewed this and put measures in place to stop it happening again. The adviser also said that, given Mrs C's medical conditions, the practice should have asked her to come in for review during 2011, and should have reviewed and monitored her medication, particularly in relation to the prescribing of spironolactone (a water pill that helps shift the fluid that gathers in cases of liver disease). The practice had continued to issue prescriptions for over a year, without having seen a safe set of blood results or having discussed the medication with Mrs C, and our adviser said that this was poor medical practice. We were unable to reach a conclusion about what the GPs had said to Mr and Mrs C about the state of her health.

The practice confirmed that they had not contacted Mr C after his wife died, although they said that they usually did try to get in touch with close family members after a bereavement. They apologised for this and said they have now changed their procedures to make sure that they proactively contact the family of a patient who has died.

Having considered the evidence carefully, and taken into account the advice we received, we upheld Mr C's complaint because of the failings our investigation identified.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failings identified in this complaint;
• provide us with evidence of their policy of checking patients' summaries as a routine part of a patient's first diabetic review; and
• provide us with evidence that there is a process in place to ensure that patients' repeat medications are reviewed annually.

When it was originally published in September 2014, this case was wrongly categorised as 'some upheld'.  The correct category is 'fully upheld'.

Summary

Mr C complained on behalf of his wife (Mrs C) and his son (Mr A) that the mental health care and treatment the board provided was inadequate. In particular, he said that after being placed on the waiting list, the board delayed in providing his wife with a mental health assessment, cancelled this meeting without explanation and that the replacement meeting (and others) were not specific to her needs. He also said that they did not provide Mr A with the psychiatric support he needed and that, despite a number of appointments, they failed to get to the root of his problems and provide a proper diagnosis. The board, however, said that Mr A did not have a mental illness. Mr C also said that the board had released confidential information about the complaint to Mr A, and failed to deal properly with all of his complaints.

In investigating this complaint, we carefully considered all the complaints correspondence and relevant medical records. We obtained independent advice from a consultant forensic psychiatrist, which we also took into account.

Our investigation found that there was a delay in providing Mrs C with psychological treatment. The eventual appointment was then cancelled without explanation, and replaced by a form of treatment about which Mrs C had no input. Our adviser said that the way the treatment was carried out was not patient focused and did not appear to have any benefit.

During the same period of time, Mr A was provided with reasonable care and treatment. A thorough assessment was completed and an appropriate treatment plan was established. However, Mr A was given information about correspondence from Mr C without Mr C's permission. When Mr C complained about this, the board delayed in dealing with his complaint, contrary to their stated complaints handling process.

Recommendations

We recommended that the board:

• make a further apology to Mrs C for the failures our investigation identified;
• emphasise to relevant staff that the treatments they offer to patients should be patient centred and take the patient's (and carer's) views into account in providing this care and treatment;
• emphasise to relevant staff that psychological interventions should follow an established model to ensure focus;
• emphasise to staff concerned the importance of seeking appropriate permission before releasing 'third party' information;
• apologise to Mr C for their shortcomings; and
• emphasise to staff the importance of following their complaints procedure.

Summary

Mr C's son (Mr A) had a history of symptoms of weakness, numbness and pins and needles, and had previously been seen by neurology consultants. When he had an episode of tiredness, slurring of speech and right-sided weakness, Mr A called an ambulance and was taken to A&E at the Victoria Infirmary. He was examined but was discharged as he had a history of similar symptoms, which had already been investigated, and his condition had improved since he called the ambulance. The next day, Mr A went to his GP, who thought that he might have had a transient ischaemic attack (TIA - a 'mini-stroke'). The GP referred him urgently to a TIA clinic, and he was offered an appointment for eight days later. A couple of days after visiting the GP, however, Mr A was in some distress and Mr C took him to A&E at another hospital, where he was admitted and diagnosed with a stroke. Mr C complained that A&E doctors at the Victoria Infirmary had not treated his son properly when he went there with stroke symptoms.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaint. Our adviser said that the doctor was brief in his approach, and placed too much emphasis on Mr A's history of intermittent symptoms, which distracted from the fact that he had features of a TIA. We were critical of the A&E doctor's failure to take a detailed and accurate history from Mr A, and to make use of the history recorded by the ambulance staff and A&E nurse, which would have pointed to a TIA.

