Health

Summary

Ms C's late mother (Mrs A) was treated in hospital as an in-patient for illnesses that included pneumonia and chronic heart failure. Ms C complained that during that time the hospital communicated inadequately with her and other family members about Mrs A's medical condition. In particular Ms C said that she and family members were not made aware of the severity of Mrs A's condition before she was discharged from hospital. Mrs A died around two weeks after being discharged.

We took independent advice from one of our medical advisers, who considered all aspects of the medical evidence. We took account of his advice alongside all the documentation supplied by Ms C and the board. Our adviser said that when Mrs A was admitted to hospital she was suffering from severe illnesses. When she was discharged, these had all been treated and were not significant ongoing issues. He noted that Mrs A had suffered from a severe degree of heart failure prior to admission. The adviser said that the records showed that staff had communicated appropriately with Ms C and other family members about Mrs A's true condition, in keeping with the General Medical Council's guidance on communication. Given this, we did not uphold this complaint.

Summary

Mrs C complained about the care and treatment the board provided to her late husband (Mr C) before his death. Mr C had been diagnosed with bladder cancer, and also had heart disease, diabetes, high blood pressure and arthritis. His bladder cancer was managed through intravesical BCG treatment (a vaccine for tuberculosis put directly into the bladder, which can help stop or delay bladder cancers), because he was not considered fit to undergo cystectomy (surgery to remove all or part of the bladder). This required weekly urethral catheterisation (insertion of a tube into the bladder).

Mr C developed a reaction to his intravesical BCG therapy, called BCG-osis (where the BCG organism has spread to cause an infection outwith the bladder), and was admitted to hospital. He was treated for this and then discharged. Mr C then developed a dramatic deterioration in his renal (kidney) function and was readmitted to hospital as an emergency with nausea, vomiting and anorexia. He was found to have developed acute kidney injury and pulmonary oedema (build-up of fluid in the lungs) and required kidney dialysis. Mr C died in the hospital from a presumed heart attack around ten days later.

Mrs C complained that the board failed to provide appropriate clinical treatment when her husband developed the reaction to his treatment. We took independent advice on this from one of our medical advisers, a specialist in treating bladder cancer, and found that it had been reasonable to manage Mr C's cancer by intravesical BCG treatment. We also found that the action taken to investigate, diagnose and treat his reaction to it was reasonable and appropriate. Mr C was appropriately discharged from hospital and our adviser did not consider that there were deficiencies in his care and treatment, nor alternatives that would have improved Mr C's prognosis. There was no evidence that the reaction that arose from the BCG therapy, or the treatment Mr C was given for this, contributed to the deterioration in his renal function. Our adviser said that it was likely that the deterioration resulted from the effects of gastroenteritis (inflammation of the stomach and intestines). We did not uphold Mrs C's complaint as we found that the medical care provided to Mr C was of a good standard.

Summary

Mr C's late mother (Mrs A), who suffered from dementia, was admitted to hospital with hip pain after a fall. X-rays suggested that she had fractured a bone in her pelvis. Healthcare professionals assessed her as having moderate cognitive impairment (a condition affecting the ability to think, concentrate, formulate ideas, reason and remember) and noted that she was confused and disorientated. Mrs A had a further fall some days later, when no injuries were noted. However, she then fell again several weeks later and fractured her left hip which was repaired in an operation. She fell again in early December 2012. Her medical records said she made no complaints of pain, and she was discharged to another hospital for rehabilitation shortly afterwards. Five days later, Mrs A was transferred back to the first hospital complaining of hip pain, and a fracture to her right hip was identified. Following surgery to repair the fracture, Mrs A died.

Mr C said that the family were very distressed that Mrs A suffered two fractures while in the care of the hospital and that the board failed to take reasonable steps to prevent her from falling. He was also concerned about the lack of documentation concerning Mrs A's fall in early December and said that the board failed to provide a reasonable standard of nursing and medical care after the falls. The medical records showed that Mrs A fractured her left hip following her third fall, and that a second hip fracture was diagnosed in mid-December 2012. Mr C, however, believed that the second fracture occurred during her fall in early December.

