Health

Summary

Mrs C's late father (Mr A) saw a GP at his medical practice about, amongst other things, a cough. He had a chest x-ray, the results of which were normal. Some seven months later, in June 2012, he had three further consultations at the practice about chest problems and a persistent cough, and a further chest

x-ray, taken after the third appointment showed an abnormality in the lung. After collapsing and being admitted to hospital, Mr A went to the practice again in July and was referred urgently to the respiratory clinic because of his persistent cough. Mr A also attended a cardiology (heart) clinic where a scan was arranged. The clinic told the practice that the scan showed that Mr A might have a pulmonary (lung) tumour. The respiratory clinic then found that the scan showed metastatic malignancy (cancer that had spread) in his lung. They wrote to the practice about this and said they had not discussed the potential diagnosis with Mr A but had told him that there was a shadow on the lung that needed investigation. Several weeks later Mr A saw a GP, who did not explain the result of the scan but wrote in the medical notes that Mr A was aware that cancer was a possibility. Mr A was then referred to oncology (cancer specialism) and at the end of October a cancer nurse told the practice that Mr A had now been told his diagnosis. After this Mr A asked the practice for an appointment but they told him they could no longer treat him because he had moved out of their area. Mr A died shortly afterwards.

Mrs C complained that the practice did not provide reasonable care and treatment to her late father. She said that they did not carry out appropriate investigations and/or tests within a reasonable time and failed to communicate with him and his family about his diagnosis. Mrs C was also concerned that the practice refused to treat him after he moved house, although he had been a patient there for over 25 years and they were well aware of his medical history.

We took independent advice on this case from one of our medical advisers, who is a GP. Our adviser said that the failure to refer Mr A for a chest x-ray after his first two consultations in June 2012 was not reasonable and did not follow the guidelines for referral in such cases, although his care after the chest x-ray was eventually carried out was of a reasonable standard. The adviser also said that the practice's communication with Mr A was reasonable, and that it was the responsibility of hospital doctors to tell him about test results and treatment plans. We recognised how distressing it must have been for Mr A and his family waiting for results and a definitive diagnosis, but noted that the practice was not responsible for telling Mr A about these. Turning finally to the practice's decision not to treat Mr A after he moved house, our adviser said that while the practice acted correctly as far as the terms of the GP contract were concerned, they did have discretion to keep Mr A on their list on compassionate grounds if this was geographically feasible. In the circumstances, while accepting this was for them to decide, we took the view that the practice should have given more consideration to keeping Mr A on their list. Given this, and the failure to arrange a chest x-ray within a reasonable time, we upheld Mrs C's complaint.

Recommendations

We recommended that the practice:

• ensure that the GP who saw Mr A at his first two appointments in June 2012 discusses this complaint and findings as part of their annual appraisal and that the diagnosis and management of lung cancer forms part of their learning needs;
• consider their approach to de-registering patients in light of this case; and
• apologise to Mrs C for the failures identified.

Summary

Mrs C's late father (Mr A) had moved house just as he had been given a diagnosis of terminal lung cancer. Because of this, he had de-registered from his previous medical practice, and registered as a new patient at the medical practice about which the complaint was made. The GP there noted the cancer diagnosis, and compiled a full summary of Mr A's medical history. The GP also referred him to hospital that day as he was acutely unwell. After his discharge, he was seen twice by GPs at the practice, and in the following month he was again admitted to hospital. He was discharged shortly after to the care of his GP and district nurses. The next month, Mr A was admitted again, by emergency ambulance. This time, when he was discharged his consultant advised the practice that any future admission should be to a hospice. Shortly after this, a GP visited him at home and noted how Mr A and his family were struggling and that the situation was difficult and stressful. The GP arranged a hospice bed for the following day and noted in the records that Mr A's wife (Mrs A) and family were happy with this plan. A specialist nurse also visited and, with the GP, provided specialised pain relief equipment. Mr A was admitted to the hospice the next day, and passed away during the early hours of the following morning.

Mrs C complained about the end of life care provided to Mr A and that GPs showed a lack of care and empathy. She was unhappy that, after hospice care had been arranged, Mr A could not be admitted until the next day. She also told us that Mrs A was very distressed that during the time with the practice she had to explain her husband's medical history to a number of GPs. Mrs A had said that several of them appeared to have failed to read his clinical notes before visiting.

We took independent advice on this case from one of our medical advisers. The adviser said that the practice provided a reasonable standard of care to Mr A in relation to pain relief and support. We noted that events on the day before he was admitted to the hospice appeared to have been extremely distressing for all involved, and in particular for Mr A and his family. However, the adviser said that the GP took all reasonable measures to secure a bed for him, and we were satisfied that there was nothing more that she could have done.

