Health

Summary

Mr C's GP referred him to Queen Margaret Hospital's orthopaedic department because he was having pain in his knee despite having received physiotherapy treatment. Mr C was reviewed by an orthopaedic registrar who said that he had a medial meniscal tear (cartilage problems). After Mr C had a scan of his knee, an orthopaedic consultant wrote to him advising that there was no tear and surgery was not required but recommended more physiotherapy. Mr C then attended a private consultation with an orthopaedic doctor who thought that Mr C did have a meniscal tear. Mr C had private surgery a few weeks later and told us that he was able to return to work within four weeks. He complained to us about the treatment he received at Queen Margaret Hospital, saying that he was not offered surgery and that the orthopaedic consultant reached a decision without examining him.

After taking independent advice from one of our medical advisers, we found that the scan did not show that Mr C had a meniscal tear. There was, however, an indication of degenerative changes (osteoarthritis - a common form of arthritis) behind the knee cap, and the board had treated him in accordance with the national guidance for the management of this that was in place at the time. Our adviser also said that there was no assurance that the surgery was the sole cause of Mr C's improvement, as the symptoms of degenerative knee disease may improve on their own. We concluded that the orthopaedic registrar's examination was appropriate, and that it was reasonable for the consultant to not have seen Mr C in person, given that he had reviewed the scan results.

Summary

Ms C complained about the treatment that her late partner (Mr A), received after he was diagnosed with rectal cancer (cancer of the lower part of the large bowel). He had chemotherapy, and radiotherapy to try to shrink the tumour to the point where it could be operated on. Mr A needed three admissions to the Victoria Hospital to manage the pain caused by his condition. During the second admission, his recent CT scan (computerised tomography - a scan that uses a computer to produce an image of the body) was reviewed, and the clinical team thought that the tumour might be operable if Mr A was referred to a surgeon who had the expertise to provide a non-standard form of surgery. Mr A was referred to such a surgeon, but the cancer was advanced and an operation could not be carried out. Mr A died some 20 months after his diagnosis.

Ms C complained that she and Mr A had been led to believe that his tumour was operable and that his prognosis (forecast of the likely outcome of his condition) was good. She said that, because of this, Mr A's decline and death were unexpected and, had he known his true prognosis, he would have lived the final months of his life differently. She considered that there were avoidable delays in treatment and said that she and Mr A were cut off at home without support from the board. She was particularly concerned about the apparent lack of effective management of Mr A's pain outside hospital.

The evidence we saw indicated that Mr A's tumour was advanced by the time his cancer was diagnosed. We took independent advice from one of our medical advisers, who is a consultant clinical oncologist (cancer specialist). Our adviser confirmed that the course of treatment proposed was appropriate and that the timescales involved were reasonable. However, it was clear that clinical staff considered Mr A's prognosis to be poor from an early stage. Our investigation found that the board had not fully explained Mr A's condition and prognosis to him and Ms C. We also found that his pain was inadequately managed during two of his hospital admissions and when he was at home. We considered that there was a breakdown in communication between the hospital, his GP and the family and considered that the board's community palliative care (care provided solely to prevent or relieve suffering) team could have been used to coordinate his pain management.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted in our decision letter;
• review Mr A's case with a view to identifying ways of improving communication with patients and their families and ensuring that patients' potential and likely prognoses are explained clearly where applicable;
• conduct an audit of staff compliance with their responsibilities for monitoring patients' pain levels and reviewing pain medication; and
• review Mr A's case and give consideration to how best to involve the community palliative care team in such cases.

Summary

Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or excellent. Mrs C and other family members were aware that Mrs A was in the final few days of her life, and had stayed with her throughout the night. She said that Mrs A suffered unnecessarily because staff failed to check or assess her condition despite family members reporting her distress to them.

The board told us that Mrs A was assessed every time family members asked staff for help, although they also noted that drugs that might have provided some relief for Mrs A could have been given earlier. We found, however, that Mrs A's medical records did not contain the necessary entries to support the statement about assessment, and that there were some gaps in these records. Based on the information available we could not, therefore, conclude that they properly assessed Mrs A's needs, and we upheld the complaint.

Recommendations

We recommended that the board:

• provide us with an update on the service manager for medicine's review of this complaint and any action plan arising from this;
• undertake a further review of this complaint in the light of our findings and provide us with an action plan arising from this;
• apologise that there was no assessment at an earlier point of whether pain and symptom relief should be provided; and
• provide us with evidence of their current plan for terminal and end of life care and of the staff training undertaken to support this.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) in Borders General Hospital. She said that her mother was not provided with reasonable care and treatment and that the board's responses to her complaints were unreasonable.

