Health

Summary

Mrs C complained on behalf of her late brother-in-law (Mr A) that the medical practice delayed twice in referring him to hospital. Mr A visited his GP nine times between September 2011 and November 2012, with various symptoms, including a sore throat. He was finally referred to the ear, nose and throat (ENT) department in November 2012, and was diagnosed with throat cancer, for which he had surgery and radiotherapy.

When he then reported ear pain to the ENT surgeons he was told that this was likely nerve damage following his treatment. He continued to experience pain and in May 2013 went to his GP. The GP found evidence of inflammation, prescribed various drops, and told Mr A to come back if the pain did not resolve. Mr A went back to the practice the next week and saw a locum (temporary) GP who diagnosed nerve damage and prescribed a drug for nerve pain. He also advised Mr A to come back if the pain did not stop. Mr A contacted the practice by phone a week later and told another GP that he was still in pain. The GP made an urgent referral to ENT that day, and Mr A was seen by an ENT consultant some four days later. After further investigations he was diagnosed with inoperable throat cancer in July 2013 and he died in January 2014.

Our investigation included taking independent advice from one of our medical advisers, who is a GP. We did not uphold the first complaint as the adviser said that there was no unavoidable delay in making the first referral to ENT. The clinical records showed that although Mr A reported throat pain on some occasions, this was not a constant feature and there was evidence that at times certain treatments resolved or improved this. When, however, Mr A reported a 'red flag' symptom (a symptom especially likely to indicate a particular serious illness) in November 2012, the GP had spoken to an ENT specialist and urgently referred Mr A that day.

On the second complaint, the adviser found that there was a delay of one week between Mr A being seen by the locum GP, who appeared to have considered making an urgent referral, and the referral actually being made after Mr A's phone call. The adviser said that in view of Mr A's recent medical history, the locum should have referred him immediately. It was not clear from the records whether the locum prepared the referral but it was not sent, or if the referral was not made until later. Either way, there was an avoidable delay of one week on the part of the practice and we upheld this complaint.

Recommendations

We recommended that the practice:

• take steps to ensure that such delays in urgent referrals do not occur again.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Miss A) that the medical practice unreasonably failed to investigate Miss A's reported symptoms and make timely and appropriate referrals. Ms C also complained that when a referral was made, it was marked as routine, rather than urgent.

Miss A had suffered for a number of years with a condition causing discomfort and pain in her joints, for which she had received various treatments and referrals, including physiotherapy. Since January 2012, however, she had also been reporting a lump and pain in her right groin and felt that physiotherapy was making matters worse. Her GP then referred her to a specialist physiotherapist who in turn referred her to an orthopaedic surgeon (dealing with conditions of the musculoskeletal system). After tests and examinations, the orthopaedic surgeon referred Miss A to a bone cancer specialist. Miss A was then diagnosed with chondrosarcoma (cancer of the cartilage) with an overlying osteochondroma (a benign (not progressive or destructive) bone tumour). Miss A has since had successful treatment.

Our investigation, which included taking independent advice from one of our medical advisers, found that the GPs had acted reasonably in referring Miss A for physiotherapy for her pre-existing condition. We also found that when she reported the lump in her groin that she thought was increasing in size, appropriate and timely referral was made. The adviser said that the osteochondroma was masking the more aggressive and serious chondrosarcoma so that it was not unreasonable for the GP to have made a routine, rather than urgent referral. The adviser said that overall the care and treatment provided to Miss A was reasonable, and we did not uphold this complaint.

Summary

Ms C, who is an advice worker, complained to the medical practice on behalf of her client (Mr A) about his care and treatment. Ms C said she wrote to the practice several times, and phoned them, but they did not reply. Because of that, Ms C complained to us that the practice failed to adequately respond to the complaint.

The practice told us that they did not receive Ms C's initial complaint and only became aware of it a few months later when she submitted it again. They also told us that, after meeting Mr A, he told them he no longer wanted to pursue the complaint, and that they wrote to Ms C to tell her that.

The NHS guidance Can I help you? outlines what should happen when an NHS provider receives a complaint. In particular, it confirms that a complaint should be acknowledged within three working days and investigated, with a full response provided within 20 working days. If the NHS provider is unable to meet that timescale, they should provide a written explanation for the delay and an update on progress and when they expect to be able to reply. They should also tell a complainant that they have the right to seek a review from the SPSO if they are unhappy with the reasons for the delay. In this case, the practice clearly failed to comply with that guidance when handling Ms C's complaint.

Recommendations

We recommended that the practice:

• provide a fuller response to the issues raised by Ms C;
• apologise for failing to deal with the complaint appropriately; and
• review their complaints handling procedure to ensure it complies with the requirements of the Can I help you? guidance.