Recommendations

We recommended that the board:

• issue a written apology to Mr C and Mr A for the failings our investigation identified; and
• ensure that the findings of this investigation are raised with the doctor concerned for reflection.

Summary

Mr C complained about the care and treatment that his late wife (Mrs C) received over a four-year period. Mrs C suffered from haemochromatosis (a condition where the body absorbs an excessive amount of iron which is then deposited in organs, mainly the liver) and had cirrhosis of the liver as a result. She also had a number of other medical conditions. Mrs C died in 2012.

Mrs C had been an out-patient at a liver clinic at Gartnavel Hospital since 2009. Mr C was concerned about a number of issues, including that medical staff had not sufficiently considered causes other than alcohol as the reason for his wife's liver condition and had not considered her need for a liver transplant. He also said that Mrs C's consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas) had never warned Mr and Mrs C about the seriousness of her condition and her prognosis (forecast of the likely outcome). We took independent advice from one of our medical advisers, who is a consultant in gastroenterology and hepatology (liver disease). The adviser said that Mrs C's medical records showed that she had asked to be seen at the liver clinic less often. Her doctors had agreed to this because she was also regularly attending a specialist hepatology clinic. The adviser said that Mrs C had not been a suitable candidate for a liver transplant at the time, and that it was appropriate for the consultant to have discussed with her whether alcohol was a contributing factor in her illness. The adviser found no evidence of a marked deterioration in Mrs C's condition while under review by the hospital. The available evidence did not show exactly what she was told, but having seen the medical records our adviser took the view that the potential severity of her condition would have been explained to her. Overall, we found no failings by medical staff in their care and treatment of Mrs C.

In 2012 Mrs C was admitted to the Royal Alexandra Hospital with shortness of breath and a pleural effusion (a collection of fluid next to the lung). She discharged herself six days later, as she and Mr C were unhappy with her care and treatment there. Among Mr C's concerns were that Mrs C was left unattended, particularly when she needed to use the toilet, and that nursing staff were unsupportive and had failed to treat skin sores. He also said that he was not told when Mrs C was transferred to another ward, and no-one could tell him where she had been moved to.

Our adviser said that the records showed that Mrs C was correctly diagnosed and that appropriate investigations were carried out after she was admitted. The adviser also said that it was appropriate, given Mrs C's liver condition, to have transferred her from an acute medical ward to a gastroenterology ward.

We obtained independent advice about the nursing care from our nursing adviser, who said that an entry in Mrs C's nursing notes on the day of admission gave the impression that a nurse lacked empathy towards Mrs C. The evidence also showed that Mrs C had fallen while on the ward and that nursing staff had not explored the reasons behind her fall or completed an incident form, which would have helped assess how the risk of further falls could be reduced. The nurse who completed the falls risk assessment form had also failed to record that Mrs C had fallen before, and the nursing admission assessment form wrongly said that she had no breathing problems and was fully mobile and independent. There was evidence from the nursing records that nursing staff were communicating with Mr and Mrs C. There appeared, however, to be no system in place for recording information about transfers, which is why Mr C was unable to locate his wife when she was transferred between wards. As we found a number of failings in relation to Mrs C's nursing care in the Royal Alexandra Hospital, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings in respect of Mrs C's nursing care whilst she was a patient in the Royal Alexandra Hospital;
• ensure that the comments of our nursing adviser, in relation to communication and record-keeping, are shared with the nursing staff involved with Mrs C's care whilst she was a patient in the Royal Alexandra Hospital and provide evidence of this; and
• provide evidence that the Royal Alexandra Hospital has robust information systems in place in relation to inter-ward transfers.

