Health

Summary

Mr C complained that he had been inappropriately treated by his dentist. He was unhappy with the insertion of two crowns on teeth in his upper jaw and the removal of a crown from a tooth from his lower jaw. Mr C said that the upper crowns had not been fitted properly, and had left unsightly gaps between his teeth, which had never been there before. Mr C said that the dentist had then referred him to a dental hospital, because the dentist found him too difficult to deal with. Mr C also complained that when attempting to remove the crown from his lower jaw, the dentist had removed almost the entire tooth. He said he had not been warned that this was a possibility and, had he known this, he would not have agreed to the removal of the crown.

We took independent advice on Mr C's complaint from our dental adviser. He said the decision to replace the two upper crowns was appropriate, and was supported by the x-rays of the teeth, and that the same applied to the removal of the crown from the lower tooth. He said that gaps between the teeth would have appeared as inflammation of the gums (caused by previous poorly fitting crowns) receded. It was appropriate for the dentist to have referred Mr C to the dental hospital, in line with General Dental Council guidelines, once it became clear he was still unhappy with the treatment he had received. The adviser said that the dental records for the removal of the crown from the lower tooth showed that the treatment options were explained to Mr C. He also pointed out that, had the tooth been left in place, it would have fractured. We did not uphold Mr C's complaints as our investigation found no evidence to support his claims of inadequate and unnecessary treatment.

Summary

Mrs C complained about the care and treatment she received in Borders General Hospital following an operation for an umbilical hernia (where fatty tissue or a part of the bowel pokes through into an area near the navel). She said that for a number of months afterwards she suffered problems with the stitches in her wound and the hospital did not deal with these adequately; she also said that she was wrongly told that the stitches used were dissolvable. English is not Mrs C's first language, and she told us that she has difficulty with it. Mrs C said she was also told that further surgical investigations could not be carried out at the time because she was pregnant and, as a result, she suffered worry and distress.

We took independent advice on this case from one of our medical advisers. The adviser explained that if stitches close to the skin are causing pain, they may be removed to prevent a breach in the skin and/or possible infection. Mrs C was, however, pregnant and it is accepted practice that non-urgent surgery should not be performed in the first three months of pregnancy. After that, as surgery carries an increased risk of premature labour and miscarriage it is still better to defer non-urgent procedures until after the baby is born. We accepted that the hospital had acted appropriately and in accordance with accepted medical practice when dealing with the problems with Mrs C's stitches. The evidence also showed that both dissolvable and non-dissolvable stitches had been used. It was unclear what, if any, allowances medical staff had made for the fact that English is not Mrs C's first language, and the board accepted that explanations may not have been communicated as clearly as they could have been. We could not reconcile the differing accounts of what the doctors say they told Mrs C and what Mrs C understood she was told. However, there was no evidence that Mrs C was given incorrect information. Although we did not uphold this complaint, we made a recommendation based on the board's acceptance that it was possible that explanations had not been clear due to language difficulties.

Recommendations

We recommended that the board:

• remind the medical staff involved in Mrs C's care and treatment that consideration should be given to the use of the board's Interpretation and Translation Guidelines where a patient's first language is not English.

Summary

Mrs C complained on behalf of her partner (Mr A) about a procedure to remove his gallbladder at Borders General Hospital. Mrs C said they had originally been told that the procedure would be performed by keyhole surgery but that, if complications arose, it would be performed as open surgery, and Mr A would need to be kept in hospital for several days. Mrs C said that when she phoned the hospital on the day of the operation, she was told complications had arisen. When she visited Mr A after his surgery, he was in great pain, which she did not believe was being managed properly. When Mrs C visited the next day, she found Mr A being prepared for a scan. Mrs C said she had repeatedly asked nurses and medical staff about Mr A's wound and the frequency of his dressing changes. She believed that it was only as a result of her questioning that Mr A's wound was examined, leading to Mr A's transfer to a specialist unit.

