Health

Summary

Mr C complained about the care and treatment provided to his late mother (Mrs A) by her medical practice. He also complained that they failed to refer her to hospital for definitive diagnosis. Mrs A had been living in a care home. She was examined by a doctor from the out-of-hours service in the early hours of the morning. He recorded that there were signs that she had vomited blood and that her abdomen was soft and 'non-tender'. He recorded that his diagnosis was gastritis and that the care home should observe Mrs A. Mrs A was seen by a GP from the practice later that day. The GP considered that she had melaena (passing blood in the stool), haematemesis (vomiting blood) and an upper digestive tract bleed. He did blood tests and stopped some of her medication. He also prescribed omeprazole (medication used to reduce the amount of acid produced in the stomach). Mrs A was examined by the practice on a number of occasions over the next few weeks and was admitted to hospital three weeks after the first GP had examined her. Mrs A died of a small bowel obstruction in the hospital nine days later.

The practice GP who examined Mrs A decided to keep her at the care home and carry out non-invasive investigations, and to adapt her medication. After taking independent advice from one of our medical advisers, we considered that this was reasonable. Mrs A was bleeding from the digestive tract, and there was no evidence to suggest that she had a small bowel obstruction at that time. Our adviser said that even if she had been admitted to hospital earlier, the decision not to carry out invasive procedures would still likely have been made, given her overall frailty and general poor health. There would also have been no benefit in admitting Mrs A to hospital as an emergency, when there were nursing staff in the care home who could monitor her condition. We found that the practice's management of Mrs A's care and treatment was reasonable and there were no failings in the clinical treatment provided.

That said, Mr C was welfare power of attorney for his mother, and so her care should have been discussed with him. There was no evidence that the practice consulted him about the treatment provided to Mrs A and about her future care plans. We found that the practice had incorrectly assumed that the care home staff would have told Mr C about this. However, there was no evidence that the practice checked that this had happened or that they spoke directly to Mr C to discuss his mother's condition. In their response to Mr C's complaint, they had apologised and said that they would review their communication processes to improve on this.

Recommendations

We recommended that the practice:

• provide evidence that they have taken action to review their processes for communicating with relatives in light of Mr C's complaint.

Summary

Mrs C had a history of myeloma (a type of cancer arising from plasma cells found in the bone marrow). She began to suffer from sickness and diarrhoea and arrangements were made for her to have a gastroscopy (a medical procedure during which a thin, flexible tube called an endoscope is used to look inside the stomach) and a colonoscopy (an examination of the lining of the bowel using a long flexible tube-like camera). Before these could be done, Mrs C's condition deteriorated and she had to attend a hospital accident and emergency department (A&E). She was told that her problems could be related to her myeloma. Blood tests and an x-ray were arranged and steps were taken to hydrate her (give her more fluids).

Mrs C had the gastroscopy two days later and a hiatus hernia (a protrusion of part of the stomach) was discovered which could be controlled by medication. The colonoscopy, however, could not take place as Mrs C was feeling unwell. She attended A&E again a few days later, as her legs were swollen, and was admitted to hospital. Five days later, the hospital contacted her husband (Mr C) to tell him that doctors had found a tumour in Mrs C's bowel and that it had ruptured. Mrs C died the following week.

Mr C complained that staff failed to carry out appropriate investigations in order to arrive at an accurate diagnosis for his wife. We found that there were some failures in the care and treatment provided. In particular, there was a failure to adequately assess some of Mrs C's symptoms; to perform examinations; and to consider her blood tests in sufficient detail. Although there were only a few days for a diagnosis to be made, we found that the hospital had missed opportunities. They initially considered that she might have infectious diarrhoea, possible clostridium difficile (a type of bacterial infection that can affect the digestive system) or that there might be a cardiac cause. These were excluded and doctors concluded that it was likely she had a new acute illness. However, the blood test results did not fit with diagnosis of new acute illness, but suggested a significant period of illness, iron deficiency and malnutrition. Mrs C was already having her bowel investigated for an alternative diagnosis of iron deficiency anaemia, which was unrelated to her myeloma. We found that a more balanced view of Mrs C's symptoms, clinical signs, and blood results would have considered chronic bowel disease, including malignancy, at least as likely as acute diarrhoea and vomiting caused by infection. We found that the level of care provided to Mrs C was below acceptable standards.

