Health

Summary

Miss C's mother (Mrs A) went to a medical practice with abdominal (stomach) pains. She was repeatedly referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body), but did not attend on three separate occasions and no further appointment was made. Ten months later, Mrs A again went to the practice and was treated for a suspected infection. However, Miss C was very concerned about her mother's weight loss and took her to A&E, where she was treated for a suspected urinary tract infection and discharged. Two months later, Mrs A went again to the practice with worsening back pain, nausea and weight loss. A GP told Mrs A that it was possible she had cancer, and arranged for x-rays, which showed that Mrs A had arthritis. However, as no cause for Mrs A's weight loss had been found, the GP arranged for an urgent abdominal scan, which showed possible cancer of the liver. Further tests confirmed this diagnosis and Mrs A died six weeks later.

A few days before Mrs A's death, the GP visited Mrs A at home and there was an altercation between the GP and the family. Miss C and the GP gave slightly different versions of what happened, including what was said about Mrs A's treatment and whether the GP intended to leave without prescribing pain relief. Miss C then complained that the practice had failed to investigate Mrs A's symptoms appropriately, causing a delay in accurately diagnosing her cancer, and that the GP did not appropriately communicate with Mrs A and her family during the home visit.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our adviser said that the practice had acted correctly in referring Mrs A for a scan each time she went to them with abdominal pain. However, Mrs A had decided not to go for the scans. Once a scan was carried out, the practice acted promptly in making the appropriate referrals to confirm the diagnosis and arrange treatment. In relation to communication, our adviser said that the reasonableness of the GP's actions depended on precisely what had happened. As there were different versions of events, which were not resolved one way or the other by the GP's written records from the time of the event, we could not find evidence to uphold Miss C's complaint.

Summary

Mr C, who is a prisoner, complained that the board were failing to follow his agreed dental treatment plan and failed to provide adequate care and treatment for his sleep disorder.

We found nothing in Mr C's dental records to suggest that the board were not following the plan suggested at his initial appointment. We took independent advice from our GP medical adviser about the treatment for his sleep disorder. After reviewing Mr C's medical records, our adviser said that the board's actions had been reasonable in the circumstances. We did not uphold either complaint.

Summary

Mr C complained about his care and treatment while he was being treated by a consultant surgeon in Ninewells Hospital. He said that, although he had lost weight, lost his appetite and become increasingly thin and lethargic, the surgeon discharged him and referred him to the care of a consultant gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). Mr C said that it was only by chance that the seriousness of his condition was appreciated. He also complained that the board delayed in responding to his complaint about this.

We considered all the complaints correspondence and Mr C's relevant medical records as well as taking independent advice from one of our medical advisers. We found that a scan had showed that Mr C had a narrowing of his colon (part of the large intestine). A later review noted that he felt well, had no pain and his bowel habit was unchanged, and it was decided to keep him under review and to scan him again later. Some 14 months after this, he went to a surgical out-patients' clinic and as he was complaining of a swollen stomach and the inability to eat, a scan was arranged for the following month. This showed further thickening in his colon and in the small intestine, and doctors decided to review him again in six months. By that time, his symptoms had settled but he was lethargic and nauseous, and the surgical team felt that there was no surgical solution to the problem. They referred him to gastroenterology for advice and further management.

Mr C continued to lose weight and was prescribed intravenous nutrition (fed directly into a vein), but his condition continued to decline and another scan was organised. This showed evidence of chronic small bowel obstruction and he was referred back for surgery. Because of this, Mr C felt that the surgical team should not have discharged him to gastroenterology when they did. Our adviser, however, said that given Mr C's symptoms at the time this was not an unreasonable approach to take, and that the thickening of his colon could have been considered to be due to disease and not a bowel obstruction. We accepted this advice, and did not uphold Mr C's complaint.

