Health

Summary

Mrs C complained that the care and treatment provided to her husband (Mr C) were inappropriate. She also complained that it was unreasonable for staff to communicate directly with her husband, who is profoundly deaf and cannot speak, when he had asked staff to communicate through Mrs C.

Mr C had heart problems for which he was taking warfarin (a blood-thinning medication). When he developed blood in his urine, he was initially treated as an out-patient but was then scheduled for surgery as an in-patient at Gartnavel Royal Hospital. Following surgery Mr C was catheterised (a tube was inserted into the bladder to drain urine). It took some time for the blood in Mr C's urine to resolve and he had to receive blood transfusions and antibiotics (drugs to fight bacterial infections) when he developed an infection. Mrs C complained that something must have gone wrong with the operation and said that she suspected that there had been a problem with the instruments used. She also complained that, unusually, Mr C suffered pain from the catheter used after his operation.

Our investigation, which included taking independent medical and nursing advice from two of our advisers, found no evidence that anything had gone wrong with either the instruments or the actual operation. Our medical adviser said that the records of the operation were very clear and documented a straightforward and uneventful procedure. There was no evidence of a problem with the instruments. The medical adviser said that when Mr C went into hospital his warfarin medication was changed to heparin (an anti-coagulant) which was reasonable. Patients taking long-term warfarin or heparin are prone to increased bleeding and that this was the reason for Mr C's extended blood-loss, which was treated appropriately. Both advisers were of the view that the type of catheter used, although larger than the type that Mr C was used to, was appropriate for his condition at the time. This was a 'three-way' catheter that allowed nursing staff to irrigate Mr C's bladder with sterile water which the advisers considered was appropriate.

On communication with Mr C, both advisers were of the view that it was reasonable for staff to use hand-written notes to communicate directly with him, and noted that he engaged in this without objection. Healthcare staff have to tread a fine line between respecting the wishes of the patient and their family and doing what is necessary to provide care safely and with the informed consent of the patient. Mrs C could not be with her husband at all times and it was important that staff were able to communicate with him to provide care. The nursing adviser also commented that, even when Mrs C was present, there would be times when staff would have to ensure they had Mr C's consent before providing care.

Summary

Mr C complained about the care and treatment that a medical practice provided to his late mother (Mrs A) before her death. He said that GPs had not taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. He also said that they had unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We obtained independent advice on this complaint from our GP adviser. We found that in general, the practice had taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. However, we upheld this complaint as they should have ensured that arrangements were in place to review Mrs A and that this was noted in the medical records, after her medication was increased on one occasion and it was identified that she had a chest infection. At the very least, they should have phoned to find out if the medication was effective or was causing problems. There was no evidence that they did so.

Our investigation also found that the practice had considered admitting Mrs A to hospital or to a hospice when her condition deteriorated. They discussed this with the family and with the nursing staff caring for Mrs A. They decided that she should not be admitted and that they would start the Liverpool Care Pathway. We did not uphold this complaint as, although we considered that the GP should have recorded more detail about the decision we found that, based on the information available at the time, the decisions not to admit Mrs A to hospital and to start the Liverpool Care Pathway were, on balance, reasonable. That said, we found that the practice's responses to Mr C about the matter had not been satisfactory and that they had failed to respond in detail and we made a recommendation to address this.

Recommendations

We recommended that the practice:

• make the staff involved in Mrs A's care and treatment aware of our findings;
• issue a written apology to Mr C for the failure to satisfactorily respond to his complaints;
• take steps to ensure that in the future complaints are investigated and responded to appropriately; and
• remind the GPs of the need to maintain clear and thorough medical notes.

Summary

Mrs C complained that nursing staff failed to provide support to her daughter (Ms A) after she was discharged from hospital. She said that they had failed to act appropriately in relation to two visits made to the local housing office to try to secure accommodation for Ms A. Mrs C also complained about the handling of her complaints.

To investigate the complaint, we took all relevant documentation into account, including Ms A's clinical notes and the complaints correspondence. We also obtained independent advice from two of our medical advisers.

The investigation showed that there were differing accounts of what happened after the first visit to the housing office, which we could not reconcile. Based on the available evidence and our advisers' comments, we found that Ms A's discharge was planned and that the support provided by the nursing staff was reasonable. We were, however, concerned about a lack of detail in the nursing notes, and made a recommendation about this. We also found that, while the board had provided a reasonable response to the issues Mrs C raised, they failed to respond within the timescale set out in the NHS complaints procedure.

