Health

Summary

Mr C's wife (Mrs C) had hip replacement surgery. She recovered well, but suffered constipation afterwards because of the painkilling medication she was prescribed. After having had no significant bowel movements for more than a week, Mrs C began vomiting and had a painful, hard stomach. Mr C phoned NHS 24 and asked for a home visit from a GP. Mrs C's case was prioritised as serious and urgent and Mr C was told that a district nurse would come within two hours. When the nurse did not arrive, Mr C called NHS 24 again. They investigated and learned that the district nurse would not visit new patients with constipation. Instead it had been arranged for a GP to call Mrs C for a further phone assessment.

Mr C was not happy with this, and was then told that NHS 24 would request an out-of-hours GP to visit within two hours. The out-of-hours GP was, however, required for another more serious call, and arrived about six hours after Mr C's initial call to NHS 24. He gave Mrs C two enemas and a prescription for laxatives. Mr C was advised to monitor his wife overnight and contact her own GP in the morning if she did not improve. As Mrs C did not improve, her own GP visited and immediately referred her to hospital, where she was diagnosed with a perforated bowel that needed emergency surgery. Mr C complained that NHS 24 did not prioritise Mrs C's case appropriately and that she could have been admitted to hospital more quickly had the out-of-hours GP attended sooner.

After taking independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaint. We found that Mrs C's case was treated seriously and given the highest priority, but that NHS 24 should have requested a GP visit rather than a district nurse visit at the start. We were critical of NHS 24 for not gathering relevant information about Mrs C's bowel habits and pre-existing kidney failure, which would have helped staff decide the action to take.

We concluded that, although there was a clear delay in the out-of-hours GP attending, this was partly due to communication problems between NHS 24 and the local health board. NHS 24 and the board had already identified this and had taken action to improve communication. We were satisfied that, although his attendance was delayed, the out-of-hours GP's conclusions and treatment would not have been different had he visited Mrs C earlier. However, we recognised that she would have received the enemas and laxatives sooner and that this might have improved her chances of avoiding a perforated bowel, if it had not already occurred by then. We also recognised that the delays added to the discomfort and anxiety that Mrs C was experiencing.

Recommendations

We recommended that NHS 24:

• apologise to Mr and Mrs C for the issues highlighted in our investigation;
• remind their clinical staff of the importance of establishing each patient's level of renal failure and of taking this into account when progressing their treatment; and
• consider briefing their clinical staff on the need to consider whether patients have passed stools or gas in cases of severe constipation.

Summary

Mr C complained that his GP practice failed to properly diagnose his symptoms for several years, and did not undertake a simple blood test that finally revealed the cause of his illness. However, as he did not then respond to our correspondence, we were unable to investigate his complaint, and closed his case.

Summary

Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, where the on-call doctor thought she might have acute sinusitis (inflammation causing facial pain). Later that month, Mrs C went back to the practice with her sister. She said the medication had not worked. She also had other problems, including being increasingly unable to socialise or attend to her personal hygiene. She was treated for sinusitis, but her symptoms became even worse, and she went back to the practice at the end of the month. She described increasing withdrawal, problems with her eyesight and that she had been off work for a number of weeks. The day after this appointment, NHS 24 were called again, and Mrs C was immediately admitted to hospital for a scan. She was diagnosed with a brain tumour and had an operation to remove it.

Mrs C complained that the GP at the practice failed to pick up on her serious illness and refer her to hospital. She said that as a consequence her life had been put at risk.

We obtained all the complaints correspondence and Mrs C's relevant clinical records and took independent advice from one of our medical advisers, who is a GP. Our investigation found that the GP missed a number of classic features associated with brain tumours. The adviser said that on her second visit to the practice Mrs C was demonstrating enough of these to merit urgent referral. He said that although some of the changes could be interpreted as being associated with depression, in his opinion that would be a secondary consideration in a patient with persistent headache and such a significant change in personality. The symptoms should have alerted the GP to a possible serious diagnosis and she should have made a comprehensive assessment including a detailed clinical examination, then referred Mrs C urgently if she felt that any element was beyond her clinical competence. We made recommendations, noting that the GP had already acknowledged that she had missed an important diagnosis and apologised for this, and that the practice had carried out a significant event analysis.

