Health

Summary

Mrs C 's late husband (Mr C) had a pancreatic cancer operation, and afterwards agreed to have chemotherapy treatment (a treatment that uses medicine to kill cancerous cells). She complained that the board had failed to tell her husband the true survival rate after chemotherapy. She said that had he been given full information of the survival rates he would never have contemplated having chemotherapy, the side effects of which had made him very ill. Mrs C also said that the board failed to conduct scans at appropriate intervals during Mr C's chemotherapy, and she was concerned that there was a delay in starting treatment for blood clots in his lung.

As part of our investigation, we obtained independent advice from one of our advisers, who is a consultant clinical oncologist (cancer specialist). After taking this advice, we found that it was appropriate for the board to offer chemotherapy, which does improve survival after surgery for pancreatic cancer. Our adviser explained that communicating information about this cancer is an extremely sensitive area, as death rates from it are very high. Most oncologists do not give patients the blunt statistics unless specifically requested and, given General Medical Council guidance on how to communicate with patients, this is appropriate. However, we were satisfied that, in line with good medical practice, Mr C was made aware that there was a high risk of recurrence and of the high risk nature of the disease, and that, on balance, consent for the treatment was appropriately sought. Our adviser also explained that routine scanning has not been shown to improve the outcome in such circumstances. An earlier scan would not have altered the fact that Mr C struggled with the side effects of chemotherapy, nor would it have shown any earlier that the cancer had come back. The adviser confirmed that Mr C was reviewed properly, and according to the appropriate cancer guidelines. We did not uphold these elements of Mrs C's complaint about her late husband's treatment. However, we found no evidence that Mr C was told about the likely side effects of the drug, or that his tumour markers (substances found at higher than normal levels in the blood, urine, or body tissue of some people with cancer) remained slightly elevated, and we made a recommendation about this.

Finally, the board accepted that, when the blood clots were identified, Mr C was not told about this immediately. Our adviser said that the delay in starting treatment for them did not affect his overall condition. We were, however, critical that there was a delay, and upheld this element of Mrs C's complaint.

Recommendations

We recommended that the board:

• review the guidance and revised consent form to satisfy themselves that adequate information about side effects and the risk of disease recurrence is given; and
• take steps to ensure there is no recurrence of such a delay in commencing treatment.

Summary

Mr A had been suffering from a number of serious medical conditions including lupus (an autoimmune condition that affects the body's defences against illnesses and infections). Mr A was discharged from hospital into the care of his medical practice. He was readmitted several days later, after a visit from an out-of-hours doctor, and died the day after readmission. Mr A's son (Mr C) complained that after Mr A was discharged from hospital there was a lack of reasonable care by the practice. Mr C was concerned that no doctor from the practice visited his father at home, despite both Mr A and Mr C speaking to different doctors there.

In response to the complaint, the practice said that they would not routinely visit a patient after they were discharged from a hospital unless there were special circumstances. They took the view that there were no urgent concerns about Mr A at that time. They had received Mr A's discharge summary from the hospital after he had already been at home for several days. Doctors in the practice had spoken with both Mr C and Mr A by phone, and with the district nurse who had been visiting Mr A at home, and the practice had arranged for a doctor to visit Mr A at home in the coming days for review.

We took independent advice about the complaint from one of our medical advisers. The adviser was of the view that the practice had not failed in their care of Mr A, and that the hospital discharge letter, received several days after Mr A's discharge, did not indicate any issue that needed a doctor to visit. In addition, the adviser said that the information that Mr A, Mr C and the district nurse gave the practice did not highlight anything suggesting that Mr A needed to be reviewed sooner than planned. We accepted the adviser's view that, from the information presented to the practice at the time, the care and treatment they gave Mr A after he was discharged from hospital was reasonable and appropriate.

Summary

After Mr C suffered blackouts and dizziness in 2009, a GP at his medical practice diagnosed hypertension (high blood pressure). Mr C said he made many visits to the practice after that with symptoms that including falling asleep involuntarily during the day. In August 2010, he told them that he was suffering numerous headaches, he felt dizzy and faint and felt he was going to collapse. In 2012, the GP prescribed an anti-depressant, saying that Mr C's problems were related to his mental health and that an appointment would be made with a psychiatrist. When abroad later that year, Mr C saw an ear, nose and throat surgeon, who diagnosed a number of problems, including hypertension and problems with his nose and airways linked to breathing difficulties. The surgeon referred Mr C to hospital there, where he was diagnosed with obstructive sleep apnoea (OSA – a sleep disorder). He said he was given medical advice, including that he should stop taking the anti-depressant as it was dangerous, given his condition. When he returned to Scotland and went to the practice, they stopped the anti-depressant medication. He told them about the diagnosis of OSA and was referred to a sleep clinic the following month.

