Health

Summary

Mr C was admitted to Monklands Hospital with suspected kidney damage. He was already suffering from end stage alcoholic liver disease. Mr C was initially cared for in the Emergency Receiving Unit (ERU), where he fell twice. He was then transferred to a ward. Mr C's condition continued to deteriorate. Four days after he was admitted he was reviewed by a consultant, and staff contacted his wife (Mrs C) and asked her to come to the hospital urgently as he was considered to have a very poor prognosis. Mr C died that day.

Mrs C complained that her husband did not receive appropriate medical or nursing care when admitted to hospital, and that he was not properly assessed as a fall risk whilst in the ERU. She also said that when he was transferred from the ERU to a ward there was no proper handover and nurses had lost a crucifix he wore. This was returned to her after he died, but had been irreparably damaged. Mrs C said that medical staff were slow to assess her husband's problems and failed to provide him with the appropriate treatment, as they had not considered him for a liver transplant. She was also unhappy with the board's response to her complaint, which listed Mr C's entire medical history and emphasised the role alcohol had played in his ill health, which she felt was insensitive.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that although the medical treatment provided to Mr C was appropriate, communication by medical staff fell below a reasonable standard. He said that they had not discussed with Mrs C the decision to designate her husband as 'Do Not Attempt to Resuscitate' (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). They had also not explained either his poor prognosis or the decision not to refer him for a liver transplant, contrary to General Medical Council guidance. The adviser said that the decision not to refer Mr C for a transplant was, however, in itself reasonable in the circumstances.

The nursing adviser said the standard of basic nursing care was reasonable, but the record-keeping of staff in ERU fell below an acceptable standard. They had not completed the falls assessment in a timely fashion and had not responded quickly enough to Mr C's first fall. It was not possible to be certain his second fall could have been prevented, but nursing staff had not taken the appropriate action, which was unacceptable. The adviser also said staff had not shown empathy or compassion to Mrs C while her husband was dying, and end of life care was a key part of the nursing and midwifery code.

We upheld most of Mrs C's complaints, as our investigation found that the nursing and medical care provided to Mr C fell below an acceptable standard. We did not uphold the complaint that he was not considered for a transplant.

Recommendations

We recommended that the board:

• apologise in writing for the failings identified in our investigation;
• ensure patients are provided with up to date information on their suitability for liver transplant referral;
• remind all nursing staff responsible for Mr C's care of the importance of communication with family members during end of life care;
• remind nursing staff in the ERU of the importance of ensuring records are accurate and contemporaneous;
• remind nursing staff in the ERU of the importance of the timely assessment and implementation of falls reviews;
• review their procedures for assessment and care planning for patients at risk of falls;
• review the handover process for ERU staff to ensure that it is being carried out appropriately;
• remind the medical staff responsible for Mr C's treatment that where a patient has been designated DNAR for medical reasons, the earliest opportunity should be sought to discuss this with the patient and their family; and
• remind the medical staff responsible for Mr C's treatment of the importance of discussing a patient's prognosis with them and their family at the earliest opportunity.

Summary

Mr C's daughter (Miss A) woke with an inflamed eye. She bought eye drops, but the symptoms got much worse overnight, and she woke the following day with pain, swelling and blurred vision. She went to A&E at Monklands Hospital, where anaesthetic was applied. A doctor examined her, identified a lesion (an area of damage) and said that as Miss A normally wore contact lenses, this would be treated with antibiotics not routinely stocked in A&E. The doctor spoke by phone to the junior ophthalmologist (eye doctor) on call, who said that Miss A should start using an ointment similar to the drops, but stronger, and arranged her an ophthalmology clinic appointment for the next morning.

When the anaesthetic wore off, the pain returned and Miss A contacted her father, who took her to an eye infirmary, where it was confirmed that she had bacterial keratitis (infection of the cornea - the transparent front part of the eye), and she was admitted for intensive antibiotic therapy. Mr C said hospital staff told his daughter that the delay in starting treatment had badly damaged her eye. Her treatment was continuing and if this failed to improve her vision, she might need a corneal transplant. Mr C complained about the care and treatment his daughter received at Monklands and about the way the board handled his complaint, saying they did not fully address it and blamed Miss A for the outcome of inappropriate treatment.

We took independent advice on this case from two of our medical advisers, specialists in emergency medicine and opthalmology, and upheld both complaints. Our advisers said that Miss A's symptoms and history should have triggered an immediate review by the on-call ophthalmologist, and that the decision to change her medication from drops to similar, stronger ointment and review her in 24 hours was not reasonable. We were critical that, given the information the doctor provided on the phone, the on-call ophthalmologist did not see Miss A as a matter of urgency, and that they advised her to use the ointment when the drops had not been effective. This led to a significant injustice to Miss A, who now has a degree of irreversible damage to her vision.

We found that the board completed their investigation and drafted a response without input from the relevant clinical expert. The investigation was not in line with the NHS complaints procedure, and they failed to address the main issues. There was an inference in the response that Miss A should bear some responsibility for what happened. We did not consider it reasonable for the board to suggest that, having been assessed in A&E and told to come back for a review, she should have returned a few hours later with the same symptoms and expected different treatment. The board in fact failed to consider whether the initial treatment was adequate, and we took the view that it was lack of ophthalmic care that led to the sequence of events. Miss A, quite reasonably, did not go to A&E the next day because when she discussed the problem with her family, they appropriately decided that her condition was not being adequately managed and reasonably sought medical care elsewhere.