Recommendations

We recommended that the practice:

• formally apologise to Mrs C for a failure to properly examine her and then refer her on;
• confirm the actions taken to amend their procedures; and
• provide evidence that the matter has been addressed at the GP's next appraisal.

Summary

Mr C complained that a dentist had failed to fit a crown properly. He said that the crown was too big and that he could not close his teeth together. He also said that it eventually fractured because it had been too big.

We took independent advice on this complaint from our dental adviser. The crown had initially been too big, and Mr C had gone back to the dental practice the day after it was fitted to have it adjusted. The adviser said that minor adjustments are often required to a crown to fit the biting surface correctly, and that this was not unreasonable. The dental notes indicated that Mr C had accepted the adjustment that was made. There was no evidence in the dental records that he later complained about the size of the crown before it broke over two years later. We found no evidence that the care and treatment the dentist provided to Mr C was unreasonable.

Summary

Mrs C complained on behalf of her husband (Mr C) who had suffered from rheumatoid arthritis for many years. In 1996 he began taking a low dose of methotrexate (MTX - a disease modifying drug.) In 2003, Mr C had a biopsy (tissue sample) taken, which showed fatty changes to his liver. Mrs C felt that at this stage the MTX should have been stopped. However, Mr C went on to take the drug for a further two years before he was told to stop it. The board said this was because the benefits of a low dose of MTX in terms of treating Mr C's rheumatoid arthritis outweighed any potential detrimental effects on his liver. Mr C was later diagnosed with cirrhosis of the liver (scarring of the liver as a result of continuous, long-term damage). Mrs C complained that this was because of the MTX.

To investigate the complaint, we took all the relevant information, including the complaints correspondence and Mr C's clinical records, into account. We also obtained independent advice from one of our medical advisers. Our adviser said that in 2003 it was reasonable for Mr C to continue with MTX as the risks associated with it, although serious, were rare and the decision was taken in the full knowledge of all the factors involved. The adviser also said that at the same time Mr C was strongly advised about weight reduction, glucose control and close monitoring of his blood pressure. In 2005, Mr C's liver function tests showed a mild disturbance and, taking into account the existing fatty liver disease, his increasing weight and diabetes, it was decided then to stop the MTX. While Mr C had taken a low dose of MTX for a number of years, our adviser confirmed that it was not the length of time for which someone was exposed to the drug but rather the overall exposure that was likely to increase the risk. In light of this, we did not uphold the complaint.

Summary

Mrs C 's late husband (Mr C) had a pancreatic cancer operation, and afterwards agreed to have chemotherapy treatment (a treatment that uses medicine to kill cancerous cells). She complained that the board had failed to tell her husband the true survival rate after chemotherapy. She said that had he been given full information of the survival rates he would never have contemplated having chemotherapy, the side effects of which had made him very ill. Mrs C also said that the board failed to conduct scans at appropriate intervals during Mr C's chemotherapy, and she was concerned that there was a delay in starting treatment for blood clots in his lung.

As part of our investigation, we obtained independent advice from one of our advisers, who is a consultant clinical oncologist (cancer specialist). After taking this advice, we found that it was appropriate for the board to offer chemotherapy, which does improve survival after surgery for pancreatic cancer. Our adviser explained that communicating information about this cancer is an extremely sensitive area, as death rates from it are very high. Most oncologists do not give patients the blunt statistics unless specifically requested and, given General Medical Council guidance on how to communicate with patients, this is appropriate. However, we were satisfied that, in line with good medical practice, Mr C was made aware that there was a high risk of recurrence and of the high risk nature of the disease, and that, on balance, consent for the treatment was appropriately sought. Our adviser also explained that routine scanning has not been shown to improve the outcome in such circumstances. An earlier scan would not have altered the fact that Mr C struggled with the side effects of chemotherapy, nor would it have shown any earlier that the cancer had come back. The adviser confirmed that Mr C was reviewed properly, and according to the appropriate cancer guidelines. We did not uphold these elements of Mrs C's complaint about her late husband's treatment. However, we found no evidence that Mr C was told about the likely side effects of the drug, or that his tumour markers (substances found at higher than normal levels in the blood, urine, or body tissue of some people with cancer) remained slightly elevated, and we made a recommendation about this.

