Health

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.

Summary

Mr C, who is an independent advocate, complained on behalf of his client (Mrs A) that the board did not take reasonable steps to prevent Mrs A's husband (Mr A) from developing a pressure ulcer (bed sore) during his stay in Inverclyde Royal Hospital. Mr A had terminal cancer and was admitted to hospital for palliative care (care provided solely to prevent or relieve suffering). He was there for ten days, and was then discharged home with no mention of a pressure ulcer. Later on the day of his discharge from hospital, a district nurse examined Mr A and found that he had a pressure ulcer.

We took independent advice from our nursing adviser, who said that the board had not thoroughly assessed Mr A during his admission and so had not recognised his increased risk of developing a pressure ulcer. If this had been done then Mr A's condition would have been more regularly assessed. The adviser was critical that staff relied on the assessments made when he was admitted, and said they had not exercised good clinical judgement. The adviser also said that the record-keeping was poor. In light of these failings, we upheld the complaint. As, however, the board had already taken positive steps to stop this happening again, we made only one recommendation.

Recommendations

We recommended that the board:

• provide Mrs A with information about steps taken to address the shortcomings identified.

Summary

Ms C, an advice worker, had written to her client (Mr A)'s medical practice to seek clarification about whether a request that Mr A made to his GP for a referral had been carried out. She received no response. After two follow-up letters were also ignored and two months had gone by, Ms C complained to us.

The practice told us that they did not consider that entering into correspondence with Ms C would serve any practical purpose as the issues Mr A was concerned about had been dealt with some years previously. We decided, however, that the practice should have explained this to Ms C. We, therefore, upheld her complaint that the practice did not reasonably respond to her correspondence.

Recommendations

We recommended that the practice:

• apologise to Ms C and Mr A for the failure to reply to correspondence; and
• review their communication policies to ensure that they clearly advise correspondents when a decision is taken that correspondence will not be responded to, and explain the reasons for that decision.

Summary

Mr C complained that his medication was stopped after a spot check of his cell revealed a discrepancy in the medication he should have had in his possession. The check showed that capsules had been emptied and, as a result, the prison health centre stopped the medication. Mr C complained, saying that his cellmate had told a prison officer that it was he, the cellmate, who had taken the contents of the capsules. Mr C could not see why he was being punished for something that someone else had done without his knowledge.

We took independent advice on this case from two of our medical advisers, one of whom is a GP and the other is a nurse. Our investigation confirmed that the cellmate had told a prison officer that he had taken the medication. However, the medication in question, gabapentin, is one that is prone to misuse in prisons. Drug security in prison is particularly important, and as someone - regardless of who - had tampered with the medication, the NHS policy is to stop supplying the medication. Mr C had signed a medication contract in the prison, confirming that he was aware that medication would be stopped if there was any discrepancy and that it was his responsibility to keep any of his medications safely.

We, therefore, considered the health centre had acted appropriately in stopping the medication when the discrepancy was discovered and we did not uphold Mr C's complaint.

Summary

Mr C complained on behalf of his wife (Mrs C) who suffers from various life-limiting medical conditions, including Raynaud's Disease (a condition where the blood supply to the extremities is severely restricted, causing pain and ulcers). Mrs C receives regular infusions of a drug to help with this condition, and Mr C complained about the way this treatment was administered during one period of time. He also complained about the way the board handled his complaints about this.

Mrs C is admitted to Ninewells Hospital every three months to have a series of seven-hour infusions over a five-day period. Normally 17 hours of rest are allowed between infusions. However, the board's protocol for the treatments says that they can be given with a minimum of 12 hours between them. During one admission Mrs C's treatment was compressed according to this protocol, to allow her to be discharged from hospital earlier. Mrs C developed severe headache, nausea and vomiting, and asked that this should not happen again. Despite this, she felt that her treatment was compressed on her next admission.

Our investigation included taking independent advice from a medical adviser with experience in treating patients with Raynaud's Disease. The adviser said that there are no national guidelines on administering this treatment, but that the board's protocol was in line with normal NHS practice to give infusions over a six to eight hour period across three to seven days. The adviser reviewed Mrs C's treatment and found that the infusion was given after less than a 12 hour break only once - when one was given after 11 hours. However, the adviser was of the view that this was still within normal NHS practice. They also said that staff took appropriate action to address the side effects Mrs C suffered, and noted that headache, nausea and vomiting were common side effects. After considering this advice, we did not uphold Mr C's complaint about treatment as we were satisfied that, overall, this was reasonable. We also noted that Mrs C now has a patient-held treatment plan confirming that no compression will take place in future.

We did, however, uphold his complaint about the board's complaints handling, as there were unacceptable delays in their responses. Our investigation found that Mr C complained in August, September, and November 2012, and again in May 2013. The board responded by arranging a meeting in June 2013 and sending a written response two weeks after the meeting. Mr C then made a further complaint about that response, to which the board replied two months later. The board said that Mr C several times added new complaints before previous complaints had been responded to, which caused part of the delay as the response due dates were amended. However, they also acknowledged that there were some avoidable delays due to staff error and staff shortages and that it would have been better to have dealt with each complaint separately. They explained that they had since made changes in their complaints department to address the issues identified.

Recommendations

We recommended that the board:

• issue a written apology for the unacceptable delays that occurred in dealing with Mr C's complaints; and
• provide us with evidence of the improvements that have taken place within the complaints department since Mr C's complaint and evidence of the progress of any ongoing work to improve complaints handling.