Health

Summary

Mr and Mrs C complained to the board about how a bone marrow sampling procedure was carried out on Mrs C. Some weeks after making the complaint Mrs C died. Mr C felt the board's response to their complaint was inadequate, and so he complained to us.

We looked at information from Mr C and from the board. We found that Mr and Mrs C did not make a written complaint to the board, but spoke to a member of staff who made a note of the complaint. The board investigated it, and wrote to Mrs C. Their letter to Mrs C mainly contained apologies rather than explanations, particularly apologising that staff did not acknowledge sooner the level of pain and discomfort she experienced during the procedure.

As there was no written complaint, we could not say with certainty exactly what answers Mr and Mrs C told the board they wanted about the procedure. We found, however, that much of the detail the board gave us when we contacted them was considered during their investigation of the complaint, but was not in their letter. Given this, we decided it would have been reasonable for the board to have included some of this in their letter, to reassure Mrs C that the procedure was carried out in line with normal standards. Their letter did not achieve an appropriate balance between apology and explanation. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• ensure notes made by staff of verbal complaints contain sufficient detail on the specific points of complaint to enable the board to respond to those points in their letters; and
• consider how the evidence gathered during the investigation of Mr and Mrs C's complaint could have, empathetically, been included in the board's response letter to Mrs C.

Summary

Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later, she was diagnosed with breast cancer.

After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations.

Summary

Mrs C complained about the care and treatment she received at Galloway Community Hospital for her injured wrist. She said that the locum consultant orthopaedic surgeon who dealt with her did not provide a proper diagnosis, treatment and advice when he saw her at the hospital trauma clinic. She said he only looked at one of four x-rays taken in A&E before telling her that her wrist was not fractured. She said that it was fractured and that the consultant's actions compromised her recovery.

We took independent medical advice on this case from a consultant in trauma and orthopaedics. Our adviser said that the x-rays indicated that Mrs C had fractured her wrist and that the consultant failed to identify this when he saw her at the trauma clinic. His notes and his comments on Mrs C's complaint indicated, however, that he reviewed Mrs C's x-rays. Without independent evidence, it was not possible for us to say whether he failed to examine all four x-rays and this was why he did not correctly identify the fracture. Our adviser explained, however, that in spite of the incorrect diagnosis, Mrs C received the correct treatment for her condition and her recovery was not compromised. We concluded that, on balance, the care and treatment she received was reasonable, although we made recommendations about the incorrect diagnosis.

Recommendations

We recommended that the board:

• feed back the adviser's comments on the consultant's review of Mrs C's x-rays to the consultant, to try to ensure that a similar situation does not occur in future; and
• provide Mrs C with a written apology for failing to provide her with the correct diagnosis.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) received at University Hospital Ayr for prostate cancer and the palliative care (care to prevent or relieve suffering only) he had at home during the last weeks of his life. Mrs C said that her father's cancer was not properly monitored, and that this meant that doctors were not aware when it started to spread. She complained that had he been properly monitored this could have been treated, he would have lived longer, and would have suffered less pain. She also complained that the palliative care was inadequate and, because he was too unwell to be at home, this led to him being transferred to a hospice shortly before his death, against his wishes.

We took independent advice from two of our advisers - an oncology adviser (cancer specialist) and a nurse. The oncology adviser found that there were monitoring failures, with appointments cancelled and not reinstated. However, he said that Mr A was given appropriate treatment, and that the delay in some consultations did not affect the decisions doctors made about treatment. Our nursing adviser said that Biggart Hospital, where Mr A was an in-patient towards the end of his life, should have involved the district nurse in planning for his discharge while he was still in hospital. She also said that once the district nurse was involved, Mr A's palliative care was not sufficiently assessed and planned, and that the family's needs were not appropriately taken into account. She was critical that the family's concerns were not responded to when they were first raised, and continued to be overlooked, even when Mr A was becoming very unwell.

On the basis of the advice we received, we found that the board did not monitor Mr A's cancer appropriately. However, they had already identified this and had taken steps to ensure this did not happen again. We did not consider that this failing had any significant impact on Mr A's medical treatment. In relation to Mr A's palliative care, we found failings by both hospital and district nursing staff.

