Health

Summary

Mrs C was referred to a hospital chest clinic in 2008 with a troublesome cough, breathlessness and wheezing. A diagnosis of chronic obstructive pulmonary disease (an airways disease) was considered, but excluded several months later following further investigations. A diagnosis of asthma was considered and Mrs C was prescribed treatment to see if this improved matters. Mrs C also had episodes of palpitations and her medical records noted that she had a faster than normal heartbeat (supraventricular tachycardia - SVT), and had been prescribed verapamil (a drug widely used to treat this) from 1991. When she was reviewed by the respiratory consultant in 2011, it was noted that she had different symptoms to the previous ones that might have been related to SVT. She was referred to a consultant cardiologist and tests were carried out. These did not show any abnormalities and the prescription of verapamil was stopped.

Mrs C complained that she was treated for asthma for two and half years when there was no definitive diagnosis, and prescribed verapamil for over 23 years without being routinely reviewed by the hospital cardiology department to update the diagnosis and consider treatment options that might be more relevant. Mrs C also said that the board failed to fully respond to her complaint, to respond within a reasonable time and to take appropriate action.

Our investigation took account of the information Mrs C provided, alongside her medical records, and we took independent advice from one of our medical advisers. The advice, which we accepted, was that both the diagnosis of Mrs C's symptoms and potential conditions, and the resulting treatment, were reasonable. In 2009, it appeared that Mrs C's symptoms were well controlled by treatment for asthma. As soon as it became apparent in 2011, however, that this was potentially exacerbating the symptoms of her fast heart rate, she was referred promptly to cardiology. In relation to the prescription of verapamil, we found that the care and treatment provided by the relevant consultants was reasonable. Our adviser said that where medication controls the symptoms, as in Mrs C's case, then it can reasonably be continued without regular review. As soon as her symptoms could be interpreted as relating to her heart, the medication was stopped and alternative treatment was considered. We did not, therefore, uphold Mrs C's complaints about her care and treatment.

We did uphold her complaint about the complaints handling. We were satisfied that the time the board took to deal with the complaint at first was reasonable. They responded within 20 working days and addressed three of the issues, saying that the consultant would address the remaining issues. The consultant then said that these would be difficult to put in writing and easier to discuss. As our adviser confirmed that the issues were extremely complex, we took the view that this was reasonable. In addition, the consultant followed up the discussion with a written record, which was good practice. The board, however, did not at first tell Mrs C that they could not address a complaint she raised about her GP practice, although they later told her about the practice’s position and arranged a meeting with them. We also found that the board failed to respond to Mrs C's complaint about the long-term prescription of verapamil, until we investigated this. Given the significance of the issue in her complaint, we criticised the board for this.

Recommendations

We recommended that the board:

• take steps to ensure that, in future, all elements of a complaint are responded to; and
• apologise to Mrs C for failing to fully address her complaint.

Summary

Mr C, who is a prisoner, complained about the care and treatment provided to him by the prison doctor. The prison doctor had diagnosed Mr C as having external piles (small lumps that develop on the outside edge of the anus), but Mr C disagreed with this diagnosis.

We took independent advice on this complaint from one of our medical advisers, who considered Mr C's medical records. The adviser told us that the symptoms reported by Mr C did indicate that he had external piles and because of that, the prison doctor's diagnosis and treatment were reasonable and appropriate.

Summary

Mr C, who is a prisoner, complained that it took five months for him to see a dentist. He was dissatisfied with the board's response to his complaint, in that they did not tell him what had gone wrong or what they would do to ensure this did not happen again. After Mr C asked to see the dentist, the healthcare team gave him an acknowledgement slip advising that he would be placed on the waiting list. However, a member of staff lost Mr C's paperwork and he was not listed to see the dentist. When the health care team became aware of the problem, they placed Mr C on the waiting list and he was later seen by the dentist.

We were concerned that during our investigation the board sent us conflicting responses about the guidance they were using as a standard for treating prisoners. This showed that there was confusion for their staff in relation to the standards they applied. We noted, however, that since taking over responsibility for NHS care in prisons, the board aim to have routine patients seen by a dentist within ten weeks. They also apologised to Mr C for the delay in his case, and told us that they would introduce a new appointments system to reduce the likelihood of this happening again.

We were aware that at the time of the complaint the Scottish Government had developed draft guidance for a robust framework for oral health improvement and dental services in Scottish prisons. This says that prisoners will have access to a dentist within ten weeks (the current target timescale). Whilst the board had apologised for the delay, we concluded that it was unreasonable for Mr C to wait 22 weeks to see a dentist and we upheld his complaint. We were satisfied that the board were introducing a new system but considered that they should have explained to Mr C what had gone wrong and the improvements they were making, in order to reassure him.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to inform him that there had been an error in his paperwork being lost and the steps being taken to improve their appointment system;
• highlight to relevant staff that responses to complaints should contain information about what happened and any improvements identified, in line with the Scottish Government's complaint handling guidance; and
• provide a copy of their new guidelines once the Scottish Government's national guidance on oral health and dental services is published.