When it was originally published in September 2014, this case was wrongly categorised as 'some upheld'. The correct category is 'fully upheld'.

Summary

Mr C, who was a prisoner, complained that the board unreasonably delayed in arranging for him to see an optician over a period of time while he was in prison. We considered Mr C's relevant medical records and the complaints correspondence, and obtained independent advice on his care and treatment from one of our medical advisers. The adviser said that Mr C did not need an urgent appointment, and that delay would not have caused him a permanent eyesight problem. However, as the board said that the average time to wait to see an optician is two to four weeks we were concerned that, during two periods of his time in prison, Mr C waited more than four weeks to be seen, and we upheld his complaint.

Recommendations

We recommended that the board:

• apologise for the delay in Mr C being seen by the optician; and
• review their process to ensure that when a prisoner is listed to see an optician, an appointment is scheduled and appropriate checks are carried out if the prisoner does not attend the appointment.

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received in the Glasgow Western Infirmary. Mrs A was admitted to hospital after a fall at home. She was treated for a chest infection, but tests found that she also had a cancerous tumour on her lung which had spread to her liver. Clinical staff decided that active treatment for this was not appropriate and that palliative care (care provided solely to prevent or relieve suffering) should be provided. Although discussions took place around potential discharge options for Mrs A, her condition deteriorated and she died in the hospital within two weeks of her admission. Mrs C complained about the nursing care that Mrs A received, discharge planning, nutrition and hydration and communication from staff.

We took independent advice on this case from a medical adviser and a nursing adviser. The clinical records indicated that Mrs A had varying levels of confusion throughout her admission, which made it difficult for staff to assess the extent to which she could consent to treatment or take part in discussions about her care. Generally we were satisfied that Mrs A's formal consent was not needed for the tests that she underwent, and we found that staff clearly recorded information about her preferences in terms of discharge arrangements and what she wanted to know about her diagnosis. We found that Mrs A's wishes about this were ultimately respected, and that all of the clinical treatment she received was appropriate. However, we were critical of some aspects of her nursing care. We found that staff failed to properly assess what additional support Mrs A might have needed during her admission. Mrs A had experienced problems early in her admission and we found that staff later kept drinks and snacks out of her reach to avoid spillages, rather than providing suitable utensils to help her eat and drink when she wished. We took the view that help with this might have made her time in hospital more comfortable, and that failure to provide this was poor practice. Overall, we found that the board failed to take adequate account of Mrs A's specific personal needs and upheld this complaint. We also upheld Mrs C's complaint that the board's responses to her formal complaints were unreasonably delayed.

We did not, however, uphold Mrs C's complaint about communication. Although we recognised that she was unhappy with the level and quality of communication from staff, we generally found this to have been reasonable. That said, we were critical of the board for failing to provide a private room for discussions about Mrs A's diagnosis.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation;
• provide us with up-to-date details of the action they have taken to improve nursing staff's compliance with completion of patient admission and assessment documentation, including the provision of suitable utensils for patients with special needs;
• remind relevant staff of their responsibilities in obtaining patient consent to discuss care and treatment with family members;
• apologise to Mrs C for their poor handling of her complaint; and
• take steps to ensure their investigations and responses are not unreasonably delayed.

Summary

Mr C had had a childhood illness that resulted in facial paralysis. Over the years, he had undergone a number of surgical procedures to improve his facial appearance. However, he complained he had been left with increased paralysis, loss of function and facial pain. He said that his appearance was worse and he had suffered nerve damage. He was at a loss to understand how this had happened and questioned the care and treatment he had been given. He complained to the board, who said that all the procedures undertaken were done with his informed consent and that his treatment was appropriate to his condition.