In relation to Mrs C's complaint that Mrs A had to tell visiting GPs about her husband's medical history, the practice said it was standard practice to question patients. Our adviser said that, in this respect, they provided a reasonable standard of care to Mr A. Given this, we did not uphold the complaint. However, clearly Mrs C and her family were extremely distressed by their experience and we drew the adviser's comments about the practice giving consideration to changing the way they provide palliative care to the practice's attention.

Summary

Miss C complained about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with acute appendicitis. She complained about a procedure that was carried out when her wound became infected and was reopened on the ward several days after surgery. Miss C complained that excessive force was used during the procedure and that her pain was not adequately managed. She also complained about the level of scarring she suffered, and said that the board failed to explain the procedure or obtain her consent for it, and had failed to respond appropriately to her complaint.

We took independent advice from one of our advisers, who is a consultant surgeon. There was no evidence to allow us to comment on how much force was used or about the management of Miss C's pain, although there was evidence of three types of pain relief being prescribed that day. Our adviser said that it was reasonable for the procedure to be carried out on the ward without anaesthetic, as local anaesthetic is much less effective in infected tissue. He also said that it would be expected that staff would consider, as part of the implied consent for the procedure, whether it would be appropriate to provide pain relief in advance. He said that there was no need for this consideration to be documented. We also found that it was unlikely that the procedure was the source of the scarring that Miss C suffered, which was more likely to result from the wound infection. We did not, therefore, uphold her complaint that the procedure was not carried out appropriately.

Although our adviser said that written consent was not required for this type of procedure, we upheld Miss C's complaint about failure to explain, as we were concerned that she was not given enough information on how the procedure was to be carried out. We did not make any recommendation as the board had already taken action to address this for the future.

Finally our investigation showed that, while the board's initial response failed to address all of the issues Miss C raised, they had later met with her and provided a further response. We did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that the senior specialist registrar reflects on how implied consent is taken and how it might be recorded; and
• ensure that the senior specialist registrar reflects on this episode to guide future practice in relation to the consideration of a patient's comfort, analgesia and overall experience of care.

Summary

Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the healthcare team, and between staff and Mr A and the family.

In November 2012 Mr A was admitted to hospital for treatment of blood clots in his wrist and arm which were surgically removed. After five days in hospital Mr A was discharged. Mrs C came to collect him but, as they were leaving the ward, Mr A fainted. He was re-admitted and discharged again four days later. Two weeks after the second discharge Mr A was admitted again to treat an infection in his arm where he had had the surgery. This time he was in hospital for five days before being discharged.

Our investigation, which included taking independent advice from our medical and nursing advisers, found that both discharge decisions had been reasonable, in that Mr A was clinically stable and the various investigations and observation results were within the normal range. Both advisers commented that Mr A's collapse on leaving the ward following the first discharge could not have been predicted, as it was due to his existing heart condition, which could cause sudden and unpredictable symptoms.

On the matter of communication, however, we did find some failings. Both advisers expressed concern at some of the verbal and written communication, and in particular about an event when Mr A was taken alone by ambulance to the hospital's emergency department. Ambulance staff had noted that he was confused and unsteady on his feet. When he arrived at the hospital Mr A was reviewed by a triage nurse (who assesses a patient's condition and the urgency of treatment required) who noted that he had dementia. Despite this, he was moved several times during the 80 minutes he spent in the emergency department, and our medical adviser said that this would have added to Mr A's confusion. In addition, when he was moved there was no evidence that information about him was shared between members of the healthcare team. Mr A later left the department unaccompanied and arrived home as Mrs C was preparing to go to hospital to see him. Although a staff member had seen Mr A leaving alone in a taxi, no one had contacted Mrs C to alert her to this.

Recommendations

We recommended that the board:

• apologise for the failings identified in our investigation;
• consider putting in place a protocol for the monitoring and supervision of dementia patients within the accident and emergency department; and
• feed back to the staff involved in this complaint the importance of effective communication between staff and patients' families / carers.

Summary

Mrs C complained that when she was in labour in the Royal Infirmary of Edinburgh, a doctor conducted an intimate examination without introducing herself or obtaining Mrs C's consent for the examination. Mrs C also complained that the examination was very painful, and that although she asked the doctor to stop, she did not do so right away. The doctor told Mrs C that she needed a forceps delivery (where a specially designed instrument is used to assist with the delivery of the baby) and would need to go to theatre. The baby was successfully delivered but Mrs C had been hoping for a natural birth and complained that she was not offered any alternative options.

Mrs C wrote to the board three months after the birth to complain about her care and treatment. Although the letter of complaint was acknowledged promptly, she then waited almost three months for the response. Before she received the response, Mrs C brought her complaint to us. She also complained that, while she was still waiting for the board to respond, she had to attend an out-patient appointment. She was upset to be met there by the doctor about whom she had complained. We also investigated this additional complaint.

