Health

Summary

Mr C complained about a surgical procedure that was carried out in hospital. He said a biopsy was taken, and although he had understood that three sebaceous spots would be removed from his groin/penis area, they were still there. In addition, he now had seven stitches on his penis. He was discharged from hospital the same day, and was told the stitches would dissolve naturally. However, the wound opened the next day, and he self-cared for it. He questioned why no follow-up treatment was planned for him and why nobody explained what the procedure would entail. He said that he did not give consent for anything other than the removal of the cysts.

The board explained that the proper procedure was carried out, to which Mr C had consented. In addition, staff had explained the procedure along with any potential risks of the surgery and an advice leaflet was provided on discharge from hospital. Before we finished our investigation, however, the board told us that Mr C had instructed legal action against them. As a result we discontinued our investigation, as we are unable to look at a complaint where the matter complained about is being determined in court.

Summary

Miss C complained that she and her elderly mother (Mrs A) were unreasonably removed from the practice's list of patients without any discussion. She had received no prior warning from the practice, nor had she been invited to the practice to discuss this. The practice believed that they had followed procedures by informing the health board and that they were only responsible for Miss C and Mrs A's care and treatment for a period of ten days after notifying them of the removal.

We upheld the complaint, as our investigation found that the practice had not followed the guidance from various organisations and the NHS General Medical Services Contract that where deregistration was a possibility it should only be as a last resort. Although a practice is entitled to remove a patient from their list, action should only be taken after giving the patient prior warning that their behaviour is giving cause for concern, and advising that should matters not improve then there is a risk of deregistration. The only exception to this is where a patient has demonstrated violence, which would result in immediate deregistration - this was not the case here.

Recommendations

We recommended that the practice:

• remind staff to act in accordance with the various pieces of guidance regarding the removal of patients from a practice list; and
• apologise to Miss C for their failure to follow the guidance on the removal of patients from the practice list.

Summary

Miss C, who had a number of health problems, complained about the care and treatment she received when she re-registered with her medical practice. After taking independent advice from one of our medical advisers, we did not uphold her complaint about treatment, as we found that it was reasonable in terms of Miss C's health conditions, and there was no fault with the medical care she had received. We also accepted that, given the need for continuity of care, it was reasonable that Miss C was seen by one GP there, with a 'buddy' GP in his absence. We noted that Miss C was able to see a female GP in the event of any gynaecological health issues, and was also able to use unscheduled care services for non-routine matters. We did not uphold her complaint, but made a recommendation as we felt that it would have been beneficial if the practice had involved Miss C in deciding which GP she should see regularly.

Recommendations

We recommended that :

• should in future consider agreeing patient consultation arrangements in partnership with the patient, rather than advising the patient (without their involvement) of who they are allowed to see.

Summary

Mr C had a a temporary dental bridge put in place while he was abroad. He complained that the board delayed in providing appointments after his dentist referred him to the dental institute for a treatment plan to replace it. Mr C said that the delays resulted in additional damage to his teeth, which meant that his preferred treatment plan was no longer possible. In response to the complaint the board said that Mr C had been seen twice within the guaranteed waiting time of 12 weeks for an out-patient appointment.

We confirmed that Mr C's first appointment was within the national waiting time target for new out-patient referrals. Although the institute agreed the treatment plan at this appointment, one of Mr C's teeth then fractured, so his dentist had to refer him there again because it affected the new bridge design. We did not consider that it was reasonable for Mr C to wait a further 13 weeks to have his original treatment plan reviewed, and we upheld his complaint. However, after taking independent advice from our dental adviser, we noted that his tooth could have fractured at any time, even if the new bridge had been in place.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in his treatment plan being re-assessed; and
• consider reviewing the referral process so that patients who require their original treatment plans to be reviewed are seen in a timely manner.

Summary

Mr C said that he had to call NHS 24 for assistance twice in two days. He said that he told staff he would not be able to explain his problem and because of this it was incorrectly interpreted that he was complaining about an absent prescription. Mr C said that within hours of his second call he was admitted to intensive care due to the onset of starvation and while there, suffered an unknown cardiac event. Although the first doctor who saw Mr C said that he should be admitted, Mr C said that the second said that he could be discharged. Mr C said that this was unreasonable and likely to cost him his life.

