Health

Summary

Miss C was unhappy with the care and treatment that her late mother (Mrs A) received from district nurses in the weeks prior to her death, and in particular in relation to pressure ulcers (bed sores).

As part of our investigation, we took took independent advice from our nursing adviser, and carefully considered all the complaints correspondence and Mrs A's clinical records. We recognised how distressing this had been for Miss C and her family, but our investigation did not find that there had been any failings in the care or treatment provided to her mother. Our adviser said that that this had been of a good standard and was in keeping with current standards and guidance.

Summary

Ms C complained that the care and treatment she received from her dentist on two occasions was unreasonable, both when a temporary filling was inserted into a tooth in her lower jaw, and when she attended a week later for a permanent filling. Ms C said that from the time the temporary filling was applied she felt sick and had a bad taste in her mouth. She also said that part of it broke off, and she swallowed it, after which she also experienced stomach problems. When she went for the permanent filling, she said the dentist injected a local anaesthetic but then did not wait long enough before starting to work on her tooth. When she complained of pain, the dentist injected her again, leaving her face temporarily paralysed on one side, so that she could not close her eye.

Our investigation included taking independent advice from one of our dental advisers, who said that the material (Cavit G) was widely used for temporary fillings, and was approved by the relevant regulatory authorities as being safe for use. The adviser said that it was reasonable and appropriate for the dentist to use this in Ms C's case, but that, very rarely, a few patients report similar side effects to those Ms C experienced. The adviser was unable to say whether Cavit G was the direct cause of these in Ms C's case, and noted that the dentist had provided Ms C with a list of its ingredients to take to her GP if the symptoms continued.

In terms of what happened with the permanent filling, the adviser explained that local anaesthetic in the lower jaw has to be placed close to the facial nerve and usually takes between two and four minutes to work. However, as the dentist cannot see the facial nerve, and each patient's physiology is different, the placing of the injection can only be an educated guess. This can sometimes mean that a second injection is needed in a slightly different place, which can have the effect of temporarily paralysing the facial nerve. The adviser found no evidence that the dentist's treatment had been unreasonable, and noted that they had offered Ms C an eye patch that day to cover her eye, and had phoned the next day to ensure she had recovered. The notes said that Ms C had told them she was fine, and that the paralysis had worn off by the time she arrived home on the day of the appointment.

Summary

Mr C, who is a prisoner, complained about the management of his sleep disorder by the prison health centre team. He was unhappy that his zopiclone (a drug used to treat sleeping problems) prescription was reduced and stopped. In addition, Mr C said that an alternative drug he was given did not agree with him as he was also on methadone (a drug substitute for heroin).

After taking independent advice from one of our medical advisers, we found that the health centre team acted reasonably in reducing Mr C's zopiclone, as it is a drug that is licensed for short term use of insomnia. Mr C was aware of this at the time it was first prescribed. There was also evidence to show that Mr C was reviewed appropriately and told of the need to reduce the zopiclone prescription on more than three occasions.

Summary

Mr C had surgery at Inverclyde Royal Hospital in July 2011 to fix a finger flexion (where one or more fingers start to bend into the palm of the hand) of the right little finger. Afterwards, Mr C was given a splint for his finger, and started physiotherapy. In early August, the surgeon noted that the wound had healed. Mr C was discharged from physiotherapy later that month. The discharge report was, however, dated early October. It outlined the physiotherapy treatment provided, said that the range of movement had worsened and noted that Mr C was happy to continue with exercises at home. In September, the surgeon saw Mr C and noted that his little finger had stiffened up dramatically, and had no movement at the middle joint. His ring finger joint had also stiffened. The surgeon also noted that Mr C had returned to work and had stopped wearing a splint at night. Mr C was referred to a hand therapist and for further splinting, which did not take place, and he then sought a second opinion.

Mr C complained to us that he cannot use the finger, and another finger is now bent over. He said that within weeks of starting physiotherapy, the physiotherapist advised him that nothing more could be done and discharged him to the care of the surgeon. Mr C said he is now in constant pain and may have to have further surgery. He said that he believed the operation was not successful.

We took independent advice on Mr C's complaint from one of our medical advisers. The adviser said that from the evidence available it appeared that the operation was carried out to a reasonable standard, noting that the surgeon believed that the operation was successful, but that Mr C's post-operative rehabilitation was poor. The adviser outlined a number of factors that might explain this, including pre-existing arthritis at the middle joint of the finger; a complication of the operation; a lack of physiotherapy from the end of August, and failure to wear a splint for the recommended period. We noted that Mr C said that he wore the splints as instructed and that the physiotherapist discharged him saying she could not do anything further. The board said that he declined further physiotherapy, but were unable to substantiate this. Moreover, we found that it was some six weeks before the physiotherapist told the surgeon that Mr C's range of movement had worsened, and that physiotherapy had stopped. Our adviser was concerned about this, given its importance to a positive outcome. We recognised that the operation itself appeared to have been carried out appropriately, and that there were a number of factors that could explain the poor outcome Mr C experienced. However, we upheld his complaint because there was no evidence to support the board's view that it was Mr C's decision to stop physiotherapy, and because of the shortcomings in communication between the physiotherapist and the surgeon.

