Health

Summary

Mrs C's daughter (Ms A) was admitted to Forth Valley Royal Hospital after taking an overdose of a mixture of medications, including venlafaxine (an anti-depressant) and propanolol (a beta blocker, used to treat conditions such as heart problems, blood pressure and anxiety), which are absorbed into the system slowly. She had called an ambulance herself and was taken to the emergency department, where she was seen immediately by a staff nurse. She was assessed before being seen by a trainee doctor. Ms A was groggy and her blood pressure was low. She was treated with intravenous fluids (fluids put directly into a vein). Blood tests and an electrocardiograph (a test that records the electrical activity of the heart) were also arranged. Over the following hours, Ms A's blood pressure remained low. Around seven hours after being admitted she began to have seizures and breathing difficulties. Her condition deteriorated further and the intensive care unit was asked to review her. Shortly afterwards, Ms A's heart stopped. Attempts were made to resuscitate her and she was treated with glucagon (medication used to increase blood sugar levels, which can be used in the treatment of propanolol overdose). This failed to improve her condition, however, and she died.

Mrs C complained that staff did not provide glucagon until it was too late. She considered that, had this medication been provided earlier, Ms A might have survived. She also complained about the board's record-keeping. The board said in response to her complaint that glucagon is not the first line of treatment for propanolol overdose and, as Ms A had been responding to intravenous fluids, it was not considered a necessary treatment for her at the time.

After taking advice on this complaint from one of our medical advisers, who is a consultant in emergency medicine, we upheld both of Mrs C's complaints. The adviser reviewed Ms A's medical records, and said that she had not been responding adequately to the intravenous fluids and that glucagon should have been considered far sooner. Although we found evidence that clinical staff consulted TOXBASE (the national poisons information database) we were critical that there was a delay in doing so. We found that Ms A's overdose would have been treated differently had the guidance been consulted and followed earlier in her admission. We were also critical of the board's record-keeping. Important information about medication had been lost from Ms A's records and there was no documented record there of staff having consulted TOXBASE.

Recommendations

We recommended that the board:

• provide a copy of our decision letter to the doctor to ensure that he is fully aware of the outcome of our investigation and discuss any learning points with him at his next appraisal;
• apologise for the lack of appropriate record-keeping in this case; and
• remind all nursing and medical staff of the importance of maintaining accurate contemporaneous records.

Summary

Mrs C complained that when her medical practice increased the dosage of her medication, it had side effects on both her heart rate and blood pressure. The practice said that they had acted in line with the appropriate guidelines when doing so. Mrs C remained unhappy and brought her complaint to us.

As part of our investigation we took independent advice from one of our medical advisers, who is a GP. He considered Mrs C's medical records and confirmed that the practice had decided to increase the dosage because of blood test results, and that the increased dosage was in keeping with standard practice in most GP surgeries. He also said that the internal systems the practice had in place to review Mrs C's medication in future were in line with good practice. As such, although we recognised that the change in dosage had affected Mrs C, we found no evidence to suggest that the practice acted unreasonably in prescribing this.

Summary

Mrs C complained that a nurse delayed in making a referral for a claim for benefit for her late husband (Mr C) when he was diagnosed with a terminal illness. The nurse specialised in palliative case (care to prevent or relieve suffering only). Mrs C said that the nurse visited her husband at home and, during a discussion with him, said that she would make a referral to another agency, who would take his benefit claim forward. There was a delay of several weeks before the claim was processed, and Mrs C said that her husband lost a month's benefit because of this. She believed that the reason for the delay was that the nurse delayed in making the referral.

In response to our enquiries about the complaint, the board told us that community specialist palliative care nurses are not responsible for submitting benefit claims for patients. However, they can help by signposting patients, or contacting the agency who will then take the claim forward on their behalf. The nurse had completed a statement saying that she contacted the agency a week after discussing the matter with Mr and Mrs C. There was a note in her diary that suggested she had contacted them then, but it was not conclusive evidence. The agency who dealt with the claim said that they did not receive the referral until a month after the nurse discussed the matter with Mr C. They then took the claim forward and, in line with the relevant legislation, awarded benefit from the date they said they received the referral from the nurse.

