Health

Summary

Mr C complained that he did not get adequate care and treatment at his prison's health centre for nerve pain resulting from a finger injury. He also questioned the adequacy of his medical records, as the board's response to his complaint included an incorrect date for his injury.

We looked at Mr C's medical records, and took independent advice from one of our medical advisers. We found it was appropriate for prison health centre staff to try different treatments, with a view to finding one that would provide Mr C with good pain relief. We also found that, while there was one minor error in a date in Mr C's medical records, this did not impact on the care and treatment provided to him, and the correct date was included elsewhere in the records.

Summary

Mrs C was suffering from pain in her thigh some time after having a hip replacement, and her GP referred her for an x-ray. The report of the x-ray noted that there was no abnormality, but that there were also no previous images available for comparison as Mrs C's earlier x-rays were taken in another NHS board area. Mrs C was later seen by a private doctor who considered that the x-ray did show an abnormality that needed investigation. Further x-rays showed a problem with the replacement hip and a possible fracture, and Mrs C needed two more operations to fix this.

She complained that the board had failed to identify the abnormality in her

x-ray. The board took the view that the x-ray did show a subtle abnormality, but that without previous images to compare this to, it was difficult to tell if it was significant. They explained that a new system had since been introduced which made it easier to view x-rays taken elsewhere in Scotland.

After taking independent advice from one of our medical advisers, who is a consultant in radiology, we upheld Mrs C's complaint. The adviser reviewed Mrs C's x-ray and took the view that whilst the abnormality was relatively subtle, it was visible and could have been considered potentially significant for Mrs C. The adviser explained that it would have been appropriate to refer Mrs C for further investigations on the basis of the x-ray.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure to identify and report the abnormality in her x-ray; and
• provide a copy of our decision letter to the reporting doctor to allow him to reflect on Mrs C's case and discuss any learning points at his next appraisal.

Summary

Mrs A registered with the medical practice when she moved into a care home. She had several ongoing medical conditions and was seen by GPs from the practice on a number of occasions. A number of months after moving into the care home, Mrs A became quiet and was not drinking enough fluids. Staff contacted the practice and were advised to keep her under close observation. A call back was arranged for a short time later at which time the care home staff reported that Mrs A was much better and was drinking fluids. As they also advised the practice that Mrs A had very strong, foul smelling urine, an antibiotic was prescribed to treat any underlying infection. Later that night, however, Mrs A's condition deteriorated and she was admitted to hospital later that night. She died some days later.

Mrs A's daughter (Mrs C) complained that the GPs had not provided Mrs A with appropriate medical care while she was resident at the care home. In considering this complaint, we took independent advice from one of our medical advisers, who is a GP. Having reviewed Mrs A's medical records, our adviser said that she had received reasonable care and treatment from the practice. The GPs had reviewed and amended her medication, referred her to specialists in old age psychiatry and speech and language therapy, and responded to requests for advice from the care home staff as well as monitoring her general health. We did not uphold this complaint.

However, Mrs C also complained that the practice took too long to respond to her complaint. We reviewed their complaints handling procedure and agreed that the complaint had not been dealt with within their published timescales. We also noted that their complaints handling procedure had not been updated to reflect the introduction of new legislation, so we upheld this complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to respond to her complaint in a timely manner; and
• update their complaints handling procedure.

Summary

Mr C visited his dentist because he had toothache. The dentist found an abscess that was discharging pus from the gumline of the third and fourth teeth on the lower right side of Mr C's mouth. As Mr C was already taking a course of antibiotics prescribed by his GP, the dentist said that he should let the inflammation settle before returning to have the teeth extracted. Mr C returned and his teeth were extracted but the pain and swelling continued. He went for an emergency appointment, and the abscess was found on the first lower right tooth. Mr C was referred to local maxillofacial surgeons (specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) who provided intravenous antibiotics before removing all his lower teeth.

Mr C complained that his dentist did not provide reasonable treatment during the first consultation. He said he was not already taking antibiotics and that these were prescribed when he found it necessary to visit his GP having been unable to secure an emergency appointment with his dentist.

