Health

Summary

Ms C complained on behalf of her daughter (Ms A) about the care and treatment she received at the Western Infirmary for appendicitis. She complained that her daughter was not fully diagnosed soon enough, as there was a delay to her initial scan, and she was not monitored appropriately. She also said that a delay in operating to remove Ms A's appendix caused a rapid deterioration in her condition and a more complex operation. Ms A was operated on some 24 hours after she was admitted to hospital. Ms C also complained about the board's handling of her complaint.

The board had accepted that there was poor communication in relation to some elements of Ms A's care, and that the family were misled in relation to when the operation might take place. They apologised for the distress this caused.

After taking independent advice from two of our advisers - a consultant surgeon and a nursing adviser - we upheld both complaints. The surgical adviser was satisfied that Ms A's treatment was reasonable, and that the operation took place within a reasonable timeframe. However, the nursing adviser was concerned that Ms A was not monitored frequently enough, given that the reason for admitting her to hospital was to keep her under close observation. We were also critical of the communication between ward staff and Ms C. She was given inaccurate information on at least three occasions, increasing the family's distress.

We found that the board had delayed in responding to Ms C's complaint, and did not act on assurances they had given during that process. The board explained to us, however, what they had since done to ensure that this did not happen again, so we made no recommendation about this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• reflect on the failures in communication that our investigation identified, and consider how communication with patients and their families could be improved to ensure information is as accurate as possible; and
• ensure that nursing staff within the surgical unit are aware of the importance of carrying out vital signs observations as part of their role in the assessment and monitoring of surgical patients.

Summary

Mrs C's late father (Mr A) had a rare type of lung cancer and was admitted regularly to the Victoria Infirmary for problems related to this, particularly chest infections. In early 2013, he was admitted there and started on antibiotics to cover the possibility of another chest infection. A few days later, a doctor described him as being frail and it became apparent, as Mr A deteriorated further, that he was at the end of his life. He received palliative care (care provided solely to prevent or relieve suffering), and he was reviewed by several doctors and prescribed pain relief for agitation. Mr A died two weeks after being admitted to hospital.

Mrs C complained about the end of life care her father received, saying that he was not given reasonable pain relief or antibiotic treatment and that there was a lack of senior clinical input. She also said that nursing staff failed to assess his pain and keep comprehensive records. Mrs C said that her father was screaming out in pain during the latter stages of his illness, and she was extremely concerned that staff failed to respond to this appropriately.

We took independent medical advice on the case from two of our medical advisers, one of whom is a doctor specialising in care for the elderly, and the other a nurse, after which we did not uphold Mrs C's complaint. We found that we were unable to reconcile the different accounts of the level of pain that Mr A experienced, and the advice we received was that Mr A had symptoms of breathlessness, anxiety and agitation, which were treated adequately. There was no evidence in the medical records or statements from staff of Mr A screaming in pain. We noted that a delay in providing antibiotics and failure by senior staff to review Mr A had been raised with the staff concerned, but our medical adviser (a doctor specialising in care for the elderly) said that these did not affect what happened or the management of Mr A's condition. Our nursing adviser also noted a lack of documentation in relation to pain assessment and end of life care, and we made a recommendation about this. However, again these did not impact on the care Mr A received, which she said was of a reasonable standard.

Recommendations

We recommended that the board:

• ensure the failures in record-keeping, in particular completion of SEWS (Scottish early warning system - a set of patient observations) are raised with relevant staff.

Summary

Mrs C attended A&E at Monklands Hospital in the early hours of the morning with her daughter (Miss A), who was given a liquid steroid to treat croup (an infection of the voice box and windpipe) before being discharged. Later that same day, and after speaking with NHS 24, Mrs C returned to A&E because she felt that Miss A's condition had not improved. Mrs C said she was advised that an out-of-hours (OOH) appointment had been booked for her daughter that evening but that she did not know about it. A nurse examined Miss A, and after a discussion with the duty consultant, advised Mrs C that she could take her daughter home. The following day, Mrs C visited her doctor for an unrelated issue and whilst there, the doctor examined Miss A and confirmed there was a slight wheeze so prescribed steroids. Because of this, Mrs C complained that the care and treatment provided to her daughter in A&E was unreasonable.

