Health

Summary

Mr C, who is a prisoner, was being prescribed medication to treat nerve pain. However, after an incident in which a nurse suspected Mr C was trying to conceal his medication, the decision was taken to change it to an alternative. Mr C complained about this and that there was an unreasonable delay in him being seen by a doctor.

We took independent advice on Mr C's case from our GP medical adviser. The adviser explained that because the nurse thought that Mr C had tried to conceal his medication, it was important for the prison health centre to act. The adviser confirmed that if there is evidence that a patient is not complying with their treatment regime, for example by concealing medication, then it is reasonable for medical staff to review this. In Mr C's case, our adviser said the prison health centre appeared to have properly assessed the situation. Our adviser said that because Mr C was previously on the alternative medication, with good benefit, and given there was no evidence of misuse of that medication, the prison doctor's decision was clinically correct. Our adviser said the decision was supported by Mr C's pain specialist's advice to rotate his type of medication. In light of the information available, and our adviser's advice, we did not uphold Mr C's complaint.

Mr C said that after the alleged incident, he was left without pain medication for nearly three weeks. The board told us that following the decision to withdraw the medication, Mr C asked to see a doctor. This was classed as a routine appointment and he was listed for the first available appointment after a public holiday period. On the day Mr C was to see the doctor, he did not attend. The board explained that the Scottish Prison Service were responsible for escorting prisoners from the main prison to the health centre. Sometimes, due to operational issues within the prison, prisoners did not attend scheduled appointments. The board said Mr C was then given a new appointment, which he attended. The board also confirmed that the prison health centre aimed to see prisoners with non-urgent referrals within seven to ten days. In Mr C's case, his appointment to see the doctor was classed as routine and he was seen eleven days after first asking to see a doctor. Because the time Mr C waited overlapped with public holidays, we did not think this was unreasonable and we did not uphold his complaint.

Summary

Mr C, who is a prisoner, asked to be prescribed an alternative medication, and night sedation, to help him with his opioid addiction. The prison health centre refused because they were satisfied that Mr C's current prescription, and the additional support available to him, were appropriate. Mr C complained to us their decision was unreasonable.

We reviewed national guidance which deals with the provision of medications for the management of opioid dependence. We also sought independent advice from one of our medical advisers. In light of this, we were satisfied the prison health centre's decision to refuse Mr C's request was reasonable.

Summary

Mr C, who is an advice worker, complained on behalf of his client (Ms A) after the birth of her baby. He said that when Ms A was admitted to Glasgow Royal Infirmary to have the birth of her baby induced, staff did not fully consider her previous medical history, did not provide her with enough pain relief, and failed to adequately repair three tears that she sustained during the birth.

Our investigation, which included taking independent advice from one of our medical advisers, found that Ms A's previous history had been fully recorded. We also found that she was provided with appropriate medication to induce the birth of her child, taking into consideration her previous medical history, and that when she started having painful contractions, Ms A was provided with appropriate pain relief. However, her labour progressed very quickly and when she needed more pain relief, there was not enough time to assess her and provide an epidural (local anaesthetic injected into the spine). It was not safe to her unborn child to provide her with opiates (very strong pain killing drugs). While it was clear from the records that Ms A suffered a painful labour, our adviser said that the care and treatment provided was reasonable, appropriate and timely.

The tears Ms A sustained were repaired by a senior specialist trainee doctor, using local anaesthetic and inserting one or two stitches in each wound. The local anaesthetic had begun to wear off by the time the doctor was repairing the third tear, and Ms A was given the option to continue, or to have more local anaesthetic inserted. This in itself can be painful, and Ms A decided to go ahead without further anaesthetic. She later continued to have problems with pain and what she considered to be an unsightly result of the repair. Two months after the birth she went to an A&E department, where she was examined and referred for reconstructive surgery. Our medical adviser reviewed all the clinical notes from the birth and the reconstructive surgery and found no evidence that the problems Ms A suffered had been caused by poor technique during the original repair. The adviser explained that such tears are fairly common and often require reconstructive surgery some time after a birth. The adviser said that the doctor had used appropriate materials and technique, and there was no evidence of an inadequate repair.

Summary

Mrs C complained on behalf of her son (Mr A) that his medical practice failed to provide him with appropriate care before and during appointments when he attended the practice with concerns about his physical and mental health. She also complained that the practice had, following the appointments, unreasonably removed her and her son from their list of patients.

We reviewed the clinical records and obtained independent advice from our medical adviser. Having considered the medical records, he said that the care given to Mr A was reasonable, so we did not uphold this element of the complaint. We noted that, after the second appointment, the police had to be called because of Mr A's violent and threatening behaviour and Mrs C's abusive behaviour, and that it was following this that both were removed from the practice list.