We took independent advice from one of our medical advisers, a specialist in gallbladder surgery. He explained that Mr A's procedure had not been converted into open surgery, due to the complications that the surgeon had identified, and that this was an appropriate course of action. The notes of the operation showed that there were significant difficulties in performing the operation, due to existing damage to the gallbladder. The adviser said that the notes also showed that the care plan for Mr A was to perform a scan to identify the complications from the operation, and to consult with a specialist unit. The adviser said that the surgeon had acted appropriately and in Mr A's best interests when complications occurred. We found no evidence that Mr A had not been appropriately treated, and did not uphold Mrs C's complaint, as we found no evidence to support her claim that Mr A was only transferred due to her intervention.

Summary

Mr C complained about the care and treatment given to his late father (Mr A) after he was admitted to Ayr Hospital. Mr A had respiratory (breathing) and kidney disease. When he was in hospital he said he did not wish, nor was he able to tolerate, non-invasive ventilation (help with breathing, using a facemask or similar device). He was also recorded as not for cardio-pulmonary resuscitation (DNACPR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). After 24 hours of being fairly stable after admission, Mr A was moved to a general medical ward (Station 16) but he began to decline, and he died after his breathing stopped, although medical staff tried to resuscitate him.

Mr C said that Mr A's care and treatment plan were not discussed with his family. He was also unhappy that after being admitted to the Medical High Care Unit (MHCU) Mr A was then moved to a general medical ward. He said that the notes that accompanied Mr A were unclear, and that the ward was ill-equipped to deal with him. He was also unhappy that although DNACPR was recorded in Mr A's records, an attempt had been made to resuscitate him.

The complaint was investigated and all the complaints correspondence and Mr A's relevant clinical records were carefully considered. We also took independent advice from one of our medical advisers, who is a consultant in medicine for the elderly. Our investigation found that following Mr A's admission to hospital there had been confusion and uncertainty, particularly when he was transferred from the MHCU to the general medical ward (although it appeared that his condition had been discussed with his family). We found this uncertainty unacceptable, and also noted that the medical documentation was unclear regarding DNACPR, which led to unnecessary confusion at the end of Mr A's life.

Recommendations

We recommended that the board:

• make a formal apology for the confusion and uncertainty caused;
• conduct a Critical Incident Review/Significant Event Analysis and provide the Ombudsman with a copy of the outcome;
• audit the completion of Do Not Resuscitate and ward-to-ward transfer forms in the MHCU and Station 16;
• audit documentation and communication of care needs and care planning on these wards; and
• review their procedure regarding handover between wards (particularly from a higher environment to a lower one) to satisfy themselves that it is fit for purpose.

Summary

Ms C complained that the care and treatment provided to her late mother (Mrs A) by two hospitals was unreasonable. She said that Mrs A's transfer between the two was delayed; she had to wait some hours for a bed once transferred; she was not treated for possible blood clots; she was not given enough pain relief; and that nursing care was poor.

Mrs A had had a stroke and was undergoing rehabilitation, firstly in Ayr Hospital (a general hospital) and then in Ailsa Hospital (a mental health hospital). When Mrs A's condition started to deteriorate in Ailsa Hospital, her daughters were concerned and asked for a medical review with a view to transferring Mrs A back to Ayr Hospital. Ms C thought that Mrs A might have suffered another stroke. Mrs A was not, however, examined by a doctor (in this case, a psychiatrist) until that evening when, after consultation with Ayr Hospital, it was decided not to transfer her. The following day Mrs A's condition had deteriorated further and she was transferred, with the receiving doctors noting that she was very unwell and treating her for an infection. The board's standard admission documentation has a section for doctors to complete saying whether or not the patient is thought to be at risk of blood clots (deep vein thrombosis - DVT), but this was not completed.

Our investigation included taking independent advice from two of our advisers - a doctor specialising in elderly medicine, and a nurse. We found that there were problems with Mrs A's care in both hospitals, and we upheld some of Mrs C's complaints. Our advisers said that there was delay in obtaining a medical review in Ailsa Hospital, and that when the review did take place it was inadequate. There was also a delay in arranging to transfer Mrs A. The medical adviser said that when Mrs A was admitted to Ayr Hospital, consideration should have been given to her susceptibility to blood clots. National guideline 122 issued by the Scottish Intercollegiate Guidance Network (SIGN) recommends that patients who have mobility problems and illnesses such as infection - as in Mrs A's case - should be treated with preventative drugs to minimise the risk of developing blood clots. This did not happen in Mrs A's case, and she went on to develop blood clots.

