Health

Summary

Ms C, an advice worker, complained on behalf of her client (Mrs A) who had concerns about her late husband (Mr A)'s, treatment at the Royal Alexandra Hospital. Ms C complained to the board about numerous issues including a breakdown in communications from staff about Mr A's deterioration, and inadequate treatment. Ms C also said the board had not addressed all of Mrs A's concerns. The board, when considering Ms C's complaint, decided that there were grounds to conduct a significant clinical incident review (SCI) and on completion forwarded a copy of the report to Ms C.

We found that, while the board's decision to hold a SCI was an indication they had taken the complaint seriously, they failed to address all the concerns Ms C raised. They simply referred her to the SCI report and apologised for other failings, but did not specify what they would do to prevent this happening again. We also had concerns about the time taken to provide a final response to the complaint.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings in communication which we have identified; and
• revisit this complaint and issue a further response which specifically addresses the issues raised with appropriate explanations, and provide information about actions which will be taken to prevent a similar occurrence happening again.

Summary

Mrs C attended at an out-of-hours (OOH) service at Monklands Hospital on two separate occasions suffering from pain across her lower back and abdomen. The OOH service provides access to GPs outwith normal working times. On the first occasion Mrs C was diagnosed with a possible abdominal aortic aneurism (a weak point in the large artery that carries blood from the heart, causing it to balloon out) or lower abdominal pain with an unknown cause. She was referred directly to a surgeon at the hospital. Tests ruled out an aneurism and Mrs C was sent home with antibiotics for a urinary tract infection.

On the second occasion, just over a month later, two potential diagnoses were recorded, renal colic (pain caused by kidney stones) or a possible pelvic mass. Mrs C was given a painkilling injection, encouraged to drink lots of fluids and sent home with advice to return if her pain worsened. She was also advised to contact her own GP on the next working day to arrange an ultrasound scan of the possible mass.

After a referral from her GP, Mrs C was discovered to have an ovarian cyst (a swelling on the ovary) and was diagnosed with cancer of the left ovary. She complained that neither of the doctors who examined her admitted her to hospital for assessment and that, had this happened, the ovarian cyst would have been picked up earlier.

After taking advice on this case from one of our medical advisers, we did not uphold Mrs C's complaint. Our adviser explained that both the doctors who saw Mrs C at the OOH service provided a reasonable standard of care and that her symptoms had not been typical of ovarian cancer.

Recommendations

We recommended that the board:

• ensure that the adviser's comments regarding the management and investigation of suspected pelvic mass (including the benefit of pelvic examinations) are fed back to the relevent doctor.

Summary

Mr C complained that the board had failed to investigate his concerns about a number of issues affecting his daughter (Miss A)'s clinical treatment. These included whether appropriate clinicians were involved, the method of transfer used to another facility, information about hospital equipment and that staff had said that he had been verbally abusive.

Our investigation found that the board treated Mr C's complaints seriously and had devoted a large amount of staff resources in an effort to address his concerns. They had agreed to appoint new clinical staff, provided explanations about the accuracy of hospital equipment and explained why staff had felt uncomfortable about Mr C's behaviour.

Summary

Mrs C's mother (Mrs A) had a history of urinary problems. She was referred for a CT scan of her kidneys in 2011 which highlighted a mass on her kidney. Further tests diagnosed cancer, and a plan was made to discuss this with Mrs A at her next scheduled appointment. Before this could happen, however, Mrs A became unwell and was admitted to Gartnavel Hospital, where a doctor told her about the cancer. A cystoscopy and uteroscopy (examinations of the tubes that carry urine and the kidneys, using a narrow tube-like telescopic camera) were performed but it was not possible to obtain tissue samples for further analysis. Mrs A was discharged home and attended follow-up clinics. Following a multi-disciplinary team discussion about Mrs A's case, it was decided that she should have surgery, but the operation she needed was not routine. Before it could be arranged, Mrs A was admitted to hospital again, as she had suffered a suspected stroke. A scan showed an acute intracerebral bleed (where blood suddenly bursts into brain tissue). Staff felt that this was indicative of a brain tumour, so they started radiotherapy (a treatment using high-energy radiation) and postponed treating Mrs A's kidney tumour. It was later found that Mrs A did not have a brain tumour. Mrs A died shortly afterward.