We did, however, uphold his complaint about complaints handling. The board acknowledged that there was delay, and said this was because their complaints team were awaiting clinical information so that they could respond fully. They had already highlighted to the team as a learning point both this failure and the fact that the team should explain such delays when writing to the person who has complained. As they had already taken this action, we made only one recommendation.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to respond to his complaints within published timescales.

Summary

Mr C, who is a prisoner, fell and injured his hand. He complained that, after seeing the doctor the following day, he had to wait a further five days to be taken for an x-ray. In responding to his complaint, the board advised that his referral was treated as non-urgent, and that an appointment was made for him at the earliest opportunity.

We took independent advice on this complaint from one of our medical advisers, who is a GP. He noted that Mr C had a suspected scaphoid fracture (a fracture of one of the wrist bones that sits at the base of the thumb). He explained that this can often be difficult to diagnose. However, he considered it highly unusual for an initial x-ray to be delayed for five days. Most NHS users would have been x-rayed on the day of the injury or the day after. He said that it appeared that the delay in Mr C's case might have been to allow the prison to make arrangements to escort him to hospital. Although the injury was correctly managed by ensuring that Mr C had pain relief and ordering the x-ray, our adviser considered the delay in taking him for the x-ray to be unreasonable, as in his view it appeared to have been purely for operational reasons. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in arranging for him to receive an x-ray; and
• inform us of the steps they intend to take to ensure that patients with possible fractures are assessed in good time in future.

Summary

Mr C, who is a prisoner, complained that prison doctors refused to prescribe him tramadol for his back pain. He said he had previously been prescribed this by his community GP. The prison doctors prescribed alternative medication, which Mr C said was not effective in controlling his pain.

We took independent advice on this complaint from one of our medical advisers, who is a GP. He told us that strong opiates (morphine related drugs) like high dose tramadol should only ever be used on a short term basis for lower back pain. He noted that the recent re-classification of tramadol to a higher category reflected the concerns that doctors have had for some time about the drug, its potential side effects and its potential to be abused. In the circumstances, he considered that the prison doctors had acted reasonably in offering Mr C alternatives to tramadol. We accepted this advice and did not uphold the complaint.

Summary

Mrs C's late mother (Mrs A) was admitted to the Western General Hospital as an emergency, and had an operation to release pressure in her bowel. She was told that her case would be discussed by a multi-disciplinary team (MDT) in a few days, and that they would advise on her future treatment. Before this could happen, Mrs A fell and broke her hip and was transferred to the Royal Infirmary of Edinburgh for an operation, where two days later she suffered a heart attack and died. Mrs C complained that the board did not keep her fully informed about her mother's condition and what was happening. She said she had understood that her mother's case was to be discussed at the MDT meeting at the Western and this had not happened, which caused both her and her mother upset and confusion. Mrs C was also unhappy because she said that her mother's risk of falling was not properly assessed and prevented by the Western General and that the board took too long to answer her complaints.

We took independent advice from two of our advisers, one a consultant surgeon and the other a nurse. We also considered all the relevant information, including all the complaints correspondence and Mrs A's clinical records, after which we did not uphold three of Mrs C's complaints. Our surgeon adviser said that, after Mrs A's fall, the priority was, correctly, to address her broken hip and make sure that she was recovering from it well before moving on to discuss her future treatment. We noted that although it was not unreasonable that discussions did not take place because of what happened, the board had said that in future the MDT would not cancel discussions without telling the patient and their families why. The records also showed that Mrs A had been assessed as not being at risk from falling, and although she did fall, this could not have been anticipated. Although Mrs C said that the board took too long to address her complaints, we found that they did respond within acceptable time limits. We upheld the complaint about communication, however, as it was clear that the board had not kept Mrs C as well informed as she should have been, particularly about her mother's fall.

Recommendations

We recommended that the board:

• apologise for their failure in this matter; and
• remind staff of the importance of keeping relatives and their families informed, in a timely manner, when an accident/injury occurs.