We found clear evidence that the antibiotics were prescribed before Mr C visited his dentist. Based on the information available at that time, we were satisfied that the dentist could not provide any immediate treatment, and we did not uphold this complaint. We were, however, critical that the dentist did not take additional x-rays to identify the true location of Mr C's abscess. The failure to do so delayed treatment by around two weeks and so we upheld the complaint that the care and treatment was unreasonable. However, we were satisfied that the two teeth that were extracted had to come out in any case. We found no evidence to suggest that emergency appointments were requested and refused and did not uphold that complaint.

Recommendations

We recommended that the dentist:

• apologise to Mr C for the delay to the treatment of his abscess; and
• take note of the adviser's comments regarding the need for additional x-rays with a view to identifying any points of learning for future treatment.

Summary

Mrs C raised a number of concerns about the care and treatment that her late mother (Mrs A) received at the Victoria Hospital during two separate admissions. Mrs A was taken to hospital with symptoms suggestive of a stroke. Tests showed that she had a lung tumour, and a biopsy (tissue sample) was taken several days later. She was discharged, but was readmitted four days later having suffered a major stroke. Mrs A died three months later.

We took independent advice on this case from our nursing adviser and one of our medical advisers, who is a GP. The GP adviser identified that a number of aspects of Mrs A's medical care fell below a reasonable standard. At the time of the first admission, more consideration could have been given to the stroke diagnosis and treatment, and there was an unreasonable delay in the lung biopsy being processed although we took the view that the board had since taken reasonable steps to address this. In respect of the second admission, the GP adviser said there was a lack of communication between specialist stroke staff and the family. We also found that, although Mrs A's medication was managed well on a daily basis, there was a need for more strategic consideration of this. There was delay in providing medication to address Mrs A's high calcium levels and her low mood. In addition, medication for nausea was stopped, and there was no reason for this given in the medical records. Our GP adviser was also critical that there were a number of undated entries in relation to blood results.

We noted that the board had acknowledged Mrs C's concerns that Mrs A's dignity was compromised and that on one occasion she was not properly clothed, and our nursing adviser was satisfied with the measures the board took to address this. In relation to the management of incontinence, pain levels, involvement from speech and language therapy and dieticians, along with Mrs A's care planning and rehabilitation work, there was evidence in the medical records to support that the overall nursing care was of an acceptable standard.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• review the comments of our GP adviser on this complaint and reflect on the decision-making processes used by GPs individually and collectively in assessing Mrs A, and provide us with evidence of this reflection having taken place and its outcome.

Summary

Mrs C complained that psychiatric staff in Stratheden Hospital treated her son (Mr A) unreasonably while he was a patient there. Our investigation considered a number of individual issues that she raised in relation to this, and in doing so we took independent advice from our mental health adviser.

Mrs C said that staff had failed to check whether Mr A had any dangerous items in his possession when he was being admitted to the hospital, which meant that he was able to start a fire in a room. We found, however, that he had not been formally admitted to the hospital at this point. Staff had not completed his admission assessment, as they had been called away to deal with a medical emergency involving another patient. Had this assessment (which would have included a risk assessment and a plan to minimise risk) been completed, any potentially dangerous articles would have been removed from Mr A's possession. In the circumstances, we did not consider that staff acted unreasonably, but we said that the board should treat this as a learning point.

Mrs C also said that staff delayed in arranging for an injury to Mr A's hand to be treated. We found that Mr A had initially refused to allow staff to carry out an examination, and that once he had consented to being examined and treated, staff had acted appropriately. Mrs C also complained to the board that Mr A was assaulted and molested by staff in the hospital. We found, however, that an adult protection investigation had been carried out into these matters, led by the local council, and that the board had also satisfactorily considered and investigated these allegations. In addition, we found that staff had acted reasonably in relation to getting Mr A an advocate, and were entitled to decide that Mrs C could not use a camera in the hospital to take photos. We also found that Mr A had been prescribed medication in line with the relevant guidelines and that staff had acted reasonably in relation to this.