Mr C complained that GPs at the medical practice failed to diagnose OSA in 2009. He said that they then continued to maintain that his condition was psychological, and unreasonably failed to accept the diagnosis of sleep apnoea. He said his life was put at risk because of the misdiagnosis.

We took independent advice on this case from one of our medical advisers, who is a GP. Their advice, which we accepted, was that the GPs at the practice acted reasonably in the way they approached Mr C's multiple symptoms. The diagnosis was, however, potentially delayed by the lack of good communication at all consultations, and the adviser noted some issues regarding Mr C's compliance with appointments and medication. This might have partly arisen through a lack of understanding because of language difficulties (English is not Mr C's first language). Although the practice tried to use interpreters in many of their consultations with Mr C, there was scope for them to improve their systems around this. It was, however, impossible to say whether the diagnosis would have been arrived at earlier had an interpreter assisted at all consultations. On balance, given the advice that the practice acted reasonably when responding to Mr C's symptoms, we did not uphold the complaint. However, given that more could have been done to provide an interpretation service for Mr C, we made a recommendation.

Recommendations

We recommended that the practice:

• review their process regarding interpreters and referral letters in the light of our adviser's comments.

Summary

Ms C complained about the treatment that she received from the board for heel pain (plantar fasciitis), and was unhappy with the advice and information provided in relation to this treatment. As Ms C was dissatisfied with the treatment offered by the board she attended a private podiatrist. After receiving treatment from them, she also complained that the board had not offered her that type of treatment.

While investigating the complaint, we took into account all of the complaints correspondence and Ms C's podiatry record. We took independent advice from one of our advisers, who is a experienced podiatrist. We found that the treatment and actions taken by the board were, in the main, appropriate and evidence based and followed best practice. We also found that there was no justification for the suggestion that the board should have offered Ms C the approach adopted by the private podiatrist, and that advice on heel pain management had been clearly presented. Although we did not uphold the complaint, we did make recommendations, as Ms C had not been examined and our adviser said that it would have been advisable for this to have happened, to rule out the possibility of another condition and to check that insoles purchased were the correct fit. We also took the view that information given to a patient should emphasise that medium to long term management of the condition is usually needed.

Recommendations

We recommended that the board:

• consider introducing a protocol, when attempting to manage plantar fasciitis without an examination of the feet, to ensure that any serious conditions that represent differential diagnoses are not missed;
• ensure that, when recommending that patients purchase insoles/orthoses for use in their shoes, the fit is checked by an appropriately trained professional; and
• consider amending the presentation given on the management of plantar heel pain to emphasise the fact that medium to long term management is usually required, along with anticipated time periods.

Summary

Mr and Mrs C's son (Master A) has numerous complex medical conditions and needs constant care. They complained about a number of issues, including the care and treatment provided to their son during a series of admissions to hospital. Their concerns included that their son was not observed frequently enough, signs of deterioration were not detected, medication was not given at the right time, he developed infections and there was a general failure to assess his cognitive ability or communicate with him.

Having taken independent advice from our nursing and medical advisers we found that, generally, the medical and nursing care provided to Master A was appropriate and demonstrated effective management of his symptoms and conditions. We did not find evidence of many of the concerns raised by Mr and Mrs C. However, we upheld the complaint on the basis that there was evidence that Master A had been left unattended in a cubicle and, as a child with a tracheostomy (an artificial airway), this was a potentially unsafe practice.

Mr and Mrs C also complained that the board failed to provide appropriate home nursing care for their son. However, we did not uphold that complaint as we found that the care package provided was in line with national guidelines for children with exceptional healthcare needs. We also found no evidence to reconcile a difference in opinion between the board and Mr and Mrs C about the number of nursing shifts that had not been covered.

Finally, Mr and Mrs C had complained that they were not involved in discussions and decisions about their son's care, and that staff at the board had victimised and bullied them. Again, we could not find evidence of this. We did find evidence of good levels of communication from the clinical and nursing staff involved in Master A's care - in terms of updating Mr and Mrs C, taking into account their views, and discussing care and treatment. Although we did not uphold these complaints, we pointed out to the board that some of the steps they had taken during the latter stages of their contact with Mrs C demonstrated potentially unreasonable restrictions.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C and Master A for failing to ensure Master A was supervised at all times; and
• remind staff who may be caring for children with tracheostomy of the need to ensure constant supervision of these children, with reference to the guidelines provided by Great Ormond Street Hospital.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A) about care and treatment provided by a dentist. Mrs A said that when she visited the dentist, he x-rayed her jaw and told her there was a gap in it, but it was nothing to worry about. However, Mrs A later found out she had a cancerous tumour which caused a break in her jaw bone, for which she needed treatment.

