Health

Summary

Ms C went into premature labour and was taken to Aberdeen Maternity Hospital as an emergency. She said that, after admission, staff failed to manage her labour and delivery properly, as a consequence of which her daughter was deprived of oxygen and suffered serious brain injury. Ms C also said that when she made a formal complaint about this, the board failed to deal with it properly.

During our investigation, we took into account all the relevant documentation, including the complaints correspondence and the clinical records. We also took independent advice from a consultant obstetrician and an experienced midwife.

We upheld Ms C's complaints. We found that the board delayed in dealing with Ms C's complaint, and that the evidence showed that her labour was not managed reasonably, as there had been some delays by nursing staff in seeking medical assistance and Ms C should have been transferred to a labour ward earlier than she was. However, despite these failings, we found no evidence to suggest that Ms C's baby should have been delivered sooner, or that care was compromised.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified by the investigation and in particular that they did not keep Ms C updated about her daughter and failed to change her soiled bed;
• remind staff of the necessity and importance of keeping accurate and timely records and of their responsibility for signing them and detailing the reasons for any amendments. Midwifery staff should also be reminded of the NICE Clinical Guideline 5 and Nursing and Midwifery Guidance;
• provide details of the action they have taken in order to resolve the communication issues which existed and which were acknowledged by the chief executive; and
• remind staff of the necessity of adhering to their stated complaints policy.

Summary

Mr C, who is a prisoner, submitted a request to the prison health centre for an appointment with the mental health team. This was on the advice of the forensic psychologist who was running the offending behaviour programme that Mr C was attending. As Mr C did not receive a response to his request, he complained to the health board. The board told him that the mental health team had assessed his request and decided that he did not need input from them. Mr C did not dispute this decision, but complained to us that the board had not told him about the decision when it was made.

In response to our investigation, the board told us that due to staff shortages in the prison health centre there had been a backlog of referrals at the time Mr C submitted his request. This meant that it was not assessed until almost six weeks later. They confirmed the decision that had been taken but acknowledged that this did not appear to have been communicated to Mr C until he complained. They explained that a reply slip should have been issued, informing Mr C of the decision, and confirmed that they had reminded staff to adhere to this process in future. They also took steps to speak to Mr C and apologise to him. We upheld the complaint, due to the failure to communicate the outcome of the referral to Mr C, but in light of the action already taken by the board to address this, we had no further recommendations to make.

Summary

Mrs C's mother (Mrs A) died from complications following surgery for an abdominal aortic aneurysm (bulging of part of the aorta, the body's largest artery). Mrs C complained that there was a delay in diagnosing the aneurysm (a weak point in the blood vessels, which causes them to bulge or balloon out). She said that her mother had been visiting the practice for two years and had been diagnosed with sciatica (back and leg pain, caused by irritation of or pressure on the sciatic nerve). However, she felt that her mother should have been referred to hospital earlier for further tests. She also complained about the follow-up care after her mother had surgery, in particular a delay in identifying post-operative complications.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from one of our medical advisers.

Our investigation found that the practice had acted reasonably, and that there was no evidence of an unreasonable delay in referring Mrs A to hospital for tests. Our adviser said that there was no evidence of specific symptoms that would have alerted the practice to an aortic aneurysm, and that it was in fact picked up by chance during an x-ray to investigate back pain. She also said that as there are usually no symptoms, such aneurysms are often not discovered until they leak or burst. Once the aneurysm was identified, appropriate action was taken to investigate it further and to resolve it. We also found no evidence that the practice had failed to assess Mrs A after her operation or that there was a delay in diagnosing the post-operative complications. The operation was clearly a risky one, as Mrs A had other health conditions. The medical records show that the procedure was complicated, and we noted that doctors had discussed the risks with Mr and Mrs A (Mrs C's parents) before the operation was carried out.

Summary

Mr C's late wife (Mrs C) had chronic obstructive pulmonary disease (a disease affecting the lungs). She was admitted twice in one month to Forth Valley Royal Hospital with pneumonia and treated with antibiotics. The following month she was admitted for another two days with vomiting and diarrhoea. During this last admission, tests showed abnormal temperature and blood results. On the day of her discharge, Mrs C felt very unwell and an advanced nurse practitioner found a wheeze in her right lung, but the consultant who reviewed Mrs C decided to discharge her. Mrs C's condition continued to deteriorate and she was admitted to another hospital five days later where pneumonia was again diagnosed. After being discharged from there, she developed a severe infection and irregular heartbeat and was diagnosed with an inflammatory condition of the bowel. She sent us her complaint but died before we could investigate it, and her husband carried it on on her behalf.