Recommendations

We recommended that the board:

• ensure that all patients receive clear information on how prostate cancer is monitored, what treatment options are available, and when they might be applicable;
• review arrangements for the discharge of terminally ill patients to ensure district nursing staff are fully involved in discharge planning;
• ensure all district nursing staff have up to date training in their role in the provision of palliative nursing care; and
• apologise to Mrs C and her family for the considerable distress experienced by her father and her family, due to the board's failure to provide appropriate palliative care in the final weeks of Mr A's life.

Summary

Mrs C was concerned by the care and treatment provided to her late mother (Mrs A) by a GP at the medical practice. Mrs C was unhappy that although Mrs A was complaining of pain and discomfort in her leg, the GP failed to consider the possibility of deep vein thrombosis (DVT - a blood clot in a vein). A month later, Mrs A died of a bilateral pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

To investigate the complaint, we carefully considered all the relevant information (including the complaints correspondence and Mrs A's relevant clinical records) and obtained independent advice about Mrs A's care and treatment from one of our medical advisers, who is a GP. We found that the GP's treatment of Mrs A was reasonable and that the records showed why he had not suspected DVT, given the symptoms that Mrs A had at the time. The adviser said that a clinical picture may at the time not be as clear cut as when looking back and considering a matter with hindsight. In the circumstances, the adviser thought that it was reasonable for the GP not to consider DVT. We noted that, since Mrs C's complaint, the GP had clearly reflected on what had happened, and had reviewed local guidelines in attempt to prevent this happening again. Although we did not uphold the complaint, we made recommendations that the GP takes further steps to ensure good clinical practice.

We upheld Mrs C's complaint about complaints handling, as we found that timescales were not met when responding to her letters.

Recommendations

We recommended that the practice:

• ensure that the GP considers the available national guidelines and includes his reflection on these in his next annual appraisal;
• ensure that the GP considers how he completes his clinical notes and seeks advice to do so;
• make a formal apology for their delay in dealing with the complaint; and
• implement and adhere to NHS guidance on dealing with complaints.

Summary

Mr C, who is a prisoner, complained that the health centre at his prison did not provide appropriate treatment for his difficulties in coping with a recent bereavement, which included lack of sleep. To investigate this complaint, we needed Mr C's written consent for us to get his medical records. We asked for this and reminded him about it, but Mr C did not provide consent. We, therefore, closed his complaint as we could not carry out an investigation without it.

Summary

Ms C said that she had a contraceptive implant fitted and when it was near the end of its life, she attended her GP for a replacement. She complained that she was told that because of her high blood pressure (BP) it was not possible to do so. As it appeared that Ms C was not taking her medication to reduce her BP, she was advised to do so and return to the practice in six to eight weeks time for review.

Ms C attended again to have her implant reinserted but again her BP was noted to be very high. She was told that if there was an attempt to replace it there was a risk of uncontrolled bleeding and it was agreed that she should attend a local hospital for replacement. Ms C felt that she had been given unreasonable care and treatment because the reason why she had an implant fitted in the first place was because of her BP. She complained that the GP's actions left her without effective contraception.

During our investigation, we took independent advice from one of our medical advisers, who is a GP. The adviser said that although the GP said she had acted in Ms C's best interests and followed national advice on implantable progesterone contraception like the type used by Ms C, she had in fact misunderstood the advice. In cases similar to Ms C's, the benefits of remaining on the contraceptive, despite her BP, would likely outweigh the risks as it was recognised as a safer option for women with high BP. In the circumstances, we considered it unreasonable that Ms C was left without an effective form of contraception for over seven weeks.

Recommendations

We recommended that the practice:

• ensure the GP apologises for the fact that Ms C was left for some time without contraception; and
• ensure the GP undergoes specific training with regard to the safety and contraindications of that particular contraceptive.

Summary

Mr C complained that he did not have continuity of mental health care, as he had been seen by eleven different consultant psychiatrists. Mr C said this was frustrating for him, and caused him concern about whether he was receiving consistent care and treatment.

We looked at Mr C's medical records, and took independent advice from our mental health adviser. We also asked the board what they were doing to deal with staffing issues in community mental health. The board explained the reasons for the lack of consistency in staffing, and provided reassurance about the steps being taken to improve the situation. They also remedied Mr C's specific situation by placing him on the caseload of a senior member of staff.