Mr C complained to us that staff at the out-of-hours centre failed to provide him with appropriate medical treatment as did staff in the emergency department. He also complained that he was inappropriately discharged from hospital.

We did not uphold Mr C's complaints. As part of our investigation, we considered the relevant records and obtained independent advice on the circumstances about which he complained. This confirmed that Mr C was at all times treated appropriately. We found that he had not been admitted to intensive care nor had he been determined to have been suffering from starvation or an unknown heart event. He had been appropriately discharged.

Summary

Mr C complained on behalf of his late aunt (Mrs A) who was admitted to hospital from her nursing home with sudden pain in her legs. She had been previously diagnosed with dementia (her solicitor held welfare power of attorney) and chronic peripheral vascular disease (a long-term condition where the blood supply to the leg muscles is restricted). Mrs A was prescribed medication for pain and agitation and discharged back to the nursing home the next day. The hospital wrote to her GP and the nursing home detailing her care and said that the vascular surgical team felt that this represented an acute episode of her long term vascular disease, but had decided that surgery was not in her best interests and she should be treated with simple pain relief. They said Mrs A had complained of some pain before discharge and it was decided that this would be better controlled in her normal environment at the nursing home. The nursing home, meanwhile, had identified that Mrs A needed morphine on the day of her discharge and three days later, for the first time, there was an entry in her medical records about palliative care (care purely to prevent or relieve suffering). She was prescribed additional medication for palliative care on the following day, and the nursing home requested more morphine for her. Mrs A died six days after being discharged from hospital.

Mr C said that Mrs A's GP, nursing home and solicitor all knew that she was terminally ill when she was discharged from hospital and that this diagnosis was made while she was a patient there. Mr C said that within a few days of Mrs A being discharged, the GP told Mrs A's solicitor that she had a major inoperable blood clot in one of her main arteries and was being kept comfortable at the nursing home, but that otherwise nothing beneficial could be done and that the 'time-frame' could be days. Mr C also complained that the board failed to provide him with a proper answer about why Mrs A was not immediately referred for palliative care.

After taking independent advice from a medical adviser, who specialises in care of the elderly, we upheld Mr C's complaints. The adviser said that the care and treatment in relation to diagnosis, discharge, communication and record-keeping was below a reasonable standard and impacted adversely on the board's decision-making about palliative care. Mrs A was a vulnerable adult, and we found that the clinicians underestimated her symptoms and their severity and significance, leading to an inaccurate diagnosis and a failure to meet her palliative care needs. We also found that the board failed to provide a detailed explanation of the clinical thinking at the time of Mrs A's discharge to justify their position, which would have added to the distress of Mrs A's family.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff;
• review the admission of older adults to assess whether staff have sufficient expertise (such as consultant geriatricians) to assess such patients;
• bring the failures in record-keeping to the attention of relevant staff;
• bring the failures identified in this investigation to the attention of the board's complaints team; and
• apologise for the failures identified this investigation.

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from her medical practice before her death. Mrs C had a number of falls and twice fell down the stairs at home. This resulted in an ulcer on her leg and a large boil-like growth on her elbow. Mr C complained that although the practice treated Mrs C's elbow, they did nothing about the ulcer on her leg, which deteriorated.

We took independent advice from our GP medical adviser who said that although GPs do not treat leg ulcers, they should refer a patient to nurses or a service to administer dressings and compression bandages where appropriate. We found that the practice had appropriately referred Mrs C to the practice nurse and the district nursing service for treatment for her ulcers. We also found that it was reasonable that the practice did not initially consider the wound on Mrs C's leg to be an issue and did not consider that it required treatment until they reviewed it a few weeks later. We took the view that Mrs C's ulcers were appropriately treated.

