Health

Summary

Mr C, who is a prisoner, told us that he suffered from severe pain that restricted his ability to leave his cell. He said that gabapentin (pain-killing medication) had been effective in controlling this and complained that the prison health centre had stopped his prescription for it and prescribed various alternative medications. He said these had not helped with his pain and had in fact made him more unwell. He acknowledged that there were security implications about having gabapentin in the prison environment but said that he was prepared to take it under supervision.

We took independent advice on this complaint from one of our medical advisers, who is a GP. After reading Mr C's medical records, he said that there was evidence, from these and by Mr C's own admission, of him misusing medication and sourcing drugs from other prisoners. The adviser explained that, as well as the security implications, this dramatically increased the risk of drug interactions which could, in some cases, be fatal. He noted that it was important for there to be trust between the patient and doctor before a drug with dangerous side effects and the potential for abuse could reasonably be prescribed. In addition, he said Mr C was potentially suffering from the recognised side effects of gabapentin and that he was participating in a methadone programme, on which it was important to allow doctors to remove any medications they felt he should not continue. In the circumstances, we found that it was reasonable that the doctors discontinued the prescription.

Summary

Miss C was diagnosed as having labrynthitis (an inner ear infection affecting hearing and balance). She found this very debilitating and had to take time off work. She went to A&E at Stirling Royal Infirmary twice and after the second time she had a scan, which was reported as normal. Her problems continued and her GP made an urgent referral for her to attend the hospital's ear, nose and throat (ENT) department. Miss C said that the person she saw (who she described as a nurse) told her that everything was normal and that she could stop taking the medication she had been prescribed. She was discharged. Miss C said she had since learned that she should have been weaned off her medication slowly, and she questioned the care and treatment she had received. She complained that this was inadequate and contributed to her illness and the length of time she was ill.

We obtained independent advice from one of our medical advisers, who is a consultant ENT surgeon, who considered all Miss C's medical records. We also took into account all the complaints correspondence. Our investigation showed that, contrary to Miss C's belief, when she attended ENT she was seen by a specialist doctor who advised her to stop taking her medication and said that her condition would improve with time. Although Miss C said that she understood that she had to wean herself off this medication, this was not the case. We found that Miss C had been assessed and treated entirely appropriately, and we did not uphold her complaint.

Summary

Miss C said that she first went to her medical practice about continuing dizziness in April 2011 and was diagnosed with labrynthitis (an inner ear infection affecting hearing and balance). Worsening headaches led her to attend the emergency department in her local hospital and she then had a scan, which was normal. Miss C said her symptoms got worse and she was no longer able to work. The practice made an urgent referral for her to attend a hospital clinic, but after examination and tests everything was found to be normal and the clinic reassured her that her condition would improve over time. She continued to feel ill, however, left the practice, and complained that despite many visits there, they did little to help her. She said that they should have made more timely referrals for her to receive a specialist opinion.

We obtained independent advice from one of our medical advisers, who considered all Miss C's medical records. We also took into account all the complaints correspondence. Our investigation showed that over the period concerned, Miss C attended the practice regularly and doctors made a referral for her to be seen urgently at the hospital ear, nose and throat department. She had had a normal scan and further examination and tests confirmed labrynthitis. She was referred to physiotherapy for therapy to retrain her brain to deal with the problems associated with dizziness. We decided that the GPs provided her with good care and support and tried alternative medication for her.

Summary

Mrs C cared for her late husband (Mr C) at home with assistance from carers, district nurses, Mr C's GP and the board's palliative care (care provided solely to prevent or relieve suffering) team when necessary. On the day Mr C died, Mrs C had phoned the board's palliative care line as her husband was in severe pain. An out-of-hours (OOH) GP arrived within 47 minutes of her call to provide pain relief to Mr C, who died around an hour later. Mrs C complained about the length of time it took for the OOH GP to attend and administer the pain relief.

The palliative care line is part of the board's OOH service and it helps palliative care patients to get help without having to go through NHS 24. It is not an emergency service but the board aims to respond to priority calls within one hour. Mr C was visited within 47 minutes of Mrs C's phone call and, even although Mr C was in a lot of pain, we concluded that this was within a reasonable timescale. We noted that when a palliative care patient is nearing the end of their life, an anticipatory pack of medication is often provided to help with distressing symptoms, such as pain, nausea, agitation and breathlessness. This is, however, a decision for the primary care team involved in the patient's care, not the OOH service. Although we did not uphold the complaint, we made recommendations to address our concerns about this.