Our adviser said that although there was a lack of consistency in the consultants who saw Mr C, there was no evidence in the medical records that his care and treatment were adversely affected in a significant way, or that there was a lack of continuity in his treatment. The standard of medical record-keeping and communication with his GP was reasonable, and ensured that important clinical information was appropriately passed on. Our adviser also said there had been greater consistency in terms of community psychiatric nursing provided, which helped offset any difficulties created by the problems with medical staffing.

Summary

Mr C complained that the board failed to appropriately investigate the cause of his severe back pain following his admission to Perth Royal Infirmary. He said the board failed to carry out an MRI scan (used to diagnose health conditions that affect organs, tissue and bone) to allow an accurate diagnosis to be reached at an earlier date, and that he had to arrange for this to be done privately.

We obtained independent medical advice on Mr C's case from one of our medical advisers, a consultant in orthopaedic and trauma surgery. Our adviser explained that Mr C's clinical picture after he was admitted should have guided the board's management of his condition. He explained that this could only be properly ascertained after taking an adequate history and clinical investigations. It appeared that the consultant orthopaedic surgeon did not fully examine Mr C, and relied on a junior doctor's examination, but this was reasonable as long as the junior doctor's assessment was thorough. However, as the board were unable to provide a copy of Mr C's medical notes for his time in hospital, we could not say whether he was properly examined. On the MRI scan, our adviser said that Mr C was not displaying 'red flag' (warning sign) symptoms but that, in view of his condition, the benefits of arranging an MRI scan outweighed the risks. He said that an MRI scan could have been arranged either as an in-patient or after Mr C's discharge, but this did not happen.

Having considered the matter carefully, we were unable to say that Mr C's symptoms were appropriately investigated while he was in hospital to find the cause of his pain. If an MRI scan had been arranged when Mr C was an in-patient, he would not have had to arrange one himself, and if one had been arranged for him as an out-patient, then it was unlikely he would have arranged his own scan. We, therefore, considered it reasonable for the board to reimburse Mr C the cost of his private MRI. We were also very critical of their management of Mr C's medical records and that they were unable to provide us with these for his hospital stay.

Recommendations

We recommended that the board:

• feed back our decision on this case to the staff involved to ensure that a similar situation does not happen in future;
• reimburse Mr C the cost of his private MRI scan;
• review their practice on the storage of patients' medical records to prevent a recurrence of the failure to store Mr C’s medical records securely; and
• provide Mr C with a written apology for the failings identified.

Summary

Miss C, an advice worker, complained to us on behalf of her client (Miss A) about the handling of Miss A's Shetty Gastro-Jejunostomy (SGJ) procedure (the insertion of a feeding tube into part of the intestines). Miss A suffers from gastroparesis (paralysis of the stomach) which does not allow food to empty from her stomach. She was scheduled for the procedure as a day-surgery case and told that a particular radiologist would carry it out. On the day, however, a different radiologist tried to perform the procedure, without success. They were only able to insert a tube into Miss A's stomach, to prepare for a later attempt to insert the SGJ. Miss A suffered pain after the procedure and was kept in overnight for pain relief. Miss C also said that no written information was passed to the ward about the problems encountered during the SGJ. Miss A eventually had a SGJ inserted some seven weeks later.

Our investigation included taking independent advice from one of our advisers, who said that the attempted SGJ was done in a reasonable manner with evidence of good, and even best, practice. The adviser said that this is a difficult procedure and Miss A's condition made it particularly so. There was no evidence that the radiologist who attempted it did not do so in a reasonable way. The adviser also said that the board's decision to allocate Miss A's procedure to the first available suitably qualified radiologist was a reasonable clinical decision, and that the radiologist's decision to insert a tube into the stomach to help a further attempt of the SGJ procedure was good practice. There are two approaches that could have been taken towards a further attempt - either to do so a few days after the first, or to wait for the track made by the stomach tube to mature (a period of four to six weeks) before making a second attempt. Either approach is reasonable and in this case the clinicians chose the latter, which was successful. Overall, we were satisfied that the care and treatment provided to Miss A was reasonable.

The only concerns we had were about a lack of information on the consent form that Miss A signed and a failure to provide written information to the ward about the problems with the procedure. There had been verbal communication but nothing in writing. The board told us that they have amended their procedures to prevent this happening again, and so although we did not uphold the complaint we made a recommendation about this.

Recommendations

We recommended that the board:

• provides evidence that the remedial action taken in respect of the written information provided by the radiology department is sufficiently robust to prevent a recurrence, and that appropriate information is recorded on consent forms.