Health

Summary

Mr C and his mother (Mrs A) received a visit from two community psychiatric nurses (CPNs) who assessed his and his mother's needs. At the end of the interview they mentioned that the results might be shared with colleagues in the social work department. Mr C was at that time involved in a dispute with that department about guardianship of his mother and was concerned that the information obtained might be used against him. He contacted the CPNs shortly after the assessment and said that he would not allow disclosure of the information without his permission. He complained to the board that the CPNs had not been open with him at the start of the assessment that information would be shared with the department to be considered as part of the application for guardianship.

We did not, however, uphold Mr C's complaint. Our investigation found that a consultant psychiatrist had asked the CPNs to carry out the assessment to establish if Mrs A had any health or social care needs, and not as part of the guardianship application.

Summary

Miss C and her mother complained about the care and treatment provided to Miss C's late father (Mr A) after he attended hospital for a day-case urology procedure (urology is a specialty in medicine that deals with problems of the urinary system and the male reproductive system). He had been unwell in the days leading up to the appointment. During the appointment, Mr A was found to have a fast heart rate and shortness of breath. The procedure was cancelled, and he was immediately admitted to the accident and emergency department, then transferred to a ward. Despite treatment, Mr A's condition deteriorated, and he was moved to the intensive care unit (ICU) where he was treated for six days. Although Mr A's condition was stabilised, his prognosis (the forecast of the likely outcome of his condition) was poor and he was transferred back to the ward to be more comfortable during the final days of his life. Mr A died two days later.

Miss C and her mother complained about the board's treatment of Mr A and said that they had failed to manage his pre-existing medical conditions. They also complained that staff in the ICU did not provide an adequate handover to ward staff when Mr A returned to the ward. As such, the ward staff did not know about his poor prognosis and did not ensure that end-of-life arrangements, such as extended visiting times and a single room, were in place.

As part of our investigation, we took independent advice from one of our medical advisers. We found that Mr A had a number of medical problems, including that his heart was failing and his kidney function had deteriorated significantly. Treating one condition led to a deterioration of the other and we acknowledged that managing Mr A's condition was a fine balancing act. Although staff gave Mr A a poor prognosis, we found that they agreed to his family's wishes that his kidney problems be treated in the ICU. This led to his condition being stabilised, although his prognosis remained poor and we were satisfied that this was explained clearly to the family. Our adviser said that the records showed that Mr A's underlying medical conditions were treated appropriately throughout his admission.

With regard to the handover between ICU and the ward, we acknowledged that the ICU had told family members that Mr A's prognosis was poor and that he did not have much time left. However, ward staff were also told that Mr A's condition was stable and were given no indication that a sudden decline in his condition was imminent. Under such circumstances, we found it appropriate that normal ward care was given, with normal visiting times in operation until such time as the patient entered the terminal phase of their illness. After Mr A's condition deteriorated significantly on the morning of his death, his family were given the opportunity to visit him outwith normal visiting times.

Summary

Ms C was a voluntary patient at the board's eating disorders unit. Some four months after she first attended there, the clinician responsible for her overall care told her that he intended to apply for a Compulsory Treatment Order (CTO - an order that allows professionals to treat a person's mental illness). A CTO can, however, only be implemented with the support of a Mental Health Officer (MHO), and they did not agree. A GP who knew Ms C agreed with the MHO and the application was dropped. Ms C was discharged from the unit and continued her treatment in the community.

Ms C complained that the period leading up to the application for the CTO was not managed responsibly, in that she was not provided with a proper explanation for the application. She said that she had been complying with her treatment programme and that there was no need for compulsory measures. Ms C also said that she was not provided with appropriate levels of support, that her family and other health professionals were not effectively communicated with and that her right to confidentiality was not respected.

Our investigation found that there was a failure to communicate effectively with staff as well as inappropriate wording in an anticipatory care plan, which meant that Ms C was effectively detained on the unit, despite being a voluntary patient, so we upheld that part of her complaint. We did not, however, find that Ms C was not provided with appropriate emotional or psychological support or that her confidentiality was breached.

Recommendations

We recommended that the board:

• issue Ms C with an apology for the failings identified in this investigation;
• develop a policy to reflect the Mental Welfare Commission’s guidance in relation to short term detention, for staff use and guidance and ensure this is distributed to all staff;
• remind medical staff of the need to ensure anticipatory care plans have sufficient flexibility to allow practitioners to exercise their clinical judgement; and
• ensure all staff are aware that communication with patients about a CTO application must comply with Mental Welfare Commission guidance.

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.