Health

Summary

Mr C had suffered prostate problems since his forties and his prostate health was regularly monitored. Until 2011, the tests had shown that although his prostate was enlarged, he was not suffering from cancer. Early in 2011, Mr C's blood test results began to indicate that he might have prostate cancer. Tissue samples were taken but these showed no sign of cancer. Mr C was given an appointment for a review within 12 weeks. However, this was cancelled and Mr C was not seen again until December that year. Following this appointment Mr C was diagnosed with advanced prostate cancer, which was incurable.

Mr C complained that the delay in rescheduling his review appointment was unacceptable. He felt that this happened because staff did not follow departmental procedures properly and because the board failed to appropriately implement a new appointment management system. Mr C said he believed the delay had adversely affected his treatment options and that when he complained the board did not handle his complaint reasonably or appropriately.

We took independent advice from a medical adviser on the clinical aspects of Mr C's case, and upheld most of his complaints. We found that the delay in rescheduling the appointment was unreasonable. The board did not give a reason for the delay and our adviser said that they should have explained why he needed the review appointment. Their failure to do so meant that Mr C did not pursue a rescheduled appointment after the original was cancelled. We did not uphold the complaint that his treatment was adversely affected, however, as our adviser said that it was likely that the cancer had already spread outside the prostate and the delay in rescheduling the appointment did not affect Mr C's prognosis or the available treatment.

We upheld Mr C's other complaints. The board could not show that they had implemented their appointment management system correctly, or that they had identified learning from the failures in Mr C's case. Their handling of his complaint was inadequate and there was no evidence that they had since introduced robust complaints handling procedures to stop these mistakes happening again.

Recommendations

We recommended that the board:

• review the urology department procedures, to ensure that patients are informed of the reason for a follow-up appointment and the timescale for this;
• provide us with evidence that they have identified the causes of the delay in manually transferring appointments during the introduction of the Patient Management System to prevent a reoccurrence, including the checks carried out to ensure that all patients were manually transferred at the time;
• provide evidence that the new Patient Management System will alert medical staff when appointments are cancelled;
• provide evidence of the steps they have taken to improve the accuracy of complaint responses;
• provide evidence that all staff have been reminded of the importance of using appropriate language when corresponding about patients;
• audit their new complaints process to ensure complaint investigations are conducted with appropriate rigour and that adequate records of the investigation are be maintained; and provide us with a copy of the findings; and
• apologise in writing for the failings our report identified.

Summary

Mr C complained that his former medical practice did not keep correct medical records and failed to give him the correct care and treatment. He also complained that the practice dealt inappropriately with urine samples presented for testing.

We obtained independent advice on the complaint from one of our medical advisers, who is a GP, and considered all the relevant information, including Mr C's medical records and the complaints correspondence. Our investigation found no evidence to suggest that the practice had failed to keep correct records and the records showed that Mr C had been appropriately treated for his symptoms. We also found that five urine samples were taken, all of which were presented for results which were also recorded.

Summary

Mr C complained about the end of life care and treatment provided to his late mother-in-law (Mrs A) in Glasgow Royal Infirmary. Mr C said that the family found it distressing to see Mrs A in the latter stages of her illness, and that the board failed to provide reasonable pain relief and refer her to the palliative care (care provided solely to prevent or relieve suffering) team within a reasonable time. He also said healthcare professionals failed to take account of the views of Mrs A's daughter, who held welfare power of attorney (a legal document appointing someone to act or make decisions for another person), and that there were failures in communication and record-keeping, particularly around the provision of a morphine pump. Finally, Mr C complained about the the way the board handled his complaint, saying that they failed to carry out an objective and transparent investigation.

Having taken independent advice from a medical adviser and a nursing adviser, we upheld some of Mr C's complaints, as we found that while the frequency of communication between healthcare professionals and the family was reasonable, the board did not ask Mrs A's family about power of attorney (particularly in light of Mrs A's incapacity) or formally discuss the medical procedures in advance with Mrs A's daughter. Having said that, we found that the board's records of several conversations with the family about the provision of a morphine pump were reasonable in that they reflected the views of the clinicians concerned. We accepted advice that Mrs A's pain relief and end of life care were generally reasonable and that Mrs A's symptoms were adequately managed by the medication prescribed. We were not, however, satisfied that the board's complaint investigation was carried out in accordance with the NHS complaints procedure, as it appeared from the board's responses that it was done by the members of staff who were the subject of the complaint.

Recommendations

We recommended that the board:

• review their patient profile and documentation and its completion in light of our nursing adviser's comments;
• bring the failures our investigation identified to the attention of the relevant healthcare professionals concerned;
• ensure the relevant healthcare professionals appropriately consider referrals to the palliative care team at the earliest opportunity, in light of our medical adviser's comments;
• bring the failures identified in complaints handling to the attention of relevant staff; and
• apologise to Mr C for the failures this investigation identified.

