Health

Summary

Mr C was admitted to the Western Infirmary with symptoms of nausea and vertigo. He was kept in overnight and discharged the following day, with a prescription for medication to take on an 'as required' basis to relieve his symptoms. As the hospital pharmacy was closed, he was given a small amount from the ward's supply until he could get his own prescription, but was given the wrong medication. In responding to Mr C's complaint, the board acknowledged that he had been given the wrong medication in error and apologised.

Mr C complained to us because the board had not fully addressed his concerns that a nurse had advised him to take the medication three times a day for three months, instead of on an 'as required' basis, and instructed him on the use of a spray he already used. He also said that the medication might have been intended for another patient, which could have had serious consequences for them. In responding to our enquiries, the board acknowledged that they should have provided Mr C with a fuller response. They explained that they had put an action plan in place to highlight to all staff the importance of ensuring safe medication practice.

We took independent advice on this complaint from one of our medical advisers. He did not think it likely that there was a mix-up with another patient, but rather that there had been a basic dispensing error. He noted that the frequency advice appeared to relate to the incorrect drug that was provided, and confirmed that there would have been no serious consequences had Mr C taken that drug. In relation to the advice on using the spray, the adviser noted that it was common for a hospital to prescribe medication that forms part of a patient's usual prescription, and that they may just have been making sure his medication supply was complete.

As Mr C was given the wrong medication and advice, we upheld his complaint. However, as we were satisfied that in this instance the drug error was not serious in nature, and that the board had acknowledged the error, apologised and taken steps to try to prevent this happening again, we did not need to make any recommendations.

Summary

Mrs C attended the practice for a routine check-up, and returned several days later for treatment to fill a small hole in her upper left molar. Mrs C assumed that the person who carried out the procedure was a dentist, although they were actually a dental therapist. That evening, the side of Mrs C's face became extremely swollen and next day she had a large area of bruising and was in pain. The following week, an x-ray showed that there was an infection in the tooth, and the practice prescribed a course of antibiotics. The pain settled four days later, and the bruising took another four days to disappear. Mrs C said that a dentist at the practice told her that it had been a very deep filling, which had possibly damaged the nerve, and he would have to remove the crown to treat it. Mrs C was concerned when she saw the extent of the planned work, and that it would cost over £400 to restore the appearance of her tooth.

We took independent advice on this complaint from one of our advisers, who is a dentist. The adviser said that it was reasonable not to carry out an x-ray before the procedure, but that there were communication failures. There was no evidence that Mrs C's consent was obtained in relation to the status of the healthcare professional carrying out the procedure, and during the procedure it appeared that Mrs C was not told about the degree of the decay and possible consequences of future treatment. However, the adviser also said that the treatment Mrs C received when she went back and the proposed course of treatment to address the problems were reasonable. Overall, we upheld Mrs C's complaint as although we were satisfied there was no evidence that the treatment was unreasonable, we found failures in care in relation to communication and consent.

Recommendations

We recommended that the practice:

• ensure the failures identified in relation to communication and consent issues are raised with relevant staff; and
• apologise to Mrs C for the failures identified.

Summary

Mr C's son (Master A) was unwell, and was taken to A&E at Yorkhill Hospital (also known as the Royal Hospital for Sick Children). The family were due to go on holiday two days later and Mr C said that he told hospital staff this. Master A was examined and discharged, and his parents were told to bring him back if his condition worsened or he was sick. This did not happen, and the family went on holiday. Two days later, Master A had to have emergency surgery abroad to remove his burst appendix. He was in hospital for five days being treated with antibiotics (drugs to fight bacterial infection), strong painkillers, and a drain to remove infected fluid from his abdomen. Mr C complained that staff at Yorkhill Hospital failed to diagnose that his son had appendicitis (inflammation of the appendix).

Our investigation, which included taking independent advice from one of our medical advisers, found that the care and treatment provided to Master A was reasonable and appropriate. Having studied Master A's medical records, the adviser said that the clinical signs and symptoms with which Master A presented gave insufficient evidence to make a definitive diagnosis of appendicitis. The likely cause of his illness was thought to be a viral infection. Appendicitis was not ruled out, but included as a differential (alternative) diagnosis. The adviser said that this was reasonable and that it was appropriate to discharge Master A with advice to come back to A&E if his condition worsened.

There had been some dispute over whether or not the staff who dealt with Master A were aware of the planned holiday. Mr C said that it was the first thing they told staff, but staff said that they could not recall being told this. However, the adviser said that, even if staff had this information, it should not have changed the management of Master A's condition and it was appropriate to discharge him with advice to seek further medical help if his condition deteriorated. Based on all the evidence and advice, we decided that Master A's care and treatment was reasonable.

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.