We took independent advice on this complaint from one of our medical advisers. The adviser said that while there was clear evidence of risk assessment and planned interventions, these did not take account of Mrs A's cognitive impairment. Moreover, there was a lack of an overall score in the risk assessment tool used, which was significant as the score could have indicated the need to use falls prevention aids or to consult a falls specialist. The adviser also said that there was evidence of ineffective record-keeping of pain assessment, which was not suited to patients who were less able to report this themselves. In light of this, we were not satisfied by the entry in the medical records of early December that said that Mrs A was not in pain, particularly as we noted that Mrs A's sister, her main carer, had said that Mrs A was in more pain than usual on the evening of the fall. In the absence of records relating to Mrs A's admission to the second hospital and her return to the first hospital, however, we could not say definitively when Mrs A fractured her hip.

Having said that, we were extremely concerned about the board’s failure to properly assess Mrs A's levels of pain and the lack of evidence to show that Mrs A was checked by medical staff following her fall (including that there was no evidence of their findings). We were also concerned about a lack of nutritional screening and of effective use of the adults with incapacity legislation. The board acknowledged shortcomings in record-keeping, in particular following the fall in early December. They said they had raised this matter with the staff concerned and had apologised to Mr C for this. We found failures in record-keeping by nursing and medical staff in relation to all three falls. Given the risk this posed to Mrs A, we were very critical of these failures, particularly of those by medical staff. We upheld Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• ensure the failures in record-keeping are raised with relevant staff;
• ensure that the systems for transferring records from one care setting to another and for storing and retrieving medical records securely are robust;
• review the falls assessment documentation and policy in light of our adviser's comments;
• ensure that effective nutritional screening of all patients in the hospital takes place;
• introduce a pain assessment tool appropriate for people with dementia;
• ensure effective compliance with adults with incapacity legislation; and
• apologise to Mr C for the failures identified.

Summary

A Member of Parliament (Mr C) complained to us on behalf of Mr and Mrs A whose daughter (Ms A) died from skin cancer. Mr and Mrs A felt that their daughter's diagnosis and treatment was unreasonably delayed because a mole was not properly removed from her scalp four years previously, and that there was a failure to make appropriate follow-up arrangements. They also said that the board refused Ms A’s requests for surgery when she developed a breast lump and unreasonably insisted that she attend an appointment at a time when bad weather made travelling to hospital very difficult.

As part of our investigation, we took independent advice from two medical advisers, a skin specialist and a cancer specialist. Our investigation found that Ms A’s mole was at first only partially removed because of where it was on her scalp. A biopsy (tissue sample) was taken and analysed, and it was reported that the results did not show that the mole was malignant. Based on this, it was reasonable that there was no formal follow-up after the mole was removed. However, our investigation found that histopathology reporting (the study of changes in tissues caused by disease) was unsatisfactory, as the biopsy was reported incorrectly and the sample taken did show signs of malignancy. One of the advisers also said that it would have been good practice to remove the mole fully, as it was clearly possible to have done so. Ms A then developed lumps on her neck and, later, a lump on her breast. Although we found that the board carried out appropriate investigations into these lumps and provided relevant treatment, we found that there had been some avoidable delays because Ms A was not prioritised as a suspected cancer patient. We upheld Mr C's complaints about removal of the mole and about diagnosis.

We did not uphold the complaints about the appointment, or about refusal to offer surgery earlier. We found that three separate tests had found that Ms A’s breast lump was benign and skin cancer in the breast of a woman of her age would be very rare. As such, we were satisfied that the board’s initial advice that surgery was not necessary was reasonable. Surgery was arranged appropriately when the lump persisted and began to irritate Ms A. We were also satisfied that the board did not insist that Ms A attend her appointment during the difficult weather conditions. They did give appropriate advice about how long it might take to reschedule the appointment, should she decide not to attend.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs A for their failure to remove all of Ms A's mole and for the incorrectly reported biopsy;
• review their systems for clinical pathological correlation with a view to avoiding a similar misdiagnosis in the future;
• apologise to Mr and Mrs A for the delay to Ms A's diagnosis; and
• conduct a review within their breast, radiology and pathology departments of their sampling techniques and histopathology reporting quality.

