Health

Summary

Mr C, who is a prisoner, complained that the health centre at his prison did not provide appropriate treatment for his difficulties in coping with a recent bereavement, which included lack of sleep. To investigate this complaint, we needed Mr C's written consent for us to get his medical records. We asked for this and reminded him about it, but Mr C did not provide consent. We, therefore, closed his complaint as we could not carry out an investigation without it.

Summary

Ms C said that she had a contraceptive implant fitted and when it was near the end of its life, she attended her GP for a replacement. She complained that she was told that because of her high blood pressure (BP) it was not possible to do so. As it appeared that Ms C was not taking her medication to reduce her BP, she was advised to do so and return to the practice in six to eight weeks time for review.

Ms C attended again to have her implant reinserted but again her BP was noted to be very high. She was told that if there was an attempt to replace it there was a risk of uncontrolled bleeding and it was agreed that she should attend a local hospital for replacement. Ms C felt that she had been given unreasonable care and treatment because the reason why she had an implant fitted in the first place was because of her BP. She complained that the GP's actions left her without effective contraception.

During our investigation, we took independent advice from one of our medical advisers, who is a GP. The adviser said that although the GP said she had acted in Ms C's best interests and followed national advice on implantable progesterone contraception like the type used by Ms C, she had in fact misunderstood the advice. In cases similar to Ms C's, the benefits of remaining on the contraceptive, despite her BP, would likely outweigh the risks as it was recognised as a safer option for women with high BP. In the circumstances, we considered it unreasonable that Ms C was left without an effective form of contraception for over seven weeks.

Recommendations

We recommended that the practice:

• ensure the GP apologises for the fact that Ms C was left for some time without contraception; and
• ensure the GP undergoes specific training with regard to the safety and contraindications of that particular contraceptive.

Summary

Mr C complained that he did not have continuity of mental health care, as he had been seen by eleven different consultant psychiatrists. Mr C said this was frustrating for him, and caused him concern about whether he was receiving consistent care and treatment.

We looked at Mr C's medical records, and took independent advice from our mental health adviser. We also asked the board what they were doing to deal with staffing issues in community mental health. The board explained the reasons for the lack of consistency in staffing, and provided reassurance about the steps being taken to improve the situation. They also remedied Mr C's specific situation by placing him on the caseload of a senior member of staff.

Our adviser said that although there was a lack of consistency in the consultants who saw Mr C, there was no evidence in the medical records that his care and treatment were adversely affected in a significant way, or that there was a lack of continuity in his treatment. The standard of medical record-keeping and communication with his GP was reasonable, and ensured that important clinical information was appropriately passed on. Our adviser also said there had been greater consistency in terms of community psychiatric nursing provided, which helped offset any difficulties created by the problems with medical staffing.

Summary

Mr C complained that the board failed to appropriately investigate the cause of his severe back pain following his admission to Perth Royal Infirmary. He said the board failed to carry out an MRI scan (used to diagnose health conditions that affect organs, tissue and bone) to allow an accurate diagnosis to be reached at an earlier date, and that he had to arrange for this to be done privately.

We obtained independent medical advice on Mr C's case from one of our medical advisers, a consultant in orthopaedic and trauma surgery. Our adviser explained that Mr C's clinical picture after he was admitted should have guided the board's management of his condition. He explained that this could only be properly ascertained after taking an adequate history and clinical investigations. It appeared that the consultant orthopaedic surgeon did not fully examine Mr C, and relied on a junior doctor's examination, but this was reasonable as long as the junior doctor's assessment was thorough. However, as the board were unable to provide a copy of Mr C's medical notes for his time in hospital, we could not say whether he was properly examined. On the MRI scan, our adviser said that Mr C was not displaying 'red flag' (warning sign) symptoms but that, in view of his condition, the benefits of arranging an MRI scan outweighed the risks. He said that an MRI scan could have been arranged either as an in-patient or after Mr C's discharge, but this did not happen.

Having considered the matter carefully, we were unable to say that Mr C's symptoms were appropriately investigated while he was in hospital to find the cause of his pain. If an MRI scan had been arranged when Mr C was an in-patient, he would not have had to arrange one himself, and if one had been arranged for him as an out-patient, then it was unlikely he would have arranged his own scan. We, therefore, considered it reasonable for the board to reimburse Mr C the cost of his private MRI. We were also very critical of their management of Mr C's medical records and that they were unable to provide us with these for his hospital stay.

