Health

Summary

Mrs C complained about the care and treatment provided to her late brother (Mr A). She said that in summer 2012 his GP urgently referred him to the ear, nose and throat (ENT) department at University Hospital Crosshouse. Mr A had a history of heart disease and ulcers but over recent months had been having difficulty swallowing. An ENT consultant arranged tests, the results of which appeared to be normal, and the consultant wrote to Mr A reassuring him and saying that she did not intend to follow him up. However, Mr A's symptoms did not improve and he was seen again as an emergency in October 2012. He was found to have a large mass in his neck. This was later confirmed to be an extensive tumour, and Mr A died some seven months later. Mrs C complained that Mr A's care and treatment were inadequate and that there had been a lack of urgency to progress this and a failure to diagnose him.

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

Our investigation found that Mr A's lifestyle indicated he was at very low risk from this type of illness and confirmed that initial tests did not reveal anything untoward. It was also clear, however, that although the ENT consultant had later reassured Mr A about his condition, this proved to be a false reassurance. The consultant had since told the board that, with hindsight, it would have been better if she had arranged to see Mr A again. Our adviser agreed that this would have been advisable and said that, when deciding whether to see him again after the tests, the ENT consultant only had sight of a copy of her letter to Mr A's GP and not his notes, in which it was clear she had noted that she intended to see him again. Her letter did not accurately reflect what she had written in the notes and what she had intended, and so we upheld this complaint. Mrs C also complained about the board's response to her written complaint but we did not agree with her that this was inappropriate.

Recommendations

We recommended that the board:

• apologise to Mrs C for the additional stress and anxiety caused; and
• ensure that the ENT consultant discusses these events at her next formal appraisal.

Summary

Mrs C complained that the board unreasonably failed to diagnose the cause of her pain. Mrs C told us that she had experienced pain in her rib cage area since 2009 and had provisionally been diagnosed with gallstones. However, despite several hospital admissions, various tests and treatment, including the removal of her gall bladder, she remained in pain with no cause being identified. Mrs C said that the doctors treating her appeared to be accepting that her pain was unexplained and taking steps to help her cope with it, rather than seeking to diagnose the problem.

After taking independent advice from an adviser who is a specialist in pain management, we found that all the different specialists who had seen Mrs C had taken her concerns seriously and had carried out many appropriate investigations, including surgery, to determine the cause of her pain. When, however, a conclusive diagnosis for the root cause of it could not be made it was appropriate to shift the emphasis of treatment onto pain management and to refer her to a hospital pain clinic. Although Mrs C did not consider that the treatment she had received there addressed her pain, we considered it to be appropriate and in line with current medical practice. A decision to then refer Mrs C to a clinical psychologist had also been appropriate. Our medical adviser told us that there were no other investigations that the board should have reasonably considered to try to establish the cause of Mrs C's pain.

Summary

Mr C complained that there was a failure to provide his elderly mother (Mrs A) with appropriate care and treatment during two hospital admissions. Mrs A was first admitted to University Hospital Crosshouse when she fractured her pelvis after a fall at home. Mr C complained about the length of time his mother spent in the emergency department before being transferred to a ward. He also complained that her medication was changed and that she was discharged to a rehabilitation centre suffering from severe jaundice.

After taking independent advice from one of our medical advisers and our nursing adviser, we found that the time taken by medical staff to assess Mrs A and admit her to a ward was reasonable, and we identified no failings in nursing care. There was not enough evidence for us to say whether her medication was changed but we were satisfied that there was no evidence that when Mrs A was transferred to the rehabilitation centre she was suffering from severe jaundice. However, we were concerned that Mrs A did not appear to have been reviewed by a consultant within 24 hours of admission. Although our adviser said that such an assessment would not have altered the outcome for Mrs A, we considered this to be a failure of care. We were also concerned that there was a failure to assess Mrs A's bone health for possible osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break) and the reasons why she fell and suffered a fracture. In view of these failures we decided that the board failed to provide appropriate care and treatment to Mrs A during her admission.

Mrs A was readmitted to University Hospital Crosshouse the following month because her sodium level was low and she had a slow pulse. Mr C complained that medication prescribed prior to admission was changed, and that when she was transferred to Ayrshire Central Hospital she received poor nursing care.

Our medical adviser explained that there were sound medical reasons why Mrs A's medication was changed, and our nursing adviser found no evidence of any failings in Mrs A's nursing care while she was a patient in Ayrshire Central Hospital. There had been issues in relation to Mrs A's clothing, but the board had already apologised for this and taken action to address the failings identified. We were, therefore, satisfied that the board dealt with this appropriately. However, we had a number of other concerns about Mrs A's care and treatment during this admission. There was insufficient documentation in her medical notes to suggest that the assessment of her condition was sufficiently detailed and her condition severe enough to merit the medication she was prescribed for vertigo (the sensation a person has that they, or the environment around them, is moving or spinning). Also, we did not find evidence that medical staff had discussed or explained the diagnosis of vertigo or the changes to medication with her, or with Mr C. We also found that Mrs A's GP was only given a very basic level of information about her condition and treatment, with no information about her sodium level at the time of discharge or the changes to her medication. Finally, we considered that Mrs A's medical notes for this period were difficult to interpret because of poor handwriting. Because of all these issues, we found that aspects of Mrs A's care and treatment fell below a standard that could reasonably have been expected, and we upheld this complaint too.

Recommendations

We recommended that the board:

• apologise to Mr C and to Mrs A for the failings identified;
• ensure there is appropriate consultant assessment, including at weekends, for patients admitted as an orthopaedic emergency in University Hospital Crosshouse;
• ensure that the reasons why a patient has sustained a fall and the consequences of the fall are both assessed;
• ensure that medication changes are discussed as appropriate with the patient or, where appropriate, a patient's carer prior to their discharge;
• ensure that a patient's discharge summary contains all relevant information; and
• remind staff of the need to ensure that entries in a patient's records are legible.

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.