Recommendations

We recommended that the board:

• ensure that the relevant primary care team review whether anticipatory care planning was in place for Mr C in line with NHS Scotland Palliative Care Guidelines (March 2012) and, if any areas of improvement are identified, prepare an action plan for implementation.

Summary

Mrs C went to her GP twice after noticing a lump in her abdomen. She complained to us that he did not perform appropriate examinations to establish the cause of her symptoms and did not offer her a NHS referral.

Mrs C said that the doctor was dismissive of her concerns about the lump, and she asked him to give her a private referral for specialist opinion. This resulted in a diagnosis of ovarian cancer. She said that there had been a delay in diagnosis and that, had she not insisted on a private referral, there would have been further delay. The GP said that he had carried out appropriate examinations and that it was his intention to make a NHS referral but Mrs C had insisted on a private referral.

We took independent advice on the complaints from one of our medical advisers, who is a GP. As our investigation found that the GP had carried out appropriate clinical assessments and made an appropriate referral, we did not uphold the complaint. We did not make any recommendations, although we did point out to the GP that if a similar situation arises in future he should record why a private referral has been requested and agreed.

Summary

Mr C's GP referred him to Queen Margaret Hospital's orthopaedic department because he was having pain in his knee despite having received physiotherapy treatment. Mr C was reviewed by an orthopaedic registrar who said that he had a medial meniscal tear (cartilage problems). After Mr C had a scan of his knee, an orthopaedic consultant wrote to him advising that there was no tear and surgery was not required but recommended more physiotherapy. Mr C then attended a private consultation with an orthopaedic doctor who thought that Mr C did have a meniscal tear. Mr C had private surgery a few weeks later and told us that he was able to return to work within four weeks. He complained to us about the treatment he received at Queen Margaret Hospital, saying that he was not offered surgery and that the orthopaedic consultant reached a decision without examining him.

After taking independent advice from one of our medical advisers, we found that the scan did not show that Mr C had a meniscal tear. There was, however, an indication of degenerative changes (osteoarthritis - a common form of arthritis) behind the knee cap, and the board had treated him in accordance with the national guidance for the management of this that was in place at the time. Our adviser also said that there was no assurance that the surgery was the sole cause of Mr C's improvement, as the symptoms of degenerative knee disease may improve on their own. We concluded that the orthopaedic registrar's examination was appropriate, and that it was reasonable for the consultant to not have seen Mr C in person, given that he had reviewed the scan results.

Summary

Ms C complained about the treatment that her late partner (Mr A), received after he was diagnosed with rectal cancer (cancer of the lower part of the large bowel). He had chemotherapy, and radiotherapy to try to shrink the tumour to the point where it could be operated on. Mr A needed three admissions to the Victoria Hospital to manage the pain caused by his condition. During the second admission, his recent CT scan (computerised tomography - a scan that uses a computer to produce an image of the body) was reviewed, and the clinical team thought that the tumour might be operable if Mr A was referred to a surgeon who had the expertise to provide a non-standard form of surgery. Mr A was referred to such a surgeon, but the cancer was advanced and an operation could not be carried out. Mr A died some 20 months after his diagnosis.

Ms C complained that she and Mr A had been led to believe that his tumour was operable and that his prognosis (forecast of the likely outcome of his condition) was good. She said that, because of this, Mr A's decline and death were unexpected and, had he known his true prognosis, he would have lived the final months of his life differently. She considered that there were avoidable delays in treatment and said that she and Mr A were cut off at home without support from the board. She was particularly concerned about the apparent lack of effective management of Mr A's pain outside hospital.

The evidence we saw indicated that Mr A's tumour was advanced by the time his cancer was diagnosed. We took independent advice from one of our medical advisers, who is a consultant clinical oncologist (cancer specialist). Our adviser confirmed that the course of treatment proposed was appropriate and that the timescales involved were reasonable. However, it was clear that clinical staff considered Mr A's prognosis to be poor from an early stage. Our investigation found that the board had not fully explained Mr A's condition and prognosis to him and Ms C. We also found that his pain was inadequately managed during two of his hospital admissions and when he was at home. We considered that there was a breakdown in communication between the hospital, his GP and the family and considered that the board's community palliative care (care provided solely to prevent or relieve suffering) team could have been used to coordinate his pain management.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted in our decision letter;
• review Mr A's case with a view to identifying ways of improving communication with patients and their families and ensuring that patients' potential and likely prognoses are explained clearly where applicable;
• conduct an audit of staff compliance with their responsibilities for monitoring patients' pain levels and reviewing pain medication; and
• review Mr A's case and give consideration to how best to involve the community palliative care team in such cases.