On balance, we found that there was insufficient evidence to decide that it was definitely the nurse who delayed in making the referral. The evidence was conflicting, in that the nurse said that she made the referral on a specific date, but the agency said they had not received it until a number of weeks later. Having carefully considered the matter, we did not uphold the complaint.

However, we recognised that Mr C had lost over three weeks' benefit because of the delay, through no fault of his own, and that this had caused him some distress before his death. The other agency involved does not fall within our jurisdiction, so we could not look at what they did. As it had not been possible to prove which organisation was responsible for the delay, we made recommendations to address this.

Recommendations

We recommended that the board:

• award Mrs C a payment for 50 percent of the benefit that she and her late husband lost out on due to the delay in his claim being actioned; and
• provide the Ombudsman with an update on the action they are taking to prevent this problem recurring.

Summary

Miss C, who is an independent advocate, complained to us on behalf of her client (Miss A). Miss A had previously had input from the board's speech and language therapy (SaLT) and learning disabilities teams, and was looking for further input from them. The board, however, did not provide this. They said that the SaLT team could not identify a clinical risk to Miss A that would benefit from further intervention, and that the learning disabilities team had identified behavioural family therapy as being appropriate, which was begun. Miss C complained about these decisions.

The board investigated the complaints but remained of the view that their decisions had been reasonable. Miss C then raised her complaints with us.

We obtained independent advice from one of our medical advisers, who is an experienced mental health professional. He read Miss A's relevant records and considered the situation carefully. He explained that the use of both services has a particular purpose, and that the board had to take this into account. He agreed that the way the decisions were taken was correct, and that the board's decision not to offer further direct engagement was reasonable. We accepted his advice and did not uphold Miss C's complaints.

Summary

Mr C, who is a prisoner, wanted his prescription increased due to extreme pain in his knee, and lower back pain. After the consultation, he complained about the medical treatment he received, and was unhappy with the way he had been treated and spoken to by the GP.

We took all the available information into account, including Mr C's relevant clinical records and the complaints correspondence. We also obtained independent advice on Mr C's care and treatment from one of our medical advisers.

We did not uphold the complaint, as our investigation found no specific shortcomings in the way that the GP dealt with Mr C. We were also satisfied that, based on his medical records, Mr C had access to different GPs and was referred for further investigation as well as for a specialist physiotherapy review. Our adviser said that the examination and medication dosage were reasonable, and that the GP had taken Mr C's individual needs into account. However, we were concerned that there was no evidence that the GP spoke to Mr C to exclude any potentially serious cause for his back pain, and we made a recommendation about this.

Recommendations

We recommended that the board:

• draw to the attention of the GP involved our adviser's comments on excluding potentially serious causes for back pain.

Summary

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital.

Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Recommendations

We recommended that the board:

• provide the Ombudsman with a copy of the board's own implementation plan relating to the national standards for dementia care implemented in 2011;
• undertake an audit of current practice of skin care in the hospital and report back to the Ombudsman;
• provide the Ombudsman with a copy of an action plan to illustrate learning from this complaint in relation to the prevention and management of pressure ulcers;
• provide the Ombudsman with a copy of an action plan to address the failings identified in relation to medical records;
• apologise to Miss B and Miss C for the failings identified;
• review their processes to ensure that they meet relevant standards;
• remind physiotherapy staff of the need to maintain full and accurate records in line with the Chartered Society of Physiotherapy guidance; and
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned, and report back to the Ombudsman.

Summary

Mr C complained that he had raised concerns with the board about the service provided by his local community pharmacy, and that he was dissatisfied with their response. We did not, however, uphold his complaint as we found that the board treated Mr C's concerns seriously. They spent a considerable amount of time trying to resolve them and sent him comprehensive responses, after seeking advice from appropriate sources both internally and externally.