Finally, the board accepted that, when the blood clots were identified, Mr C was not told about this immediately. Our adviser said that the delay in starting treatment for them did not affect his overall condition. We were, however, critical that there was a delay, and upheld this element of Mrs C's complaint.

Recommendations

We recommended that the board:

• review the guidance and revised consent form to satisfy themselves that adequate information about side effects and the risk of disease recurrence is given; and
• take steps to ensure there is no recurrence of such a delay in commencing treatment.

Summary

Mr A had been suffering from a number of serious medical conditions including lupus (an autoimmune condition that affects the body's defences against illnesses and infections). Mr A was discharged from hospital into the care of his medical practice. He was readmitted several days later, after a visit from an out-of-hours doctor, and died the day after readmission. Mr A's son (Mr C) complained that after Mr A was discharged from hospital there was a lack of reasonable care by the practice. Mr C was concerned that no doctor from the practice visited his father at home, despite both Mr A and Mr C speaking to different doctors there.

In response to the complaint, the practice said that they would not routinely visit a patient after they were discharged from a hospital unless there were special circumstances. They took the view that there were no urgent concerns about Mr A at that time. They had received Mr A's discharge summary from the hospital after he had already been at home for several days. Doctors in the practice had spoken with both Mr C and Mr A by phone, and with the district nurse who had been visiting Mr A at home, and the practice had arranged for a doctor to visit Mr A at home in the coming days for review.

We took independent advice about the complaint from one of our medical advisers. The adviser was of the view that the practice had not failed in their care of Mr A, and that the hospital discharge letter, received several days after Mr A's discharge, did not indicate any issue that needed a doctor to visit. In addition, the adviser said that the information that Mr A, Mr C and the district nurse gave the practice did not highlight anything suggesting that Mr A needed to be reviewed sooner than planned. We accepted the adviser's view that, from the information presented to the practice at the time, the care and treatment they gave Mr A after he was discharged from hospital was reasonable and appropriate.

Summary

After Mr C suffered blackouts and dizziness in 2009, a GP at his medical practice diagnosed hypertension (high blood pressure). Mr C said he made many visits to the practice after that with symptoms that including falling asleep involuntarily during the day. In August 2010, he told them that he was suffering numerous headaches, he felt dizzy and faint and felt he was going to collapse. In 2012, the GP prescribed an anti-depressant, saying that Mr C's problems were related to his mental health and that an appointment would be made with a psychiatrist. When abroad later that year, Mr C saw an ear, nose and throat surgeon, who diagnosed a number of problems, including hypertension and problems with his nose and airways linked to breathing difficulties. The surgeon referred Mr C to hospital there, where he was diagnosed with obstructive sleep apnoea (OSA – a sleep disorder). He said he was given medical advice, including that he should stop taking the anti-depressant as it was dangerous, given his condition. When he returned to Scotland and went to the practice, they stopped the anti-depressant medication. He told them about the diagnosis of OSA and was referred to a sleep clinic the following month.

Mr C complained that GPs at the medical practice failed to diagnose OSA in 2009. He said that they then continued to maintain that his condition was psychological, and unreasonably failed to accept the diagnosis of sleep apnoea. He said his life was put at risk because of the misdiagnosis.