Summary

Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or excellent. Mrs C and other family members were aware that Mrs A was in the final few days of her life, and had stayed with her throughout the night. She said that Mrs A suffered unnecessarily because staff failed to check or assess her condition despite family members reporting her distress to them.

The board told us that Mrs A was assessed every time family members asked staff for help, although they also noted that drugs that might have provided some relief for Mrs A could have been given earlier. We found, however, that Mrs A's medical records did not contain the necessary entries to support the statement about assessment, and that there were some gaps in these records. Based on the information available we could not, therefore, conclude that they properly assessed Mrs A's needs, and we upheld the complaint.

Recommendations

We recommended that the board:

• provide us with an update on the service manager for medicine's review of this complaint and any action plan arising from this;
• undertake a further review of this complaint in the light of our findings and provide us with an action plan arising from this;
• apologise that there was no assessment at an earlier point of whether pain and symptom relief should be provided; and
• provide us with evidence of their current plan for terminal and end of life care and of the staff training undertaken to support this.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) in Borders General Hospital. She said that her mother was not provided with reasonable care and treatment and that the board's responses to her complaints were unreasonable.

Mrs A was 93 years old and lived alone, with assistance from her family. She had a history of heart and lung problems and was registered blind. She went into hospital because she had a chest infection that was making her existing lung disease worse. Mrs A was treated with antibiotics and oxygen therapy, but her condition continued to deteriorate and three days after going into hospital she asked staff to stop treating her. She died later that day.

Mrs C was concerned that her mother was not considered suitable for cardiopulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops) or for transfer to the intensive care unit. Mrs C did not find out that doctors had completed a Do Not Attempt CPR (DNACPR) form for Mrs A until she saw it in her mother's notes. After a discussion with the doctor in charge of Mrs A's care, the decision was reversed to a limited degree (where Mrs A's heart would be shocked into a normal rhythm if it became irregular but full CPR would not take place) but the form was not removed from the notes. Mrs C was also concerned when Mrs A started to refuse food, fluids and medications, and said that Mrs A told her that this was because she did not trust staff after being given a bed bath by a male nurse that morning. Mrs C discussed this with a nurse on the ward and was assured that a female nurse had given the bed bath but that a male nurse would have assisted with changing the bedsheets.

During our investigation we took independent advice from two of our advisers - a doctor specialising in the care of the elderly and a senior nurse. We found that the care and treatment provided to Mrs A was reasonable and appropriate. The advisers considered that there was evidence in both the medical and nursing notes that appropriate and timely assessments, monitoring and evaluation of Mrs A's treatment took place, and that the actions around the DNACPR decision complied with national guidance. We also found evidence that when Mrs A began to refuse treatment, appropriate assessments were done to establish that she had the capacity to decide this for herself. Mrs C had been concerned that Mrs A had wished to die at home and that staff ignored this. However, the medical notes showed that Mrs A's desire to go home was noted and considered, but the doctor in charge of her care at that time thought that she would be unlikely to survive the journey. Our medical adviser agreed with this view.

Summary

Miss C's mother (Mrs A) had been diagnosed with cancer, and admitted to Ayr Hospital. She was discharged, but was readmitted four days later with a chest infection. During Mrs A's admission, Miss C and her sister met with the palliative care nurse (a nurse specialising in care solely to prevent or relieve suffering) to discuss support for caring for Mrs A at home. They told the nurse and doctor that Mrs A wished to return home as soon as possible, and the nurse agreed to refer Mrs A to the hospice home care team.

The palliative care nurse was away from the hospital the next day, but intended to make the referral when she returned the day after. At that time, the nurse and the doctors expected that Mrs A would be in hospital until the next week for treatment for her chest infection. However, Mrs A discharged herself, against medical advice. The ward staff were not able to contact the palliative care nurse, but told Mrs A's GP that she had discharged herself, and arranged for district nurses to visit. Miss C called the hospice home care team for support, but was told that no referral had been made and that hospice support would, therefore, not be available until the following week. The hospice team then called the palliative care nurse, who immediately processed the referral. Mrs A died at home three days after discharging herself, before hospice support was put in place. Miss C then complained that the nurse had unreasonably delayed in referring Mrs A to the hospice home care team.

After taking independent advice on Miss C's complaint from one of our advisers, who is an experienced nurse, we did not uphold it. Our adviser said that, in the circumstances, it was not unreasonable for the nurse to wait a day before making the referral, as she had expected Mrs A to be in hospital until the following week. Our adviser also said that ward staff had taken reasonable steps to try to contact the palliative care nurse and to arrange some support for Mrs A by contacting her GP and district nursing.