Mr C also complained that the practice did not ensure that Mrs C was admitted to hospital when her condition deteriorated. The notes made by both the district nurses and the practice showed that Mrs C did not want to go into hospital at first. However, her condition deteriorated and the next day, she confirmed that she was now willing to go there. The practice then contacted two hospitals to try to arrange admission. We found that the delay in arranging this was not due to the practice's failure to respond, but due to problems in getting the hospitals to accept Mrs C as an in-patient, and that the actions of the practice had been reasonable and appropriate. Although we did not uphold Mr C's complaints, during our investigation we identified that the district nurses, who were employed by the local health board, had not given the practice all the relevant details about the deterioration in Mrs C's condition and so we made a recommendation about this.

Recommendations

We recommended that :

• hold a joint significant event analysis discussion with the district nurses in order to reflect and learn from this case.

Summary

Following a stroke, Mr C's late aunt (Mrs A) was transferred to a hospital for rehabilitation and discharge planning. Mrs A's solicitor had welfare power of attorney for her. Mrs A had a degree of cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember), which got worse while she was in hospital. Several months later, Mrs A was discharged to a nursing home. Mr C complained about the way the board discharged his aunt, which he said was done too quickly and without input from her family or her advocate, and about the handling of his complaint, including that the board inappropriately contacted Mrs A's solicitor about it.

We took advice on this complaint from one of our medical advisers, who specialises in mental health. Our investigation found that the views of Mrs A and her family were not fed into the decision-making process, contrary to the board’s discharge policy, and that Mrs A was denied the opportunity to visit the nursing home before being discharged there. Her family were not kept updated and there is no evidence that the board made Mrs A, her welfare power of attorney or her family aware of her right to independent advocacy. Finally, the principles underpinning the Adults with Incapacity Act were not adhered to - as Mrs A was unable to give informed consent to treatment or to make reasoned decisions, a certificate of incapacity should have been completed and the interventions being authorised should have been set out in a care plan.

We were satisfied that the board acted properly when they told Mr C that they could not release confidential information about Mrs A without her or her solicitor's consent, because the solicitor had welfare power of attorney. However, our investigation found that early in the complaints process the board were aware of information that brought Mrs A's capacity to consent into question. We were, therefore, critical that they did not make Mr C aware of this until some five months later, after he had obtained and sent Mrs A's consent to his complaining on her behalf. Although the board provided detailed responses to Mr C's concerns, we noted delays and inaccuracies in these (particularly around Mrs A's reaction following her visit to another nursing home).

In relation to the board's handling of Mr C's complaint, we were satisfied that their actions were reasonable in light of the legal advice they received. They carried out several investigations, including having an independent healthcare professional review Mrs A's care. Mr C was disappointed that a senior official was not available to meet him when he arrived at their office (having travelled from abroad), but the board had made no arrangements to meet him at that time. Instead, they met him the following month, and although they withdrew their offer of a teleconference (following legal advice), this was not in itself evidence of maladministration. Finally, the board properly referred Mr C to the council for a response about his concerns relating to the actions of the social workers involved in his aunt's discharge.

Mr C was unhappy that the board had potentially breached confidentiality by seeking comments from Mrs A's solicitor about his complaint. It is not for us to decide whether there has been a legal breach in relation to data protection, but we can consider whether the board's actions were reasonable in the circumstances. Normally, when a family member complains on an individual's behalf, health boards do not directly contact the individual affected by a complaint, rather they would tell the family member they needed to get consent from the individual before the board would look at the complaint. In this case the board contacted the solicitor who was speaking for Mrs A, which was the equivalent of contacting Mrs A herself. Our view was that the existence of a welfare power of attorney did not mean there should be any change to the normal practice, as there are good reasons for that practice and we were aware of no reason why this situation required an unusual approach. We were critical that the board contacted the solicitor about Mr C's complaint, which would not have occurred under ordinary circumstances. We upheld both Mr C's complaints and made recommendations for improvement.

Recommendations

We recommended that the board:

• ensure patients who lack capacity are treated in line with the relevant legislation;
• inform patients with dementia and their families of the right to independent advocacy (and how to access the service) and ensure advocates are given the opportunity to express the views of their clients;
• review their complaints handling procedures in the light of this complaint to ensure that communication with families and/or individuals with welfare power of attorney are appropriate; and
• make a further apology to Mr C in light of the findings of our investigation.

