Health

Summary

Ms C was operated on at the Western Isles Hospital for a labial abscess (a painful swelling caused by a build-up of pus in part of the female genitals). Ms C had undergone a kidney and pancreas transplant in 2007. She complained that although her medical records said that the transplant team should be contacted prior to any surgical procedures, this had not happened. Ms C said that this had placed her at great risk, as the drugs she took to prevent her body rejecting the transplant suppressed her immune system, meaning she was at increased risk of infection.

Ms C also complained that she was not provided with reasonable care after the surgical procedure. She was discharged, despite being in great pain, and was then readmitted as the wound had become infected. Ms C suggested that she should not have been operated on in the first place and said her view was supported by the fact that on her second admission she was transferred to another hospital for treatment.

We took advice from two medical advisers, a specialist in the management of transplant patients and a specialist in gynaecological surgery (surgery of the female reproductive system). They said that the records showed that attempts had been made to contact Ms C's transplant team. However, the advisers said that the nature of the infection, combined with Ms C's suppressed immune system, meant it would not have been reasonable to delay her operation. They said that a reasonable care plan had been put in place, and the medical record showed that she was free of infection at the time of her discharge.

Our investigation found that Ms C had undergone the appropriate surgical procedure for a labial abscess, and that the care she received after the procedure and the decision to discharge her had both been reasonable. We found it would not have been appropriate to delay surgery whilst awaiting the response of the transplant team. Our investigation also found, however, that the attempt to obtain advice from the transplant team was not followed up, which would have been appropriate, so we made a recommendation about this.

Recommendations

We recommended that the board:

• remind all staff of the importance of obtaining advice from the appropriate specialist transplant unit when treating patients who have a compromised immune system as a consequence of transplant surgery.

Summary

Mr C attended his medical practice suffering from vomiting, diarrhoea and pains in his stomach. A GP diagnosed gastroenteritis (inflammation of the stomach and intestines) but some five days later Mr C was taken to hospital, where it was found that his appendix had burst, leading to peritonitis (inflammation of the tissue lining the abdomen). He had to have further surgery when he developed complications including kidney problems and a haematoma (a localised collection of blood outside the blood vessels). Three months after the original appendectomy he developed a fistula (an abnormal opening between organs) which had to be closed with a skin graft.

Mr C complained to us that the GP failed to diagnose that he was suffering from appendicitis. We took independent advice on this from one of our medical advisers, and did not uphold the complaint. The adviser said that the GP had made a reasonable assessment and diagnosis of Mr C's symptoms, which were highly suggestive of gastroenteritis. The GP had asked Mr C to return to be reviewed if his symptoms did not settle down, but he did not do this. Our adviser pointed out that there is a shared responsibility between doctor and patient, and it was not the doctor's responsibility that Mr C did not return when his symptoms did not improve.

Summary

Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of the operation he was told that he had been moved to last on the theatre list. When he asked why, he was told it was because he previously had methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to some common antibiotics, can cause infection and can be difficult to treat). This caused Mr C some distress. He complained that his history of MRSA had impacted on how his surgery was managed, although he had told staff - both at his pre-operative appointment and on the morning of the operation - that he had been given the all-clear a few years before.

In responding to Mr C's complaint, the board acknowledged that it was unfortunate that he did not receive the information booklet in advance. They also said that there was no requirement to screen day surgery patients for MRSA, and that their infection control policy did not require MRSA-positive patients to be last on the theatre list, as measures were in place to mitigate against cross infection risks. However, they then went on to say that the consultant had placed Mr C last on the list as he had a history of MRSA and there was nothing in his records indicating that he was clear of the infection.

As part of our investigation, we obtained independent advice from one of our medical advisers. Having done so, we upheld the complaint. We noted that the board had failed to provide pre-operative information to Mr C at the right time. We also found that they had deviated from their normal policy without properly explaining the reason for this. Their response to Mr C's complaint had been contradictory, in failing to explain why the consultant had not adhered to their policy.

Recommendations

We recommended that the board:

• bring their infection control policy to the attention of staff and highlight the importance of adhering to this;
• review their process for ensuring patients receive any relevant pre-operative information in a timely manner;
• remind staff who handle complaints of the importance of providing clear and consistent responses; and
• apologise to Mr C for the failures highlighted in our decision.

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. An ambulance was called on one occasion, but was cancelled when Mrs A became more alert. However, an ambulance was again called later that day after Mrs A collapsed for a second time. The ambulance crew reportedly helped her into bed, but said that there was not much more that could be done at that point, even if they took her to hospital. Mrs A continued to struggle with her breathing the next day and, in the early hours of the following morning, an ambulance crew attended and took her to hospital. Shortly after arriving there, Mrs A collapsed 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 might have survived had an ambulance crew taken her to hospital after the first attendance, or had the crew that did eventually take her to hospital acted with more urgency.