Mr C complained that the consultant's decision to discharge Mrs C after the episode of vomiting and diarrhoea was unreasonable in light of her symptoms, and said that further investigations should have been carried out. He also complained that the advanced nurse practitioner's findings were unreasonably dismissed and that these failures led to a prolonged period of suffering for Mrs C before she was properly diagnosed and received appropriate treatment. Finally, Mr C complained about the board's complaints handling.

We took independent advice on Mr C's complaint from one of our medical advisers, who agreed that Mrs C's discharge should have been delayed for further investigation of her symptoms, and of the abnormal temperature and blood test results. We found that Mrs C was discharged with no clear diagnosis and that she endured symptoms for longer than she should have before she was diagnosed and treated appropriately. The adviser said that the consultant who discharged Mrs C had to make a difficult decision, and was seeing Mrs C for the first time. He said that responsibility for the decision should be viewed as an overall system failure involving several healthcare professionals who had been responsible for Mrs C's care.

We found that the board at first failed to fully respond to the complaints, but then fully addressed them after receiving a further letter from Mrs C. We appreciated that Mr C disagreed with the board's response and, as indicated above, we reached a different view to that of the board on the reasonableness of Mrs C's discharge. However, that is not evidence in itself of administrative fault by the board in their complaints handling, and we were satisfied that the board's interpretation of the complaints was reasonable. We, therefore, found that on the whole the board reasonably investigated the complaints.

Recommendations

We recommended that the board:

• review the ward round procedures to investigate and address why medical staff were unaware of Mrs C's temperature and why it was not discussed;
• review the investigation process to ensure that abnormal results are highlighted and considered; and
• apologise to Mr C for the failures identified.

Summary

Ms C, a former prisoner, complained that while in prison her pain relief medication (pregabalin) was stopped suddenly. This was after a spot check of medicines found that she had removed powder from the capsules and not taken them as instructed. Ms C had been prescribed pregabalin for pain caused by nerve damage, and told the prison health centre that she had taken extra medication to help her cope with difficult family circumstances. She also said that she was unable to appropriately progress her complaint through the NHS complaints procedure.

We took independent advice on this complaint from one of our medical advisers. Although we found that the prison health centre doctor had noted that Ms C had not demonstrated objective neuropathy (nerve damage), it appeared from the records that the stopping of her medication was influenced by her interference with the capsules (Ms C had been given a warning two months earlier to be more careful with her medication). Our medical adviser said that pregabalin can also be used to treat anxiety, and explained that a patient's perception of pain and their mental health are closely linked, and that treating anxiety can improve the management of pain. We decided that the prison doctor did not give proper consideration either to whether pregabalin assisted Ms C in managing her anxiety, or to gradually reducing the dosage in line with best practice.

In terms of the complaints handling, we found that even after Ms C met with the clinical manager to discuss her concerns about a lack of response, she still did not get a reply. Her complaints were logged but not responded to, contrary to the NHS complaints handling guidance. It also appeared that some complaints information was inappropriately held in Ms C’s medical records.

We upheld both Ms C’s complaints.

Recommendations

We recommended that the board:

• draw to the doctor's attention the British National Formulary's guidance on avoiding abrupt withdrawal of pregabalin;
• put in place suitable guidance for prisoners in the prison about the consequences of misusing prescribed medication;
• apologise to Ms C for failing to handle her complaint in line with the NHS complaints procedure guidance; and
• ensure that health centre staff in the prison do not record complaints information in a patient's medical records, in line with the NHS complaints procedure guidance.

Summary

Mr C complained that he had been inappropriately treated by his dentist. He was unhappy with the insertion of two crowns on teeth in his upper jaw and the removal of a crown from a tooth from his lower jaw. Mr C said that the upper crowns had not been fitted properly, and had left unsightly gaps between his teeth, which had never been there before. Mr C said that the dentist had then referred him to a dental hospital, because the dentist found him too difficult to deal with. Mr C also complained that when attempting to remove the crown from his lower jaw, the dentist had removed almost the entire tooth. He said he had not been warned that this was a possibility and, had he known this, he would not have agreed to the removal of the crown.