Mrs C complained that there were delays in diagnosing and treating Mrs A's kidney tumour. She also complained about the misdiagnosis of a brain tumour, explaining that this diagnosis caused Mrs A to enter a deep depression.

After taking independent advice from two of our medical advisers - a cancer specialist and a kidney specialist - we found that Mrs A's clinical treatment was largely good. We did find that there were unacceptable delays to two diagnostic scans, but there was nothing to suggest that this had any impact on Mrs A's overall prognosis (the forecast of the likely outcome of her condition). We accepted advice that, based on the evidence available to the clinical team, the diagnosis of a brain tumour was reasonable and that it was reasonable to start radiotherapy. That said, we were critical of the board's communication with Mrs A about her diagnosis and the treatment she received.

Recommendations

We recommended that the board:

• apologise to Mrs C that the overall time from the first suspicion of cancer to proposed treatment exceeded 62 days in her mother's case; and
• apologise to Mrs C that her mother was not advised sooner of the scan results.

Summary

Mr C complained that a prison psychiatrist left out relevant information when referring him to a specialist clinic. Mr C was concerned that the letter did not inform the clinic of details of his diagnosis and previous input he had from psychiatry and psychology. He was of the view that this could have delayed his treatment.

We took independent advice on this complaint from one of our mental health advisers, who reviewed the referral letter. He observed that the letter did specifically refer to Mr C's previous psychiatric treatment and, while it did not refer to a formal diagnosis, it mentioned the issues that Mr C was facing. He noted that there was no reference to previous input from psychology but could not say whether the psychiatrist would have been aware of this. In any event, he noted that the clinic would wish to carry out their own detailed assessment, exploring all relevant history, before starting any treatment. He, therefore, did not consider that the omission of some information would significantly impact on Mr C's future treatment. We accepted this advice and did not uphold the complaint.

Summary

Mrs C complained that staff at the Royal Hospital for Sick Children failed to provide her baby (Baby A) with a reasonable standard of clinical treatment. Baby A was born with hypoplastic left heart syndrome (a complex congenital heart condition) and needed surgery shortly after birth. Baby A became unwell and on the advice of her GP Mrs C took the baby to the hospital for assessment. Staff there considered whether intussusception (a condition in which one segment of intestine 'telescopes' in to an adjacent segment) might have been the problem but discounted this. They carried out additional investigations, including blood tests, but Baby A died shortly after this.

Mrs C said the blood tests were unnecessary and caused her baby distress. She felt that if medical staff had recognised the problems sooner and started treatment earlier, then the outcome might have been different.

We took independent advice from one of our medical advisers, who is a consultant paediatrician. The adviser explained that Baby A was born with a complex and very serious heart condition. Despite the surgery received following birth, this heart condition meant that Baby A was particularly susceptible to sudden and unexpected death.

The adviser said that a diagnosis of intussusception was immediately suspected when Mrs C took Baby A to hospital, but a cause is not always found for the condition. Our adviser also could see no evidence that a delay in a registrar reviewing Baby A had any impact on the final outcome. There was no evidence that Baby A suffered from a treatable or correctable problem that was missed or that treatment was delayed because of the delay in the availability of a registrar. There was also no evidence that a blood sample should have been taken earlier or that earlier involvement of the cardiology (heart) team would have made a difference. While the adviser considered that Baby A's oxygen saturation level should have been constantly monitored, it was impossible to say whether this would have made a difference. In light of the evidence, we found that, on the whole, the actions of the medical staff who treated Baby A were reasonable.

