Health

Summary

Mr C said that he had been suffering pain from his rib cage for a number of years and believed he had a displaced rib. He complained that the board delayed in providing him with treatment or a firm diagnosis. He wanted to be referred to a chiropractor (a practitioner who uses their hands to treat disorders of the bones, muscles and joints) and was unhappy that the board declined to provide this.

After taking independent advice from one of our medical advisers, and considering Mr C's medical records, our investigation found that while the treatment given to Mr C took place over a considerable period of time, there were no periods of unreasonable delay. The x-rays carried out were appropriate and timely. Although Mr C wanted to be referred to a chiropractor, our adviser said that physiotherapy was an acceptable, reasonable alternative, and the board had provided this.

Summary

Mrs C's son (Mr A) sustained a head injury while playing sport. He attended A&E at Perth Royal Infirmary where he was examined and discharged. He was later found to have suffered a fracture to his neck which required surgery to correct. Mrs C complained that her son was not properly assessed in A&E and should have been sent for medical imaging. The board stated that they had followed established guidance on the decision-making process regarding medical imaging and that on the information available at the time regarding Mr A’s symptoms there was no reason to perform any medical imaging.

We took independent medical advice on this complaint from one advisers, who told us that Mr A's assessment in A&E was thorough and adhered to the relevant guidance. The adviser also said when Mr A was examined there was no obvious reason to refer Mr A for imaging. We considered Mr A’s treatment to have been reasonable and did not uphold the complaint.

Summary

Mrs C complained about the treatment she received as an out-patient at Perth Royal Infirmary. She was being treated for a bladder complaint and was prescribed a drug (trospium chloride) as part of her treatment. Shortly after this she had a relapse of a previous mental health problem, and she attributed this to being prescribed the drug.

Our investigation included taking independent advice from one of our medical advisers, who was of the view that the choice of drug was reasonable for a patient in Mrs C's age group, and with her medical history and medical condition. The adviser said that this type of drug was less, rather than more, likely to cause a worsening of a patient's mental health, that it was an appropriate choice of therapy and that Mrs C's reaction was very unusual.

The outcome Mrs C was seeking was to have her medical notes annotated with a warning not to prescribe this drug to her in the future and the board had told us during the investigation that they had already put notes in the relevant records. We asked the board to confirm in writing to Mrs C, and to us, that this had been done.

Summary

Mr C had an accident at work and was taken to Perth Royal Infirmary A&E, where his back and neck were examined and x-rayed. No bony injuries were identified and Mr C was discharged. He said that he told hospital staff that his arms and shoulders were extremely painful and heavy, but the only test that they carried out was that he was asked to squeeze the doctor's fingers. Mr C continued to have pain in his shoulders and arms and his GP referred him for an MRI scan (magnetic resonance imaging - used to diagnose health conditions affecting organs, tissue and bone). This showed that he had torn the rotator cuffs (the muscles around the shoulder joint) in both shoulders. Mr C continued to have shoulder problems, and complained that the A&E examination was inadequate and did not properly assess the extent of his injuries.

After taking independent advice from one of our medical advisers, we found that Mr C was examined in line with good practice. The range of movement in his arms and shoulders was checked and the finger squeezing test was carried out to check for nerve damage (which might have indicated a neck injury). The examination indicated that Mr C had soft tissue injuries, which would not show up on an x-ray. We did not uphold his complaint,as we found the decision to allow his injuries time to settle, with pain medication, to be appropriate. However, we noted a delay to Mr C's MRI scan and diagnosis when his pain did not resolve and made a recommendation related to this.

Recommendations

We recommended that the Board:

• share our decision with the staff involved in Mr C's treatment and diagnosis with a view to identifying any points of learning that may be used to improve the treatment of future patients; and
• remind their A&E staff of the importance of inviting patients to return to hospital or their GP should their symptoms persist, and of documenting the advice given to patients discharged from their care.

Summary

After Mr C's daughter (Miss A) was in a road traffic accident, paramedics took her to A&E at Ninewells Hospital strapped to a spinal board (a specialised stretcher, designed to protect patients with spinal damage). Mr C complained that the board then failed to adequately assess and treat Miss A, and said that she was not x-rayed at any point before she was discharged. Following her discharge she remained in significant pain and discomfort and Mr C took her to the family GP who, after a brief examination, referred her as an emergency to a different hospital. An x-ray taken there revealed a fractured vertebrae in Miss A's back and a CT scan (a scan that uses a computer to create an image of the body) revealed two further fractures.

We took independent advice from one of our medical advisers. He said that while the initial examination of Miss A was of a reasonable standard, a second more comprehensive examination should have identified the need for an x-ray of the spine. The adviser also said there was no record of Miss A's mobility having been assessed and that, as she was suffering pain in her abdomen, she should have been assessed for liver damage, given the speed at which the vehicle was travelling immediately before the crash.