We took independent advice on Mr C's complaint from our dental adviser. He said the decision to replace the two upper crowns was appropriate, and was supported by the x-rays of the teeth, and that the same applied to the removal of the crown from the lower tooth. He said that gaps between the teeth would have appeared as inflammation of the gums (caused by previous poorly fitting crowns) receded. It was appropriate for the dentist to have referred Mr C to the dental hospital, in line with General Dental Council guidelines, once it became clear he was still unhappy with the treatment he had received. The adviser said that the dental records for the removal of the crown from the lower tooth showed that the treatment options were explained to Mr C. He also pointed out that, had the tooth been left in place, it would have fractured. We did not uphold Mr C's complaints as our investigation found no evidence to support his claims of inadequate and unnecessary treatment.

Summary

Mrs C complained about the care and treatment she received in Borders General Hospital following an operation for an umbilical hernia (where fatty tissue or a part of the bowel pokes through into an area near the navel). She said that for a number of months afterwards she suffered problems with the stitches in her wound and the hospital did not deal with these adequately; she also said that she was wrongly told that the stitches used were dissolvable. English is not Mrs C's first language, and she told us that she has difficulty with it. Mrs C said she was also told that further surgical investigations could not be carried out at the time because she was pregnant and, as a result, she suffered worry and distress.

We took independent advice on this case from one of our medical advisers. The adviser explained that if stitches close to the skin are causing pain, they may be removed to prevent a breach in the skin and/or possible infection. Mrs C was, however, pregnant and it is accepted practice that non-urgent surgery should not be performed in the first three months of pregnancy. After that, as surgery carries an increased risk of premature labour and miscarriage it is still better to defer non-urgent procedures until after the baby is born. We accepted that the hospital had acted appropriately and in accordance with accepted medical practice when dealing with the problems with Mrs C's stitches. The evidence also showed that both dissolvable and non-dissolvable stitches had been used. It was unclear what, if any, allowances medical staff had made for the fact that English is not Mrs C's first language, and the board accepted that explanations may not have been communicated as clearly as they could have been. We could not reconcile the differing accounts of what the doctors say they told Mrs C and what Mrs C understood she was told. However, there was no evidence that Mrs C was given incorrect information. Although we did not uphold this complaint, we made a recommendation based on the board's acceptance that it was possible that explanations had not been clear due to language difficulties.

Recommendations

We recommended that the board:

• remind the medical staff involved in Mrs C's care and treatment that consideration should be given to the use of the board's Interpretation and Translation Guidelines where a patient's first language is not English.

Summary

Mrs C complained on behalf of her partner (Mr A) about a procedure to remove his gallbladder at Borders General Hospital. Mrs C said they had originally been told that the procedure would be performed by keyhole surgery but that, if complications arose, it would be performed as open surgery, and Mr A would need to be kept in hospital for several days. Mrs C said that when she phoned the hospital on the day of the operation, she was told complications had arisen. When she visited Mr A after his surgery, he was in great pain, which she did not believe was being managed properly. When Mrs C visited the next day, she found Mr A being prepared for a scan. Mrs C said she had repeatedly asked nurses and medical staff about Mr A's wound and the frequency of his dressing changes. She believed that it was only as a result of her questioning that Mr A's wound was examined, leading to Mr A's transfer to a specialist unit.

We took independent advice from one of our medical advisers, a specialist in gallbladder surgery. He explained that Mr A's procedure had not been converted into open surgery, due to the complications that the surgeon had identified, and that this was an appropriate course of action. The notes of the operation showed that there were significant difficulties in performing the operation, due to existing damage to the gallbladder. The adviser said that the notes also showed that the care plan for Mr A was to perform a scan to identify the complications from the operation, and to consult with a specialist unit. The adviser said that the surgeon had acted appropriately and in Mr A's best interests when complications occurred. We found no evidence that Mr A had not been appropriately treated, and did not uphold Mrs C's complaint, as we found no evidence to support her claim that Mr A was only transferred due to her intervention.

Summary

Mr C complained about the care and treatment given to his late father (Mr A) after he was admitted to Ayr Hospital. Mr A had respiratory (breathing) and kidney disease. When he was in hospital he said he did not wish, nor was he able to tolerate, non-invasive ventilation (help with breathing, using a facemask or similar device). He was also recorded as not for cardio-pulmonary resuscitation (DNACPR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). After 24 hours of being fairly stable after admission, Mr A was moved to a general medical ward (Station 16) but he began to decline, and he died after his breathing stopped, although medical staff tried to resuscitate him.