Summary

Mr C complained on behalf of his wife (Mrs C) about the care she received from the maternity triage service at Forth Valley Royal Hospital immediately prior to the birth of her daughter. Mrs C had phoned the service twice for advice about coming into hospital as she was concerned about the progress of her contractions, and felt she was dissuaded from going to hospital after speaking to a midwife during her second phone call. Around an hour later, Mrs C gave birth to her daughter at home with the assistance of her husband. She suffered heavy blood loss, paramedics attended and she was transferred by air ambulance to another hospital.

We took independent advice on this case from one of our medical advisers, who is a specialist in midwifery. Our adviser was critical of the midwife's actions during the second phone call, as they should have asked Mrs C to attend hospital for assessment of whether or not she was in active labour, given that she had experienced complications during a previous birth. We also found that the maternity triage phone template did not prompt staff to ask women about their previous medical history. We, therefore, upheld Mr C's complaints about the advice Mrs C had received by phone, and the lack of adequate documentation of the advice given.

In responding to Mr C's complaints, the board agreed to make triage staff aware that patients should not feel as if they need permission to attend hospital, and acknowledged that the midwife had not documented any advice she had given Mrs C about coming into the hospital. They also took steps to introduce a new national maternity triage template to ensure that appropriate information is captured, and introduced peer review.

Although we took the view that the board made reasonable improvements to shortcomings in the triage process, we did not find that the structure in place at the time was inadequate. We also concluded that it was not unreasonable for the board to have staffed the maternity triage service with a labour ward midwife, given they are qualified to determine if admission is necessary or not. We did not uphold those aspects of Mr C's complaint.

Recommendations

We recommended that the board:

• ensure that the midwife reflects on our adviser's comments as a learning tool;
• ensure midwifery triage staff appropriately document advice they provide; and
• apologise to Mrs C for the failings our investigation identified.

Summary

Mr C complained that he was prescribed medication that caused an unpleasant side effect. He said he had not been fully informed of the possibility of experiencing this side effect.

We took independent advice from one of our medical advisers, who said that GPs are only required to mention the most common side effects. The adviser said that the patient information leaflet provided with the medication details all the other possible side effects and advises patients to report to their GP immediately if they experience any of these. The adviser also said that it was not certain that the medication Mr C complained about was what was causing the side effect. In light of the advice received we did not uphold the complaint.

Summary

Mr C suffers from cerebral palsy, has a history of bladder problems and is confined to a wheelchair. He was admitted to the Southern General Hospital with swollen feet, pain and discomfort. Mr C said that during his admission he was offered no practical nursing care at all and his friend, an elderly woman, had to help him on the ward and undress him for an examination. He said he was then left unwashed and unchanged throughout his two-day hospital stay and his visitors had to help with all his personal care needs. He said he asked nursing staff for assistance to shower the morning after his admission, but this was refused. Mr C complained about the standard of nursing care he received, saying that he was not treated with dignity and respect.

We took independent advice from our nursing adviser. We found that the evidence from the medical records indicated that Mr C had an assisted wash just once during admission, which was not reasonable. We also found that nursing staff failed to document what care had been given and had failed to personalise care for Mr C as a patient with specific disabilities. However, as the board had already taken action to address the complaint and ensure improvements, we made no recommendations.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), who experienced a sudden and severe headache while on holiday visiting her daughter. Mrs A's daughter arranged for an ambulance to take Mrs A, who has a history of migraines, to A&E at Dr Gray's Hospital.

A junior doctor reviewed Mrs A and referred her to a senior doctor to determine whether a CT scan (a scan that uses a computer to produce an image of the body) would be necessary. The senior doctor reviewed Mrs A a few hours later, decided this was not required and discharged her, advising her to seek help if her condition worsened or did not improve. Mrs A said the doctor told her that it would be safe for her to fly home the next day, but the doctor did not recall saying this. Mrs A flew home the next day and arrived feeling very ill. A few days later she was admitted to hospital where, after further investigations, she was diagnosed with a brain aneurysm (a bulge in a blood vessel in the brain).

Mrs C complained about the care and treatment Mrs A received at A&E. She said that Mrs A was misdiagnosed and her symptoms were not taken seriously due to her history of migraines. She also complained that the doctor inappropriately advised Mrs A that it was safe to fly.

After taking independent advice on this complaint from a medical adviser, we upheld Mrs C's complaint. We found that the senior doctor had failed to properly investigate Mrs A's symptoms in line with relevant guidance and so missed the diagnosis of a brain aneurysm. In relation to whether the doctor had advised Mrs A that it was safe to fly, there was no evidence of this in the medical records and so we could not make any finding.

Recommendations

We recommended that the board:

• issue a written apology to Mrs A, acknowledging the failings our investigation identified; and
• raise the failings we found with the doctor involved for reflection and learning as part of their annual performance review.