We were satisfied that the ambulance crews obtained relevant information about Mrs A's recent symptoms and carried out thorough examinations during both attendances. We took independent advice from one of our medical advisers, who said that Mrs A was displaying two symptoms that could indicate pulmonary embolism, but that these were also consistent with other more common illnesses, including viral infection. We concluded that although with hindsight it was evident that Mrs A's symptoms were related to a serious underlying condition, this would not have been apparent to the ambulance crews when they attended. Although the consequences were tragic for Mrs A and her family, we found that the ambulance crews' assessments and conclusions were reasonable under the circumstances.

Summary

Mrs C's husband (Mr C) cut his hand in an accident at home. She dialled 999 and asked for an ambulance. The ambulance service's call handler took details of Mr C's injury but concluded that an ambulance was not necessary. Mrs C had to ask neighbours to help transport Mr C to hospital, where his injury needed surgery. Mrs C complained that the ambulance service's refusal to dispatch an ambulance was unreasonable, and was dissatisfied with their handling of her subsequent complaint.

We took independent advice from one of our medical advisers, who is a paramedic, and after considering their advice we upheld Mrs C's complaints. Our investigation found that the call handler used a nationally recognised system of scripts to obtain information about the severity of Mr C's injury. During the call, they also asked for help from a clinical adviser, who could ask questions that were not included on the script to obtain additional information. An appropriate script was chosen and largely followed, which determined that no ambulance was required. However, we considered that the decision-making process was skewed because the call handler input inaccurate information. Assumptions were made about the severity of the bleeding and the clinical adviser asked questions that demonstrated a lack of knowledge of hand injuries. Furthermore, changes in Mr C's condition during the course of the call were not acted upon appropriately. We concluded that an ambulance should have been dispatched to take Mr C to hospital.

We found that the ambulance service's handling of Mrs C's complaint was generally reasonable. However, they failed to follow their own complaints procedure as they did not contact her to advise that their decision would be slightly delayed.

Recommendations

We recommended that the service:

• apologise to Mr and Mrs C for failing to provide an ambulance;
• take steps to ensure their call handlers are able to identify and act upon changes in patients' conditions during the course of a call; and
• share this decision with the clinician involved.

Summary

After Mrs C had surgery in a hospital outside the area of her own health board, complications arose that led to irreparable damage to one of her kidneys. She believed that there was unreasonable delay in identifying these and that had they been diagnosed sooner her kidney might have been saved. Mrs C also believed that the care she received (after an attempt to prevent further damage to her kidney) was inadequate. She said that, although her husband was trained to change the type of dressing she was given, no-one in the community nursing service responsible for her care was familiar with it. Mrs C felt that she and her husband were not provided with adequate support following her surgery.

After taking independent advice from one of our medical advisers, we found that the complications arising from the surgery could not have been identified sooner. We also found that the board had offered alternatives to the dressing, but that Mrs C had requested that she be allowed to keep the one provided. The board had supported the couple in this decision and had acted reasonably when Mrs C indicated that she and her husband were experiencing difficulties. We also found that although the board had met with Mrs C informally and had not signposted her towards the formal complaints procedure, their response had addressed the concerns she raised about her treatment.

Although we did not uphold this complaint, we made two recommendations for improvement.

Recommendations

We recommended that the board:

• consider whether there are any other means of receiving discharge and other types of referral information from hospitals elsewhere; and
• remind relevant staff of the importance of signposting to the complaints procedure.

Summary

Mr C, who is a prisoner, complained about the late supply of medication by the health centre based within the prison. He was also unhappy with the way in which his complaint was handled, saying that he had difficulties obtaining a complaints form and that health centre staff had opened his mail.

We did not uphold the complaint about the supply of medication. The board explained that the external pharmacy had delayed in providing the medication to the health centre. Our investigation also found that there was a national shortage of this medication around that time, which was outwith the board's control. We took independent advice from one of our medical advisers who took the view that, although Mr C might possibly have experienced some pain, the delay would not have had a negative impact on his medical condition. We also took into account a recent recommendation we made to the board about previous delays in the supply of Mr C's medication.

We upheld Mr C's complaint about complaints handling, as we found that the board failed to provide him with a complaints form in a timely manner. However, we did not make any specific recommendations, as we recently recommended that the board take relevant action on another similar complaint. The board acknowledged that Mr C's mail should not have been opened, and we were satisfied with the action they took to ensure it did not happen again.

Summary

Mrs C complained that she had a day procedure in Royal Infirmary of Edinburgh to treat abnormal bleeding of the womb. She said that this had left her with pain, discomfort and nerve damage, to the extent that she has been unable to work for several months. Mrs C also said that when she signed the original consent form, nerve damage was not mentioned as a possible complication.

We took independent advice on this case from one of our medical advisers, and did not uphold Mrs C's complaint. The adviser said that the operation appeared to have been straightforward, and that nerve damage was an extremely unusual complication of the surgery and was not an issue that he would expect to be discussed when obtaining consent before the operation. We concluded that the operation was carried out according to guidelines and procedures and that Mrs C was a suitable patient for the procedure. Mrs C also complained that the board did not respond to two emails she sent. As we found that these had been incorrectly addressed, we did not uphold this.

