Health

Summary

Mr C, who is a prisoner, had a stomach ulcer for which he had emergency hospital treatment in January 2012. Helicobacter pylori (a stomach infection) is the most common cause of ulcers and the hospital arranged for him to be tested for infection in March 2012. The results were negative, but Mr C was not made aware of this. He complained that the prison health centre team had not done anything about his ongoing stomach pain and that he had not received his test results or a hospital appointment despite having being referred there in June and October 2012.

We took independent advice on this complaint from one of our medical advisers. We upheld Mr C's complaint, as although we found that the health centre team had prescribed appropriate medication for his symptoms in line with national guidance, we concluded that they had unreasonably delayed in following up his test results with the hospital. We also found that there was a failure in sending a further referral to the hospital requesting that Mr C be re-tested when the hospital apparently told staff that they had no record of a test being done in March 2012. We were unable to clearly establish why Mr C was not told the results of the test carried out in March 2012, nor why it took so long for him to be re-tested.

Recommendations

We recommended that the board:

• ensure the prison has procedures in place to follow-up test results in a timely manner and, where appropriate, arrange prompt re-testing if necessary; and
• apologise to Mr C for failing to follow-up his March test results in a timely manner along with prompt re-testing.

Summary

Mrs C complained that when she was admitted to the Western General Hospital she was mistaken for another patient. She had obtained a copy of her medical records and told us that they contained references to procedures and conditions that could not have applied to her. Although the board met with her on several occasions and apologised for failings in her care, as well as providing her with an action plan of the steps taken to improve their performance, Mrs C did not believe that they had accepted or investigated her concerns that she was mistaken for another patient and about inaccuracies in her medical records.

We took independent advice on this complaint from our nursing adviser. She said that although there were clearly failings in Mrs C's care, she did not consider that the board could carry out any more meaningful actions in respect of Mrs C's complaint. The failings identified had arisen due to errors by individual members of staff, rather than through a systemic failure. The board had apologised, and taken the appropriate action to address these failings by providing training for staff members. Mrs C had met with senior board staff and her concerns had been listened to and responded to. Although we upheld Mrs C's complaint, as our investigation found that she was not provided with a reasonable level of care during her treatment, we made no recommendations as we found that the board then acted appropriately in response to her complaint.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Ms A) about the care and treatment she received at two hospitals, the Royal Infirmary of Edinburgh (RIE) and Roodlands Hospital. Ms A had had keyhole surgery (a surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin), but felt that because of her ethnicity and the fact that she had existing scar tissue from a previous operation, she should instead have had open surgery. She was also unhappy about the level of post-operative aftercare she received and said that she was discharged inappropriately from the RIE hospital when she was suffering from low blood pressure. She complained about the level of care she received when she attended Roodlands Hospital's unscheduled care service complaining of pain and discharge from her wound.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Ms A's medical records. We also obtained independent advice from three of our advisers (two doctors and a nursing adviser). Our investigation found that the decision to perform keyhole rather than open surgery was reasonable and we did not uphold that complaint. We found, however, that the board failed to provide a reasonable level of post-operative aftercare and that the nursing decision to discharge Ms A had been unreasonable. Our advisers said that Ms A's vital signs should have been recorded more frequently and acted upon, her high pain score should have been acted on and that a surgical review should have been requested before deciding to discharge Ms A. They said that actions indicated by the Scottish Early Warning System score (SEWS - a scoring system used as an early warning of deterioration) did not appear to have taken place.

We also found the board failed to provide a reasonable level of care when Ms A attended the unscheduled care service. The advice we received was that there was no evidence that the member of staff who saw her there had taken a separate history of what had happened, or that the examination carried out was of a reasonable standard in terms of assessing post-operative complications.

Recommendations

We recommended that the board:

• apologise to Ms A for the failings identified in these complaints;
• investigate the post-operative care given to Ms A and report back to the Ombudsman with the results of this review;
• provide the Ombudsman with evidence about the education and training currently in place for nursing staff to ensure they are aware of and are following SEWS protocols; and
• ensure that as a learning requirement the nurse involved undertakes a clinical update in the history and examination of a post-operative patient and in particular abdominal examination. This should be discussed with the nurse's line management to confirm these competencies.

Summary

Mrs C complained on behalf of her son that the board had decided to discontinue their consideration of the complaints she had submitted.

During our investigation, we obtained information from the board and, based upon this, we decided it was not appropriate for us to consider the matter further.