In light of this advice we upheld Mr C's complaints, as we concluded that the board had failed to adequately assess and treat Miss A and had unreasonably failed to arrange for x-rays or scans to be taken of her spine.

Recommendations

We recommended that the Board:

• apologise for the failings identified in the care provided; and
• provide evidence that they have addressed the failings our investigation identified with the doctor responsible, through the staff appraisal process.

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice over a three-year period before she died in 2012. Mrs A had a complex medical history with many severe and debilitating conditions, which had been present for a number of years. Mr C raised a number of issues about the care and treatment provided for his late mother's conditions, including the treatment she received for leg ulcers, chronic kidney disease (CKD) and epilepsy, dietary issues, and nursing infection control methods. Mr C also complained that the GP had not communicated adequately with him and/or Mrs A.

Our investigation, which included taking independent advice from one of our medical advisers, found that the care and treatment provided to Mrs A was reasonable, appropriate and timely. The adviser reviewed Mrs A's medical records and found no evidence (other than one lapse in monitoring kidney function) that her care and treatment was deficient. National guidance on the management of CKD says that kidney function should be monitored at least every three months, and there was at one point a gap of six rather than three months in testing Mrs A's kidney function. There was no explanation for this gap but the adviser said that it had no detrimental effect on Mrs A's overall condition.

We did, however, identify failings in communication and upheld Mr C's complaint about that. We found that some of the written communications from the GP to other healthcare professionals contained subjective comments about Mrs A and her lifestyle. After Mr C complained to the practice, the GP acknowledged that the comments were not appropriate and apologised to Mr C for the distress this had caused him. The adviser agreed that the comments were not appropriate and said that they had detracted from the GP's otherwise professional approach to Mrs A's care. The adviser was also concerned that at times the GP appeared to make unilateral decisions about Mrs A's care without discussing them with her and/or Mr C.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on their practice in relation to communication and discusses any learning points at their next appraisal.

Summary

Mrs C complained about the medical care and treatment the medical practice gave to her late husband (Mr C). In particular, she was unhappy that he was not referred to hospital earlier.

During our investigation, we obtained independent advice from one of our medical advisers, who is a GP. We found that for the most part the treatment provided to Mr C was reasonable and appropriate. The adviser said that, although some GPs might have considered referring him to hospital earlier, the practice had acted within national guidelines and it was not unreasonable that Mr C was not referred earlier than he was. The medical records showed that the practice had been attentive and had managed Mr C's care as best they could.

We were, however, concerned that there was no evidence in the records that the practice had recognised and considered Mr and Mrs C's distress when deciding how best to progress his care. We were also concerned that there was no evidence to support the practice's position that Mr C was involved in the decision-making process. As a result we made a number of recommendations to further improve practice.

Recommendations

We recommended that the practice:

• provide us with evidence demonstrating how the practice involve the patient in the decision-making process; and
• consider this case to see if any further lessons can be learned, and bring the concerns raised by our investigation to the attention of the staff involved.

Summary

Ms C complained that a consultation that her late husband (Mr A) had at his medical practice was unreasonable, and was unhappy with their handling of her subsequent complaint. Mr A had been suffering from a cough and loss of appetite, and was due to see his GP but as his condition had worsened he arranged an earlier emergency appointment. The GP examined him and diagnosed pneumonia. He prescribed an antibiotic (a drug used to fight bacterial infections), took blood samples for testing, completed a referral form for Mr A to take to his local hospital for a chest x-ray later that day and planned to review Mr A again in one week, or earlier if his condition deteriorated. Mr A returned home, and, sadly, his teenage son found him dead there some three hours later. Ms C complained to the practice in July and September 2013 and the GP responded in July and October 2013. Ms C was dissatisfied with the responses and asked us to look at her complaint.

Our investigation, which included taking independent advice from one of our medical advisers, found that there were some failings in the GP's actions and his recording of the consultation and we upheld this part of Ms C's complaint. The adviser said that although the GP had noted some observations, other key observations (such as blood pressure, temperature, and respiratory rate) were not recorded. The adviser said that, although there was no indication that Mr A needed to be immediately admitted to hospital, the lack of these recordings were of concern where a patient had been diagnosed with pneumonia.