In investigating the complaint, we took independent advice from a specialist surgeon and a pain specialist, as well as carefully considering all the relevant information, including all the correspondence and Mr C's clinical records. Although we understood Mr C's concerns, the advice we received was that the treatment he had was appropriate and of a good standard, and the clinical notes confirmed that it was fully discussed with him in advance. When Mr C complained, his concerns and symptoms were appropriately and sympathetically dealt with. However, as the pain consultant said there were alternative methods of pain control that it might be helpful for Mr C to try, we made a recommendation about this.

Recommendations

We recommended that the board:

• give consideration to the provision of non-pharmacological means of pain control for Mr C.

Summary

Mrs C complained about the care and treatment her late mother (Mrs A) received at the Western Infirmary, Gartnavel General Hospital and Victoria Infirmary. Mrs A was initially admitted to the Western when she fell and fractured her hip. She had a hip replacement operation and was transferred to Gartnavel. Mrs C said that as Mrs A had developed pressure ulcers on her foot she was discharged home too soon, only to be admitted to the Victoria two days later, having fallen again. Mrs C had further concerns about the care of the pressure ulcers and a lack of physiotherapy, and said that her mother was again discharged too soon because she then had several more falls and had to go back to hospital.

We took independent advice on this case from three of our advisers (specialising in nursing, physiotherapy and acute medicine for older people). Mrs A had been assessed as being at high risk of developing pressure ulcers, but we found no evidence that nursing staff at Gartnavel and Victoria hospitals monitored her for this. Although a special pressure relieving boot was provided after the pressure ulcer was identified, staff did not start a wound chart to monitor and assess the ulcer as they should have done. We concluded that the nursing care in both these hospitals fell below a reasonable standard, and was not in accordance with guidance issued by NHS Quality Improvement Scotland. The board also acknowledged a delay of around 12 days in Mrs A starting physiotherapy in the Victoria after she had a short period of illness. We said that this was unreasonable, and prolonged her stay there.

In relation to Mrs A's discharge from Gartnavel, our adviser said that in itself a fall shortly after discharge would not mean the discharge was inappropriate. Although we were highly critical of the board for having lost some of Mrs A's medical records, we decided that evidence from the physiotherapy, occupational therapy and nursing records showed that Mrs A's mobility was reasonably assessed, and no significant changes were noted before she was discharged. In addition, there was evidence showing that the second discharge from the Victoria was appropriate and referrals had been made for Mrs A to continue to have her needs assessed at home.

Recommendations

We recommended that the board:

• audit a sample of patient records at Gartnavel General Hospital and the Victoria Infirmary to ensure skin risk assessments are being conducted, and appropriate care plans are in place in accordance with NHS Quality Improvement Scotland guidance;
• ensure patients in the Victoria Infirmary are promptly reviewed by physiotherapy after a period of sickness;
• apologise to Mrs C for losing Mrs A's medical records and for failing to identify that they were missing when responding to the complaint;
• review their practice on the storage of patients' medical records to prevent a recurrence of failing to store medical records securely; and
• ensure patients are referred in good time to the appropriate community rehabilitation team in preparation for discharge from Gartnavel General Hospital.

Summary

Mrs C complained on behalf of her sister-in-law (Mrs A) that the board cancelled Mrs A's facial reconstruction surgery at Aberdeen Royal Infirmary, and did not provide a reasonable explanation for this. From what Mrs C described, this was clearly an upsetting experience for Mrs A.

We looked at information from Mrs C and the board, and took independent advice from one of our medical advisers. We found that the board cancelled the operation because at the time there were not enough nurses to staff the intensive care bed that Mrs A needed afterwards, because of emergency admissions. The board said that this was not what they would have wanted for Mrs A, but that they had to put her safety first. They also explained to us what they had done to deal with demand for post-operative intensive care beds in future. Although we understood why Mrs A had found this distressing, we did not uphold Mrs C's complaints, as we found that the cancellation was not unreasonable in the circumstances, and that the board had provided a reasonable explanation of why it happened.