Health

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.

Summary

Mr C complained about the care and treatment provided to his father (Mr A) by the medical practice after he raised concerns about Mr A's deteriorating health. Specifically, he was concerned that doctors failed to assess his father's deteriorating mental health. Mr A refused to go into respite care, was suffering from kidney failure and liver disease and was an alcoholic. Mr C felt that his father no longer had capacity to make decisions for himself. The practice agreed that Mr A's medical condition was very poor. However, they considered that, despite not being willing to go into respite care, stop drinking or allow some visits by doctors, Mr A did have capacity to make his own decisions about his health and welfare.

We reviewed the complaints correspondence and medical records and sought independent advice from our medical adviser, who is a GP. We found that a formal mental health assessment was carried out a couple of weeks before these events and that Mr A had scored highly. In addition, our adviser noted that doctors reviewed Mr A's mental health whenever they visited him and that the records of this did not show any concerns. In addition to the reviews by doctors from the practice, Mr A attended the local renal unit for kidney dialysis, where he had to give informed consent for this procedure to be carried out three times a week. Doctors in the renal unit were also content that he had capacity to make such decisions. As we found no evidence to support the view that doctors had failed to properly assess Mr A's mental health, and as the care provided was reasonable in this regard, we did not uphold the complaint.

Summary

Mrs C complained about a specific consultation with a GP in her local practice. She attended with a flare-up of her longstanding physical health problems, which included fibromyalgia and osteoarthritis (conditions that cause the muscles and joints to become painful and stiff).

She complained that the GP was dismissive of her problems and suggested that there was nothing wrong with her. In responding to the complaint, the practice said that the GP had felt that there was no physical reason why Mrs C could not get out and go about her normal business. Mrs C strongly objected to this and reported how she struggled on a daily basis and, on some days, was unable to even get out of bed.

We obtained independent advice from one of our medical advisers, and this indicated that the advice offered to Mrs C was appropriate for her conditions. We were informed that the management of fibromyalgia would include trying to keep the muscles strong by keeping as active as possible. The adviser noted that Mrs C’s conditions were painful and debilitating and he accepted that she would be limited in her activities. However, he felt it was appropriate for the GP to have tried to encourage her to remain active.

Mrs C clearly disagreed with the advice she received, and she was unhappy with the GP's handling of the consultation, and the attitude he displayed. However, in the absence of evidence that the GP acted unreasonably, or offered inappropriate advice, we did not uphold the complaint.

Summary

When Ms C hurt her knee she went to Stirling Community Hospital where she was seen by an emergency nurse practitioner (ENP) in the minor injuries unit. She was diagnosed as having a medial collateral ligament (knee ligament) sprain and sprain of her hamstring. She was prescribed co-codamol (a pain reliever) and advised to see her GP if she had further concerns. She was encouraged to walk.

Ms C told us that the examination and care given to her were inadequate. She was not given an x-ray, nor was her knee scanned. She said that it was not until a month later, after she attended the accident and emergency department, that her knee was scanned and it was confirmed that her cruciate ligament (another knee ligament) had snapped.

During our investigation we carefully considered all the complaints correspondence and Ms C's relevant clinical records, and took independent advice from one of our medical advisers. Our investigation confirmed that Ms C's initial examination had been full and thorough and that the ENP had provided appropriate treatment in accordance with the relevant guidelines. The adviser said that Ms C did not require an x-ray as she had suffered a soft tissue injury which would not be seen on an x-ray. Although Ms C said that her knee had 'popped' and that she had reported this, there was no evidence of this in the records. We decided, on the basis of the available evidence, not to uphold the complaint, as it was not possible to provide independent verification of Ms C's recollection of events.

Summary

Mr C, who is a prisoner, complained to us about the board's handling of his complaint to them about healthcare issues. We were satisfied that the board had considered and responded to the issues Mr C raised, but our investigation found that they had failed to deal with the complaint within the timescales detailed in their complaints procedure and had not kept him advised of progress.

Recommendations

We recommended that the board:

• apologise for the failures we identified in the handling of the complaint; and
• remind staff of the need to work in accordance with the NHS Scotland complaints procedure.

Summary

When Mrs C's young daughter (Miss A) became ill, she was taken to her medical practice, where she was treated for an upper respiratory tract infection. The next day Miss A attended an emergency appointment there, as her condition had deteriorated. As she was clearly unwell, the practice referred her urgently to hospital. She was treated for a viral infection and discharged home without follow-up. A few days later, she was again taken to a further emergency appointment at the practice, where, in view of the hospital's recent diagnosis, doctors advised Mrs C to continue with the treatment previously recommended. However, Miss A's condition continued to decline and she was admitted to hospital. She later spent a number of weeks in intensive care after being diagnosed with pneumonia.

Mrs C complained that the practice showed little concern or empathy for her daughter's declining condition. She said that they had failed to take appropriate action on her symptoms as a consequence of which Miss A suffered distress and unnecessary suffering. We took independent advice on this case from one of our medical advisers, and took all the relevant information (including the complaints correspondence and Miss A's clinical notes) into account. We did not uphold the complaint, as our adviser said that the records indicated that the treatment given to Miss A was reasonable and that doctors made a reasonable working diagnosis. The adviser also said that Miss A went on to develop a rare and unusual medical condition, and there was nothing in her notes to suggest that this was developing.

Summary

Mr C complained about aspects of his mother's care and treatment in hospital but decided to withdraw his complaint and so we could not investigate his concerns further.

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 and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again 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’'s GP could, and should, have diagnosed Mrs A'’s pulmonary embolism or could have arranged for more urgent investigations to establish the cause of her symptoms.

We took independent advice on this case from one of our medical advisers. We found that, with the benefit of hindsight, it was likely that Mrs A’'s collapses at home were caused by initial smaller thromboembolic (blocking of a blood vessel by a blood clot) events. However, there was evidence to suggest that Mrs A was also suffering from a viral infection, which may have contributed to her symptoms. We accepted the adviser's view that Mrs A’'s symptoms were consistent with a viral infection rather than a pulmonary embolism. There was clear evidence that the GP had considered a number of possible diagnoses but had ruled out pulmonary embolism. Based on the information available to him at the time, we were satisfied that his examinations of Mrs A were thorough and his conclusions reasonable.