Summary

Mr C said that he had suffered from repeated bouts of sinusitis (inflammation of the lining of the sinuses, causing facial pain) since he was a teenager. He said that he had tried a variety of different treatments, but the only one that had consistently worked for him was a short course of antibiotics.

Mr C complained that when he contacted his medical practice suffering from sinusitis, he was not initially given an appointment but told to contact his pharmacist. He then called NHS 24 and was referred back to the practice, where he was given an appointment that day. Mr C was unhappy that when he went there he was seen by the practice nurse, rather than a doctor. The nurse did not accept that Mr C needed antibiotics, and refused to prescribe them. Mr C said that he was forced to return to his previous medical practice to get them. He said that the practice nurse refused to allow him to see a doctor and inaccurately recorded his symptoms to support her diagnosis.

We took independent advice on this complaint from one of our medical advisers, a specialist in general practice medicine. He said that Mr C had symptoms that corresponded with acute sinusitis, but that current guidance was not to prescribe antibiotics for this condition, as research suggested they were ineffective. He also said that it was standard practice in busy surgeries for patients to be seen initially by a practice nurse. He found no evidence of the notes being altered, or of Mr C having asked to see a doctor. Having taken this advice into account, we did not uphold Mr C's complaint.

Summary

Mr C had a long-term history of ulcerative colitis (an inflammatory condition of the intestines). He complained that there was a delay in his medical practice appropriately investigating his symptoms when he suffered a flare-up of his condition. Mr C also complained that the handling of his complaint about this was unreasonable.

Mr C had previously taken a particular drug to relieve his symptoms but was not taking it at the time of the complaint, as his condition had been under control. When he began to suffer symptoms that he thought were indicative of a flare-up, he went to his GP and asked to be prescribed the drug. The GPs Mr C saw undertook various investigations, including blood tests, which were inconclusive. Because of this they felt unable to prescribe the requested drug. Mr C was referred to a specialist for further investigations, including a colonoscopy (where a camera is inserted into the intestines). The investigations eventually confirmed Mr C's view that he was experiencing a flare-up of his condition and the specialist prescribed him the drug he had requested.

Our investigation included taking independent advice from one of our medical advisers, who is an experienced GP. The adviser said that it was reasonable, and in line with the guidance issued by the General Medical Council (the regulatory body for doctors in the UK), for the GPs not to prescribe the drug Mr C was requesting. The guidance says that doctors should only prescribe medication when they are confident they have sufficient knowledge of the patient's condition and that the medication in question is in their best interests. The adviser said that, in Mr C's case, the initial tests were inconclusive and there are other conditions with similar symptoms, which could have been made worse had he taken the drugs he was requesting. We took the view that the actions of the GPs were reasonable. There were some delays in Mr C receiving the colonoscopy but the GPs had no control over this, and there was evidence that they had taken action to try to speed it up.

On the complaints handling, Mr C had addressed his complaint to the practice manager, but the response came from one of the GPs. Mr C felt that this meant that the practice manager had washed her hands of the complaint. We found, however, that because much of Mr C's complaint was about his clinical care and treatment, it was reasonable for a GP to respond, and we were satisfied that all the issues he raised were addressed in that response. Although we did not uphold the complaint, we found that the medical practice's complaints procedure said that the final stage of the process was to refer the matter to the local NHS board. As this is no longer the case, and the final stage is referral to the SPSO, we brought this to the attention of the practice.

Summary

Mrs C was expecting a baby. When she was 35 weeks pregnant, a routine scan raised concerns about her baby's heart rate and it was suggested that she be flown by air ambulance to the mainland for an emergency caesarean section (an operation to deliver the baby). Mrs C's husband (Mr C) and young child were with her at the appointment, and she asked if they could travel with her. She was told that, whilst Mr C would be permitted to travel with her as an escort, the board would not agree to provide travel arrangements for their child. As there was no-one available locally to look after their child, Mrs C had to travel alone in the air ambulance while her husband and child followed separately on a commercial flight. Because of this, Mr C was not with her for the birth. Mr and Mrs C's baby died three days after being born.

Mrs C complained about the board's decision about the travel arrangements. She said that for the return journey, whilst the board arranged return flights for her and Mr C, they could only provide her with the phone number of the airline and a booking reference so that she could make her own arrangements for their child to travel back with them. She did not feel that the board took account of her circumstances or the physical and emotional stress she was under at the time. She also raised concerns about their handling of her complaint.