Recommendations

We recommended that the board:

• review their practice relating to the storage of patients' medical records to ensure it accords with the Scottish Government Records Management: NHS Code of Practice (Scotland); and
• ensure the failures identified are raised with relevant staff.

Summary

Mrs C had undergone knee replacement surgery at Woodend Hospital. She was not offered immediate physiotherapy treatment on discharge. At an orthopaedic (involving the musculoskeletal system) out-patient clinic appointment six weeks later, a consultant arranged for out-patient physiotherapy and a further clinic review in six weeks. Mrs C felt that she should have been offered physiotherapy appointments immediately on discharge from hospital, rather than continuing with exercises arranged by the in-patient physiotherapist. The board explained that their standard procedure is that in-patient physiotherapy advice is provided before discharge, and the patient should continue with these exercises until the six week clinic review.

We took independent advice from one of our medical advisers, who said that it is expected that patients would normally follow the exercises set by the in-patient physiotherapist for a period of rehabilitation and then discuss their condition at the orthopaedic out-patient clinic. We found that the practice of not arranging out-patient physiotherapy appointments until after a patient has attended the six week clinic review was accepted practice throughout the NHS and did not uphold Mrs C's complaint.

Summary

Ms C went into premature labour and was taken to Aberdeen Maternity Hospital as an emergency. She said that, after admission, staff failed to manage her labour and delivery properly, as a consequence of which her daughter was deprived of oxygen and suffered serious brain injury. Ms C also said that when she made a formal complaint about this, the board failed to deal with it properly.

During our investigation, we took into account all the relevant documentation, including the complaints correspondence and the clinical records. We also took independent advice from a consultant obstetrician and an experienced midwife.

We upheld Ms C's complaints. We found that the board delayed in dealing with Ms C's complaint, and that the evidence showed that her labour was not managed reasonably, as there had been some delays by nursing staff in seeking medical assistance and Ms C should have been transferred to a labour ward earlier than she was. However, despite these failings, we found no evidence to suggest that Ms C's baby should have been delivered sooner, or that care was compromised.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified by the investigation and in particular that they did not keep Ms C updated about her daughter and failed to change her soiled bed;
• remind staff of the necessity and importance of keeping accurate and timely records and of their responsibility for signing them and detailing the reasons for any amendments. Midwifery staff should also be reminded of the NICE Clinical Guideline 5 and Nursing and Midwifery Guidance;
• provide details of the action they have taken in order to resolve the communication issues which existed and which were acknowledged by the chief executive; and
• remind staff of the necessity of adhering to their stated complaints policy.

Summary

Mr C, who is a prisoner, submitted a request to the prison health centre for an appointment with the mental health team. This was on the advice of the forensic psychologist who was running the offending behaviour programme that Mr C was attending. As Mr C did not receive a response to his request, he complained to the health board. The board told him that the mental health team had assessed his request and decided that he did not need input from them. Mr C did not dispute this decision, but complained to us that the board had not told him about the decision when it was made.

In response to our investigation, the board told us that due to staff shortages in the prison health centre there had been a backlog of referrals at the time Mr C submitted his request. This meant that it was not assessed until almost six weeks later. They confirmed the decision that had been taken but acknowledged that this did not appear to have been communicated to Mr C until he complained. They explained that a reply slip should have been issued, informing Mr C of the decision, and confirmed that they had reminded staff to adhere to this process in future. They also took steps to speak to Mr C and apologise to him. We upheld the complaint, due to the failure to communicate the outcome of the referral to Mr C, but in light of the action already taken by the board to address this, we had no further recommendations to make.

Summary

Mrs C's mother (Mrs A) died from complications following surgery for an abdominal aortic aneurysm (bulging of part of the aorta, the body's largest artery). Mrs C complained that there was a delay in diagnosing the aneurysm (a weak point in the blood vessels, which causes them to bulge or balloon out). She said that her mother had been visiting the practice for two years and had been diagnosed with sciatica (back and leg pain, caused by irritation of or pressure on the sciatic nerve). However, she felt that her mother should have been referred to hospital earlier for further tests. She also complained about the follow-up care after her mother had surgery, in particular a delay in identifying post-operative complications.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from one of our medical advisers.