Summary

Mrs C's husband (Mr C) was referred to hospital by his medical practice because he was suffering from fatigue and shortness of breath on exertion. He had some tests, but it was not until almost five months later that he was diagnosed with lung cancer. Mr C died shortly after the cancer was diagnosed. Mrs C said that her husband had a complicated medical history, but she was concerned that there appeared to be a lack of urgency by the hospital in establishing the cause of his symptoms.

To investigate the complaint, we carefully considered all the relevant documentation, including the complaints correspondence and Mr C's medical records. We also took advice from one of our medical advisers, who is a consultant in respiratory medicine.

We upheld Mrs C's complaint. Our investigation found that there was a three week delay before Mr C was seen at the respiratory clinic and, later, it took four weeks for the GP specialist's urgent referral request to be seen by the hospital's consultant respiratory consultant, although the reasons for this could not be established. After Mr C was seen, there was then little urgency in dealing with him. Our adviser confirmed that although an earlier appointment would have led to an earlier diagnosis, the outcome for Mr C would not have been different. However, Mr C would have had more time for palliative care (care to prevent or relieve suffering), which would have alleviated his pain and discomfort.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the delay and lack of urgency; and
• ensure that, where cancer is suspected, there is a robust cancer pathway in place in accordance with the Scottish referral guidelines for suspected cancers.

Summary

Mrs C said that her husband (Mr C) first attended his medical practice in January 2012 complaining of breathlessness and low mood but that it was not until November 2012 that it was confirmed that he had lung cancer. Mr C died in December 2012 and Mrs C complained that the practice had unreasonably delayed in providing a diagnosis.

To investigate the complaint, we considered all the relevant documentation, including the complaints correspondence and Mr C's medical records, as well as obtaining independent advice from one of our medical advisers. We found that, throughout, the practice had acted reasonably and no areas of delay were identified. Our adviser said that Mr C had an extensive and significant medical history, some of which could have explained the symptoms he was experiencing. He explained that there were many causes for breathlessness and no set guidelines on how to investigate it. He said that, given Mr C's history and the fact that his examinations had been normal, the practice's approach was reasonable. He did note that, on occasion, it appeared that there was a long wait for hospital appointments, but this was not the fault of the practice, who tried to move them forward. The adviser also explained that it was regarded as good practice to approach diagnosis sequentially, particularly when the patient was not deteriorating, and said that the practice could have done little more to obtain an earlier diagnosis for Mr C.

Summary

Miss C had root canal treatment on one of her front teeth in 2012. After the treatment, she experienced pain and swelling which did not improve with antibiotics that were prescribed by her dentist. Whilst on holiday, she visited another dentist (the second dentist) who removed the root canal filling and found that she had two perforations in the tooth. He provided a temporary filling so that Miss C could discuss further treatment with her own dentist when she got home. Miss C was later referred for specialist dental surgery so that she did not have to lose the tooth. She complained that her dentist did not carry out the root canal treatment to a reasonable standard and did not provide her with a reasonable level of aftercare.

We found that the tooth had first been root canal treated in 2006, but that this work was not completed. In 2012 Miss C's dentist had removed the original root canal filling and re-filled the tooth. We took independent advice from our dental adviser, who said that Miss C's tooth was filled well and that x-rays taken after the treatment showed no sign of any perforations. The perforations were, however, visible on an x-ray taken by the second dentist, who had used a softer filling material to diagnose the problem. Our adviser explained that the perforations could have been caused either when the first dentist removed the original filling, or when the second dentist removed the first dentist’s filling. Although the infection that Miss C developed was suggestive of a perforation after the first dentist’s treatment, there was no evidence of this on the x-ray. We concluded that there was insufficient evidence to say that Miss C's dentist had caused the perforations. Furthermore, we were satisfied that he took all reasonable measures to establish whether the procedure had been successful, and that he provided appropriate medication and onward referral to a specialist when Miss C had problems following her treatment.

Summary

Mrs A had Parkinson's disease (a progressive neurological condition in which part of the brain becomes more damaged over many years) and an Alzheimer's-type condition and needed help with a number of day to day tasks. Her son (Mr C) was her next of kin, carer and power of attorney. He complained that when Mrs A was admitted to hospital, staff failed to recognise his status and include him in discussions about her treatment. Mr C felt that he had to actively seek information from staff, rather than this being openly discussed with him. He also complained about the quality of the nursing care and the appropriateness of a decision to discharge Mrs A.

We found that, although Mr C was eventually appropriately included in discussions about Mrs A's treatment, he was not adequately involved during the first days of her admission. As such, important background medical information was not gathered, as Mrs A could not provide this herself. We noted that the board have useful tools for staff to establish whether there is a carer available, but these were not used. We were satisfied that appropriate consideration was given to Mrs A's suitability for discharge and that there was clear evidence of Mr C being consulted and of his comments influencing the decision-making process. However, we were critical of the board's handling of Mr C's complaints, as their investigation into his concerns was substantially delayed.