We upheld both of Mrs C's complaints. We found that the board's decisions were made with reference to their patient travel policy, which is primarily designed to reclaim relevant expenses incurred when travelling to and from mainland hospital appointments. This was appropriate for the return element of the travel, and we were satisfied that the policy was correctly applied for that journey. However, the policy specifically says that it does not apply in emergencies, or cases where the patient is being transferred between hospitals. Both of these criteria applied to the outward journey in Mrs C's case, and we concluded that it was not appropriate to refer to the policy for decisions about the air ambulance journey. Our investigation found that it was the board's patient transport staff who took the decision not to allow Mr and Mrs C’s child to travel in the air ambulance. Although the ambulance service specifically asked if Mrs C would be accompanied by an escort, they were told that she would be travelling alone. The ambulance service told us that they would have tried to take Mr C and the child, had they been asked to do so and had there been capacity on the aircraft. However, we noted that they were not asked to decide this. We considered that, under such circumstances, there should have been scope for the patient transport staff to use their discretion. This would have meant referring the decision to the ambulance service, so that they could decide whether they could carry all three passengers in the air ambulance.

We found that the board's complaints handling was reasonable in most regards. However, they failed to properly investigate who had reached the decision that Mrs C’s husband and child could not travel on the air ambulance. This led to inaccurate information in the board's response to her complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to pursue the option of their child travelling in the air ambulance with them;
• refund to Mrs C all reasonable costs incurred for her family’s outward flight; and
• consider introducing a policy to cover situations such as that encountered by Mrs C.

Summary

Mrs C complained about the care and treatment the board provided to her two-year-old son (Master A). She said that he had a high temperature and had been unwell for three to four days, when she took him to Gilbert Bain Hospital accident and emergency department. Mrs C complained that the board did not keep her son under appropriate observations after initial assessment and that he was inappropriately discharged home. Mrs C and her son returned to the hospital the following day, as his condition had deteriorated. After initial assessment, he was seen by a doctor and was admitted to hospital and later flown by air ambulance to a mainland hospital, where he was diagnosed and treated for a type of flu. Mrs C again complained that staff failed to keep Master A under appropriate observation after initial assessment of his condition. She also said that on both occasions there were delays before a doctor saw her son.

We took independent advice on this case from one of our medical advisers, a consultant in emergency medicine. He explained that the doctor's decision to discharge Master A on the first occasion was reasonable. The documentary evidence suggested that Master A was seen 19 minutes after triage (the process of deciding which patients should be treated first, based on how sick or seriously injured they are). The adviser explained that although a target time for Master A to be seen would have been ten minutes, the wait of 19 minutes was reasonable, given that Master A had none of the symptoms of an exceptionally unwell child. On the following day, Master A was triaged, was observed again just over an hour later, and was seen by a doctor about 20 minutes after that. Although his total waiting time was considerably longer than the target time of ten minutes, the adviser indicated that, in the circumstances, this was not unreasonable if there was greater need elsewhere in the department. We also noted that there was a handover between clinical shifts while Master A was waiting to be seen. The adviser noted that on both occasions Master A had a thorough medical review, and there was a defined care pathway for him. Although we did not uphold the complaints, we did make recommendations about two elements on which the adviser commented.

Recommendations

We recommended that the board:

• feed back to the staff involved our adviser's view that it would have been good practice for a member of staff to have come and seen Master A on the second hospital visit, when Mrs C asked for this; and
• feed back our adviser's comments on record-keeping to the staff involved.

Summary

Mrs C complained to us about the care and treatment of her late mother (Mrs A) while she was in the care of St Michael's Hospital. She raised concerns about her mother's oral health care, and her enteral tube feeding (she was fed by a percutaneous endoscopic gastrostomy (PEG) tube into her stomach, also known as 'enteral tube feeding').

We took independent advice from one of our advisers, who is an experienced nurse. We found that Mrs A was an in-patient for 13 months. A care plan was put in place when she was admitted, which identified her oral health care needs, and we found that this was followed. However, it was not reviewed and updated on a monthly basis, and did not take into account Mrs A's increased risk of mouth problems due to the enteral tube feeding. Mrs A was also given a mouth wash on an ongoing basis, as she had a painful mouth due to gum disease. Our adviser pointed out that the guidelines for the use of the mouthwash indicate that it should only be used for seven days, after which its use should be reviewed. This did not happen.

In relation to Mrs A's enteral tube feeding, Mrs C raised concerns that the care and management of her mother's tube was insufficient, and that on occasion she was fed while lying flat. This then led to her aspirating (breathing in foreign material) her food, and contracting aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). Mrs A died of aspirational pneumonia. Our investigation found that Mrs A's enteral tube feeding was in line with her care plan. However, the documentation of this care was on an 'exceptional' basis, in that staff only recorded events that were outside the normal care provision. The evidence indicated that Mrs A had not been laid flat to feed, and that when she was found flat, appropriate action was taken to remedy the situation. We found that the board's actions in relation to Mrs A's tube feeding were reasonable, but that their care in relation to her oral health was inappropriate.

Recommendations

We recommended that the board:

• ensure that staff are aware of the need for monthly reviews of oral care plans and the level of detail that should be recorded; and
• provide a written apology for the failure to provide appropriate oral health care for Mrs A.