Having reviewed the case we established that the practice had followed the correct procedure in terms of removing Mr A from their list because of his violent behaviour, and we did not uphold this aspect of the complaint. However, Mrs C had not been violent and they did not give her a written warning, allowing her the opportunity to modify her behaviour. Before removing a patient whose behaviour is non-violent, but unacceptable, the practice are required to warn them about this, and so we upheld this aspect.

Recommendations

We recommended that the practice:

• review their removal policy to ensure that it reflects the terms of the NHS General Medical Services Contracts (Scotland) regulations and associated guidance, particularly in respect of giving patients relevant prior warning if they are at risk of removal; and
• apologise to Mrs C for not following the proper procedure when removing her from their list of patients.

Summary

Ms C attended the medical practice a number of times with various symptoms including constipation, low abdominal pain, recurrent urinary symptoms and diarrhoea. She was also treated in hospital for kidney inflammation. Ms C was eventually diagnosed with pelvic inflammatory disease (PID) and said she was told that she was infertile as a result of the delay in diagnosing and treating this. She complained that the practice did not provide her with adequate care and treatment by failing to investigate her repeated symptoms and diagnose PID.

We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the care and treatment Ms C received was not unreasonable. The adviser said that PID is a difficult condition to diagnose, with symptoms that may also be indicative of other more common diseases, or that may not appear at all. There was nothing typical or suggestive of a diagnosis of PID in Ms C's consultation records, and the adviser agreed with the practice that Ms C did not present with a clear cut case of PID. While we did not uphold this aspect of Ms C's complaint we recommended that the practice reflect on issues raised by the adviser in relation to their record-keeping and symptom review in relation to PID.

Ms C also complained that the practice delayed in responding to her complaint. We found there was delay in their investigation of Ms C's complaint and a failure to keep her updated about the investigation.

Recommendations

We recommended that the practice:

• reflect on our adviser's comments about the lack of detailed recording of negative findings, and discuss ways to improve this;
• reflect on the learning identified in our investigation about the presence of sterile pyuria (the presence of elevated numbers of white cells in urine which appears sterile using standard culture techniques), which can be linked to PID;
• issue a written apology to Ms C for the unreasonable delay in responding to her complaint; and
• review their complaints handling guidance and training to ensure that this includes: the obligation to promptly investigate and respond to complaints; the obligation to advise the complainant of any delay, together with an explanation for the delay and an estimated time-frame for response; and where an investigation exceeds 20 days, the obligation to advise the complainant that the SPSO may be willing to consider the complaint before their investigation is concluded.

Summary

Mr and Mrs C complained to the board about how a bone marrow sampling procedure was carried out on Mrs C. Some weeks after making the complaint Mrs C died. Mr C felt the board's response to their complaint was inadequate, and so he complained to us.

We looked at information from Mr C and from the board. We found that Mr and Mrs C did not make a written complaint to the board, but spoke to a member of staff who made a note of the complaint. The board investigated it, and wrote to Mrs C. Their letter to Mrs C mainly contained apologies rather than explanations, particularly apologising that staff did not acknowledge sooner the level of pain and discomfort she experienced during the procedure.

As there was no written complaint, we could not say with certainty exactly what answers Mr and Mrs C told the board they wanted about the procedure. We found, however, that much of the detail the board gave us when we contacted them was considered during their investigation of the complaint, but was not in their letter. Given this, we decided it would have been reasonable for the board to have included some of this in their letter, to reassure Mrs C that the procedure was carried out in line with normal standards. Their letter did not achieve an appropriate balance between apology and explanation. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• ensure notes made by staff of verbal complaints contain sufficient detail on the specific points of complaint to enable the board to respond to those points in their letters; and
• consider how the evidence gathered during the investigation of Mr and Mrs C's complaint could have, empathetically, been included in the board's response letter to Mrs C.

Summary

Mrs C complained about the care and treatment she received from her medical practice when she attended with clearly visible changes in her left breast. The GP told Mrs C that there was nothing wrong other than a blockage and suggested that she buy starflower oil. Mrs C's health deteriorated over the next few months and nine months later, she was diagnosed with breast cancer.

After taking independent advice from our GP medical adviser and considering the records and Mrs C's comments, we found that the GP had failed to adequately examine her breast. In view of the visible changes, Mrs C's age and the fact that she had a family history of breast cancer, we also found it unreasonable that the GP did not immediately refer her to the breast clinic. Our adviser said that the delay in referring Mrs C there was likely to have had a significant impact on the extent of the tumour and the level of treatment Mrs C required. However, the practice had carried out a significant event review, had demonstrated that they had learned lessons from the complaint and had apologised to Mrs C. In view of this, we did not need to make any recommendations.