Summary

After an accident, Mr C was admitted to the emergency department at University Hospital Ayr with a suspected broken collarbone. He was in severe pain and had been given pain relief by ambulance paramedics. The medical records showed that he was placed in an 'urgent' triage category, with a target time of having a medical assessment within one hour of admission. (Triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are.) However, Mr C was not assessed by an orthopaedic doctor (dealing with conditions involving the musculoskeletal system) until several hours later. The doctor ordered an x-ray and while at the radiology department, a healthcare professional adjusted Mr C's position and he felt a shooting pain. After the x-ray was taken, Mr C said the doctor told him that he had no broken bones, and that the arm might have been dislocated, but popped back into place. Mr C was told to take pain relief and soak in a hot bath, and was discharged with pain relief medicine an hour later. Nine days later, he returned to work. The next day, while involved in manual labour, he suffered a further injury and went back to the emergency department. Tests showed that he had a fracture of the neck of the shoulder blade.

Mr C complained about the time it took before he saw a doctor on his first visit, and said that the doctor did not make him aware of the severity of his injury. Mr C also said that although the board said in their response to his complaint that the use of a sling had been discussed with him and that he had a full range of movement when he left hospital, he did not agree with this. He said that he had felt relief when he returned from x-ray, but this was due to the medication. Mr C also complained about the board's complaints handling.

After taking independent advice from one of our medical advisers, we found that Mr C's wait was well within the national target timescale (four hours from admission to completion of management), particularly as dislocation of the shoulder was not initially suspected and there was no evidence to support that it had been dislocated. We also noted that, while Mr C was waiting, the emergency department had to deal with three emergencies that required more immediate medical attention than he did. Our adviser said that the care and treatment and discharge advice Mr C received was reasonable. An x-ray was performed (the results of which the adviser said were normal), and an assessment of the range of movement in the shoulder was carried out and noted. The advice Mr C received when he was discharged was, therefore, reasonable in light of the evidence of his injury, as was the doctor's decision not to provide a sling. In view of all of this, we did not uphold Mr C's complaints about his care and treatment.

We did, however, uphold the complaint about the board's complaints handling. We found that there were delays and that they did not respond all the elements of Mr C's complaint. We were also concerned that Mr C was not told that he could approach us (as he should have been) when the board contacted him about the delay in responding to his complaint.

Recommendations

We recommended that the board:

• review their complaints handling process in the light of our findings, and raise the shortcomings identified with relevant staff; and
• apologise to Mr C for their failure to fully address the complaint he raised.

Summary

Mrs C complained about the care and treatment she received for her back condition at a clinic at Ayrshire Central Hospital. She said that their treatment of her painful condition was unreasonable, and was unhappy that she was referred to a specialist hip orthopaedic consultant whom she thought did not specialise in the right area for her condition.

We obtained independent advice on this case from two of our medical advisers - a physiotherapist with a specialist interest in spinal conditions and an orthopaedic surgeon with specialist interest in lumbar spine problems. Our physiotherapy adviser explained that the main source of Mrs C's pain was not clear, and that the treatment offered and the clinical pathway followed was reasonable in these circumstances. He said that the guidelines the clinic used were in line with clinical practice and national guidelines. Mrs C was clearly in considerable pain for many months and we fully acknowledged that any delay in receiving treatment would have been very distressing and debilitating for her. However, based on the advice received, we were satisfied that the clinic's care and treatment was reasonable and in line with national standards.

Our orthopaedic adviser explained that Mrs C's pain symptoms were not typical of the type of nerve root problems that were identified on an MRI scan she had (a scan used to diagnose health conditions that affect organs, tissue and bone) but were more typical of hip pain. He, therefore, thought that the initial referral to the hip consultant was appropriate. He said that Mrs C did not have any red flag symptoms (symptoms that would have suggested a very serious underlying cause) and so an MRI referral was, correctly, not considered appropriate. He concluded that the nerve damage identified on the scan was not of a type that should have led to a change in her referral pathway and that it was appropriate for her to continue to see the hip consultant in the first instance. Based on the advice received, we concluded that the board's actions in making and maintaining Mrs C's initial referral to the consultant were appropriate.

Summary

Mr C complained to the board that he had concerns about the validity of an application to provide a community pharmacy in his local area. The board responded that the applicant had fulfilled the criteria to allow the application to proceed to the next stage of the approval process. Mr C complained to us that the board failed to address his concerns about the competency of the application.

We found that, technically, the board had acted in accordance with the procedures although we did think that they could have provided Mr C with additional information - ie that his concerns would be considered by the committee considering the community pharmacy application in due course.