Mr C said that Mr A's care and treatment plan were not discussed with his family. He was also unhappy that after being admitted to the Medical High Care Unit (MHCU) Mr A was then moved to a general medical ward. He said that the notes that accompanied Mr A were unclear, and that the ward was ill-equipped to deal with him. He was also unhappy that although DNACPR was recorded in Mr A's records, an attempt had been made to resuscitate him.

The complaint was investigated and all the complaints correspondence and Mr A's relevant clinical records were carefully considered. We also took independent advice from one of our medical advisers, who is a consultant in medicine for the elderly. Our investigation found that following Mr A's admission to hospital there had been confusion and uncertainty, particularly when he was transferred from the MHCU to the general medical ward (although it appeared that his condition had been discussed with his family). We found this uncertainty unacceptable, and also noted that the medical documentation was unclear regarding DNACPR, which led to unnecessary confusion at the end of Mr A's life.

Recommendations

We recommended that the board:

• make a formal apology for the confusion and uncertainty caused;
• conduct a Critical Incident Review/Significant Event Analysis and provide the Ombudsman with a copy of the outcome;
• audit the completion of Do Not Resuscitate and ward-to-ward transfer forms in the MHCU and Station 16;
• audit documentation and communication of care needs and care planning on these wards; and
• review their procedure regarding handover between wards (particularly from a higher environment to a lower one) to satisfy themselves that it is fit for purpose.

Summary

Ms C complained that the care and treatment provided to her late mother (Mrs A) by two hospitals was unreasonable. She said that Mrs A's transfer between the two was delayed; she had to wait some hours for a bed once transferred; she was not treated for possible blood clots; she was not given enough pain relief; and that nursing care was poor.

Mrs A had had a stroke and was undergoing rehabilitation, firstly in Ayr Hospital (a general hospital) and then in Ailsa Hospital (a mental health hospital). When Mrs A's condition started to deteriorate in Ailsa Hospital, her daughters were concerned and asked for a medical review with a view to transferring Mrs A back to Ayr Hospital. Ms C thought that Mrs A might have suffered another stroke. Mrs A was not, however, examined by a doctor (in this case, a psychiatrist) until that evening when, after consultation with Ayr Hospital, it was decided not to transfer her. The following day Mrs A's condition had deteriorated further and she was transferred, with the receiving doctors noting that she was very unwell and treating her for an infection. The board's standard admission documentation has a section for doctors to complete saying whether or not the patient is thought to be at risk of blood clots (deep vein thrombosis - DVT), but this was not completed.

Our investigation included taking independent advice from two of our advisers - a doctor specialising in elderly medicine, and a nurse. We found that there were problems with Mrs A's care in both hospitals, and we upheld some of Mrs C's complaints. Our advisers said that there was delay in obtaining a medical review in Ailsa Hospital, and that when the review did take place it was inadequate. There was also a delay in arranging to transfer Mrs A. The medical adviser said that when Mrs A was admitted to Ayr Hospital, consideration should have been given to her susceptibility to blood clots. National guideline 122 issued by the Scottish Intercollegiate Guidance Network (SIGN) recommends that patients who have mobility problems and illnesses such as infection - as in Mrs A's case - should be treated with preventative drugs to minimise the risk of developing blood clots. This did not happen in Mrs A's case, and she went on to develop blood clots.

We did not uphold Ms C's complaints about pain relief and general nursing care. Both advisers said that there was no evidence to demonstrate that these aspects of Mrs A's care were unreasonable.

Recommendations

We recommended that the board:

• provide the Ombudsman with evidence that staff training referred to in the board's response has now taken place;
• ensure that all staff involved in this complaint at Ailsa Hospital reflect on their practice in this area and discuss any learning points at their next appraisal;
• confirm that all the medical staff involved in this complaint at both hospitals reflect on their practice in this area and discuss any learning points at their next appraisal;
• as a matter of urgency, take steps to ensure that medical staff at Ayr Hospital complete admission documentation in relation to DVT and fully take into account SIGN guideline 122 in their clinical practice; and
• ensure that relevant staff are reminded that complaint responses should accurately reflect the clinical situation of the patient involved.