The board told Mrs C that because Miss A was well and had a normal set of observations, the duty consultant felt it would be best if she was allowed to attend her booked OOH appointment. They said this was because it was unlikely that she would be seen by an A&E doctor earlier than the time of the scheduled appointment later that evening. However, when we examined the evidence, we identified that the scheduled appointment had already been cancelled because Miss A was seen in A&E. When we asked the board about this, they told us that the appointment with the OOH service would have been cancelled when Mrs C arrived at reception in the A&E department. The board said the receptionists for both services sat side by side and would have liaised with each other about this.

We took independent advice from one of our medical advisers, but he said he was unable to say whether the care and treatment provided to Miss A by the A&E department was reasonable, given that the duty consultant made an incorrect assumption that her OOH appointment was still booked for later in the evening that day. We found that the consultant appeared to have taken the decision to allow Miss A to leave A&E on the basis of inaccurate information and because of that, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure our investigation identified; and
• take steps to review what happened in Mrs C's case and ensure appropriate measures are in place to prevent the same thing from happening again.

Summary

Mrs C complained about the care and treatment of her late husband (Mr C). Mr C was diagnosed with lung cancer and over a five-month period had six appointments with five different consultants. At most of the appointments, which were at both the Beatson Cancer Centre and Royal Alexandra Hospital, Mr and Mrs C had to wait around one and a half hours beyond the appointment time, which was extremely stressful for them. Mr and Mrs C also attended one of the appointments expecting to receive the results of a scan. However, this was not available until 17 days after it was taken, when Mr C began to develop increasing weakness in his legs. He was admitted to hospital the following day and developed complete paralysis of his legs and lack of sensation up to his abdomen. The cancer was found to have spread to his spine, leading to spinal cord compression, and Mr C died shortly after. Mrs C complained that if the results of the scan been available earlier, there might have been a better outcome for her husband, had treatment been administered sooner.

After taking independent advice on Mr C's case from two of our medical advisers, we found that there was a delay in making the scan available, and that the radiologist failed to flag the risk of spinal cord compression when reporting the scan. While there was only a slight possibility that earlier information would have meant that the outcome would have been different for Mr C, these failings led to a significant personal injustice as the delay caused a great deal of distress and there was a missed potential opportunity to diagnose and treat Mr C's spinal compression earlier. We also found an error in the reporting of a previous scan, which might have affected treatment decisions relating to Mr C's pain. Finally, in relation to Mrs C's complaint about the board's appointment handling, we found that there was a lack of continuity of care because of poor record-keeping and the involvement of multiple consultants. This adversely affected the information available to the consultant at each appointment, potentially impacted on Mr C's care and was particularly distressing for both Mr and Mrs C, given the ongoing situation.

Recommendations

We recommended that the board:

• take account of our medical adviser's comments about reviewing report turnaround times and reporting radiology errors, and provide us with evidence on how they intend to avoid a recurrence;
• provide evidence that multi-disciplinary team meetings play a role in the management of patients with lung cancer, in line with the relevant guidelines;
• raise the failures our investigation identified with relevant staff, and ensure it forms part of their annual appraisal;
• provide us with evidence on how they intend to avoid a recurrence of the failures that our investigation identified in the complaint about appointment handling; and
• apologise to Mrs C for the failures our investigation identified.

Summary

Mrs C went to her medical practice with a thickened and discoloured toenail. The GP suspected a fungal nail infection and sent clippings for testing but the results were negative. The practice took no follow-up action until, after seeing a private podiatrist (foot specialist), Mrs C went back to her GP almost a year later. At the recommendation of the podiatrist, the GP made an urgent referral to a dermatologist (skin specialist). Mrs C was diagnosed with a malignant melanoma (a type of skin cancer) and her toe was later amputated. She complained that the practice unreasonably failed to refer her for further diagnostic tests. She also complained that the practice did not respond appropriately to her complaint about this.

Mrs C had complained by phone to the practice manager. During the call she said that she did not want to speak to the GP. Despite this, the GP called Mrs C a few minutes later. Mrs C spoke to the manager again the following day, who confirmed that she had passed Mrs C's message to the GP but that he had phoned her anyway, thinking that it would be of help. Mrs C then complained in writing and the GP responded but Mrs C did not receive the letter. About four months later, she chased up the response and was provided with a copy.