Summary

Mr C, who is a prisoner, complained that the NHS health centre at his prison unreasonably discontinued a particular medical prescription of his and prescribed an alternative. However, as he failed to sign and return a consent form which we sent to him and which we needed in order to access his medical records, we were unable to investigate his complaint further.

Summary

Miss C, who is an advice worker, complained to us on behalf of her client (Mr B). Mr B had made a formal complaint to the board about the medical treatment provided to his late father. The board, however, said that the complaint was out of time as the matters complained about had occurred over 12 months previously, and as it was more than six months since Mr B was aware he might have had cause to complain.

We considered the evidence provided by Mr B and by the board, including the contact that took place between the board and the family and advice worker. We confirmed that the normal time limits that applied were that a complaint should be made either within six months of the event that gave rise to the complaint or up to six months from the patient/relative becoming aware of a cause for complaint ,but normally no longer than twelve months after the event. We found no indication in the information provided that the board's decision was unreasonable, and we concluded that they were entitled to decide that the complaint was made to them outwith their time limits.

Summary

Mrs C complained that a GP failed, during two consultations, to properly examine her father (Mr A) who was suffering from diarrhoea, vomiting and abdominal pain, which resulted in him being admitted to hospital where he was found to have a ruptured bowel, and needed surgery.

After taking independent advice on the complaint from one of our advisers, who is a GP, we did not uphold it. Our adviser examined Mr A's clinical records and his view was that the GP had carried out a proper examination and had diagnosed that Mr A was suffering from gastroenteritis. He said that in view of the diagnosis, which was reasonable, the GP's actions were in keeping with current guidelines for the treatment of that condition.

Summary

Mrs C complained on behalf of the family of her late aunt (Mrs A) that the care and treatment Mrs A was given whilst she was in the care of the board was unreasonable. Mrs A had died after being diagnosed with a form of cancer, which it had taken some time to identify. Mrs C said that because of this, her aunt suffered more than she should have done, and wanted to know why tests had failed to detect her condition earlier.

We considered all the complaints correspondence and Mrs A's medical records, and obtained independent advice from one of our medical advisers on the care and treatment provided. Our investigation found that Mrs A's illness was complicated and very difficult to diagnose. Doctors were considering three possible diagnoses, which were also rare. While it was reasonable for them to explore and treat the possibility of tuberculosis (which was initially considered), we concluded that insufficient acknowledgement had been given to irregularities that had been found. A scan had confirmed a mass that could be felt, and two colonic investigations (examinations of the bowel) had failed to reach a particular part of it. No single doctor took the lead in Mrs A's case, which was not ideal. In the circumstances, we upheld the complaint, as we concluded that there was a missed opportunity to make an earlier diagnosis. While this may not have affected the outcome, it might have allowed an extension to Mrs A's terminal care.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this complaint;
• review the circumstances of Mrs A's case and put in place processes to ensure that lead responsibility is taken for progressing a diagnosis; and
• ensure that those clinicians involved in Mrs A's case are made aware of these findings so that they can take forward the learning from it.

Summary

Miss C complained about the care and treatment she received from a consultant urologist. (Urology is the branch of medicine that relates to the urinary system.) She said that the level of aftercare she received was insufficient. Miss C also complained that the consultant did not communicate adequately with her, and did not communicate adequately with her GP after the procedure.

Our investigation found that Miss C was admitted to hospital for a relatively rare urological procedure. The day after the procedure she was discharged, but was not told about any follow-up care, other than an appointment in the urology clinic four months later. After she was discharged, Miss C became unwell, and went to see her GP. She told us that her GP was unable to provide effective care beyond pain management because at that time he did not have any information from the board about her admission. Miss C became more unwell, and was admitted to her local hospital ten days after the operation.