We took independent advice on this case from one of our medical advisers, who is a GP. Their advice, which we accepted, was that the GPs at the practice acted reasonably in the way they approached Mr C's multiple symptoms. The diagnosis was, however, potentially delayed by the lack of good communication at all consultations, and the adviser noted some issues regarding Mr C's compliance with appointments and medication. This might have partly arisen through a lack of understanding because of language difficulties (English is not Mr C's first language). Although the practice tried to use interpreters in many of their consultations with Mr C, there was scope for them to improve their systems around this. It was, however, impossible to say whether the diagnosis would have been arrived at earlier had an interpreter assisted at all consultations. On balance, given the advice that the practice acted reasonably when responding to Mr C's symptoms, we did not uphold the complaint. However, given that more could have been done to provide an interpretation service for Mr C, we made a recommendation.

Recommendations

We recommended that the practice:

• review their process regarding interpreters and referral letters in the light of our adviser's comments.

Summary

Ms C complained about the treatment that she received from the board for heel pain (plantar fasciitis), and was unhappy with the advice and information provided in relation to this treatment. As Ms C was dissatisfied with the treatment offered by the board she attended a private podiatrist. After receiving treatment from them, she also complained that the board had not offered her that type of treatment.

While investigating the complaint, we took into account all of the complaints correspondence and Ms C's podiatry record. We took independent advice from one of our advisers, who is a experienced podiatrist. We found that the treatment and actions taken by the board were, in the main, appropriate and evidence based and followed best practice. We also found that there was no justification for the suggestion that the board should have offered Ms C the approach adopted by the private podiatrist, and that advice on heel pain management had been clearly presented. Although we did not uphold the complaint, we did make recommendations, as Ms C had not been examined and our adviser said that it would have been advisable for this to have happened, to rule out the possibility of another condition and to check that insoles purchased were the correct fit. We also took the view that information given to a patient should emphasise that medium to long term management of the condition is usually needed.

Recommendations

We recommended that the board:

• consider introducing a protocol, when attempting to manage plantar fasciitis without an examination of the feet, to ensure that any serious conditions that represent differential diagnoses are not missed;
• ensure that, when recommending that patients purchase insoles/orthoses for use in their shoes, the fit is checked by an appropriately trained professional; and
• consider amending the presentation given on the management of plantar heel pain to emphasise the fact that medium to long term management is usually required, along with anticipated time periods.

Summary

Mr and Mrs C's son (Master A) has numerous complex medical conditions and needs constant care. They complained about a number of issues, including the care and treatment provided to their son during a series of admissions to hospital. Their concerns included that their son was not observed frequently enough, signs of deterioration were not detected, medication was not given at the right time, he developed infections and there was a general failure to assess his cognitive ability or communicate with him.

Having taken independent advice from our nursing and medical advisers we found that, generally, the medical and nursing care provided to Master A was appropriate and demonstrated effective management of his symptoms and conditions. We did not find evidence of many of the concerns raised by Mr and Mrs C. However, we upheld the complaint on the basis that there was evidence that Master A had been left unattended in a cubicle and, as a child with a tracheostomy (an artificial airway), this was a potentially unsafe practice.

Mr and Mrs C also complained that the board failed to provide appropriate home nursing care for their son. However, we did not uphold that complaint as we found that the care package provided was in line with national guidelines for children with exceptional healthcare needs. We also found no evidence to reconcile a difference in opinion between the board and Mr and Mrs C about the number of nursing shifts that had not been covered.

Finally, Mr and Mrs C had complained that they were not involved in discussions and decisions about their son's care, and that staff at the board had victimised and bullied them. Again, we could not find evidence of this. We did find evidence of good levels of communication from the clinical and nursing staff involved in Master A's care - in terms of updating Mr and Mrs C, taking into account their views, and discussing care and treatment. Although we did not uphold these complaints, we pointed out to the board that some of the steps they had taken during the latter stages of their contact with Mrs C demonstrated potentially unreasonable restrictions.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C and Master A for failing to ensure Master A was supervised at all times; and
• remind staff who may be caring for children with tracheostomy of the need to ensure constant supervision of these children, with reference to the guidelines provided by Great Ormond Street Hospital.