Recommendations

We recommended that the board:

• share with the relevant staff our adviser's comments in relation to the monitoring of Baby A's oxygen saturation and the early warning score now in use.

Summary

Mr C raised a number of concerns regarding the care his father (Mr A) received in Ninewells Hospital. Mr A had existing diagnoses of lung cancer and diabetes when he was admitted to the hospital with an infection. Mr C said that his father's initial treatment was excellent, but when he was later transferred to another ward, the standard of care dropped. Mr C raised a number of concerns regarding the standard of clinical and nursing care on that ward, where Mr A died three days after his admission. Mr C complained that family members were not made aware of Mr A's deterioration. He also complained that staff failed to adequately manage Mr A's diabetes and food and fluid intake. Mr C believed his father's death was caused by a failure to identify and treat hypoglycaemic shock (severely diminished blood sugar levels), rather than as a result of his underlying cancer and infection as the board suggested.

After taking independent advice from a nursing adviser and a medical adviser, we upheld Mr C's complaints. We were satisfied that Mr A's condition was appropriately assessed upon admission and that the proposed treatment with intravenous antibiotics was appropriate. That said, we were concerned by the ward staff's management of his blood glucose levels. Mr A's diabetes was clearly recorded when he was admitted to hospital, but we found evidence to suggest that the ward was not equipped to react to significant changes to his blood glucose levels, and the board's own procedure for managing hypoglycaemia was not followed. We also found that medication was omitted from the list of existing medications for Mr A and that this likely contributed to his hypoglycaemic episode. However, we accepted medical advice that the hypoglycaemic episode was ultimately dealt with appropriately and that there was no evidence to suggest that this contributed to the decline in Mr A's condition, or to his death. We were, however, critical of the board for failing to contact the family when Mr A deteriorated, and for their poor handling of Mr C's complaint.

Recommendations

We recommended that the board:

• provide us with an update on their plans for electronic palliative care summaries;
• conduct an audit of the ward staff's compliance with their obligations in terms of maintaining full, accurate medical records;
• provide us with an update on all of the actions taken to improve their performance as a result of Mr C's complaint;
• conduct a review of their approach to catering for in-patients with diabetes;
• share our decision with the clinical staff involved in Mr A's care; and
• apologise to Mr C and his family for the issues our investigation highlighted.

Summary

Mr C complained on behalf of his father (Mr A) who lives in a care home. Mr C was unhappy that Mr A's GP did not visit his father there, but instead spoke to care home staff by phone. He was also unhappy with the GP's responses to his complaint about this. We looked at Mr A's medical records, as well as the GP's file on the complaint, and took independent advice on the complaint from one of our medical advisers, who is a GP.

We found that on two occasions the GP did not take sufficient time to fully assess and clarify the situation after Mr A had collapsed. Instead, the GP made an assumption about why he had collapsed. We also found that the GP did not take account of key aspects of Mr A's medical history when considering how to manage his situation. In addition, we found that it was inappropriate for the GP to use the fact that Mr A was being seen as a day patient at a local hospital as a reason not to visit him.

We upheld both of Mr C's complaints. We found that, in the main response to Mr C's complaint, the GP appeared to have given up responsibility for Mr A's primary care, as they had said there was little they could do because he was being supervised by various hospital departments. The GP also made general statements about the workload of modern medical practices, and said that other patients in residential care visited the surgery. We concluded that, while this may be contextual information, it did not explain why the GP failed to visit Mr A. We found these responses unreasonable and highlighted that the GP may not have recognised the serious nature of Mr A's situation.

Recommendations

We recommended that the practice:

• ensure that the GP apologises to Mr C for failing to assess and care for Mr A appropriately, and for not visiting Mr A in the care home;
• ensure that the GP apologises to Mr C for failing to provide reasonable responses to his complaint;
• ensure that the GP apologises to the care home manager and nursing staff for failing to respond appropriately to their requests for help; and
• ensure that the GP reflects on our adviser's comments and informs us of how they would deal with similar events in future.