Mrs A was 93 years old and lived alone, with assistance from her family. She had a history of heart and lung problems and was registered blind. She went into hospital because she had a chest infection that was making her existing lung disease worse. Mrs A was treated with antibiotics and oxygen therapy, but her condition continued to deteriorate and three days after going into hospital she asked staff to stop treating her. She died later that day.

Mrs C was concerned that her mother was not considered suitable for cardiopulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops) or for transfer to the intensive care unit. Mrs C did not find out that doctors had completed a Do Not Attempt CPR (DNACPR) form for Mrs A until she saw it in her mother's notes. After a discussion with the doctor in charge of Mrs A's care, the decision was reversed to a limited degree (where Mrs A's heart would be shocked into a normal rhythm if it became irregular but full CPR would not take place) but the form was not removed from the notes. Mrs C was also concerned when Mrs A started to refuse food, fluids and medications, and said that Mrs A told her that this was because she did not trust staff after being given a bed bath by a male nurse that morning. Mrs C discussed this with a nurse on the ward and was assured that a female nurse had given the bed bath but that a male nurse would have assisted with changing the bedsheets.

During our investigation we took independent advice from two of our advisers - a doctor specialising in the care of the elderly and a senior nurse. We found that the care and treatment provided to Mrs A was reasonable and appropriate. The advisers considered that there was evidence in both the medical and nursing notes that appropriate and timely assessments, monitoring and evaluation of Mrs A's treatment took place, and that the actions around the DNACPR decision complied with national guidance. We also found evidence that when Mrs A began to refuse treatment, appropriate assessments were done to establish that she had the capacity to decide this for herself. Mrs C had been concerned that Mrs A had wished to die at home and that staff ignored this. However, the medical notes showed that Mrs A's desire to go home was noted and considered, but the doctor in charge of her care at that time thought that she would be unlikely to survive the journey. Our medical adviser agreed with this view.

Summary

Miss C's mother (Mrs A) had been diagnosed with cancer, and admitted to Ayr Hospital. She was discharged, but was readmitted four days later with a chest infection. During Mrs A's admission, Miss C and her sister met with the palliative care nurse (a nurse specialising in care solely to prevent or relieve suffering) to discuss support for caring for Mrs A at home. They told the nurse and doctor that Mrs A wished to return home as soon as possible, and the nurse agreed to refer Mrs A to the hospice home care team.

The palliative care nurse was away from the hospital the next day, but intended to make the referral when she returned the day after. At that time, the nurse and the doctors expected that Mrs A would be in hospital until the next week for treatment for her chest infection. However, Mrs A discharged herself, against medical advice. The ward staff were not able to contact the palliative care nurse, but told Mrs A's GP that she had discharged herself, and arranged for district nurses to visit. Miss C called the hospice home care team for support, but was told that no referral had been made and that hospice support would, therefore, not be available until the following week. The hospice team then called the palliative care nurse, who immediately processed the referral. Mrs A died at home three days after discharging herself, before hospice support was put in place. Miss C then complained that the nurse had unreasonably delayed in referring Mrs A to the hospice home care team.

After taking independent advice on Miss C's complaint from one of our advisers, who is an experienced nurse, we did not uphold it. Our adviser said that, in the circumstances, it was not unreasonable for the nurse to wait a day before making the referral, as she had expected Mrs A to be in hospital until the following week. Our adviser also said that ward staff had taken reasonable steps to try to contact the palliative care nurse and to arrange some support for Mrs A by contacting her GP and district nursing.

Summary

Miss C's mother (Mrs A) went to a medical practice with abdominal (stomach) pains. She was repeatedly referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), but did not attend on three separate occasions and no further appointment was made. Ten months later, Mrs A again went to the practice and was treated for a suspected infection. However, Miss C was very concerned about her mother's weight loss and took her to A&E, where she was treated for a suspected urinary tract infection and discharged. Two months later, Mrs A went again to the practice with worsening back pain, nausea and weight loss. A GP told Mrs A that it was possible she had cancer, and arranged for x-rays, which showed that Mrs A had arthritis. However, as no cause for Mrs A's weight loss had been found, the GP arranged for an urgent abdominal scan, which showed possible cancer of the liver. Further tests confirmed this diagnosis and Mrs A died six weeks later.