Summary

Mrs C's late father (Mr A) saw a GP at his medical practice about, amongst other things, a cough. He had a chest x-ray, the results of which were normal. Some seven months later, in June 2012, he had three further consultations at the practice about chest problems and a persistent cough, and a further chest

x-ray, taken after the third appointment showed an abnormality in the lung. After collapsing and being admitted to hospital, Mr A went to the practice again in July and was referred urgently to the respiratory clinic because of his persistent cough. Mr A also attended a cardiology (heart) clinic where a scan was arranged. The clinic told the practice that the scan showed that Mr A might have a pulmonary (lung) tumour. The respiratory clinic then found that the scan showed metastatic malignancy (cancer that had spread) in his lung. They wrote to the practice about this and said they had not discussed the potential diagnosis with Mr A but had told him that there was a shadow on the lung that needed investigation. Several weeks later Mr A saw a GP, who did not explain the result of the scan but wrote in the medical notes that Mr A was aware that cancer was a possibility. Mr A was then referred to oncology (cancer specialism) and at the end of October a cancer nurse told the practice that Mr A had now been told his diagnosis. After this Mr A asked the practice for an appointment but they told him they could no longer treat him because he had moved out of their area. Mr A died shortly afterwards.

Mrs C complained that the practice did not provide reasonable care and treatment to her late father. She said that they did not carry out appropriate investigations and/or tests within a reasonable time and failed to communicate with him and his family about his diagnosis. Mrs C was also concerned that the practice refused to treat him after he moved house, although he had been a patient there for over 25 years and they were well aware of his medical history.

We took independent advice on this case from one of our medical advisers, who is a GP. Our adviser said that the failure to refer Mr A for a chest x-ray after his first two consultations in June 2012 was not reasonable and did not follow the guidelines for referral in such cases, although his care after the chest x-ray was eventually carried out was of a reasonable standard. The adviser also said that the practice's communication with Mr A was reasonable, and that it was the responsibility of hospital doctors to tell him about test results and treatment plans. We recognised how distressing it must have been for Mr A and his family waiting for results and a definitive diagnosis, but noted that the practice was not responsible for telling Mr A about these. Turning finally to the practice's decision not to treat Mr A after he moved house, our adviser said that while the practice acted correctly as far as the terms of the GP contract were concerned, they did have discretion to keep Mr A on their list on compassionate grounds if this was geographically feasible. In the circumstances, while accepting this was for them to decide, we took the view that the practice should have given more consideration to keeping Mr A on their list. Given this, and the failure to arrange a chest x-ray within a reasonable time, we upheld Mrs C's complaint.

Recommendations

We recommended that the practice:

• ensure that the GP who saw Mr A at his first two appointments in June 2012 discusses this complaint and findings as part of their annual appraisal and that the diagnosis and management of lung cancer forms part of their learning needs;
• consider their approach to de-registering patients in light of this case; and
• apologise to Mrs C for the failures identified.

Summary

Mrs C's late father (Mr A) had moved house just as he had been given a diagnosis of terminal lung cancer. Because of this, he had de-registered from his previous medical practice, and registered as a new patient at the medical practice about which the complaint was made. The GP there noted the cancer diagnosis, and compiled a full summary of Mr A's medical history. The GP also referred him to hospital that day as he was acutely unwell. After his discharge, he was seen twice by GPs at the practice, and in the following month he was again admitted to hospital. He was discharged shortly after to the care of his GP and district nurses. The next month, Mr A was admitted again, by emergency ambulance. This time, when he was discharged his consultant advised the practice that any future admission should be to a hospice. Shortly after this, a GP visited him at home and noted how Mr A and his family were struggling and that the situation was difficult and stressful. The GP arranged a hospice bed for the following day and noted in the records that Mr A's wife (Mrs A) and family were happy with this plan. A specialist nurse also visited and, with the GP, provided specialised pain relief equipment. Mr A was admitted to the hospice the next day, and passed away during the early hours of the following morning.

Mrs C complained about the end of life care provided to Mr A and that GPs showed a lack of care and empathy. She was unhappy that, after hospice care had been arranged, Mr A could not be admitted until the next day. She also told us that Mrs A was very distressed that during the time with the practice she had to explain her husband's medical history to a number of GPs. Mrs A had said that several of them appeared to have failed to read his clinical notes before visiting.

We took independent advice on this case from one of our medical advisers. The adviser said that the practice provided a reasonable standard of care to Mr A in relation to pain relief and support. We noted that events on the day before he was admitted to the hospice appeared to have been extremely distressing for all involved, and in particular for Mr A and his family. However, the adviser said that the GP took all reasonable measures to secure a bed for him, and we were satisfied that there was nothing more that she could have done.

In relation to Mrs C's complaint that Mrs A had to tell visiting GPs about her husband's medical history, the practice said it was standard practice to question patients. Our adviser said that, in this respect, they provided a reasonable standard of care to Mr A. Given this, we did not uphold the complaint. However, clearly Mrs C and her family were extremely distressed by their experience and we drew the adviser's comments about the practice giving consideration to changing the way they provide palliative care to the practice's attention.