Our investigation included taking independent advice from a consultant in obstetrics and gynaecology. We upheld Mrs C's complaints about her care and treatment during the delivery. The adviser was of the view that Mrs C had been unable to give informed consent for the examination or the forceps delivery, due to her level of pain and distress and the lack of information about alternative options. The adviser was also critical that, when asked to do so, the doctor did not immediately stop examining Mrs C. The adviser considered that there was no immediate danger to Mrs C or her baby at the time of the decision about forceps delivery, and said that she should have been given time to have additional pain relief and then consider all the options, including no treatment or intervention.

On the matter of the out-patient appointment, the NHS guidance on complaints handling says that information about complaints should not normally be kept in a patient's clinical records. Because of this, neither the board nor the doctor concerned could have anticipated that Mrs C would been seen at the clinic by the doctor about whom she had complained. When the doctor realised who Mrs C was, she arranged for her to be seen by the consultant instead. That was appropriate and we did not uphold this complaint.

In regard to the delays in complaints handling, the board acknowledged the delay and that Mrs C had not been kept informed about this or about the reasons for it. We upheld this complaint, but noted that the board have since made changes within the complaints department.

Recommendations

We recommended that the board:

• ensure that all relevant staff are reminded of the guidance on taking consent from women in labour (in particular the need to record oral consent) and, where necessary, provide refresher training;
• provide a copy of our decision to the doctor involved to allow her to reflect on her practice in relation to the complaints and discuss any learning points at her next appraisal;
• provide the Ombudsman with evidence to demonstrate that the changes put in place within the complaints department have improved response timescales; and
• issue a written apology for the failings identified during this investigation.

Summary

Mr C, who is a prisoner, complained that on three separate occasions the prison health centre supplied his medication late. He was also unhappy with the way in which his complaint about this was handled.

We took independent advice on this complaint from one of our medical advisers. Our adviser said that, although he might potentially have suffered some pain, the delays would not have had a negative impact on Mr C's medical condition. We noted this, but decided that the overall delays he experienced were unreasonable. In addition, although Mr C was given an extra supply of medication in case this happened again, we made recommendations as we took the view that the board should take further action.

Our investigation also found that the board did not follow Scottish Government guidance on the NHS complaints procedure when handling Mr C's complaint. He was told he had to complete a feedback form before being allowed access to a complaints form. By not providing a complaints form on request, the board made Mr C go through an unnecessary additional stage before he could complain. In a separate complaint that we determined last year, we recommended that the board ensure that local complaints processes were in line with the Scottish Government guidance. The board provided us with evidence to show that they had since implemented this (from 1 November 2013) so we did not make a recommendation about that in this case.

Recommendations

We recommended that the board:

• review their procedures for acquiring and supplying prescribed medications, to reduce the likelihood of delays occuring in the prison; and
• apologise to Mr C for failing to handle his complaints appropriately.

Summary

Miss C complained that the medical and nursing care and treatment provided to her late mother (Mrs A) was inadequate. She also complained about inadequate communication between staff and her late mother and the family. Mrs A was admitted to hospital suffering from a blood clot in the intestine which then caused problems with her bowel. She had surgery several times while in hospital and was transferred to the intensive care unit (ICU), where she died some three weeks after being admitted.

In relation to the medical treatment, Miss C complained that when Mrs A was taken into hospital with sudden abdominal pain, there were delays in obtaining a diagnosis; in undertaking investigations; and in addressing her level of pain. Miss C also complained that it was unreasonable to have transferred Mrs A from the Accident and Emergency department to the Surgical Observation Unit before transferring her to an in-patient ward. During our investigation we took independent advice from one of our medical advisers, an experienced surgeon, who was of the view that Mrs A's medical care and treatment had been reasonable. The blood clot had caused tissue in Mrs A's intestine and bowel to die, and the adviser said that diagnosis of this condition is largely one of elimination of possible causes and that there had been no unreasonable delays in investigating and treating Mrs A's condition. The adviser said that the condition can be very painful but that strong painkillers can mask physical symptoms and so it was not unreasonable that it took some time to get Mrs A's pain under control. We did not, therefore, uphold Miss C's complaints about her late mother's medical treatment.

In relation to the nursing care and treatment, we also took independent advice from our nursing adviser, who had concerns over some of the issues Miss C had raised. In particular she was concerned about monitoring and observations, record-keeping, pain scoring, and communication by nursing staff. There were also problems with the communication of a decision to reverse a Do Not Attempt Resuscitation decision (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart stops) from medical staff. While the medical adviser was satisfied that both the original DNAR decision and the reversal decision were appropriately taken, only the original decision was discussed with the family. While such decisions are clinical ones and do not require approval or consent from the patient or family, it is good practice to discuss these issues where possible. Overall, we upheld Miss C's complaints about nursing care and communication.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the failings identified during this investigation;
• provide evidence that the standards of record-keeping meet the required professional standards across the wards/units involved in this complaint and, where necessary, provide training to meet these standards;
• ensure that there are robust systems for handover between the clinical departments identified when patients are transferred;
• ensure that the knowledge and skills of the nurses involved in this complaint when performing clinical observations, including pain assessments, meet the relevant local guidance;
• ensure that staff on the ICU ensure that alternative support strategies are in place for families/carers when visiting arrangements are reviewed; and
• remind all staff involved in this complaint of the importance of good communication between staff and patients and their families/carers.