Our investigation found that the practice had acted reasonably, and that there was no evidence of an unreasonable delay in referring Mrs A to hospital for tests. Our adviser said that there was no evidence of specific symptoms that would have alerted the practice to an aortic aneurysm, and that it was in fact picked up by chance during an x-ray to investigate back pain. She also said that as there are usually no symptoms, such aneurysms are often not discovered until they leak or burst. Once the aneurysm was identified, appropriate action was taken to investigate it further and to resolve it. We also found no evidence that the practice had failed to assess Mrs A after her operation or that there was a delay in diagnosing the post-operative complications. The operation was clearly a risky one, as Mrs A had other health conditions. The medical records show that the procedure was complicated, and we noted that doctors had discussed the risks with Mr and Mrs A (Mrs C's parents) before the operation was carried out.

Summary

Mr C's late wife (Mrs C) had chronic obstructive pulmonary disease (a disease affecting the lungs). She was admitted twice in one month to Forth Valley Royal Hospital with pneumonia and treated with antibiotics. The following month she was admitted for another two days with vomiting and diarrhoea. During this last admission, tests showed abnormal temperature and blood results. On the day of her discharge, Mrs C felt very unwell and an advanced nurse practitioner found a wheeze in her right lung, but the consultant who reviewed Mrs C decided to discharge her. Mrs C's condition continued to deteriorate and she was admitted to another hospital five days later where pneumonia was again diagnosed. After being discharged from there, she developed a severe infection and irregular heartbeat and was diagnosed with an inflammatory condition of the bowel. She sent us her complaint but died before we could investigate it, and her husband carried it on on her behalf.

Mr C complained that the consultant's decision to discharge Mrs C after the episode of vomiting and diarrhoea was unreasonable in light of her symptoms, and said that further investigations should have been carried out. He also complained that the advanced nurse practitioner's findings were unreasonably dismissed and that these failures led to a prolonged period of suffering for Mrs C before she was properly diagnosed and received appropriate treatment. Finally, Mr C complained about the board's complaints handling.

We took independent advice on Mr C's complaint from one of our medical advisers, who agreed that Mrs C's discharge should have been delayed for further investigation of her symptoms, and of the abnormal temperature and blood test results. We found that Mrs C was discharged with no clear diagnosis and that she endured symptoms for longer than she should have before she was diagnosed and treated appropriately. The adviser said that the consultant who discharged Mrs C had to make a difficult decision, and was seeing Mrs C for the first time. He said that responsibility for the decision should be viewed as an overall system failure involving several healthcare professionals who had been responsible for Mrs C's care.

We found that the board at first failed to fully respond to the complaints, but then fully addressed them after receiving a further letter from Mrs C. We appreciated that Mr C disagreed with the board's response and, as indicated above, we reached a different view to that of the board on the reasonableness of Mrs C's discharge. However, that is not evidence in itself of administrative fault by the board in their complaints handling, and we were satisfied that the board's interpretation of the complaints was reasonable. We, therefore, found that on the whole the board reasonably investigated the complaints.

Recommendations

We recommended that the board:

• review the ward round procedures to investigate and address why medical staff were unaware of Mrs C's temperature and why it was not discussed;
• review the investigation process to ensure that abnormal results are highlighted and considered; and
• apologise to Mr C for the failures identified.

Summary

Ms C, a former prisoner, complained that while in prison her pain relief medication (pregabalin) was stopped suddenly. This was after a spot check of medicines found that she had removed powder from the capsules and not taken them as instructed. Ms C had been prescribed pregabalin for pain caused by nerve damage, and told the prison health centre that she had taken extra medication to help her cope with difficult family circumstances. She also said that she was unable to appropriately progress her complaint through the NHS complaints procedure.

We took independent advice on this complaint from one of our medical advisers. Although we found that the prison health centre doctor had noted that Ms C had not demonstrated objective neuropathy (nerve damage), it appeared from the records that the stopping of her medication was influenced by her interference with the capsules (Ms C had been given a warning two months earlier to be more careful with her medication). Our medical adviser said that pregabalin can also be used to treat anxiety, and explained that a patient's perception of pain and their mental health are closely linked, and that treating anxiety can improve the management of pain. We decided that the prison doctor did not give proper consideration either to whether pregabalin assisted Ms C in managing her anxiety, or to gradually reducing the dosage in line with best practice.

In terms of the complaints handling, we found that even after Ms C met with the clinical manager to discuss her concerns about a lack of response, she still did not get a reply. Her complaints were logged but not responded to, contrary to the NHS complaints handling guidance. It also appeared that some complaints information was inappropriately held in Ms C’s medical records.

We upheld both Ms C’s complaints.

Recommendations

We recommended that the board:

• draw to the doctor's attention the British National Formulary's guidance on avoiding abrupt withdrawal of pregabalin;
• put in place suitable guidance for prisoners in the prison about the consequences of misusing prescribed medication;
• apologise to Ms C for failing to handle her complaint in line with the NHS complaints procedure guidance; and
• ensure that health centre staff in the prison do not record complaints information in a patient's medical records, in line with the NHS complaints procedure guidance.