Recommendations

We recommended that the board:

• feed back our decision on this case to the staff involved to ensure that a similar situation does not happen in future;
• reimburse Mr C the cost of his private MRI scan;
• review their practice on the storage of patients' medical records to prevent a recurrence of the failure to store Mr C’s medical records securely; and
• provide Mr C with a written apology for the failings identified.

Summary

Miss C, an advice worker, complained to us on behalf of her client (Miss A) about the handling of Miss A's Shetty Gastro-Jejunostomy (SGJ) procedure (the insertion of a feeding tube into part of the intestines). Miss A suffers from gastroparesis (paralysis of the stomach) which does not allow food to empty from her stomach. She was scheduled for the procedure as a day-surgery case and told that a particular radiologist would carry it out. On the day, however, a different radiologist tried to perform the procedure, without success. They were only able to insert a tube into Miss A's stomach, to prepare for a later attempt to insert the SGJ. Miss A suffered pain after the procedure and was kept in overnight for pain relief. Miss C also said that no written information was passed to the ward about the problems encountered during the SGJ. Miss A eventually had a SGJ inserted some seven weeks later.

Our investigation included taking independent advice from one of our advisers, who said that the attempted SGJ was done in a reasonable manner with evidence of good, and even best, practice. The adviser said that this is a difficult procedure and Miss A's condition made it particularly so. There was no evidence that the radiologist who attempted it did not do so in a reasonable way. The adviser also said that the board's decision to allocate Miss A's procedure to the first available suitably qualified radiologist was a reasonable clinical decision, and that the radiologist's decision to insert a tube into the stomach to help a further attempt of the SGJ procedure was good practice. There are two approaches that could have been taken towards a further attempt - either to do so a few days after the first, or to wait for the track made by the stomach tube to mature (a period of four to six weeks) before making a second attempt. Either approach is reasonable and in this case the clinicians chose the latter, which was successful. Overall, we were satisfied that the care and treatment provided to Miss A was reasonable.

The only concerns we had were about a lack of information on the consent form that Miss A signed and a failure to provide written information to the ward about the problems with the procedure. There had been verbal communication but nothing in writing. The board told us that they have amended their procedures to prevent this happening again, and so although we did not uphold the complaint we made a recommendation about this.

Recommendations

We recommended that the board:

• provides evidence that the remedial action taken in respect of the written information provided by the radiology department is sufficiently robust to prevent a recurrence, and that appropriate information is recorded on consent forms.

Summary

Mr C's wife (Mrs C) had hip replacement surgery. She recovered well, but suffered constipation afterwards because of the painkilling medication she was prescribed. After having had no significant bowel movements for more than a week, Mrs C began vomiting and had a painful, hard stomach. Mr C phoned NHS 24 and asked for a home visit from a GP. Mrs C's case was prioritised as serious and urgent and Mr C was told that a district nurse would come within two hours. When the nurse did not arrive, Mr C called NHS 24 again. They investigated and learned that the district nurse would not visit new patients with constipation. Instead it had been arranged for a GP to call Mrs C for a further phone assessment.

Mr C was not happy with this, and was then told that NHS 24 would request an out-of-hours GP to visit within two hours. The out-of-hours GP was, however, required for another more serious call, and arrived about six hours after Mr C's initial call to NHS 24. He gave Mrs C two enemas and a prescription for laxatives. Mr C was advised to monitor his wife overnight and contact her own GP in the morning if she did not improve. As Mrs C did not improve, her own GP visited and immediately referred her to hospital, where she was diagnosed with a perforated bowel that needed emergency surgery. Mr C complained that NHS 24 did not prioritise Mrs C's case appropriately and that she could have been admitted to hospital more quickly had the out-of-hours GP attended sooner.

After taking independent advice on this case from one of our medical advisers, who is a GP, we upheld Mr C's complaint. We found that Mrs C's case was treated seriously and given the highest priority, but that NHS 24 should have requested a GP visit rather than a district nurse visit at the start. We were critical of NHS 24 for not gathering relevant information about Mrs C's bowel habits and pre-existing kidney failure, which would have helped staff decide the action to take.

We concluded that, although there was a clear delay in the out-of-hours GP attending, this was partly due to communication problems between NHS 24 and the local health board. NHS 24 and the board had already identified this and had taken action to improve communication. We were satisfied that, although his attendance was delayed, the out-of-hours GP's conclusions and treatment would not have been different had he visited Mrs C earlier. However, we recognised that she would have received the enemas and laxatives sooner and that this might have improved her chances of avoiding a perforated bowel, if it had not already occurred by then. We also recognised that the delays added to the discomfort and anxiety that Mrs C was experiencing.