Recommendations

We recommended that the board:

• ensure that, when nursing staff on the ward record clinical events, they do so in sufficient detail that it is clear to colleagues precisely what occurred, what risks there were (if any), and how matters were dealt with and by whom; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary

Mr C, who is a prisoner, complained that the prison health centre unreasonably refused to issue him with a medical marker excusing him from work. He said that he had suffered a stroke the month before arriving in prison and had been signed off work in the community on medical grounds. When the board responded to his complaint they said that, based on his recent test results, they found no grounds upon which to excuse him from work in prison.

We took independent advice from one of our medical advisers, who reviewed Mr C's records and noted that he had had a number of tests relevant to his fitness to work. As none of these revealed any cause for concern, the adviser said that the prison health centre's decision not to excuse Mr C from work was appropriate. In light of this advice, we concluded that Mr C's fitness to work had been appropriately assessed and we did not uphold the complaint.

Summary

Mrs C's mother (Mrs A) is 92 years old. Mrs C complained about the length of time that her mother had to wait for a flu vaccination. Mrs A had requested a home visit for the vaccination and initially the medical practice had refused, saying that their policy was that only housebound patients were entitled to this. However, they then changed their mind and passed the request to district nursing staff to arrange. After a few days, Mrs A had received no contact from either the practice or the district nurses. She contacted the practice and was given a surgery appointment, where the vaccination was administered.

The practice confirmed to us that their policy was that only housebound patients were given a home visit for this, but that they had made an exception in Mrs A's case. District nurses had to prioritise flu vaccinations, and gave clinical priority to housebound patients and those in residential homes or sheltered housing complexes. The practice explained that Mrs A would have received the flu vaccination at home by the end of the month in which she got it, in line with their guidelines. We took independent advice on this from one of our medical advisers, who confirmed that the practice's actions were appropriate. He had no concerns that the home visit was not carried out earlier or that the priority afforded to the request was unreasonable, and we found no evidence of any avoidable delays in dealing with Mrs A's request.

Summary

Mrs C's daughter (Miss A) damaged her teeth in an accident on a Sunday evening. Mrs C took her to hospital where Miss A was assessed, and they were advised to visit their dentist as soon as possible for emergency treatment. Mrs C told us that she tried to leave a phone message with the dental practice that evening to let them know this, but was unable to do so. After they went there the next morning, Mrs C was unhappy about a number of issues, including that the practice was closed for staff training, meaning that they had to wait outside in the cold for a time. She was unhappy with the attitude of the staff and said that the dentist seemed angry that they were there and shouted at them; and she also felt that her daughter was treated inappropriately, including the way she was spoken to and the fact that the dentist felt that her mouth was too swollen to treat at that time.

We based our investigation on the available documentary evidence, which meant that, in the absence of entirely independent witnesses, we could not reach a robust conclusion on what was said and by whom. We took independent advice from a dental adviser, who explained that, generally speaking, he would have expected a dentist, exercising professional experience and judgment, to display a sympathetic attitude to try to put Mrs C and her daughter at ease as much as possible. However, he said there were no definitive instructions that a dentist would be expected to follow when treating a child in these circumstances, and that the available evidence appeared to indicate that Miss A was reasonably treated. On balance, in light of the advice received, we did not uphold Mrs C's complaint. However, we made a recommendation as a result of Mrs C's experience.

Recommendations

We recommended that the dentist:

• confirm that they will ensure that patients are able to leave out-of-hours messages and that their voicemail message reflects days where the practice may open later (for example for staff training).

Summary

Ms C suffers from a blood condition - Factor V Leiden - which increases the risk of blood clots. Ms C complained that her medical practice had not taken sufficient account of this condition, in that they had not monitored her blood on an ongoing basis, they had given her an inappropriate contraceptive injection and when she went to them with a possible blood clot in her calf they had not referred her to hospital.

Ms C's concerns started when she attended the practice suspecting that she had a blood clot in her calf. Her GP referred her to hospital to see whether she had a DVT (deep vein thrombosis). The assessment showed some superficial clots, but no DVT. Ms C later had an contraceptive injection at the practice, which she continued to receive on a quarterly basis for the following year. A year after she first went to the practice with pain in her leg, Ms C went back for the same reason. The GP did not refer her to hospital this time, on the basis that no DVT was found on the previous occasion. However, the next morning Ms C woke with pains in her chest, and subsequent investigations found that Ms C was suffering from pulmonary embolisms (clots in the blood vessel that transports blood from the heart to the lungs).