We looked at Mrs A's clinical records, and took independent advice from our dental adviser. We found that, based on the records, the dentist had provided adequate care and treatment in the circumstances. The dentist had told Mrs A that she had some bone loss in her jaw, and about the possible causes of mouth ulcers. He advised Mrs A to return after two weeks to check if her symptoms had improved. He had said that if the symptoms had not improved at the review appointment in two weeks' time, he would refer her to hospital for further investigations, which could include investigation for an oral tumour. However, even though the dental practice contacted Mrs A to arrange a review appointment, she did not return.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mrs A), who had injured her knee in a heavy fall whilst on holiday. She was taken to a local hospital, where the injury was treated as a sprain. She then returned home and went to the accident and emergency department of Wishaw General Hospital next day. Mrs A was assessed, but the swelling around her knee made a full examination impossible. Mrs A was reviewed there again five days later, and damage to her ligaments was suspected. She was referred to the orthopaedic (dealing with conditions involving the musculoskeletal system) fracture clinic for further assessment.

Mrs A was seen by an orthopaedic consultant, who considered it likely that she had a fracture of her knee cap, so the leg was put in plaster. Mrs A said that she repeatedly returned to the hospital, as the cast was causing her severe discomfort. She also said she repeatedly informed medical staff that her knee felt unstable and 'caved in'. Although Mrs A was first seen in July 2012 it was not until November 2012, when she started physiotherapy, that she was diagnosed with several torn knee ligaments, requiring surgical repair.

Mrs C complained to us that Mrs A’s knee was never properly examined and staff ignored her (Mrs A’s) concerns. She also said Mrs A had suffered needlessly due to the delay in diagnosing her injury and had lost income as she had to take time off work.

We took independent advice from an expert in orthopaedic and trauma surgery. He said that it was normal to wait until the swelling had gone down before attempting to examine a badly injured knee joint. He said, however, that the record of Mrs A's treatment was inadequate and there was no evidence that her knee was properly examined. Our investigation found that while the initial treatment Mrs A had received was reasonable, overall her care and treatment was not of an acceptable standard. We found that although this did not ultimately affect the outcome of her surgery, she had suffered pain and discomfort due to an avoidable delay in diagnosing her injury.

Recommendations

We recommended that the board:

• remind orthopaedic staff of the importance of a thorough, documented examination of an injury as clinically appropriate;
• apologise for the failings identified in our investigation; and
• remind staff of the importance of clear and detailed clinical record-keeping.

Summary

Mrs C's late mother (Mrs A) was admitted to Hairmyres Hospital on numerous occasions during 2012 due to heart problems. She was admitted from mid September to early October with unstable angina and, following admission to another ward a week later, she was under the care of a cardiologist (heart specialist) who thought she might have a chest infection and said that antibiotics should be prescribed. Mrs C said that while on this ward Mrs A was unable to eat and was prescribed large amounts of medication for heartburn and acid reflux. On the day of her discharge, Mrs A was seen by a dietician who noted that her food intake was poor and that Mrs A disliked hospital food. Antibiotics were not prescribed. Shortly after discharge, Mrs A's GP diagnosed her with a chest infection, and prescribed antibiotics. Mrs A was re-admitted to hospital by emergency ambulance three days after being discharged and died six days later. The death certificate stated the cause of death as infection of unknown origin, acute kidney injury (abrupt loss of kidney function), chronic renal impairment (gradual loss of kidney function), recent myocardial infarction (heart attack) and ischaemic heart disease (when the arteries narrow).

Mrs C complained that when Mrs A was discharged, she was already suffering from the infection that contributed to her death, and that communication by staff was inadequate. She was also concerned about what she described as the appalling meals being served to vulnerable people and said that it was unacceptable that families had to feed their relatives in hospital.

We found the board unreasonably failed to carry out a test and to prescribe antibiotic treatment, so we upheld this complaint. However, we noted the independent advice of our medical adviser who said that, although not prescribing antibiotics was a significant medical failure, even if they had been prescribed earlier they would not have had a significant effect on the outcome. Nonetheless, this caused a great deal of distress to Mrs C who was left with uncertainty about its impact on Mrs A's death. Problems with communication also meant that it appeared Mrs C and her family were unaware of how unwell Mrs A was during her second last admission to hospital.