Recommendations

We recommended that NHS 24:

• apologise to Mr and Mrs C for the issues highlighted in our investigation;
• remind their clinical staff of the importance of establishing each patient's level of renal failure and of taking this into account when progressing their treatment; and
• consider briefing their clinical staff on the need to consider whether patients have passed stools or gas in cases of severe constipation.

Summary

Mr C complained that his GP practice failed to properly diagnose his symptoms for several years, and did not undertake a simple blood test that finally revealed the cause of his illness. However, as he did not then respond to our correspondence, we were unable to investigate his complaint, and closed his case.

Summary

Mrs C went to her medical practice because she had been having headaches for a few months. She was given migraine medication to try, and an appointment was made for her to come back a week later. Mrs C did not go to the appointment but had called NHS 24, where the on-call doctor thought she might have acute sinusitis (inflammation causing facial pain). Later that month, Mrs C went back to the practice with her sister. She said the medication had not worked. She also had other problems, including being increasingly unable to socialise or attend to her personal hygiene. She was treated for sinusitis, but her symptoms became even worse, and she went back to the practice at the end of the month. She described increasing withdrawal, problems with her eyesight and that she had been off work for a number of weeks. The day after this appointment, NHS 24 were called again, and Mrs C was immediately admitted to hospital for a scan. She was diagnosed with a brain tumour and had an operation to remove it.

Mrs C complained that the GP at the practice failed to pick up on her serious illness and refer her to hospital. She said that as a consequence her life had been put at risk.

We obtained all the complaints correspondence and Mrs C's relevant clinical records and took independent advice from one of our medical advisers, who is a GP. Our investigation found that the GP missed a number of classic features associated with brain tumours. The adviser said that on her second visit to the practice Mrs C was demonstrating enough of these to merit urgent referral. He said that although some of the changes could be interpreted as being associated with depression, in his opinion that would be a secondary consideration in a patient with persistent headache and such a significant change in personality. The symptoms should have alerted the GP to a possible serious diagnosis and she should have made a comprehensive assessment including a detailed clinical examination, then referred Mrs C urgently if she felt that any element was beyond her clinical competence. We made recommendations, noting that the GP had already acknowledged that she had missed an important diagnosis and apologised for this, and that the practice had carried out a significant event analysis.

Recommendations

We recommended that the practice:

• formally apologise to Mrs C for a failure to properly examine her and then refer her on;
• confirm the actions taken to amend their procedures; and
• provide evidence that the matter has been addressed at the GP's next appraisal.

Summary

Mr C complained that a dentist had failed to fit a crown properly. He said that the crown was too big and that he could not close his teeth together. He also said that it eventually fractured because it had been too big.

We took independent advice on this complaint from our dental adviser. The crown had initially been too big, and Mr C had gone back to the dental practice the day after it was fitted to have it adjusted. The adviser said that minor adjustments are often required to a crown to fit the biting surface correctly, and that this was not unreasonable. The dental notes indicated that Mr C had accepted the adjustment that was made. There was no evidence in the dental records that he later complained about the size of the crown before it broke over two years later. We found no evidence that the care and treatment the dentist provided to Mr C was unreasonable.

Summary

Mrs C complained on behalf of her husband (Mr C) who had suffered from rheumatoid arthritis for many years. In 1996 he began taking a low dose of methotrexate (MTX - a disease modifying drug.) In 2003, Mr C had a biopsy (tissue sample) taken, which showed fatty changes to his liver. Mrs C felt that at this stage the MTX should have been stopped. However, Mr C went on to take the drug for a further two years before he was told to stop it. The board said this was because the benefits of a low dose of MTX in terms of treating Mr C's rheumatoid arthritis outweighed any potential detrimental effects on his liver. Mr C was later diagnosed with cirrhosis of the liver (scarring of the liver as a result of continuous, long-term damage). Mrs C complained that this was because of the MTX.

To investigate the complaint, we took all the relevant information, including the complaints correspondence and Mr C's clinical records, into account. We also obtained independent advice from one of our medical advisers. Our adviser said that in 2003 it was reasonable for Mr C to continue with MTX as the risks associated with it, although serious, were rare and the decision was taken in the full knowledge of all the factors involved. The adviser also said that at the same time Mr C was strongly advised about weight reduction, glucose control and close monitoring of his blood pressure. In 2005, Mr C's liver function tests showed a mild disturbance and, taking into account the existing fatty liver disease, his increasing weight and diabetes, it was decided then to stop the MTX. While Mr C had taken a low dose of MTX for a number of years, our adviser confirmed that it was not the length of time for which someone was exposed to the drug but rather the overall exposure that was likely to increase the risk. In light of this, we did not uphold the complaint.