Health

Summary

Mrs C complained about the care and treatment provided to her late daughter (Miss A) by two GPs at the practice. Miss A was 14 months old when she became ill with a fever, vomiting and diarrhoea. Mrs C treated her with Calpol (an over-the-counter children's medication, used to treat aches, pains and fever) and tepid baths when her temperature was high. The following day Miss A's condition had not improved so Mrs C contacted the practice, and Miss A was seen twice that day by two different GPs. A viral infection was diagnosed and Mrs C was told to continue the treatment and to introduce ibuprofen (an over-the-counter anti-inflammatory medication). Mrs C asked if her daughter should be admitted to hospital but the GPs did not think there was evidence of a condition that warranted admission at that time. Early the next morning, however, Miss A collapsed. She was taken to hospital by emergency ambulance, but could not be revived. Mrs C also complained that after Miss A's death, one of the GPs involved did not contact the family to discuss the events and despite Mrs C seeing the GP in the local area on occasion, the GP did not speak to her.

Our investigation included taking independent advice from one of our medical advisers, who said that Miss A's symptoms indicated a viral infection, and that this was confirmed by the observations and examinations by the two GPs. Having studied Miss A's clinical records, the adviser said that the care, treatment and advice provided by the two GPs was reasonable. The post-mortem report on Miss A had confirmed the presence of a viral infection, and also a bacterial infection. Our adviser explained that this can occur when a patient’s system has been weakened by a viral infection, that it was not something that the GPs could have foreseen, and there was no evidence of it when they saw Miss A. Such infections can progress very quickly and cause organ failure and death in a short time. A consultant paediatrician, who reviewed the case and the post mortem report for the board, had said that even had Miss A been admitted to hospital, the outcome would be unlikely to have been any different, and our adviser agreed with this view.

On the matter of communication, one of the GPs involved said in response to the complaint that he had personally wished to speak to Mrs C and the family after Miss A died, but that the partners in the practice took a joint decision that the other GP involved (who was the practice's senior partner) should visit the family. This visit took place five days after Miss A's death. Having considered this, we took the view that the practice did communicate in a reasonable way with Mrs C at that time.

Summary

Miss C suffers from an anxiety disorder, and had been prescribed diazepam (a medicine which helps to control feelings of anxiety) for a number of years. When she requested a repeat prescription, Miss C was told to call the practice. Miss C said she was then told in a phone conversation with her GP that her prescription for diazepam would be stopped after a period of reduction and that, in future, she would have to attend an appointment at the practice before a repeat prescription would be issued. Miss C told us that her prescription had not previously been monitored, and had been increased over the previous years. Miss C considered that it was wrong to stop the medication. She was dissatisfied with the explanation provided by her GP and also the manner in which he responded to the complaint, which she considered to be inappropriate and unsympathetic.

We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the practice had not failed in their care of Miss C in relation to prescribing medication. However, in relation to the complaints handling, we found that although the GP provided reasonable explanations, the tone of his letters was unnecessarily sharp and at times insensitive, and his response could and should have been more considerate and empathetic.

Recommendations

We recommended that the practice:

• ensure that they and the GP reflect on the handling of this complaint to ensure that in future complaints are handled in an appropriate manner; and
• apologise to Miss C for the failures identified by this investigation.

Summary

Mrs C complained about the care and treatment that her late husband (Mr C) received after an angiogram (a type of x-ray used to examine blood vessels) showed that he had two cerebral aneurysms (weak points in the blood vessels supplying blood to the brain, causing them to bulge or balloon out). Mr C's right leg had suddenly given way and he was unable to stand. He saw his GP two days later and was referred to a stroke clinic, where he was seen by a consultant the following day. The consultant found no evidence of any neurological problems and noted that Mr C's right thigh was tender, which would not be expected if a stroke had occurred. The consultant considered two other possible diagnoses: a drug side effect; or that the leg weakness related to back pain. However, he decided to request a scan of Mr C's head, given the history of vascular (circulatory) disease in his family.