We did not uphold Ms C's complaints about pain relief and general nursing care. Both advisers said that there was no evidence to demonstrate that these aspects of Mrs A's care were unreasonable.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that staff training referred to in the board's response has now taken place;
• ensure that all staff involved in this complaint at Ailsa Hospital reflect on their practice in this area and discuss any learning points at their next appraisal;
• confirm that all the medical staff involved in this complaint at both hospitals reflect on their practice in this area and discuss any learning points at their next appraisal;
• as a matter of urgency, take steps to ensure that medical staff at Ayr Hospital complete admission documentation in relation to DVT and fully take into account SIGN guideline 122 in their clinical practice; and
• ensure that relevant staff are reminded that complaint responses should accurately reflect the clinical situation of the patient involved.

Summary

Ms C was operated on at the Western Isles Hospital for a labial abscess (a painful swelling caused by a build-up of pus in part of the female genitals). Ms C had undergone a kidney and pancreas transplant in 2007. She complained that although her medical records said that the transplant team should be contacted prior to any surgical procedures, this had not happened. Ms C said that this had placed her at great risk, as the drugs she took to prevent her body rejecting the transplant suppressed her immune system, meaning she was at increased risk of infection.

Ms C also complained that she was not provided with reasonable care after the surgical procedure. She was discharged, despite being in great pain, and was then readmitted as the wound had become infected. Ms C suggested that she should not have been operated on in the first place and said her view was supported by the fact that on her second admission she was transferred to another hospital for treatment.

We took advice from two medical advisers, a specialist in the management of transplant patients and a specialist in gynaecological surgery (surgery of the female reproductive system). They said that the records showed that attempts had been made to contact Ms C's transplant team. However, the advisers said that the nature of the infection, combined with Ms C's suppressed immune system, meant it would not have been reasonable to delay her operation. They said that a reasonable care plan had been put in place, and the medical record showed that she was free of infection at the time of her discharge.

Our investigation found that Ms C had undergone the appropriate surgical procedure for a labial abscess, and that the care she received after the procedure and the decision to discharge her had both been reasonable. We found it would not have been appropriate to delay surgery whilst awaiting the response of the transplant team. Our investigation also found, however, that the attempt to obtain advice from the transplant team was not followed up, which would have been appropriate, so we made a recommendation about this.

Recommendations

We recommended that the board:

• remind all staff of the importance of obtaining advice from the appropriate specialist transplant unit when treating patients who have a compromised immune system as a consequence of transplant surgery.

Summary

Mr C attended his medical practice suffering from vomiting, diarrhoea and pains in his stomach. A GP diagnosed gastroenteritis (inflammation of the stomach and intestines) but some five days later Mr C was taken to hospital, where it was found that his appendix had burst, leading to peritonitis (inflammation of the tissue lining the abdomen). He had to have further surgery when he developed complications including kidney problems and a haematoma (a localised collection of blood outside the blood vessels). Three months after the original appendectomy he developed a fistula (an abnormal opening between organs) which had to be closed with a skin graft.

Mr C complained to us that the GP failed to diagnose that he was suffering from appendicitis. We took independent advice on this from one of our medical advisers, and did not uphold the complaint. The adviser said that the GP had made a reasonable assessment and diagnosis of Mr C's symptoms, which were highly suggestive of gastroenteritis. The GP had asked Mr C to return to be reviewed if his symptoms did not settle down, but he did not do this. Our adviser pointed out that there is a shared responsibility between doctor and patient, and it was not the doctor's responsibility that Mr C did not return when his symptoms did not improve.

Summary

Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of the operation he was told that he had been moved to last on the theatre list. When he asked why, he was told it was because he previously had methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to some common antibiotics, can cause infection and can be difficult to treat). This caused Mr C some distress. He complained that his history of MRSA had impacted on how his surgery was managed, although he had told staff - both at his pre-operative appointment and on the morning of the operation - that he had been given the all-clear a few years before.