In relation to the complaint about dietary requirements, we found no evidence of any shortcomings in respect of food and nutrition. Our investigation found that Mrs A was referred to a dietician at the right time, was seen within a reasonable time and that food and fluids charts were started when appropriate.

Recommendations

We recommended that the board:

• carry out a significant event analysis to address why a c-reactive protein test was not carried out, why antibiotics were not commenced and the communication failure; and
• apologise to Mrs C for the failures identified.

Summary

Mr C, who is a Member of Parliament, complained on behalf of his constituent (Mrs B) about the care and treatment that her father (Mr A) received at Kilsyth Victoria Cottage Hospital. The hospital is a rehabilitation facility, and medical cover is provided by GPs from a local medical practice. Mr A was admitted to the hospital because of general weakness and after having fallen at home. He remained there for approximately six weeks before being discharged to a nursing home. Mrs B was dissatisfied that her father was given dihydrocodeine (strong pain relief) for a chest infection, which she felt made him unwell. Mrs B also felt that her father was discharged from hospital too early.

In responding to the complaint, the board explained that the dihydrocodeine had been prescribed for pain relief and not for a chest infection. They also said that Mr A's discharge was appropriate as his observations (including his temperature, blood pressure, pulse and oxygen levels) were satisfactory.

We took independent advice on Mr A's case from our GP medical advisers. Our investigation found that the records made by medical staff about why dihydrocodeine had been prescribed were poor. The drug prescribing sheet recorded that it was prescribed for pain, but there was no record showing where the pain was located or how bad it was. However, the board provided further evidence that Mr A had sustained a fracture after falling several months earlier and was prescribed dihydrocodeine four times a day for this, indefinitely. We concluded that it was reasonable to prescribe dihydrocodeine and that the dosage was appropriately changed to an 'as required' basis, and so we did not uphold this complaint.

In terms of Mr A's discharge from hospital, we found a lack of detailed entries by the GPs to show that they assessed Mr A's condition properly during his admission, and that he was not reviewed by a GP on the day he was discharged, despite having had a high temperature for three days. We were critical of this, and also noted that although the board told us that Mr A's observations were satisfactory they also said that they were not within his usual range. We, therefore, upheld this complaint as we could not conclude from the evidence that Mr A's discharge was reasonable.

Recommendations

We recommended that the board:

• emphasise to GPs at the hospital the necessity of clearly recording the reasons for prescribing medication in the clinical records, and that the nursing staff accurately record a patient's level of pain;
• apologise to Mr C for the failings identified in our investigation;
• draw to the attention of medical staff at the hospital the importance of ensuring discharge paperwork has been checked and signed by medical staff; and
• carry out an audit of clinical records at the hospital to ensure the medical staff are recording sufficient information regarding a patient's medical history, general condition and examinations carried out.

Summary

Mrs C complained about the care and treatment that her late mother (Mrs A) received in Belford Hospital. Mrs A had been admitted to hospital after collapsing. She was discharged home some fifteen days later with a package of care, and was later moved to respite care. Her condition, however, deteriorated and she died about a month after being discharged home. Mrs C said that hospital staff did not encourage Mrs A to eat or drink; did not tell her if Mrs A had a urine infection while she was in hospital; did not go through the discharge medication with her, and discharged Mrs A before she was ready.

We took independent advice on this complaint from our nursing adviser, who said that hospital staff had taken reasonable steps to encourage Mrs A to eat and drink, and there was no evidence that she had a urine infection. We also found that, taking into account the detailed notes and the fact that Mrs A was medically fit for discharge, it had been appropriate to discharge her home with a package of care in place. We found that, on balance, the level of communication with Mrs C had been reasonable. Although there was no record that the discharge medication was explained to Mrs C, this would not always be recorded. In view of all of this, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that a community nurse's actions in respect of Mrs A's catheter (a thin tube used to drain and collect urine from the bladder) were unreasonable. Mrs A had a long-term catheter and this meant that there was a high risk of urinary infection. Good hygiene and prevention were, therefore, important. Mrs C said that the community nurses failed to change the catheter when it was reported to be badly blocked with sediment.

We found that a catheter care plan had been completed, which was good practice, and a good record of the care required. Our nursing adviser also said that community nurses had provided good care in relation to the catheter and had followed the guidance in the care plan. Changing the catheter when it was initially noted to have a lot of sedimentation might have caused further trauma, distress and a higher risk of infection. We considered that the care and treatment by the community nursing team in relation to the catheter had been reasonable.