Summary

Mrs C has complex health and mobility issues and has seen a number of hospital consultants over several years. After she saw a consultant orthopaedic surgeon she said she was not given enough information about her diagnosis, and the consultation was rushed. The surgeon arranged a scan, but Mrs C was unable to go through with it and a different scan was carried out instead. Mrs C said that when she raised concerns about the proposed treatment the surgeon did not then discuss alternatives, and she was unhappy with the way the surgeon described events on the day of the scan when writing to her GP about it. Mrs C then attended another consultant's clinic, but he was not there to see her. Mrs C complained to the board about both consultants. The board responded in writing and met with her, but she came to us as she was not happy with the way they handled her complaints. She said that she did not receive an amended agreed copy of the minutes of the meeting, although she provided detailed comments and followed this up with several phone calls and emails. She was also unhappy about the board's response to her complaint about the surgeon, and said that they had not explained how the missed appointment with the second consultant had come about.

We found that the board did not tell Mrs C what had happened about the updated minutes of the meeting, and that, while they responded to her complaint about the surgeon's communication and attitude during consultations, they had not properly addressed the issue of the use of inappropriate language when writing to her GP. We were satisfied that they provided a reasonable explanation and response about the missed appointment with the second consultant.

Recommendations

We recommended that the board:

• clarify in writing to Mrs C the status of the amendments in relation to the meeting note;
• bring the failures in their complaints handling identified in our investigation to the attention of relevant staff; and
• apologise to Mrs C for the failures our investigation identified.

Summary

Mr C complained about the board's treatment of his wife (Mrs C) when she was admitted to the Royal Infirmary of Edinburgh. Mrs C, who had a history of severe renal (kidney) failure, had hip replacement surgery and was kept in for five days. During that time she experienced constipation and although she asked staff for laxatives, these were not provided before she was discharged home. Mrs C continued to suffer from constipation there. She developed a sore, swollen stomach and began vomiting black liquid. Concerned about her condition, Mr C phoned NHS 24 and requested a home visit from an out-of-hours GP. The GP examined Mrs C and prescribed two enemas and laxatives. He advised Mr C to monitor her overnight and to call Mrs C's own GP in the morning if she did not improve. As she did not improve, Mr C called the GP, who examined her and immediately referred her to hospital, where she was diagnosed with a perforated bowel and had emergency surgery. Mr C complained that this could have been avoided had his wife been given laxatives in the hospital and had the out-of-hours GP recognised the seriousness of her condition.

We upheld the complaint about Mrs C's hospital treatment, as we found that that staff clearly failed to provide her with laxatives during her admission, despite her requests. We accepted independent medical advice that patients with renal failure are particularly sensitive to medications and their side effects, noting that Mrs C was on pain medication containing codeine, which is known to cause constipation. Staff should have been aware of the increased risk of constipation and should have closely monitored her for this. Although tools were available to prompt them to ask patients about their bowel movements, staff did not use these and Mrs C was discharged without a proper assessment of her bowel activity. We did not, however, uphold the complaint about the out-of-hour GP's examination of Mrs C, as we found that medical records showed that her symptoms at the time did not suggest a perforated bowel. As such, the treatment provided and the advice offered was entirely reasonable under the circumstances.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to implement the safeguards that they had in place to identify and manage constipation during Mrs C's admission; and
• conduct a review to assess whether their post-operative care pathway and patient information are sufficiently rigorous, particularly for patients with renal failure.

Summary

Ms C's late father (Mr A) had a complex medical history including heart disease. He had a chest x-ray, which showed a mass on the lung but was wrongly reported as normal. After further tests and body imaging Mr A was diagnosed with advanced lung cancer. Ms C said Mr A was told that his tumour was inoperable, and it was decided to treat him with chemotherapy and radiotherapy. Mr A developed kidney disease after the first cycle of chemotherapy, which was stopped, and he was then treated with radiotherapy. However, he became more unwell and was diagnosed with radiation pneumonitis (lung damage arising from radiotherapy). A scan the next month showed lung changes that were reported as relating to emphysema (lung disease that causes shortness of breath). Shortly afterwards, however, an underlying lung condition was detected. Mr A continued to deteriorate and he was admitted to the Western General Hospital where, despite treatment, he died.