Recommendations

We recommended that the board:

• ensure this complaint is raised with relevant staff as part of their annual appraisal and address any training needs;
• review their complaints process to establish when a complaint should trigger a significant event analysis in light of our adviser's comments;
• review the out-of-hours ophthalmic care at the hospital to ensure an adequate level of care is provided;
• ensure that the failings in complaints handling are raised with relevant staff; and
• apologise to Mr C for the failings our investigation identified.

Summary

Mr A was admitted to Monklands Hospital with abdominal pain and vomiting. He had a hernia operation, then suffered a heart attack a week later. Despite a range of treatment, he died due to the severity of the blockages in his arteries. Ms C, who is an independent advocate, then complained on behalf of Mr A's wife (Mrs A) that the board did not investigate Mr A's underlying heart condition during his many hospital admissions over the previous 18 months. Mrs A was concerned that her husband was at high risk of developing heart disease, but only had one appointment with a cardiologist.

In their response to the complaint, the board said that Mr A had been receiving treatment to control his risk factors, including advice about smoking, and medication prescribed to reduce the likelihood of a blood clot developing, and to lower his blood pressure and cholesterol. They said that during his previous admissions to hospital there was no indication that Mr A had a specific problem with his heart. His shortness of breath was thought to be related to his underlying lung disease, and his indigestion to a history of stomach ulcers.

We took independent advice on this case from one of our medical advisers, who is a cardiologist (a heart specialist). The adviser said that Mr A had a severe respiratory (breathing) disorder and that tests carried out on his heart did not show any problems that required him to be kept under regular review by a cardiologist. During the admissions to hospital, his heart was examined but no significant abnormalities were identified other than a fast heart rate which could reasonably be attributed to his respiratory problems. We did not uphold the complaint.

Summary

Mr C complained that his front tooth had been extracted unnecessarily and that his dentist had refused to provide him with the type of bridge work to replace it that he wanted. This was on the grounds that Mr C's oral hygiene was too poor to allow it to be carried out successfully, which Mr C disputed.

We took independent advice from a dental adviser. He advised that the x-ray of Mr C's tooth did not show a clinical need for removal. He said that the x-ray did not differ substantially from an x-ray taken a year earlier, and this showed there had been little change in the prognosis for the tooth. The adviser said the tooth should have been allowed to remain in place and then monitored for any further deterioration.

The adviser also noted that Mr C had, following a change of dental practice, been provided with the bridgework treatment he wanted. The adviser said that the clinical notes did not support the refusal to provide the type of bridgework Mr C requested, as the gum disease he had would have benefited from this type of treatment. He also said that the new dentist's decision to provide this treatment suggested that Mr C's gum disease should not have prevented the treatment being carried out.

We accepted this advice and found that Mr C had had his tooth extracted unnecessarily and should not have been refused the type of bridgework he requested to replace it.

Recommendations

We recommended that the dentist:

• issue an apology in writing to Mr C for the failings identified in our investigation;
• refund Mr C the cost of the extraction and the cost of the bridgework carried out by his new dentist as a consequence of the unnecessary tooth extraction;
• provide us with an undertaking that he will address the concerns raised in this complaint through his continuing professional development (including consideration of whether it would be appropriate to undergo refresher radiography training); and
• confirm that he will ensure that patients are informed of any conditions that may impact on their treatment and that these discussions are recorded in the patient's records.

Summary

Mr C complained that an out-of-hours (OOH) dentist had failed to provide him with appropriate treatment when extracting one of his teeth. He said that the dentist was unable to administer the anaesthetic competently, causing him unnecessary pain and discomfort. Mr C said that the extraction was also incompetent, causing the fracture of the tooth and damage to the adjacent tooth.

Mr C raised his concerns with the board, and they investigated his treatment. They found that the records of his appointment were too brief for the treatment to be assessed. They asked the dentist in question to voluntarily remove himself from the OOH rota until he had received training on his record-keeping. The board apologised to Mr C for his dissatisfaction with the treatment he had received and arranged for him to be reviewed by a senior member of the OOH dental service.

We took independent advice on the case from a dental adviser, who said that the standard of record-keeping was inadequate. Because of this, it was not possible to comment on Mr C's description of his treatment. The adviser said that the extraction was appropriate, given Mr C's symptoms and that in difficult extractions, damage could occur to surrounding teeth. There was no evidence from later treatment, however, that the extraction had caused damage. Our investigation found that although the record-keeping was inadequate, the board had taken action to address this before Mr C made his formal complaint. The lack of records did not allow us to comment on how Mr C's treatment was carried out, but we found that extraction was the appropriate treatment in the circumstances.

Summary

Mrs C told us that during a consultation on another matter she had mentioned to her GP that she had a lump on her thigh. She said the GP dismissed the lump as being of no consequence. She mentioned the lump again during a consultation three years later, after it began to grow. She was referred to hospital and was later diagnosed with a malignant tumour. Mrs C said she thought the GP was unreasonably dismissive of the concerns she had raised at the earlier consultation.

We found that there was no written record of the earlier discussion between Mrs C and her GP. The GP had no recollection of the consultation, but the practice had accepted Mrs C's account of the discussion. They said that the lump would not have been referred unless it was bigger than five centimetres, was deep or was increasing in size. They said that Mrs C's own account of the lump was that it was very small and had not changed during the three year period between consultations.

We concluded that the original decision not to refer Mrs C was reasonable and consistent with the guidance relating to the referral of lumps, and did not uphold Mrs C's complaint. Although it would have been best practice for the GP to record that discussion, in the circumstances we did not consider it unreasonable that they did not.

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.