That said, we found that Mr A had been transferred to another ward in his underwear and without shoes, which we found inappropriate. We also found that staff had failed to adequately observe or supervise him when he was moved into a seclusion room, and there was no evidence of a plan to ensure that he had appropriate access to food, fluids and a toilet during seclusion. This was not acceptable and, in view of these specific failings, we upheld Mrs C's complaint. However, we noted that the board had apologised to her for what happened when her son was transferred, and had acknowledged that there were failings when he was put in the seclusion room. This had prompted a review of seclusion practice and procedures in the hospital. The board sent us evidence of this review and we were satisfied that they had taken action to address these failings. We did, however, draw their attention to some failings in relation to a significant event review carried out in relation to the matter.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings identified in relation to putting her son in a seclusion room.

Summary

Mr C complained that when he attended his medical practice the GP who saw him did not tell him that he could stop his diabetic medication. As a result, he had continued to take it for a year, and he wondered whether this was detrimental to his health. The practice apologised and explained that the GP recalled discussing the matter with Mr C at the time but forgot to amend the repeat prescription list. They said that by continuing with the medication, Mr C did not come to any harm.

After taking independent advice from one of our medical advisers we found that, although we could not establish exactly what the GP and Mr C discussed, it was the GP's intention to stop the medication at that time. However, human error prevented the medication from being removed from the repeat prescription list. Because of this, we upheld Mr C's complaint. However, as the practice had already apologised to Mr C and reminded staff about properly documenting conversations with patients, we did not make any recommendations.

Summary

Mr and Mrs C were not satisfied with the board's investigation of their complaint about the behaviour of staff at clinic appointments at Ayr Hospital. The board told them that the relevant staff had been interviewed, and their recollection of events was different from that of Mr and Mrs C. Staff had said that it was Mr and Mrs C who exhibited unacceptable behaviour. Mr and Mrs C then complained to us that the board did not respond appropriately to their complaint.

It appeared that Mr and Mrs C and the staff had interpreted events differently, and we could not say which version of events was more accurate. We did find evidence that the board had treated the matter seriously and had thoroughly investigated the complaint. We were satisfied that they took Mr and Mrs C's concerns into account along with the evidence from the staff involved and had provided a reasonable response, including explaining the main issues involved.

Summary

Mr C complained that the board failed to provide him with appropriate ongoing psychiatric treatment and support after he was admitted to a hospital psychiatric unit. After taking independent advice from one of our medical advisers - a consultant psychiatrist - we found that Mr C was treated appropriately whilst he was in the hospital. However, several months after he left there, he was diagnosed with borderline personality disorder. We found that psychiatrists had failed to adequately document a detailed medical history, and that the diagnosis was not adequately founded or justified. It was not made with sufficient rigour and was not reviewed appropriately.

There was no evidence that assessment for psychological treatments was carried out so that Mr C could be offered treatment promptly. His care and management were not coordinated and there was no evidence that his care plan had been reviewed. In addition, it was not clear whether the findings of a scan were adequately communicated to him. We found that this delayed Mr C's treatment for a number of months. In view of all of this, we upheld the complaint. However, we found that a psychiatrist who had later taken over Mr C's care had been following an appropriate plan of further investigation in collaboration with Mr C's GP.

Mr C also complained that staff had failed to admit him to the psychiatric unit when he was discharged from another hospital after attempting suicide. The discharge letters from the other hospital, however, did not say that Mr C should be admitted to the unit. We found that it had been reasonable for the board not to readmit Mr C at that time and did not uphold this aspect of his complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the delay in providing him with appropriate psychiatric treatment and support;
• review his current treatment to ensure that it is appropriate;
• take steps to ensure that clinicians are more rigorous in the way that they diagnose personality disorders and that appropriate treatment is provided; and
• take steps to ensure that care management for psychiatric patients is co-ordinated.

Summary

Ms C complained that the board failed to diagnose a large volume of fluid on her lungs when she was treated in hospital in Scotland. She said that when she was treated later in another country a large amount of fluid was drained from her lungs.

We obtained independent advice on this case from one of our medical advisers. Our adviser explained that the records showed that the board did diagnose fluid on the lungs but that it was a small amount. Having looked at Ms C's chest

x-rays our adviser said that this was the correct description and there was no evidence of the litres of bloody fluid that Ms C told us she had drained later. The adviser said the difference might have been due to progression of her condition over a period of time, which is not uncommon. Based on the advice received, we were satisfied that the board's care and treatment of Ms C was reasonable.