The scan showed no evidence that Mr C had had a stroke or of what had caused the problems with his leg. It did, however, show a possible cerebral aneurysm. An angiogram was then carried out, which showed that Mr C had two cerebral aneurysms. The radiologist who interpreted the results suggested referral to a neurosurgical unit (dealing with surgery of the brain or other nerve tissue) but the consultant in the stroke clinic considered that the aneurysms were incidental and had not caused the problem with Mr C's leg. He arranged to see Mr and Mrs C to discuss the findings and then referred Mr C to a neurological unit for assessment. However, Mr C collapsed and died a few weeks later before attending the neurological unit.

We took independent advice on this case from two of our medical advisers - a GP and a neurosurgeon. We found that it was reasonable for the consultant in the stroke clinic to consider that the aneurysms had not caused the problems with Mr C's leg. We also found it reasonable that the consultant met Mr C before referring him to the neurological unit, and we noted that Mr C was referred to the unit two days after that meeting. As it was not considered that the aneurysms had caused the symptoms, an urgent referral was not necessary. We did not uphold the complaint as we did not find any failings on the part of the board.

Summary

Ms C complained on behalf of an elderly lady (Mrs A) who was admitted to hospital as an emergency. Mrs A had terminal cancer and diabetes and a number of other health problems. Ms C complained that the standard of nursing care was unreasonable, and that Mrs A was discharged in an inappropriate manner. We took independent advice on this complaint from our nursing adviser and our hospital adviser.

In terms of nursing care, Ms C said that Mrs A was given no food or fluids while she was in the hospital's accident and emergency (A&E) department waiting to be admitted to a ward. Our nursing adviser said that these should not generally be provided in A&E, as this may compromise later treatment but that, given her circumstances, Mrs A should perhaps have been offered a drink of water. We saw nothing to suggest that the wait had an adverse impact on Mrs A’s health, but we drew this matter to the board’s attention. Ms C also complained that a nurse on the ward administered the wrong eye drops and did not follow hygiene procedures, and that a disruptive patient received attention while others were ignored. Our investigation found no specific evidence to show that the nursing care was unreasonable. We noted, however, that the board had acknowledged Mrs A’s negative experience and had put in place an improvement plan and a period of supervision for the nurse, which we considered a reasonable response to Ms C's concerns.

On the day Mrs A was expected to be discharged, she did not see a doctor until late in the day. By that time, her husband (Mr A) - who would have driven her home - had left. Mr and Mrs A lived 75 miles from the hospital, and so, although Mrs A was considered fit to go home, the doctor agreed that she should not be discharged until next day. Despite this, Mrs A was discharged that evening, and was sent home alone in a taxi dressed in her bed clothes. The board said this happened due to a breakdown in communication between the ward and the bed manager. When Mrs A arrived at her house, her husband was not there and, as she had no keys with her, she had to wait for a short time in the taxi until he arrived.

We upheld this part of the complaint. Our medical adviser noted that the discharge documents were incomplete, and he was not able to identify who authorised the discharge. As Mrs A required a walking aid, he considered it particularly inappropriate for her to be discharged alone in a taxi. The board had already acknowledged that Mrs A’s discharge was handled inappropriately. They had apologised, and reviewed their policy of discharging patients in taxis without outdoor clothing. However, we made recommendations as we took the view that there were wider issues to be addressed in their approach to discharge, in particular that checks that should be made and patients' individual circumstances recognised.

Recommendations

We recommended that the board:

• further review their discharge planning arrangements in the light of the comments in our decision letter and provide the Ombudsman with a copy of their revised arrangements;
• review communications between wards and the bed manager to ensure that a situation like this does not happen again; and
• draw our decision letter to the attention of the staff involved in Mrs A's discharge to ensure that they learn from the failings identified.

Summary

Mr C injured his neck and back when he fell from his bike. He attended hospital, where he was admitted, treated and discharged. Several weeks later he had a scan at an out-patient appointment at another hospital. This identified a small fracture in one of his vertebrae (the bones of the spine) and injuries to discs in his back. When Mr C complained to the board that only the second hospital identified this, the board acknowledged that the small fracture had been visible on the first hospital's x-rays, although they said they did not believe that this had led to Mr C’s later problems. Mr C was also unhappy that the board told him that the damage to his discs had been caused by an existing, underlying condition and not the fall.