Recommendations

We recommended that the board:

• review their processes for establishing and communicating the level of involvement in care for patients with a welfare guardian or power of attorney;
• introduce a process that ensures that the relatives or carers of any patient who lacks capacity or is confused are engaged in meaninful communication from the earliest point practicable following admission; and
• ensure that they have a structured process in place to act upon all points of learning arising from complaints.

Summary

Mrs C complained on behalf of her daughter (Ms A), who had been diagnosed in 2003 with bipolar disorder. Mrs C said that in 2011, despite her concerns, Ms A's diagnosis was changed, as was her medication. Ms A was not offered a second opinion and Mrs C said that her daughter’s condition went into 'free fall', reaching a crisis point in the summer of 2012. She complained that Ms A was offered little in the way of psychiatric support, and that appointments with a community psychiatric nurse were often cancelled without being rescheduled.

We gave all the relevant documentation, including the complaints correspondence and Ms A's medical records, careful consideration. We also obtained independent advice on the case from a consultant forensic psychiatrist and a mental health nurse. Our investigation found that despite Mrs C's concerns, it was entirely correct for Ms A's diagnosis and medication to be kept under review and that the board had acted appropriately and reasonably in doing so. Mrs C's disagreement with this was well recorded, and was not discounted. However, in the circumstances, our adviser said that it might have been prudent to offer Ms A a second opinion.

The investigation also established that there had been no delay in providing new appointments when some were cancelled. However, there was evidence that the frequency of appointments was inconsistent and not as planned.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C and Ms A for inconsistencies in the timing of appointments.

Summary

After Mr C was discharged from hospital following an operation on his bladder, he complained that his GP failed to visit him to review his wound or to provide him with treatment for a urine infection.

The clinical records showed that when Mr C contacted the practice, the GP had asked a district nurse to visit him to dress his wound. When the nurse attended, she noted that Mr C was feeling well. She visited again a couple of days later and noted that he was still improving. When the GP called him six days later, Mr C reported that he was still feeling well, but when the GP mentioned that a urine infection had been noted after an initial post-discharge district nurse's visit, Mr C became upset. Two days later Mr C contacted the practice to complain of significant pain and cloudy urine. He was then prescribed antibiotics.

We took independent advice on this case from one of our medical advisers, who is a qualified GP. He said that it was appropriate for Mr C's wound to be dealt with by district nursing staff. He also advised that it was reasonable, given the continued improvement in Mr C's condition, that the practice did not initially prescribe antibiotics for the urine infection. As the care provided by the GP was reasonable, we did not uphold the complaint. We did, however, make a recommendation to ensure that in future patients are kept fully informed about test results.

Recommendations

We recommended that the practice:

• review the way test results are communicated to patients, either by contacting them directly to provide the results or by requesting that patients contact the practice within a set timescale to obtain their results.

Summary

Mr C complained about the care and treatment he received after he was diagnosed with prostate cancer. Before the diagnosis, Mr C had been treated with finasteride and tamsulosin (drugs used to treat benign enlargement of the prostate). After the diagnosis of cancer, he was prescribed bicalutamide (hormonal therapy used to treat prostate cancer), which he took for eight months. In this time, he developed gynaecomastia (enlargement of the male breast tissue), which is a side effect of the treatment.

We took independent advice on this case from one of our medical advisers, a consultant in clinical oncology with a specialist interest in urological cancers. Mr C said that the board had recorded his PSA level (prostate-specific antigen level in the blood) incorrectly. He said that he had been on finasteride long-term at that time, which artificially reduces the PSA level. He said that the level recorded by the board should have been doubled, as research shows that finasteride cuts the true reading in half. We found, however, that the board had recorded Mr C's PSA level correctly. Although finasteride does reduce the PSA level, there is no accurate method to determine this, so routine practice is that the measured PSA level is recorded.

Mr C also complained that the board had not recorded his cancer staging (the extent of the primary tumour and the degree of cancer spread) at the time of his diagnosis. We found that the board should have recorded it, but had failed to do so. There had then been some confusion about Mr C's staging. That said, the confusion about this was of no clinical significance and would not have led to any differences in Mr C's clinical management. The board had apologised to Mr C and had also confirmed that staging is now routinely collected at the multi-disciplinary team meeting for each patient.

We found that the board had failed to advise Mr C of the risks or the options for the prevention of gynaecomastia before he began hormone treatment, although they had apologised to him for this. They sent us an information leaflet that they now give to men with prostate cancer considering hormone treatment, which includes information about gynaecomastia.

In addition, Mr C complained that the board did not monitor the risk of him developing gynaecomastia or take reasonable steps to prevent or mitigate this during the hormone treatment. We found that, in general, Mr C had been adequately managed and this management conformed with the treatment guidelines. That said, the board had delayed in reviewing the hormone treatment and so Mr C received it for longer that the planned six months. Our adviser said, however, that it was unlikely that the additional two months treatment would have had a significant impact on the extent of the gynaecomastia. We noted that the board had also apologised for this in their response to Mr C's complaint and, as they had already taken steps to address this as well as the other failings in this case, we did not find it necessary to make any recommendations.