After taking independent advice on this case from a urology adviser and a general medical adviser, we upheld both Miss C's complaints. The urology adviser was critical that Miss C's clinical notes did not mention any discussions with her before the procedure about what was involved and what the risks were. He also said that Miss C had not had a scan a week after her procedure, although this had clearly been intended, and that the scan was not mentioned on the immediate discharge letter for her GP. This meant that neither Miss C nor her GP could follow up with the board appropriately when arrangements for the scan were not made.

In relation to communication with the GP, we found that the board appropriately prepared the immediate discharge letter and a discharge summary letter. We could find no evidence to show when the medical practice received these, but the immediate discharge letter had clearly not been received by the time Miss C consulted her GP. We were also concerned that it did not contain information about the scan, making it impossible for Miss C or her GP to ensure that appropriate aftercare was given.

Recommendations

We recommended that the board:

• remind urology department staff of the need to ensure that all aftercare appointments are in place prior to discharging patients;
• ensure that discussions about consent, including the risks of a procedure, are documented at the time they take place;
• take steps to ensure patients are informed of any follow-up appointments on discharge and that the GP is advised appropriately; and
• apologise to Miss C for their failure to provide appropriate aftercare and for their failure to communicate appropriately with her and her GP.

Summary

Mrs C's father (Mr A) has a complex medical history, including cancer. Early in 2012, Mr A began to suffer backache, and a GP visited him at home. The GP believed the problem was musculoskeletal and prescribed anti-inflammatory gel and pain relief (tramadol). Mr A continued to suffer a great deal of pain and went to the medical practice three days later. The GP saw no obvious signs of infection and diagnosed muscular pain, but also took blood tests to exclude any spread of the cancer. Mr A continued to suffer severe pain and was reviewed by the GP again over the next few weeks. The GP arranged for a chest x-ray and, when the results for this were abnormal, arranged for Mr A to have a scan.

On the day the scan was due, Mr A also had an appointment at a cancer centre, which he attended on his GP's advice. Because of the appointment, the scan was carried out seven days later than planned. The scan results were also abnormal, suggesting possible malignancy or infection in the spine (discitis). The GP urgently referred Mr A to the oncology (cancer) department at the hospital. Mrs C said that Mr A’s pain became excruciating and over several weeks increasingly strong painkillers were prescribed. He was then admitted to hospital by ambulance and diagnosed with discitis. After further investigations and treatment (including an operation) Mr A lost the use of both legs and became doubly incontinent.

Mrs C complained that the GP failed to properly investigate her father's symptoms, provide reasonable pain relief and admit him to hospital, and that the delay in diagnosis was not reasonable. She said that had the relevant scans been carried out sooner, then the outcome for Mr A would have been more positive. She was also unhappy that Mr A's attendance at the cancer centre meant a delay in the scan being carried out.

We took independent advice on this complaint from one of our medical advisers. With hindsight, the significance of the delay in Mr A having a scan, caused by the cancer centre appointment, was apparent. However, what we had to consider was whether the GP's advice that the appointment at the centre should be kept was reasonable in light of the information available to him at that time. Given that this arose from the GP's concern that the abnormality indicated in the x-ray was a spread of cancer (which our adviser said was a reasonable working diagnosis at that time) we were satisfied that his advice was appropriate in the circumstances. On the delay in diagnosis, our adviser said that while discitis is a rare and difficult condition to diagnose (particularly in general practice), there was a delay in carrying out appropriate investigations, in that an x-ray should have been carried out two weeks earlier. However, the adviser also told us that the pain relief was appropriate and that the decision not to admit Mr A to hospital earlier was reasonable. Nevertheless, we were concerned about the delay in arranging a chest x-ray, particularly in light of Mr A's complex medical history, and the impact this had on him. We upheld Mrs C's complaint and made recommendations.

Recommendations

We recommended that the practice:

• review the handling of Mr A's case in light of the findings of our investigation; and
• apologise to Mrs C for the failures identified.