In responding to Mr C's complaint, the board acknowledged that it was unfortunate that he did not receive the information booklet in advance. They also said that there was no requirement to screen day surgery patients for MRSA, and that their infection control policy did not require MRSA-positive patients to be last on the theatre list, as measures were in place to mitigate against cross infection risks. However, they then went on to say that the consultant had placed Mr C last on the list as he had a history of MRSA and there was nothing in his records indicating that he was clear of the infection.

As part of our investigation, we obtained independent advice from one of our medical advisers. Having done so, we upheld the complaint. We noted that the board had failed to provide pre-operative information to Mr C at the right time. We also found that they had deviated from their normal policy without properly explaining the reason for this. Their response to Mr C's complaint had been contradictory, in failing to explain why the consultant had not adhered to their policy.

Recommendations

We recommended that the board:

• bring their infection control policy to the attention of staff and highlight the importance of adhering to this;
• review their process for ensuring patients receive any relevant pre-operative information in a timely manner;
• remind staff who handle complaints of the importance of providing clear and consistent responses; and
• apologise to Mr C for the failures highlighted in our decision.

Summary

After Mr C's daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days. An ambulance was called on one occasion, but was cancelled when Mrs A became more alert. However, an ambulance was again called later that day after Mrs A collapsed for a second time. The ambulance crew reportedly helped her into bed, but said that there was not much more that could be done at that point, even if they took her to hospital. Mrs A continued to struggle with her breathing the next day and, in the early hours of the following morning, an ambulance crew attended and took her to hospital. Shortly after arriving there, Mrs A collapsed and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C felt that Mrs A might have survived had an ambulance crew taken her to hospital after the first attendance, or had the crew that did eventually take her to hospital acted with more urgency.

We were satisfied that the ambulance crews obtained relevant information about Mrs A's recent symptoms and carried out thorough examinations during both attendances. We took independent advice from one of our medical advisers, who said that Mrs A was displaying two symptoms that could indicate pulmonary embolism, but that these were also consistent with other more common illnesses, including viral infection. We concluded that although with hindsight it was evident that Mrs A's symptoms were related to a serious underlying condition, this would not have been apparent to the ambulance crews when they attended. Although the consequences were tragic for Mrs A and her family, we found that the ambulance crews' assessments and conclusions were reasonable under the circumstances.

Summary

Mrs C's husband (Mr C) cut his hand in an accident at home. She dialled 999 and asked for an ambulance. The ambulance service's call handler took details of Mr C's injury but concluded that an ambulance was not necessary. Mrs C had to ask neighbours to help transport Mr C to hospital, where his injury needed surgery. Mrs C complained that the ambulance service's refusal to dispatch an ambulance was unreasonable, and was dissatisfied with their handling of her subsequent complaint.

We took independent advice from one of our medical advisers, who is a paramedic, and after considering their advice we upheld Mrs C's complaints. Our investigation found that the call handler used a nationally recognised system of scripts to obtain information about the severity of Mr C's injury. During the call, they also asked for help from a clinical adviser, who could ask questions that were not included on the script to obtain additional information. An appropriate script was chosen and largely followed, which determined that no ambulance was required. However, we considered that the decision-making process was skewed because the call handler input inaccurate information. Assumptions were made about the severity of the bleeding and the clinical adviser asked questions that demonstrated a lack of knowledge of hand injuries. Furthermore, changes in Mr C's condition during the course of the call were not acted upon appropriately. We concluded that an ambulance should have been dispatched to take Mr C to hospital.

We found that the ambulance service's handling of Mrs C's complaint was generally reasonable. However, they failed to follow their own complaints procedure as they did not contact her to advise that their decision would be slightly delayed.

Recommendations

We recommended that the service:

• apologise to Mr and Mrs C for failing to provide an ambulance;
• take steps to ensure their call handlers are able to identify and act upon changes in patients' conditions during the course of a call; and
• share this decision with the clinician involved.