Recommendations

We recommended that the board:

• consider holding a significant event analysis in order to reflect and learn from this case; and
• issue a written apology to Mr C for their failure to adequately examine Mrs C and assess her symptoms and blood tests and for the delay in making an accurate diagnosis.

Summary

Mr C (an MSP) made a complaint on behalf of his constituent (Mrs B) about the clinical treatment and nursing care provided to Mrs B's late mother (Mrs A). The complaints included a delay in undertaking a CT scan (a specialised type of x-ray using a computer); the insertion and monitoring of a drain to remove fluid from Mrs A's abdomen; and failures in communication.

We upheld Mr C's complaint and made a number of recommendations. Our investigation included taking independent advice from two of our medical advisers - an oncologist (a cancer specialist) and a senior nurse. Both advisers were critical that there was a lack of documentation about Mrs A's care and treatment, and noted that this made it difficult to know what had or had not been done for her. Our investigation also found that there were many failures in communication between staff and Mrs A and her family. This was particularly difficult for the family when Mrs A was nearing the end of her life and was placed on the Liverpool Care Pathway (a tool used to assist clinicians and nursing staff to support patients and their families as the patient is dying. The aim is to address the patient's symptoms rather than aggressively pursue a cure for the underlying terminal condition.)

We also noted that there was a delay of some four weeks before the radiology department received an urgent CT scan request made by Mrs A's GP, and then it was a further two weeks before the scan took place. The board could provide no explanation for this delay other than human error in not following it up. While the delay was unlikely to have altered the eventual outcome for Mrs A, we found it unacceptable.

Recommendations

We recommended that the board:

• remind all staff involved in processing requests for referrals and investigations of the importance of arranging appointments to meet the two-week NHS target time;
• ensure that all relevant staff are made aware of the revised medical protocol for the management of ascites (fluid)/drainage;
• ensure that all relevant staff are made aware of the requirement to seek informed consent for any invasive procedure to be undertaken, and where necessary provide appropriate training;
• conduct an audit of record-keeping in the ward concerned, and address any learning issues identified;
• remind all relevant staff of the need for effective communication with patients, relatives and/or carers, and provide refresher training where necessary; and
• apologise for all of the failings identified during our investigation.

Summary

Ms C, who was acting on behalf of Mr and Mrs A, complained about the care and treatment that their son (Master A) received after he fell from a tree and hurt his arm. He went to the accident and emergency department of a hospital, and was discharged after the wound was cleaned and glued. He later visited his GP and was referred to hospital where he had surgical treatment for the wound. However, this did not identify that two pieces of bark were lodged in it, which were only removed during a later private surgical procedure. Master A's parents felt that by not identifying the bark in the wound, the board had failed to reach the correct diagnosis.

We took independent advice from one of our medical advisers, an experienced orthopaedic surgeon. He reviewed the board's notes and all of the associated correspondence and said that, based on the evidence available at the time, the treatment was reasonable. He said that while it may seem to a member of the public that a foreign object should be identified within a wound, such objects can easily move within the body. By the time the private procedure was carried out, it was highly likely that Master C's body had been trying to expel the bark and so it may have been more evident at that point. We agreed that, without the benefit of hindsight, the board's treatment was reasonable. We also noted that the board had explained to the family that they had identified learning points from their complaint. We checked on these and, in light of this confirmation and the advice received, we were satisfied that the board had acted reasonably and that we did not need to make any recommendations.

Summary

Mrs A, who lived in a care home, became ill in the early hours of the morning. The care home contacted the out-of-hours service, and one of their doctors came and examined Mrs A. He recorded that there were signs on her teeth that she had vomited blood and that her abdomen was soft and non-tender. He diagnosed gastritis (inflammation of the stomach lining) and said that the care home should observe Mrs A, and if she vomited blood again or complained of pain in her abdomen, they should call 999. He also said she should see a GP from her own practice. One of the practice doctors visited later that day, and considered that she had an upper gastrointestinal tract bleed. She was then examined by the practice on a number of occasions and was eventually admitted to hospital three weeks after the out-of-hours doctor first examined her. Mrs A died in hospital of a small bowel obstruction nine days later.