Ms C complained that the hospital did not detect her father's underlying lung condition quickly enough. She said that, had it been spotted earlier, Mr A could have had surgery instead of radiotherapy, which she believed would have led to a more positive outcome. She was concerned about a consultant's communication with her family about her father's treatment options, and said that the board failed to treat his heart condition. She was also unhappy with the way they handled her complaint.

We took independent advice from two of our medical advisers, who specialise in oncology (treatment of patients who have cancer) and radiology (the analysis of images of the body). They said that it was reasonable that Mr A's underlying lung condition was not detected earlier and, while knowing about it might have made radiotherapy a more risky option, surgery was also a high risk option with no guarantee of a cure. The oncologist said that the management of Mr A's conditions was appropriate based on information available at the time of treatment (including for his heart condition). We appreciated that, for the family, learning about Mr A's underlying lung condition was extremely distressing and clearly caused them a great deal of uncertainty about the potential outcome. However, our adviser said that it was very unlikely that Mr A's life expectancy would have been different had treatment changed. Our radiology adviser criticised the radiologist's interpretation of the x-ray, although they also said that the failure to identify the mass would not have affected the outcome. Although a number of aspects of Mr A's care and treatment were reasonable, we upheld the complaint as there was an unreasonable delay in identifying the mass, which was a significant failure and led to a delay in diagnosis.

We did not uphold Ms C's complaint that the consultant did not discuss surgery or heart treatment. The advice we accepted was that communication was reasonable and there was evidence that treatments were fully discussed. This was on the basis of the information available to board staff at the time and, as already noted, it was reasonable that they did not pick up Mr A's underlying lung condition earlier. Our oncology adviser also said that there was evidence that the consultant had explained the issues and obtained Mr A's consent for treatment.

On the complaints handling, we were satisfied that the board fully addressed the complaint and that the time they took to respond was reasonable as there were delays in obtaining consent from the family. However, it was clear after further contact from Ms C that she wanted clarification and a further response to the issues raised, and the board should have taken earlier steps to provide this.

Recommendations

We recommended that the board:

• raise the failures identified with relevant staff; and
• apologise to Ms C for the failures identified.

Summary

Ms C complained that after her GP referred her to orthopaedics (the specialty for conditions of the musculoskeletal system) at Wishaw General Hospital, she was inappropriately allocated to podiatry (specialising in disorders of the foot, ankle and lower limb). She had previously attended private podiatry appointments with no improvement to her condition, and thought she should have been referred to an orthopaedic surgeon. She thought that this would have resulted in quicker treatment and would have meant that she did not need to obtain a private referral to an orthopaedic surgeon. She also said that the board should have told her that she was being allocated to a podiatrist, to allow her to decide whether to request further private referrals and avoid delays in treatment.

We considered the information she provided and that from the board. We found that Ms C's GP gave her a routine referral to orthopaedics and was initially triaged (deciding where patients should be treated, based on their condition) by an extended scope practitioner (ESP) podiatrist in the orthopaedic team. This person can give an onward referral to podiatry or other specialisms, and can also request specialist investigations, such as radiology and scans. Triage could include a further review by other ESPs and surgical staff. We noted that the review by the ESP podiatrist was in line with the board's protocols. Although the board had not told Ms C or her GP that she would be triaged this way, this did not disadvantage her as this is what happens to all routine orthopaedic referrals. The board explained, and we accepted, that it would be impractical to tell all patients and GPs who would carry out the triage. As the board had clearly followed their protocols, we did not uphold Ms C's complaints.