Summary

Mrs C complained about the care and treatment that the Royal Infirmary of Edinburgh provided to her late mother (Mrs A) who passed away 12 days after being admitted there after having had a stroke. Mrs C was also concerned about poor staff communication about Mrs A's deteriorating condition, and the way in which the board dealt with her complaint.

After taking independent advice on Mrs C's complaints from one of our medical advisers, we did not uphold her complaint about her mother's care and treatment. The adviser said that although Mrs A’s condition was complex, the care and treatment she received was in line with national guidance recommended by the Scottish Intercollegiate Guidelines Network on the management of stroke patients. We found evidence that accident and emergency (A&E) staff assessed Mrs A and arranged a brain scan in a timely manner. Furthermore, A&E staff sought prompt advice from specialist staff. Although aspirin could have been given to Mrs A sooner, it was administered within the 48 hour guideline recommended by NHS Quality Improvement Scotland, and the adviser thought it unlikely that Mrs A's outcome would have been any different even had it been given sooner. We also concluded that Mrs A was promptly assessed by both physiotherapy staff and speech and language therapy staff after she was transferred to the stroke ward. In addition, frequent medical reviews were carried out and appropriate monitoring and treatment of her heart rate to help keep it under control.

We did, however, uphold Mrs C's other complaints about communication and complaints handling. When the board met with Mrs C to discuss her complaint, they apologised for the lack of information about Mrs A's deteriorating condition on the day of her admission to A&E and accepted that there were significant communication problems when Mrs A was transferred to the combined assessment unit and then to the stroke ward. They said that they were taking steps to address this.

The board accepted that there were mistakes in their written response to Mrs C's complaint. They apologised for these, issued an amended version of the correspondence, and reimbursed Mrs C for the money she had to pay to receive their letter, which had insufficient postage on it. We also found that, although Mrs C told the board that they had written to her at the wrong address, there was a delay of three months before she received a further letter from them responding to her complaint as they had used the incorrect address again. We also established that: they had not responded within the 20 working day target set out in the Scottish Government's complaints procedure guidance; contrary to that guidance, the board's internal complaints policy permitted them to suspend the 20 working day response target when the person complaining accepted the offer of a meeting, and they had not kept Mrs C updated about when their response would be issued.

Recommendations

We recommended that the board:

• provide evidence to support the action they have taken to improve communication between staff and relatives regarding patients who have suffered a stroke;
• feed back to relevant staff the importance of ensuring timely and accurate responses to complaints, and of providing updates when the 20 working day timescale cannot be met, in accordance with the Scottish Government's complaints guidance; and
• review their internal complaints policy to ensure that it is in line with the Scottish Government's complaints guidance.

Summary

Mr C, who is a prisoner, complained that the board failed to arrange for him to see the prison psychiatrist following a suicide attempt. Mr C had been treated in hospital and said that the psychiatrist there told him that he would be seen by the prison psychiatrist when he returned to prison. After taking independent advice from one of our medical advisers, our investigation found that there was no evidence that Mr C was told this, and that the hospital discharge summary said no psychiatric action was required at that time. In addition, Mr C was reviewed by the clinical manager in mental health when he returned to the prison, and this review was then discussed with the prison psychiatrist. In view of this, we found that that it was reasonable that Mr C was not seen by a psychiatrist on his return to prison.

Mr C also complained that the board failed to provide him with appropriate treatment for blood loss after he self-harmed when he returned to prison. We found that the immediate follow-up care provided to him was reasonable in many aspects. The records also showed that Mr C had refused medical treatment on at least one occasion. However, he had lost a significant amount of blood. We found that the failure to clearly state that his haemoglobin (a protein found in the red blood cells that is responsible for carrying oxygen around the body) should be monitored and to specify the timing or frequency of the monitoring in his care plan was unreasonable. Mr C's haemoglobin was not checked until two weeks later, at which time he was immediately transferred to hospital for treatment. Staff also failed to record his vital signs (signs of life including the heartbeat, breathing rate, temperature, and blood pressure) and his nutrition and fluid intake. We upheld this aspect of Mr C's complaint.

Finally, Mr C complained about the board's handling of his complaint. We upheld this complaint too, as the board had failed to respond to all the points Mr C had raised. We also found it inappropriate that in their response to his complaint the board criticised Mr C's behaviours, while noting that these were discussions that clinicians and others would clearly be entitled to have with him in another context.

Recommendations

We recommended that the board:

• issue a reminder to the staff involved in Mr C's care that care plans should clearly document the interventions planned and when/how frequently they are to be implemented;
• issue a reminder to the staff involved in Mr C's care that they should chart a patient's vital signs and nutrition/fluid when this is indicated; and
• make the staff involved in the handling of Mr C's complaint aware of our findings.