Our investigation, which included taking independent advice from a medical adviser, found that the cancer was very rare and difficult to diagnose, and that national guidelines confirmed this. The adviser commented that in general practice it is usual for patients who are having investigations to be told to return for review when the results are available. The GP had noted on Mrs C's record 'RV [review] with results' when the nail clippings were sent for investigation. Mrs C did not return for review but our adviser said that as the results were normal, no further investigation was required at this time. When Mrs C did return, having been reviewed by a podiatrist, the GP then took appropriate and timely action to follow the podiatrist's recommendations.

Mrs C was concerned that when discussing the negative fungal infection results with her, the GP did not advise her to make an appointment with the in-house podiatrist. The GP said that he was certain that he had advised Mrs C to do so, but conceded that he had not documented this. We were unable to determine which version of events was correct, but overall our adviser was of the view that the care and treatment provided to Mrs C was reasonable.

On the handling of Mrs C's complaint, our view was that in view of Mrs C's specific request not to speak to the GP, it was inappropriate for him to call her. While early and direct discussion of a complaint can bring about a speedy resolution, in this case contact was not helpful. However, we did consider that it was reasonable for the GP to have written the response letter to Mrs C. This contained the GP's personal apologies for the experience Mrs C had been through and also his explanations of why he had not thought the condition in her toe was serious at the outset.

We noted during our investigation that the practice's complaints literature was out of date, but that the timescales for both the previous and current NHS guidance on complaints handling had been met. Also, Mrs C was given the correct information about the next stage of the complaints process at the correct time. Although we did not uphold this complaint, we brought this to the attention of the practice.

Summary

Mr C complained that the board had failed to carry out an appropriate investigation into his concerns about his daughter (Miss A)'s treatment in Stobhill Hospital. His concerns included a lack of information from staff about matters affecting Miss A; inappropriate behaviour and actions of staff; and staff not displaying their name badges.

We found that the board had treated Mr C's concerns seriously, had made appropriate and detailed investigations into them and had provided him with a reasonable response. The board explained that at times staff name badges may not be visible and that they had reminded staff of their responsibilities in that regard.

Summary

Mrs C complained that a consultant at Forth Valley Royal Hospital dismissed an urgent referral from her GP for suspected lung cancer and failed to follow up the suspicion of lung cancer. Mrs C said that the consultant failed to take account of her medical history or a recent x-ray and that, as a result, diagnosis of and treatment for lung cancer were delayed.

Mrs C's GP referred her to the respiratory unit because she had a longstanding persistent cough. The consultant there reviewed the referral letter, and as he thought it unlikely that she had lung cancer he decided not to see her at his clinic. He suggested that she first stop taking medication that was known to cause coughs, to see whether this was the cause of her symptoms. After taking independent advice from one of our medical advisers, although we found it acceptable for referrals to be screened in this way we found that the consultant overlooked information in the referral about Mrs C's recent x-ray. Whilst we were satisfied that the advice to alter Mrs C's medication would have been the same had the information about the x-ray been taken into account, we upheld the complaint about the consultant's actions and criticised the board, as this was a key item of information and it was clearly overlooked.

We did not uphold the complaint about delay as we were satisfied that although there was some delay in diagnosis, this was not unreasonable in the circumstances. We did, however, uphold Mrs C's complaint about the board's complaints handling as we found that their investigation and response were not thorough enough.

Recommendations

We recommended that the board:

• apologise for failing to note that Mrs C had had a clear chest x-ray;
• draw our findings to the consultant's attention; and
• review their complaints handling procedures to ensure that detailed, impartial, investigations are carried out into issues raised by patients.

ummary

Mr C complained to us about the care and treatment given to his late wife (Mrs C). Mrs C had been diagnosed with emphysema (a lung disease) and fibrosis (scarring of the lungs) some years ago. When she attended her medical practice in 2013 complaining of a cough, she was initially treated with antibiotics but after attending again a few weeks later she was referred for a chest x-ray. This showed little change from an x-ray taken a few years before.