Summary

Ms C, who is an advocacy worker, complained to us on behalf of her client (Mrs A) who was concerned about the care and treatment of her late husband (Mr A). After Mr A fell and broke his hip, he had an operation in Monklands Hospital to repair it. That night he climbed out of bed and fell to the floor. He did not complain of any pain at the time, but when he woke in the early morning he complained of pain in his other hip. He was reviewed by a doctor, and an x-ray revealed that he had broken his other hip. Mrs A was told about this at 07:30 that morning. Mr A had another operation that day to repair his second broken hip, and was monitored closely for the rest of the day. The following day, he was found to be confused and was reviewed by a junior doctor. Mrs A was concerned that her husband should have been more closely monitored, that a doctor was not called soon enough, and that she was not informed of his fall until the following morning. She was also unhappy with the level of attention given to her husband's confusion following the second operation. She has said that this was only noted and acted upon after she raised persistent concerns with staff.

We took independent advice on this complaint from one of our advisers, who is an experienced nurse. She said that an appropriate care plan was in place for Mr A, which included the appropriate use of bed rails and that he had been appropriately monitored after both operations. She also considered that after Mr A fell, it was appropriate for staff to delay phoning Mrs A until the morning, as there was no immediate indication that he had been injured in the fall. She also reviewed the evidence in relation to Mr A's confusion after his second operation, and found that the records indicated that nursing staff took appropriate action by alerting doctors to Mr A's confusion. On the basis of this advice, we did not uphold the complaint as we found no evidence of failings in the care and treatment of Mr A.

Summary

Ms C, who is an advocacy worker representing her client (Miss A), complained that the board unreasonably told Miss A in writing about a decision to refer her to cancer services rather than in a face-to-face meeting, and unreasonably failed to discuss the diagnosis and treatment options with Miss A before making this referral.

Miss A had suffered for a number of years with a condition that caused pain and discomfort in her joints. In 2011, she also reported a swelling in her groin, which she felt was increasing in size. Her doctor referred her for physiotherapy and then to orthopaedic (involving the musculoskeletal system) services, and she was seen by a consultant orthopaedic surgeon for the first time in April 2012. After several investigations, including x-rays and a scan, the diagnosis remained inconclusive. The surgeon consulted with a colleague in a specialist cancer team by phone, and followed this up with a formal written referral. The specialist team took over Miss A's management, and diagnosed a non-cancerous lump, which was treated.

During our investigation we took independent advice from a physiotherapist and an orthopaedic surgeon. We found that the investigations and referral to the specialist team were reasonable, appropriate and timely. We found that it was reasonable that the surgeon did not tell Miss A in person that he was referring her there, as to have arranged an appointment for this purpose would have delayed the final diagnosis and treatment. Similarly, we considered it reasonable that the surgeon did not give a firm diagnosis or discuss treatment options with Miss A, because at the time of the referral and before the team took over her treatment, no such diagnosis had been made.

Summary

Mr C complained about the care and treatment provided to his mother (Mrs A) when she was admitted to Cowal Community Hospital on two occasions. Mrs A had a history of persistent and worsening diarrhoea and was diagnosed with clostridium difficile (a type of bacterial infection that can affect the digestive system). She was discharged two weeks later and returned home. However, she was readmitted to the hospital after testing positive for clostridium difficile again.

Mr C complained about a number of aspects of Mrs A's care. We found that much of the treatment provided to Mrs A had been of a reasonable standard. She was able to make her own decisions and was entitled to ask to go home in her nightclothes when she was discharged and to ask staff to wait for her own clean clothes before changing her. We also found that the board's communication with Mrs A and her family had been reasonable and that the correspondence issued to her GP was in line with the required standard. Mrs A's nutritional care was also reasonable and the board had taken action in response to concerns Mr C had raised about her dietary needs and about clostridium difficile.

That said, we did identify some failings in relation to the care and treatment provided to Mrs A. We considered that the hospital should have carried out an assessment to ensure that she could get into her house safely when she was discharged. However, we noted that the board had apologised for this and had taken reasonable steps to try to prevent similar problems recurring. They had also been unable to provide evidence that transfer documentation was sent to another hospital when Mrs A was transferred there. In view of these specific failings, on balance, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• issue a reminder to the staff involved in Mrs A's care that discharge documentation should be completed, filed and stored.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) received at Raigmore Hospital. Mr A was admitted there after having been unwell for around three weeks and having been treated by his GP for a chest infection. His condition had deteriorated and he was found to have pneumonia and kidney damage. Mr A had a past medical history of lung cancer and an abdominal aortic aneurysm (a bulge in a blood vessel caused by a weakness in the vessel wall). At first, he responded well to treatment in the high dependency unit. He was moved to a ward, but his condition deteriorated. Mr A got much worse six days after moving to the ward and did not recover. No post-mortem was carried out, but his deterioration was consistent with the aneurysm having burst. Mrs C said that although the treatment in the high dependency unit was exemplary, she felt that staff took too long to establish that Mr A's aneurysm had ruptured. She felt that the treatment provided in the ward was poor and that staff did not communicate adequately with Mr A's family. She was also unhappy with the board's handling of her complaint.