The adviser also noted that guidance on the management of lower respiratory tract infections (SIGN 59), issued by the Scottish Intercollegiate Guidance Network (SIGN) recommended that two different, but complementary, types of antibiotic should be prescribed for patients with suspected pneumonia. SIGN 59 also recommended review in 48 hours rather than the one week planned by the GP. Overall, the adviser was of the view that immediate hospitalisation might not have changed the outcome for Mr A. He said that bronchopneumonia (acute inflammation of the lungs) - which was identified as the cause of Mr A's death - can progress rapidly and aggressively. Because of the failings in the records of the consultation, however, it was impossible to say this for certain. We noted that the practice had conducted a significant events analysis (a process of examining what happened and identifying what, if anything, went wrong and what, if any, remedial action is needed). The adviser said that this had picked up some, but not all, of the learning points from this complaint.

Our investigation found that the practice acknowledged and responded to Ms C's complaint within the timescales in their complaints process, which mirrored the national guidance on complaints handling. The first acknowledgement was incorrectly dated but the practice manager had apologised for this in a later letter. Although we appreciated that Ms C was not happy with the practice's handling of her complaint, we considered that the timescales had been met and all the issues she raised were addressed - albeit not to her satisfaction. Because of this we did not uphold this part of her complaint.

Recommendations

We recommended that the practice:

• ensure that the GP reflects on his practice in relation to these events, in particular in relation to SIGN 59 and clinical note-taking, and discusses any learning points at his next appraisal;
• review their procedure for conducting a significant event analysis to ensure that all learning points are recorded and addressed; and
• issue a written apology for the failings our investigation identified.

Summary

Miss C complained about her care and treatment when she was admitted to St John's Hospital for planned surgery. In particular, Miss C said that she had left hospital with an open wound, and was given inadequate post-discharge advice and care. She also complained about the care and treatment she received after being re-admitted nine days later with a severe wound infection, and said that her wound packing had been removed on the ward without adequate pain relief, and that packing was left in it.

During our investigation, we took independent advice from two of our advisers, one who is a specialist gynaecology consultant and another who is a plastic surgery consultant. The gynaecology adviser said that the operation appeared to have been straightforward but that Miss C was at high risk of infection. He found no evidence that prophylactic antibiotics (drugs that treat bacterial infection, given in advance of a procedure to reduce the risk of infection) had been given to Miss C during surgery, although he accepted that there might have been a reason for not doing so. He also said that she should have been given antibiotic therapy on discharge. However, he said that there was no evidence that she was discharged with an open wound.

After Miss C returned to hospital she had a further surgical procedure. The plastic surgery adviser was satisfied that the initial assessment and surgery were carried out to a high standard. He also indicated that it was routine practice to remove the wound packing on the ward, but noted that Miss C had not been given any additional pain relief for this procedure which can be traumatic and that this should have been considered. He also advised that it was unlikely that the full extent of Miss C's wound was observed during the procedure and that it was likely some of the large gauze swabs used as packing were left in the wound. We were critical of these apparent failures by the board.

We found nothing in Miss C's clinical records to indicate that at her pre-operative assessment she was given the information the board said she should have. There was also nothing to indicate whether it had been explained to Miss C that she was responsible for passing a discharge letter to her GP. We noted, however, that the board said they had already taken steps to remind staff of the importance of providing appropriate information and advice.

Recommendations

We recommended that the Board:

• apologise to Miss C for the inadequate care and treatment we identified, that she was not given adequate information about post-operative care at her pre-operative assessment, and that it was not properly explained to her that she was responsible for passing on the discharge letter to her GP;
• make relevant staff members aware of our adviser's comments and give them an opportunity to reflect on these for their future practice - in particular in relation to consideration of the use of prophylactic antibiotics both during surgery and prior to discharge, and the issue of pain relief and wound observation at dressing change; and
• provide us with evidence of the steps taken to remind staff of the importance of providing appropriate information and advice as stated in the board's response to Miss C's complaint.

Summary

Mrs C complained that her medical practice had not provided her with reasonable care and treatment. Mrs C had suffered from cancer before so, when she noticed swelling on her leg and groin, she suspected it had returned and went to the practice immediately. During the following months she went there a number of times and various tests were arranged. When the practice then referred her to hospital, cancer was diagnosed. Mrs C did not feel that the care she received from the practice was appropriate.

We took independent advice from one of our advisers, who is an experienced GP, who reviewed Mrs C's medical records and explained that they showed that the practice had been alert to the possibility of cancer throughout Mrs C's consultations and had arranged appropriate tests and investigations. The adviser also said that the practice made reasonable referrals, on the basis of the information available at the time, and had considered the whole picture of Mrs C’s symptoms.

Although we recognised that this was a most significant and distressing matter for Mrs C, our role was to consider whether, based on the evidence available to the practice at the time and without hindsight, they had provided her with reasonable care and treatment. The advice we received was clear - that the practice had investigated and referred Mrs C appropriately - and on this basis we did not uphold her complaint.