We took independent advice from one of our medical advisers, an experienced consultant in orthopaedic and trauma surgery. He reviewed Mr C’s medical records and also the x-rays taken in the first hospital. He said that, although the fracture had been visible on these x-rays, it was difficult to identify. He also said that if it had been identified then, it would not have merited additional investigation nor would it have changed Mr C’s treatment at the time. The adviser also explained that Mr C’s disc injuries were caused by wear and tear over a period of years, and added that the fact that Mr C had not felt any symptoms before his accident did not mean that the accident had caused them. We also took advice from our hospital adviser. He indicated that it is standard practice for x-rays and scans to be formally reported upon fairly soon after they are taken. However, in Mr C’s case, there was a delay – which he indicated was not ideal - between a scan being taken at the first hospital and then being formally reported upon. He noted that the fracture was identified in the formal report available after Mr C’s discharge.

We accepted the advice and, on balance, considered that Mr C’s treatment – based on the information available at the time and without the benefit of hindsight - had been reasonable. We did not uphold his complaints although, in light of the delay in the formal report of the initial scan, we did make a recommendation.

Recommendations

We recommended that the board:

• review departmental processes for formal imaging reports, in light of the Royal College of Radiologists’ guidance.

Summary

Following a severe stroke a number of years ago, Mr C's wife (Mrs C) has had a number of ongoing health issues, including being unable to speak. Her shoulder (on the side affected by her stroke) has been dislocated several times. On one occasion, Mrs C attended the accident and emergency department of a hospital because her shoulder was painful. An x-ray was taken and an emergency doctor attempted to manipulate her shoulder back into position while she was sedated, fracturing one of the shoulder bones in the process. This was treated conservatively (with medical treatment that avoids radical therapeutic measures or operations) but Mrs C required hospital admission and her arm was immobilised.

Mr C complained that as a result of the fracture and bruising, Mrs C suffered a lot of pain. She also had to wear a sling and shoulder brace which made her life more difficult. Mr C said that the manipulation carried out was unreasonable and that Mrs C should not have had to cope with its consequences, particularly given the aftermath of the stroke.

During our investigation we took independent advice from one of our medical advisers, who examined Mrs C's medical records. Their advice, which we accepted, was that it was not reasonable to carry out the manipulation, because the shoulder was effectively not dislocated and there was a very high risk of a fracture occurring. These were significant failures. Furthermore, we were not satisfied from the medical records that Mrs C was fully informed of the risks of the procedure, or that the doctor properly obtained consent.

Recommendations

We recommended that the board:

• put in place a clear protocol for the treatment of chronic dislocation and subluxation (partial dislocation of a bone in a joint) of the shoulder particularly for patients with neurological abnormalities;
• ensure that written consent is obtained for invasive procedures, including the complications, which should be obtained prior to such procedures being undertaken and clearly recorded in the notes;
• ensure these issues are raised with the emergency department doctor as part of his annual appraisal; and
• apologise to Mr C for the failures identified in this investigation.

Summary

Ms C complained about the care and treatment provided to her son (Master A) after a circumcision operation. She said that hospital staff inappropriately discharged her son after the operation; failed to provide the family with information leaflets or advice about what aftercare was required and failed to provide appropriate follow-up treatment when it was evident that the wound was not healing.

After we took independent advice on this case from one of our medical advisers, a paediatric surgeon, we upheld all of Ms C's complaints. The adviser said that, given Master A’s level of discomfort and his difficulty in passing urine, he should not have been discharged from hospital when he was. The adviser also said that the board should have provided Ms C with a discharge summary, including plans for follow-up, when Master A was discharged. We found that the board failed to carry out an investigation into their discharge arrangements, information and documentation, as they had said they would, and to promptly convey the results to Ms C.

The adviser also said that a routine follow-up appointment should have been made for Master A, and that the board should have brought forward that appointment after his emergency reassessment, without any intervention from Ms C. Master A was later prepared for theatre without any explanation to his family, but a surgical registrar then decided not to operate and discharged him home. We found that the junior surgeon who initially saw Master A should have made Ms C aware that the final decision about surgery would be made by the surgical registrar.

Recommendations

We recommended that the board:

• ensure that this complaint is used as a learning tool for all staff responsible for the discharge arrangements for patients undergoing this type of procedure;
• ensure that patients undergoing this procedure are appropriately followed up, including ensuring any necessary follow-up appointments are made prior to discharge;
• ensure that a full review of their discharge policy is carried out for patients undergoing this type of procedure and provide the Ombudsman with evidence of the review; and
• provide both Ms C and Master A with a full apology for the failings identified.