Mrs A's son (Mr C) complained about the care and treatment provided by the out-of-hours doctor. He was of the view that the doctor had failed to diagnose that Mrs A had a small bowel obstruction and felt that he should have referred her to hospital. After taking independent advice from one of our medical advisers, however, we did not uphold his complaints. We found that the doctor's investigation, diagnosis, care and treatment of Mrs A were of a reasonable standard. Her presentation was not consistent with the symptoms or signs of bowel obstruction and we did not consider that the doctor failed to identify this. The only option the out-of-hours doctor had for referring Mrs A to hospital was as an emergency admission, and it would have been for her own GP to refer her for an out-patient assessment. We found that the medical records showed that Mrs A did not warrant emergency admission and so the doctor had arranged for her GP to see her. We also found that the doctor's clinical records were adequate and that his instructions to the care home staff were comprehensive.

Mr C was welfare power of attorney for his mother (ie he was able to take decisions about her care and welfare), and he also complained that the out-of-hours doctor failed to consult him about the treatment provided to Mrs A and about her future care plans. We found, however, that there would have been no reason for that doctor to contact Mr C in the early hours of the morning, as he made no treatment decisions when he visited Mrs A. He simply verified that she did not need to be admitted as an emergency, and referred her to her own GP the same day. There was also no requirement for him to tell Mr C that he had visited Mrs A, which we considered was the responsibility of care home staff, during normal working hours.

Summary

Mrs C complained that a dentist did not give her enough information about the treatment options available, and the costs, which she said resulted in her being treated as a private patient rather than by the NHS.

After taking independent advice from our dental adviser, our investigation found that the medical records showed that Mrs C was informed of the options and received a written estimate for the cost of her treatment. Our adviser said that she had received the appropriate treatment and that from his examination of the records, he believed she had consented to the treatment being provided privately. The dentist had clearly and correctly explained the treatment options, and that the treatment she wanted could not be provided on the NHS without a six month delay. The adviser also said there was no guarantee that the dentist could have provided it in that way, as he would first have had to obtain NHS permission to do so.

Summary

Ms C complained that a doctor refused her request to be accompanied by a friend during a lumbar puncture procedure (a medical procedure where a needle is inserted into the lower part of the spine). She said she was aware of other patients who had been allowed this, and complained that the hospital were not treating patients consistently. The board said that it was the doctor's normal practice to only have herself and a nurse in the room with a patient, because of hygiene and infection control concerns. They also said that no one would be available to offer assistance if someone accompanying the patient became unwell. They apologised that this was not explained to Ms C at the time and confirmed that the doctor was happy for her to be accompanied during other parts of the consultation.

We asked the board whether this was board policy or the doctor's policy. The board said that they did not have a policy and the approach depended on the individual consultant and on the procedure. We took independent advice on this from one of our medical advisers. He said that a lumbar puncture was a fairly minor procedure, and that some doctors would have no objections to the patient being accompanied. He was not persuaded by the board's explanations, as he said hygiene and infection control could be reasonably managed, and considered it unlikely that an observer would become unwell during such a procedure. However, as there was no board policy, and although it meant approaches were likely to vary, it was reasonable for the decision about who was allowed to be in the room to be left to doctors. He noted that it would not be appropriate for patients to be accompanied during some more invasive procedures. Having reviewed the relevant clinical records, the adviser noted that Ms C consented to the procedure going ahead and that there was no record, in either the medical or nursing notes, that she raised any concerns at the time.

We acknowledged that Ms C was distressed at not being accompanied during the procedure, but we accepted that, in the absence of a board policy, it was reasonable for the doctor to decide who was allowed in the room. In the circumstances, and as Ms C consented to the procedure going ahead on these terms, we did not uphold the complaint. We noted that there was no evidence that she made the board aware in advance of her wish to be accompanied and equally no indication of the doctor having told Ms C of her position on this. Although we did not make any formal recommendations, we suggested that the board might wish to reflect on whether they could have communicated better with Ms C.

Summary

Mr and Ms C complained about the care and treatment given to their late mother (Mrs A) while she was a patient in hospital. Mrs A had been admitted with a history of diverticular disease (disease of the colon) and schizophrenia (a long-term mental health condition that causes a range of different psychological symptoms) but her immediate symptoms included a possible gastro-intestinal bleed. After admission, Mrs A experienced increasing confusion and showed signs of dehydration. Mr and Ms C said that staff failed to address these growing problems, together with the problem with which she had originally presented, to the extent that Mrs A became dangerously ill and died. Mr and Ms C were shocked at their mother's swift deterioration and death. They said that no proper intervention had been made until the day she died and they believed staff paid more attention to Mrs A's mental health than to the physical problems she was experiencing. They complained to the board, who said that they were satisfied that the care and treatment given to Mrs A was appropriate to her needs.