Summary

Miss C's partner (Mr A) was admitted to Wishaw General Hospital with increasing shortness of breath, coughing and wheezing. Medical staff diagnosed that his chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed) had got worse and that a toe on which he had recently had surgery might be infected. The next day, Mr A's condition deteriorated abruptly. He had central chest pain and was very wheezy. As there was no intensive care bed available in the hospital, he was transferred to the intensive care unit of another hospital, where he died two days later.

Miss C complained that the board provided Mr A with inadequate care and treatment. We took independent advice on her complaint from one of our medical advisers. The adviser noted that when Mr A was admitted, it was recorded that he had previously been admitted to the high dependency unit in the hospital with breathlessness. Miss C considered Mr A should also have been admitted to the high dependency unit on this occasion. However, our adviser said that it was reasonable not to admit him there, as his condition had been stable at that time. Staff took Mr A's existing health problems into account and the care and treatment provided to him was reasonable and appropriate. A doctor acted correctly in reducing the amount of oxygen delivered when there were signs of a deterioration in Mr A's respiratory function. It was also appropriate for a consultant anaesthetist to intubate and ventilate (pass a tube into the airway and place on a mechanical ventilator to assist with breathing) Mr A in response to his vomiting and low oxygen saturation levels.

Miss C also complained that staff had failed to communicate with Mr A's family adequately. She said that they had not contacted her to let her know that Mr A's condition had deteriorated. However, we found that his deterioration coincided with Miss C's arrival at the hospital to visit him and there had not been time for staff to contact her before this. We did not consider that there were any major failings in the initial period of communication with the family. However, communication with them was not satisfactory when Mr A was stabilised and awaiting transfer to the other hospital's intensive care unit. We also found that the board had delayed in responding to Miss C's complaint. Although we upheld these complaints, we made no recommendations as we were satisfied that the board had apologised and had confirmed that lessons had been learned.

Summary

Mrs C complained about orthodontic treatment (dentistry dealing with the prevention and correction of irregular teeth) provided to her son (Mr A). Mrs C was of the view that the treatment left Mr A with an underbite (a condition in which the lower teeth and jaw protrude in front of the upper teeth) and no continuity between his top and bottom teeth.

We took advice from our orthodontic adviser. He advised that the treatment provided had focused solely on Mr A's upper jaw. This was reasonable as the rate of growth in the lower jaw was unpredictable. The orthodontist who treated Mr A was entitled to take a view on whether treatment to Mr A's lower jaw was appropriate. Our investigation found that the care and treatment provided to Mr A was reasonable and that the growth of his lower jaw could not have been affected by orthodontic treatment, making it impossible for the development of his underbite to be prevented.

Summary

Mr C complained that his wife (Mrs C) sustained injuries while she was a patient in Wishaw General Hospital. Mrs C suffered from dementia and normally lived at home. She was in hospital for some seven months, during which she fell several times, sustaining minor injuries, and was involved in a series of incidents with other patients or visitors to the ward. Towards the end of her stay in hospital, Mr C was helping his wife to change when he noticed bruising on her back, which he considered could only have come from punches. When he reported this to a staff nurse, it became apparent that no staff member had reported these injuries. One nurse had seen - but had not reported - them, assuming someone else would already have done so.

Our investigation found that there were failings in the assessment and monitoring of Mrs C's falls risk; vulnerable adult safeguarding; record-keeping and communication with the family. Although staff took appropriate action after Mrs C fell, there was no evidence that they told her family on these occasions, and it was entirely inappropriate that no-one reported the bruising on Mrs C's back. Mrs C was a vulnerable adult and staff should have taken appropriate action to report and record this, as reflected in the board's own guidance. It was not, however, possible during our investigation to establish how Mrs C had sustained these injuries.

Our investigation found that the board had investigated Mr C's concerns and had acknowledged the failings that our investigation confirmed. They had already taken some reasonable remedial action so we made recommendations aimed at confirming that this had been effective.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that all aspects of the remedial action plan formulated after the internal investigation have been implemented or are progressing within reasonable timeframes; and
• provide the Ombudsman with reassurance that all staff involved with caring for vulnerable adults have the knowledge, skills and training to recognise, raise and respond appropriately to safeguarding issues.