Summary

Mrs C complained about the care and treatment that her son (Mr A) received when he was admitted to hospital as a voluntary psychiatric patient, after being taken there by the police. He was examined on admission and a care plan was completed. He was reviewed again the following morning by a doctor who had treated him when he had previously been admitted. The doctor gave him a pass to leave the hospital for two hours. Mr A did not return to the hospital and was found dead a number of days later.

We were able to investigate only limited elements of Mrs C's complaint, because the main aspects of it had already been investigated by the Crown Office and Procurator Fiscal Service when deciding whether to hold a Fatal Accident Inquiry. We found that the care and treatment provided to Mr A during the short time he was in the hospital was reasonable and appropriate. Communication between the doctors who saw Mr A had also been satisfactory, and it was reasonable for a doctor to previously diagnose Mr A with schizophrenia.

That said, we found that no one from the hospital had phoned Mrs C back after she contacted them the morning after Mr A was admitted, asking to speak to the doctor who had previously treated him. Our investigation found that they were not required to call her back immediately, but should have done so at some stage, as it is good practice to involve family and carers when assessing and managing patients. We, therefore, found that communication with Mr A's family during his short admission was not reasonable. However, in view of the fact that a doctor had written to Mrs C to apologise for this, we did not make any recommendations.

Summary

Mrs C complained about the standard of care and treatment her elderly mother (Mrs A) received in hospital. Mrs C felt that Mrs A was handled roughly by nursing staff and had been left on an incontinence mat with her pyjama bottoms removed and the curtain drawn around her bed in the event that she needed to go to the toilet during the night. Mrs C also raised concerns that: the number of ward moves Mrs A had during her stay in hospital caused her to be unsettled; the television facilities were inadequate; there was a delay in restarting Mrs A's statin medication (a drug used to reduce cholesterol and the likelihood of further cardiac disease); and that the standard of discharge planning was poor.

Although we did not find sufficient evidence to support that Mrs A had been handled inappropriately, we were dissatisfied with the board's explanation of why her pyjama bottoms were removed. They had said that, as Mrs A had been admitted with back pain, removal of her pyjama bottoms would prevent further painful movement during the night in the event that Mrs A needed the toilet and would also prevent them from becoming soiled. We did not consider the board's reasons were justified because the staff did not appear to have given thought to providing Mrs A with a hospital gown or arranging for her to wear a nightdress in order to maintain her dignity.

In relation to Mrs A's discharge from hospital, we upheld the complaint as we considered that care fell below a reasonable standard because Mrs A had not been reviewed by a doctor 17 days prior to her discharge and no consideration was given to either transferring her to a specialist geriatric unit in the hospital or referring her to a local geriatrician for inpatient review. We also found that Mrs A's statin medication was appropriately stopped when she was noted to have impaired kidney function, as statins can affect this. However, when Mrs A's kidney function returned to an acceptable level, no consideration appeared to have been given to re-starting it until Mrs C raised the matter at the time of discharge, so we upheld this complaint.

We did not uphold Mrs C's other complaints. Although the various moves Mrs A had between wards within the hospital were not ideal, we were of the view that these were necessary for specific reasons and to improve her clinical care. In addition, we did not consider the television facilities to be unreasonable and noted that the board had already taken steps to remind staff to ensure that patients were aware of the available facilities.

Recommendations

We recommended that the board:

• share with relevant nursing staff our comments with regard to maintaining a patient's dignity in relation to continence issues;
• ensure that Mrs A's consultant reflects on our comments regarding her discharge;
• review the hospital's discharge planning process with a view to ensuring that, where relevant, patients under the care of an orthopaedic consultant should be reviewed by geriatric services;
• remind relevant nursing staff that when patients are being transferred between wards, they should ensure the patient and their family are fully informed where appropriate;
• undertake an audit of the medicines reconciliation process for patients discharged from orthopaedic wards; and
• apologise to Mrs C for all the failures identified.