A few months later, Mrs C returned to the practice and was referred again for an x-ray. This showed signs of infection and she was given more antibiotics. After at first feeling a little better, Mrs C began to experience shortness of breath and a cough and was referred urgently to the respiratory team at the local hospital. She was then given an x-ray which showed that she had a tumour. Mrs C's condition deteriorated and she died a few months later, around seven months after initially attending the practice about her cough.

Mr C complained that the care and treatment given to Mrs C by the practice was unreasonable. He was particularly concerned at the length of time it took for Mrs C to receive a scan and, therefore, the time taken to provide a diagnosis. He also said time was spent on treating her for a chest infection rather than diagnosing her condition.

We took independent advice on this complaint from one of our medical advisers, who is a GP. We found that Mrs C's case was unusual in that she had an x-ray that showed no signs of cancer only four months before having another which showed she had a fairly advanced cancer. The tumour was particularly aggressive and fast growing, and Mrs C was frail and had other illnesses. We did not find the the way in which the practice cared for and treated Mrs C unreasonable.

Summary

Mrs C complained that when she was admitted to Aberdeen Royal Infirmary staff did not take account of her specific condition when treating her, did not appropriately access her medical notes, and did not keep accurate and secure test results.

Mrs C suffers from a chronic condition which can cause an imbalance in blood chemistry, particularly sodium and potassium. She had also just had a bout of gastroenteritis (vomiting and diarrhoea) and had been prescribed dioralyte (a medication used to replace fluids and regulate blood chemistry after diarrhoea) by a locum (temporary) GP. When she saw her own GP after she had been ill for six days, she was referred to the hospital, and was admitted. Mrs C was given a saline drip (to prevent dehydration) and kept in overnight then discharged the following day. Since then Mrs C has suffered ongoing symptoms of tiredness, weakness and an inability to tolerate any foods containing sodium or potassium, which she attributes to the treatment she received.

Mrs C said that when she tried to tell medical staff that the combination of treatment she had received from the locum GP and the hospital would have a negative effect on her, they dismissed her views and began writing in the medical records of another patient with a similar surname to hers. Mrs C also said that a person wearing a white coat told her that they had amended her blood test results to read as normal to prevent her getting treatment.

Our investigation included taking independent advice from one of our medical advisers, who said that the medical records showed that Mrs C's treatment was reasonable, appropriate and would have been very unlikely to have caused the symptoms she described. We were also satisfied that there was no evidence of any gaps, inaccuracies or tampering with Mrs C's medical records or blood test results. We asked the board what they had done to investigate Mrs C's concerns about her medical records and blood test results, and were satisfied that they had carried out extensive and appropriate investigations and found no evidence to support her concerns.

Summary

Mr C complained about a number of aspects of the care and treatment the practice provided for his late mother (Mrs A). This included that there was a delay of six weeks in the practice referring Mrs A to a specialist, after a doctor at the practice told Mr C at a home visit that this would be done. Mr C also complained that when another doctor at the practice saw Mrs A at home on a later date, he failed to arrange for her to be admitted to hospital and made an inappropriate reference to her condition. Mr C said the practice failed to take his mother's deteriorating condition seriously and provide her with appropriate care and treatment.

After obtaining independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaints. Our adviser said that he would have expected the first GP to have set a time to see Mrs A to go over blood test results and to review her condition. This did not happen. The referral, which was eventually made more than six weeks after the home visit, appeared to have been prompted by Mr C and was made to a psychiatrist for the elderly, rather than a consultant geriatrician. It appeared that the practice might have taken some reassurance from tests that had suggested there was no sinister cause for Mrs A's long-term problems. The adviser said, however, that as Mrs A had red flag (warning) symptoms that could suggest underlying cancer and as some time had passed since the tests were carried out, a referral to a consultant geriatrician should have been made.

The second doctor accepted that, at the later home visit, he had referred to Mrs A inappropriately. In our view, the term he used was insensitive and would likely have added to the distress Mr C was experiencing at that time. Having correctly decided not to admit Mrs A to hospital, it then appeared that this doctor failed to assess Mrs A's social situation at the visit, although we accepted that, overall, the practice acted reasonably in trying to get social work involved in her case.

Recommendations

We recommended that the practice:

• feed back the failings identified to the staff involved to ensure that a similar situation does not happen in future; and
• provide Mr C with a written apology for the failings identified.