We found that Mr A's aneurysm had been scanned early in his admission and was found to be enlarged, but intact. However, doctors agreed that, in the event of a rupture, no surgery could be performed. We took independent advice from one of our medical advisers, who said that the clinical records showed that staff treating Mr A on the ward were aware of this and that their decision-making would be affected by the fact that no treatment could be provided for the aneurysm. On the day of Mr A's deterioration, staff clearly considered a ruptured aneurysm as a possible cause. However, they also considered his symptoms to be consistent with constipation. As Mr A could be treated for constipation, we found it appropriate that this was done in the first instance. Once he deteriorated further, staff concluded that a ruptured aneurysm was the most likely diagnosis and Mr A was made comfortable and treatment was withdrawn. We found this to be reasonable and did not uphold Mrs C's complaint about his care and treatment.

We were, however, critical of the board's communication with the family. A number of conversations between staff and relatives were not documented and there was little evidence to suggest that the family were made aware of the treatment being carried out, or involved in conversations about Mr A's care. With regard to the board's complaints handling, we were generally satisfied with the thoroughness of their responses. However, some incorrect information was included in their first letter to Mrs C and they failed to contact her when their investigation carried on longer than expected.

Recommendations

We recommended that the board:

• apologise to Mr A's family for failing to communicate adequately with them;
• remind their nursing and clinical staff of the importance of informing and involving relatives in the patient's care and of properly recording all discussions held with relatives; and
• apologise to Mr A's family for their poor handling of the family's formal complaint.

Summary

Ms C said that, when she had eyelid surgery as a day patient, Raigmore Hospital did not provide her or her GP with a discharge letter. There was confusion about where her stitches would be removed, and who would remove them, and it was only when Ms C asked her GP about this that the fact that there was no discharge letter was picked up. Ms C also needed further clinical care for her eye before the stitches could be removed, as it had not healed correctly. For this she at first went to another hospital, before deciding to go to the accident and emergency department of Raigmore Hospital, where she had successful corrective surgery.

We took independent advice from one of our medical advisers, who examined all the evidence provided. After taking account of his advice alongside all the documentation from Ms C and the board, we upheld the complaint. The adviser said that Ms C had received appropriate treatment and advice at the hospitals, but there appeared to be a lack of clarity as to what and with whom follow-up arrangements were to be made. This was made worse when the hospital did not provide a discharge letter. We also found that the board had not fully responded to Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that in similar circumstances patients are appropriately advised on follow-up arrangements following ophthalmology treatment (treatment relating to the eye); and
• advise the Ombudsman on the steps taken to ensure that the failures in the computerised generation of the discharge letter in this case do not happen again.

Summary

Miss C complained about the care and treatment she received at Raigmore Hospital. Miss C said that when she arrived at the accident and emergency department (A&E) with abdominal (stomach) pain, her symptoms were not taken seriously enough and staff dismissed her view that she had an ulcer, even when she told them she had been treated for one in the past. She also said that after she was transferred to a ward, staff inappropriately gave her a drug, which she said caused her ulcer to bleed or perforate (break open the stomach wall) and her pain to treble, resulting in her needing immediate surgery. Miss C said that, as a result of the board's failings, she had to have an operation that she did not need and now has an unnecessary scar.

We obtained independent advice on this case from one of our medical advisers, a consultant surgeon specialising in gastrointestinal (digestive system) surgery. The adviser said that the consultant who initially examined Miss C in A&E mistakenly concluded that her bowel might have been obstructed. However, as the consultant was not sure of that diagnosis, he correctly sought advice from the surgical team and organised a prompt referral to the on-call senior surgical trainee for further assessment and observation.

The senior surgical trainee, however, failed to recognise that Miss C's signs and symptoms suggested peritonitis (inflammation of the lining of the abdomen) and despite these signs, placed undue reliance on the x-ray appearance of possible constipation. He failed to seek advice from the consultant gastrointestinal surgeon and/or arrange further investigations. He prescribed a drug that was advised against, given Miss C's condition, and which may have exacerbated her pain. The adviser explained that Miss C's ulcer had almost certainly perforated when she initially went to A&E and so it was highly unlikely that the treatment she received from the board influenced her need for surgical intervention. However, the senior surgical trainee's failure to make the correct diagnosis meant that Miss C's pain was prolonged unnecessarily, and we upheld her complaint.

Recommendations

We recommended that the board:

• provide Miss C with a written apology for the failings identified in this case;
• feed back our decision to all staff involved; and
• ensure that the senior surgical trainee uses our decision letter on this case as part of his training record and discusses it with his educational supervisor as part of a reflective case-based discussion.