Summary

Mrs C complained about the care and treatment of her late brother. During our consideration of the complaint, Mrs C advised that she had decided to pursue the matter by other means, as the outcome she sought was financial compensation. We decided, in the circumstances, and under the provisions of the Scottish Public Services Ombudsman Act 2002, that we would not consider the matter further.

Summary

Ms C, who is an advice worker, complained on behalf of Ms B about the care and treatment given to her late father (Mr A) by the practice in the year before his death. Ms B was unhappy with the attitude of staff there, saying that the practice had not taken sufficient account of her father's symptoms, that they dismissed certain issues, and would only address one issue at a time. She thought that this meant they had missed symptoms that would have led them to identify his final diagnosis of lung cancer earlier.

Mr A attended the practice on numerous occasions in the year or so before his death. He reported a range of symptoms, including chest infections, incontinence, possible dementia, mobility issues, a dry mouth and a cough. He was referred for chest x-rays early in the year and again towards the end of the year, which were reported as showing no signs of active disease. He was also referred to urology and for a geriatric medicine review. It was at this review, a month before he died, that specific concerns were first raised about a possible cancer diagnosis. Mr A was referred for a scan, which found lung cancer that had spread to other parts of his body. Mr A died three days after the diagnosis.

We noted that Ms B complained that the practice were dismissive of her father's symptoms and that their attitude indicated they did not take his concerns seriously. As, however, there was no objective evidence of this, our investigation focused on Mr A's medical records. We took independent advice from one of our medical advisers, who reviewed the practice's actions in respect of each of the issues Mr A had told them about. The adviser said that the practice referred Mr A for x-rays appropriately. While they could have done more to assist him with his reports of incontinence, what they did was fairly standard practice. In relation to Mr A's mobility, our adviser said that the practice assessed the situation appropriately. There had been some confusion around whether Mr A had a diagnosis of dementia, and our adviser indicated that the records showed that he did not. He said that there were references in correspondence which could have led to this confusion, and that Mr A may have been told that he had mild dementia. However, when Mr A raised his concerns with the practice, they had responded appropriately.

We found that the care and treatment given to Mr A was appropriate. He was referred for specialist opinion appropriately, and the practice took action to investigate concerning symptoms. Although they could have done more to assist him with the management of his continence issues, we noted that the adviser identified what they did as being standard practice.

Summary

Ms C, who is an advice worker, complained to us on behalf of Ms B about the care and treatment of her late father (Mr A) during an out-of-hours GP visit. This visit came shortly after Mr A had been diagnosed with lung cancer.

Ms B said that her father had become increasingly short of breath and was looking very unwell. The family called NHS 24 and requested a home visit. Mr A spoke to a nurse on the phone, and was assessed as needing a home visit within an hour. Ms B asked that the GP not mention the new cancer diagnosis to her father, as he was not fully aware of it. About half an hour after the call, a GP arrived. She assessed Mr A's condition, and listened to his chest. She noted his vital signs, and as not all her equipment was working fully, she judged his temperature by touch and found that he did not have a fever. Following discussion with the family, Mr A was not transferred to hospital, but was given medication for his cough and to reduce pain. Shortly after the GP left, Mr A collapsed and had to be resuscitated by his family until an ambulance came. He was taken to hospital, where he died the following afternoon.

We took independent advice from one of our medical advisers, who based their findings on the notes made by the GP at the time. We noted, however, that the accounts given by the GP and Ms B in relation to what happened during the visit were somewhat different. Our adviser said that during the consultation the GP took appropriate action in relation to her assessment of Mr A's condition. She had taken account of Mr A's medical history, and took the family's views into consideration in suggesting that he remain at home and be reviewed by his GP the following morning. However, the adviser was slightly critical of the level of detail in the GP's notes.

In coming to a decision on this complaint, we were not able to determine what exactly happened during the consultation, given the conflicting accounts. However, based on the clinical records made at the time, the advice we were given indicated that the GP assessed Mr A's condition appropriately, and appropriately considered the family's wishes when planning treatment.