A few days before Mrs A's death, the GP visited Mrs A at home and there was an altercation between the GP and the family. Miss C and the GP gave slightly different versions of what happened, including what was said about Mrs A's treatment and whether the GP intended to leave without prescribing pain relief. Miss C then complained that the practice had failed to investigate Mrs A's symptoms appropriately, causing a delay in accurately diagnosing her cancer, and that the GP did not appropriately communicate with Mrs A and her family during the home visit.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our adviser said that the practice had acted correctly in referring Mrs A for a scan each time she went to them with abdominal pain. However, Mrs A had decided not to go for the scans. Once a scan was carried out, the practice acted promptly in making the appropriate referrals to confirm the diagnosis and arrange treatment. In relation to communication, our adviser said that the reasonableness of the GP's actions depended on precisely what had happened. As there were different versions of events, which were not resolved one way or the other by the GP's written records from the time of the event, we could not find evidence to uphold Miss C's complaint.

Summary

Mr C, who is a prisoner, complained that the board were failing to follow his agreed dental treatment plan and failed to provide adequate care and treatment for his sleep disorder.

We found nothing in Mr C's dental records to suggest that the board were not following the plan suggested at his initial appointment. We took independent advice from our GP medical adviser about the treatment for his sleep disorder. After reviewing Mr C's medical records, our adviser said that the board's actions had been reasonable in the circumstances. We did not uphold either complaint.

Summary

Mr C complained about his care and treatment while he was being treated by a consultant surgeon in Ninewells Hospital. He said that, although he had lost weight, lost his appetite and become increasingly thin and lethargic, the surgeon discharged him and referred him to the care of a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). Mr C said that it was only by chance that the seriousness of his condition was appreciated. He also complained that the board delayed in responding to his complaint about this.

We considered all the complaints correspondence and Mr C's relevant medical records as well as taking independent advice from one of our medical advisers. We found that a scan had showed that Mr C had a narrowing of his colon (part of the large intestine). A later review noted that he felt well, had no pain and his bowel habit was unchanged, and it was decided to keep him under review and to scan him again later. Some 14 months after this, he went to a surgical out-patients' clinic and as he was complaining of a swollen stomach and the inability to eat, a scan was arranged for the following month. This showed further thickening in his colon and in the small intestine, and doctors decided to review him again in six months. By that time, his symptoms had settled but he was lethargic and nauseous, and the surgical team felt that there was no surgical solution to the problem. They referred him to gastroenterology for advice and further management.

Mr C continued to lose weight and was prescribed intravenous nutrition (fed directly into a vein), but his condition continued to decline and another scan was organised. This showed evidence of chronic small bowel obstruction and he was referred back for surgery. Because of this, Mr C felt that the surgical team should not have discharged him to gastroenterology when they did. Our adviser, however, said that given Mr C's symptoms at the time this was not an unreasonable approach to take, and that the thickening of his colon could have been considered to be due to disease and not a bowel obstruction. We accepted this advice, and did not uphold Mr C's complaint.

We did, however, uphold his complaint about complaints handling. The board acknowledged that there was delay, and said this was because their complaints team were awaiting clinical information so that they could respond fully. They had already highlighted to the team as a learning point both this failure and the fact that the team should explain such delays when writing to the person who has complained. As they had already taken this action, we made only one recommendation.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to respond to his complaints within published timescales.

Summary

Mr C, who is a prisoner, fell and injured his hand. He complained that, after seeing the doctor the following day, he had to wait a further five days to be taken for an x-ray. In responding to his complaint, the board advised that his referral was treated as non-urgent, and that an appointment was made for him at the earliest opportunity.

We took independent advice on this complaint from one of our medical advisers, who is a GP. He noted that Mr C had a suspected scaphoid fracture (a fracture of one of the wrist bones that sits at the base of the thumb). He explained that this can often be difficult to diagnose. However, he considered it highly unusual for an initial x-ray to be delayed for five days. Most NHS users would have been x-rayed on the day of the injury or the day after. He said that it appeared that the delay in Mr C's case might have been to allow the prison to make arrangements to escort him to hospital. Although the injury was correctly managed by ensuring that Mr C had pain relief and ordering the x-ray, our adviser considered the delay in taking him for the x-ray to be unreasonable, as in his view it appeared to have been purely for operational reasons. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in arranging for him to receive an x-ray; and
• inform us of the steps they intend to take to ensure that patients with possible fractures are assessed in good time in future.

Summary

Mr C, who is a prisoner, complained that prison doctors refused to prescribe him tramadol for his back pain. He said he had previously been prescribed this by his community GP. The prison doctors prescribed alternative medication, which Mr C said was not effective in controlling his pain.

We took independent advice on this complaint from one of our medical advisers, who is a GP. He told us that strong opiates (morphine related drugs) like high dose tramadol should only ever be used on a short term basis for lower back pain. He noted that the recent re-classification of tramadol to a higher category reflected the concerns that doctors have had for some time about the drug, its potential side effects and its potential to be abused. In the circumstances, he considered that the prison doctors had acted reasonably in offering Mr C alternatives to tramadol. We accepted this advice and did not uphold the complaint.