We obtained independent advice from a medical adviser and nursing adviser, and gave careful consideration to Mrs A's medical records and the complaints correspondence. We upheld the complaint, as our investigation found that although the board had tried to address Mr and Ms C's concerns by holding a number of meetings and by writing, their initial letter failed to mention that intravenous fluids were not started when they had been suggested or that a deteriorating renal function was a key part of Mrs A's condition.

Recommendations

We recommended that the board:

• consider the use of cognitive function screening and assessment tools as routine in similar circumstances;
• ensure that nursing care plans are in place for patients; and
• review their initial letter to Mr and Ms C and consider what steps could be taken to improve the quality of future responses.

Summary

An MP (Mr C) complained on behalf of Ms A's family about the treatment Ms A had received from her GP practice. In 2008, Ms A had a mole removed from her scalp. Due to its location, the mole could only be partially removed, but tests found no signs of cancer. In May 2009, she went back to the practice having found a lump behind her ear. Blood tests initially suggested inflammation and possible glandular fever, but when further lumps appeared and did not go away, the practice arranged for a referral to a haematologist (a specialist in blood-related disorders). Tests led to a diagnosis of skin cancer, linked to the scalp mole. Ms A had further surgery on the mole and to remove a number of lumps from her neck in February 2010 . Shortly after this, Ms A told the practice that she had a new lump in her back. She asked for a GP home visit but this was declined and instead a review was proposed after a week. She was unhappy with the lack of urgency shown by the practice and transferred to a different practice.

Ms A later developed a breast lump which became malignant. Despite treatment, she died in January 2012. Mr C complained that the first practice did not recognise the severity of Ms A's condition or treat her with the required level of urgency.

After taking independent advice from one of our medical advisers, we were satisfied that there was no evidence of cancer in 2008. There was no cause for the practice to arrange any further investigations at that point, and Ms A was appropriately advised to monitor the mole herself and contact the practice should she have any concerns. When the lumps appeared in her neck, blood tests were arranged and an appropriate referral was made to haematology for a biopsy (tissue sample) to be taken. With regard to the lump in her back, we found the practice's approach to have been reasonable, as Ms A was already under the care of cancer specialists, and had an appointment arranged. We accepted advice that the delay of one week was not significant and noted that this lump was ultimately found not to be cancerous. That said, we recognised that this was a very distressing time for Ms A and took the view that, given her recent medical history, a GP could have visited. Overall, however, we were satisfied that the practice acted in good time and arranged appropriate tests and referrals for Ms A.

Summary

Miss C complained that after her mother's death, a doctor influenced the family's decision not to have a post-mortem carried out, and misrepresented the family's views to the procurator fiscal (PF). In responding to the complaint, the board advised Miss C that the doctor should have immediately reported the death of Miss C's mother to the PF rather than discuss whether or not a hospital post-mortem should be carried out at this stage or a significant event review into events leading up to Miss C's death.

We found evidence indicating that the doctor had appropriately explained to the family what a hospital post-mortem would involve and that this appeared to be in order to help them decide whether or not they wanted one carried out, rather than trying to influence their decision either way. Although the doctor did not follow the correct procedure in reporting the death to the PF, we did not consider there was evidence that he was intentionally misleading the family because he had clearly documented in the medical records and disclosed his concerns about some aspects of the care to them. We noted that a different doctor informed the PF of the death but the PF did not consider that a fiscal post-mortem was required.

We were unable to clearly establish what the doctor said to the family immediately after Miss C's mother died, as there was no independent evidence of this. However, we noted that a record made by the doctor at the time documented that the family were not keen on a post-mortem being carried out and that the PF was told about this in an email. Although we did not uphold Miss C's complaints, we made recommendations to ensure that matters are more clearly understood and explained in future.

Recommendations

We recommended that the board:

• ensure that relevant staff are aware of the situations in which reporting death to the PF is necessary; and
• ensure that relevant staff clearly explain to families the process regarding post-mortems.