Summary

Mrs C complained about the care and treatment she received at Galloway Community Hospital for her injured wrist. She said that the locum consultant orthopaedic surgeon who dealt with her did not provide a proper diagnosis, treatment and advice when he saw her at the hospital trauma clinic. She said he only looked at one of four x-rays taken in A&E before telling her that her wrist was not fractured. She said that it was fractured and that the consultant's actions compromised her recovery.

We took independent medical advice on this case from a consultant in trauma and orthopaedics. Our adviser said that the x-rays indicated that Mrs C had fractured her wrist and that the consultant failed to identify this when he saw her at the trauma clinic. His notes and his comments on Mrs C's complaint indicated, however, that he reviewed Mrs C's x-rays. Without independent evidence, it was not possible for us to say whether he failed to examine all four x-rays and this was why he did not correctly identify the fracture. Our adviser explained, however, that in spite of the incorrect diagnosis, Mrs C received the correct treatment for her condition and her recovery was not compromised. We concluded that, on balance, the care and treatment she received was reasonable, although we made recommendations about the incorrect diagnosis.

Recommendations

We recommended that the board:

• feed back the adviser's comments on the consultant's review of Mrs C's x-rays to the consultant, to try to ensure that a similar situation does not occur in future; and
• provide Mrs C with a written apology for failing to provide her with the correct diagnosis.

Summary

Mrs C complained about the care and treatment that her late father (Mr A) received at University Hospital Ayr for prostate cancer and the palliative care (care to prevent or relieve suffering only) he had at home during the last weeks of his life. Mrs C said that her father's cancer was not properly monitored, and that this meant that doctors were not aware when it started to spread. She complained that had he been properly monitored this could have been treated, he would have lived longer, and would have suffered less pain. She also complained that the palliative care was inadequate and, because he was too unwell to be at home, this led to him being transferred to a hospice shortly before his death, against his wishes.

We took independent advice from two of our advisers - an oncology adviser (cancer specialist) and a nurse. The oncology adviser found that there were monitoring failures, with appointments cancelled and not reinstated. However, he said that Mr A was given appropriate treatment, and that the delay in some consultations did not affect the decisions doctors made about treatment. Our nursing adviser said that Biggart Hospital, where Mr A was an in-patient towards the end of his life, should have involved the district nurse in planning for his discharge while he was still in hospital. She also said that once the district nurse was involved, Mr A's palliative care was not sufficiently assessed and planned, and that the family's needs were not appropriately taken into account. She was critical that the family's concerns were not responded to when they were first raised, and continued to be overlooked, even when Mr A was becoming very unwell.

On the basis of the advice we received, we found that the board did not monitor Mr A's cancer appropriately. However, they had already identified this and had taken steps to ensure this did not happen again. We did not consider that this failing had any significant impact on Mr A's medical treatment. In relation to Mr A's palliative care, we found failings by both hospital and district nursing staff.

Recommendations

We recommended that the board:

• ensure that all patients receive clear information on how prostate cancer is monitored, what treatment options are available, and when they might be applicable;
• review arrangements for the discharge of terminally ill patients to ensure district nursing staff are fully involved in discharge planning;
• ensure all district nursing staff have up to date training in their role in the provision of palliative nursing care; and
• apologise to Mrs C and her family for the considerable distress experienced by her father and her family, due to the board's failure to provide appropriate palliative care in the final weeks of Mr A's life.

Summary

Mrs C was concerned by the care and treatment provided to her late mother (Mrs A) by a GP at the medical practice. Mrs C was unhappy that although Mrs A was complaining of pain and discomfort in her leg, the GP failed to consider the possibility of deep vein thrombosis (DVT - a blood clot in a vein). A month later, Mrs A died of a bilateral pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs).

To investigate the complaint, we carefully considered all the relevant information (including the complaints correspondence and Mrs A's relevant clinical records) and obtained independent advice about Mrs A's care and treatment from one of our medical advisers, who is a GP. We found that the GP's treatment of Mrs A was reasonable and that the records showed why he had not suspected DVT, given the symptoms that Mrs A had at the time. The adviser said that a clinical picture may at the time not be as clear cut as when looking back and considering a matter with hindsight. In the circumstances, the adviser thought that it was reasonable for the GP not to consider DVT. We noted that, since Mrs C's complaint, the GP had clearly reflected on what had happened, and had reviewed local guidelines in attempt to prevent this happening again. Although we did not uphold the complaint, we made recommendations that the GP takes further steps to ensure good clinical practice.

We upheld Mrs C's complaint about complaints handling, as we found that timescales were not met when responding to her letters.

Recommendations

We recommended that the practice:

• ensure that the GP considers the available national guidelines and includes his reflection on these in his next annual appraisal;
• ensure that the GP considers how he completes his clinical notes and seeks advice to do so;
• make a formal apology for their delay in dealing with the complaint; and
• implement and adhere to NHS guidance on dealing with complaints.