Summary

Mr C, who is a solicitor, brought a complaint on behalf of his client (Mrs A) about the service she received after her GP referred her to a psychiatric department. Mrs A complained that the board failed to meet their targets and that her treatment did not meet any reasonable standard of care. She explained that she had requested referral to a psychologist.

During our investigation, we took independent advice from a mental health adviser. The adviser said that the Scottish Government's referral-to-treatment waiting time target of 18 weeks did not apply to mental health services. However, Mrs A had received treatment from a community psychiatric nurse (CPN) 12 working days after they received the referral. She was also seen by a consultant psychiatrist ten weeks after the GP referral. Both these appointments fell within the target times. Mrs A was also offered further appointments with a CPN and a senior charge nurse trained in cognitive behaviour therapy (CBT), but Mrs A declined these.

The adviser said that there were delays in relation to the referral for a psychology assessment to be carried out and, thereafter, in re-referring Mrs A to the local CBT service. We found that both these periods of delays were unreasonable, but we were satisfied that lower intensity psychological therapy had been progressed from the outset and higher intensity therapy was not initiated because Mrs A declined an appointment with the senior charge nurse trained in CBT.

The adviser was also satisfied that the care offered and delivered was reasonable. However, we were concerned that Mrs A had not signed the care plan that had been prepared, and which set out her presenting difficulties, the goals of the nursing care and the interventions planned, and that there was no evidence in the medical records that she had agreed the plan. We were satisfied that it was reasonable to refer Mrs A to a CPN in the first instance and that it had been explained to her that referral to a psychologist was not the only treatment option open to her.

Recommendations

We recommended that the board:

• review Mrs A's case with a view to identifying the reasons for the delay in referral for a psychology assessment and take action to prevent a recurrence; and
• in line with recovery-focused good practice and the principle of participation set out in the Mental Health Act, consider asking patients to countersign their care plans to demonstrate their understanding and agreement, and providing the patient with a copy of the care plan.
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Summary

Ms C complained to us on behalf of her client (Ms A). Ms A met with a health visitor after registering with a local GP. Ms A advised the health visitor that her child had issues with feeding and as a result, had not really been introduced to solid foods. The health visitor noted that Ms A's child was well above the range of weight and length expected for a child of that age. A number of issues relating to the family resulted in the health visitor making contact with the social work department. Ms A's child was voluntarily put into the care of the child's father following a meeting with a social worker and a paediatrician.

Ms A complained about the health visitor's actions and said that she held the health visitor predominantly responsible for the child being removed from her care. Ms A also complained about the way that the board handled her complaint. The board said that the health visitor had carried out her role appropriately and explained that a health visitor cannot be responsible for the removal of a child from its mother's care as they do not have this statutory duty.

We took independent advice from one of our advisers, who is a health visitor. Our investigation found that the health visitor's actions were reasonable on the basis of the information available to her. Some issues around record-keeping were highlighted for professional development but the adviser had no concerns about the health visitor's actions. We did, however, find that the board's handling of Ms A's complaint was unreasonable as they had not fully addressed all her concerns in their response and had not followed their complaints handling procedure.

Recommendations

We recommended that the board:

• highlight the issues regarding record-keeping to the health visitor for professional development;
• apologise for failing to follow their complaints handling procedure in this case; and
• take steps to ensure the investigation and written response to a complaint is in line with their complaints handling procedure.

Summary

Mrs C complained to us about orthopaedic treatment (treatment of conditions involving the musculoskeletal system) that she had on her foot. A surgeon at the Southern General Hospital operated on it twice. The operations were nearly two years apart, and both left her with ongoing symptoms. When her symptoms persisted, she was referred to another surgeon, and had a different operation. This was successful, and Mrs C's symptoms significantly improved. At this point she became concerned about whether the previous treatments had been appropriate, and complained to the board.

The board did not respond to Mrs C's complaint, as they considered it to be outwith their timescales. The surgeon provided a statement, however, in which he reviewed his assessments and treatments for Mrs C. He also referred to clinic appointments that were not appropriately recorded.

We took independent advice on this complaint from one of our medical advisers, a consultant orthopaedic surgeon. He reviewed Mrs C's orthopaedic treatments, and while he was critical that the first surgeon had not maintained appropriate clinical notes, he considered that the operations Mrs C had were appropriate. He said that the operation carried out by the second surgeon was a more complex and risky procedure, and that it was appropriate for alternative approaches to be tried first. He also noted that the last operation was normally only carried out by specialist foot surgeons. Having taken this advice, we decided that the treatment had been appropriate, and that it was reasonable for the first surgeon to try less complex and risky procedures before considering more complex treatment.

Recommendations

We recommended that the board:

• ensure that the doctor involved maintains appropriate clinical records in line with the standards set by the General Medical Council, bearing in mind the comments made by this office, and discusses any learning points at his next appraisal.