We took independent advice on this complaint from one of our medical advisers, who is a GP. After considering Ms C's medical records, he explained that her blood condition did not require ongoing monitoring. He also said that her contraceptive injections were the most appropriate for her. Finally, he considered whether Ms C should have been referred to hospital when she presented with pain in her calf on the second occasion. He said that, although this was a finely balanced judgement, the GP had acted reasonably given the evidence he had available to him at the time.

Summary

Miss C complained about the dental treatment she received from the board following a referral from her dentist. She said the board did not provide her with reasonable care and treatment during her four appointments at the board's clinic and did not reasonably respond to her attempts to complain about the care and treatment they provided. Miss C explained that shortly after her treatment was completed, one of her teeth cracked, went black and eventually had to be removed.

We took independent advice on the case from our dental adviser, a general dental surgeon. The adviser said that the treatment Miss C received from the clinic appeared to have been carried out to a satisfactory standard and within the terms of the referral from Miss C's dentist. The adviser explained that following her root canal treatment, the clinic advised Miss C that the crown on one of her teeth could be replaced to improve aesthetics but noted that she declined this treatment. The evidence suggested that the clinic completed the treatment in the referral from Miss C's dentist as far as Miss C would allow them to go. However, based on the information in Miss C's records, we were not satisfied that the clinic advised Miss C that replacement of the crown could have improved the long term health of her tooth and were critical of the clinic in this regard.

The evidence showed that over a year after her treatment was completed, Miss C made multiple phone calls to her own dentist and phoned the clinic twice about her treatment. There was no documentary evidence that Miss C made contact with the clinic in the year after her treatment. The adviser explained that the clinic's response to Miss C's attempts to complain about her treatment was reasonable and that as Miss C was under the care of her own dentist at that time it would not have been reasonable for the clinic to see her again without her being referred there by her own dentist.

Although we did not uphold this complaint, we made two recommendations for improvement.

Recommendations

We recommended that the board:

• ensure that reasons for treatment provided to patients are fully explained and documented; and
• ensure that discussions of potential risks and benefits take place when a patient has not had sedative drugs administered so that the patient is fully capable of making an informed choice.

Summary

Mrs C complained that her medical practice had removed her from their list of patients. She had visited the practice to try to get an emergency appointment. She had a sore throat and had lost her voice so she used a pen and a scrap of paper to communicate with the receptionist. As a suitable appointment was not available she became frustrated and left the practice. The following day, the practice wrote to Mrs C saying that because of her behaviour, and after seeing relevant CCTV footage, they had no option but to immediately remove her from the practice list. Mrs C told us that she disputed the practice's interpretation of her behaviour. We explained that the practice were entitled to act on any concerns they had and that it was not our role to comment on the incident itself. We confirmed that our investigation would focus on the process the practice followed in removing her from their patient list.

We reviewed the relevant regulations and guidance, and discussed the case with one of our medical advisers. In order to remove a patient with immediate effect, the incident must have been reported to the police. Failing this, the practice should send the patient a warning letter. Only where a warning has been issued in the preceding 12 month period can they remove the patient without having involved the police. We upheld the complaint, as we found that in this case, the practice did not issue Mrs C with a warning, nor did they contact the police.

Recommendations

We recommended that the practice:

• review their removal policy to ensure it reflects the terms of the General Medical Services Contracts Regulations and associated guidance, particularly in respect of giving patients relevant prior warning if they are at risk of removal; and
• apologise to Mrs C for not following the proper procedure when removing her from their list of patients.

Summary

When Mrs C’s husband (Mr C) was taken to hospital by ambulance, the crew could not get the ambulance doors open, and there was a delay getting him to the hospital. Mr C passed away the following month and Mrs C then complained that the Scottish Ambulance Service (the service) had never apologised for the incident. When looking into the complaint, the service were unable to trace any details of the ambulance journey or crew involved. However, they formally apologised to Mrs C for the incident and assured her that steps had been taken to avoid a similar future problem.

Mrs C complained to us that the service had been unable to trace details of having transported her husband to hospital. The service told us what they had done to try and trace the journey. They said that no incident report was completed on the day in question and they received no reports of a vehicle with faulty doors. We were satisfied that they had fully investigated Mrs C’s complaint and gone to considerable effort in trying to trace the ambulance and crew involved. We also recognised that, despite not having traced the incident, they had apologised. However, we did not consider that they had taken appropriate action to try to avoid this happening again. We, therefore, made a recommendation.

Recommendations

We recommended that the service:

• issue an appropriate written reminder to staff of their obligations to formally report any incidents and also any related vehicle maintenance issues.