Summary

Mr C had an accident at work and injured his shoulder. He was diagnosed with a sprain at A&E in Falkirk and District Royal Infirmary. No x-ray was taken and Mr C was told to see his GP if the pain continued. Mr C was referred to a specialist who suspected that he might have a rotator cuff tear (a tear to one of the tendons that stabilise the shoulder). The specialist arranged for a scan but no tear was found. Some time later, Mr C was referred to another specialist at Forth Valley Royal Hospital who carried out further tests and a second scan. Mr C was diagnosed with impingement syndrome, a condition where the bone and tendons of the shoulder rub together painfully. He was offered surgery and advised that this had a 60 to 70 percent chance of success. During the operation, the surgeon discovered that Mr C had an abnormality in his shoulder where pieces of bone had not fused together when he was a child. There was an unfused fragment of bone about three centimetres long, which the surgeon could not remove without causing damage. Mr C was advised that if his symptoms did not improve after the operation, he would require further surgery to fix the piece of bone using a screw. Although he was still in pain, Mr C decided not to go ahead with another operation. He then complained that an

x-ray or other imaging should have been carried out earlier as this would have highlighted the unfused fragment of bone. He was particularly concerned his surgery went ahead without this being done.

After taking independent advice from two of our medical advisers, we found that normal x-rays would not have shown the unfused piece of bone in Mr C's shoulder, as it would only have been visible on a special view x-ray that would not normally be requested. Although our accident and emergency adviser told us x-rays should have been taken after the accident and a review at the fracture clinic offered if Mr C's pain did not get better, our surgical specialist said that, even if it had been identified, an unfused piece of bone like that would not have been considered to be the cause of his pain and the treatment would have remained the same. This is because unfused fragments of bone in the shoulder do not usually cause any symptoms. Our surgical specialist also told us that

x-rays would not be carried out before such surgery and that scans are commonly used.

We found that Mr C's shoulder should have been x-rayed after his accident but there was no evidence that this would have resulted in an earlier diagnosis of the unfused piece of bone. We also considered it unlikely that an earlier diagnosis would have changed the treatment he received. Although we did not uphold his complaint, we made a recommendation.

Recommendations

We recommended that the board:

• take steps to ensure that A&E staff are made aware of our adviser's comments on x-rays and the offer of review at the fracture clinic in this case.

Summary

Mr C complained about the NHS health centre at his prison. He said that the health centre doctors did not provide adequate care and treatment when he sought medical attention for stomach, testicular and rectal (bowel) concerns.

We took independent advice from one of our medical advisers, who is a GP. We found that Mr C had been appropriately examined and assessed in respect of the rectal issues. However, we upheld that part of his complaint because, although Mr C had not been presenting with a clinical picture that suggested bowel cancer, he had visited the health centre several times on the same matter. National guidelines on the diagnosis and management of bowel cancer recommend that a specific blood sample is taken for all patients with persistent or recurring rectal bleeding (bleeding from the anus). That was not done in Mr C's case. Doing this would have better equipped the doctor to decide on the urgency of the referral that he made to the hospital. We also found that the referral letter to the hospital was not sent until two months after the doctor decided on a hospital referral. Although the clinical picture was not suggestive of bowel cancer, the part that rectal bleeding can play in bowel cancer makes that delay worrying. In due course, Mr C attended hospital and was discovered not to have cancer.

We did not uphold Mr C's complaints about the other issues as his medical records showed that the health centre had appropriately examined and assessed him in relation to these and we had no further concerns.

Recommendations

We recommended that the board:

• arrange for the prison health centre to audit a representative sample of their hospital referrals to ensure they are being sent in a timely manner;
• arrange for the prison health centre doctor to undertake a specific educational activity related to anaemia and bowel symptoms, for the purposes of Continuing Professional Development; and
• arrange for the prison health centre doctor to include the case in his annual appraisal.