Health

Summary

When Ms C hurt her knee she went to Stirling Community Hospital where she was seen by an emergency nurse practitioner (ENP) in the minor injuries unit. She was diagnosed as having a medial collateral ligament (knee ligament) sprain and sprain of her hamstring. She was prescribed co-codamol (a pain reliever) and advised to see her GP if she had further concerns. She was encouraged to walk.

Ms C told us that the examination and care given to her were inadequate. She was not given an x-ray, nor was her knee scanned. She said that it was not until a month later, after she attended the accident and emergency department, that her knee was scanned and it was confirmed that her cruciate ligament (another knee ligament) had snapped.

During our investigation we carefully considered all the complaints correspondence and Ms C's relevant clinical records, and took independent advice from one of our medical advisers. Our investigation confirmed that Ms C's initial examination had been full and thorough and that the ENP had provided appropriate treatment in accordance with the relevant guidelines. The adviser said that Ms C did not require an x-ray as she had suffered a soft tissue injury which would not be seen on an x-ray. Although Ms C said that her knee had 'popped' and that she had reported this, there was no evidence of this in the records. We decided, on the basis of the available evidence, not to uphold the complaint, as it was not possible to provide independent verification of Ms C's recollection of events.

Summary

Mr C, who is a prisoner, complained to us about the board's handling of his complaint to them about healthcare issues. We were satisfied that the board had considered and responded to the issues Mr C raised, but our investigation found that they had failed to deal with the complaint within the timescales detailed in their complaints procedure and had not kept him advised of progress.

Recommendations

We recommended that the board:

• apologise for the failures we identified in the handling of the complaint; and
• remind staff of the need to work in accordance with the NHS Scotland complaints procedure.

Summary

When Mrs C's young daughter (Miss A) became ill, she was taken to her medical practice, where she was treated for an upper respiratory tract infection. The next day Miss A attended an emergency appointment there, as her condition had deteriorated. As she was clearly unwell, the practice referred her urgently to hospital. She was treated for a viral infection and discharged home without follow-up. A few days later, she was again taken to a further emergency appointment at the practice, where, in view of the hospital's recent diagnosis, doctors advised Mrs C to continue with the treatment previously recommended. However, Miss A's condition continued to decline and she was admitted to hospital. She later spent a number of weeks in intensive care after being diagnosed with pneumonia.

Mrs C complained that the practice showed little concern or empathy for her daughter's declining condition. She said that they had failed to take appropriate action on her symptoms as a consequence of which Miss A suffered distress and unnecessary suffering. We took independent advice on this case from one of our medical advisers, and took all the relevant information (including the complaints correspondence and Miss A's clinical notes) into account. We did not uphold the complaint, as our adviser said that the records indicated that the treatment given to Miss A was reasonable and that doctors made a reasonable working diagnosis. The adviser also said that Miss A went on to develop a rare and unusual medical condition, and there was nothing in her notes to suggest that this was developing.

Summary

Mr C complained about aspects of his mother's care and treatment in hospital but decided to withdraw his complaint and so we could not investigate his concerns further.

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 and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again 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’'s GP could, and should, have diagnosed Mrs A'’s pulmonary embolism or could have arranged for more urgent investigations to establish the cause of her symptoms.

We took independent advice on this case from one of our medical advisers. We found that, with the benefit of hindsight, it was likely that Mrs A’'s collapses at home were caused by initial smaller thromboembolic (blocking of a blood vessel by a blood clot) events. However, there was evidence to suggest that Mrs A was also suffering from a viral infection, which may have contributed to her symptoms. We accepted the adviser's view that Mrs A’'s symptoms were consistent with a viral infection rather than a pulmonary embolism. There was clear evidence that the GP had considered a number of possible diagnoses but had ruled out pulmonary embolism. Based on the information available to him at the time, we were satisfied that his examinations of Mrs A were thorough and his conclusions reasonable.

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 and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again 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 complained that there was a lack of urgency from accident and emergency (A&E) staff in diagnosing the cause of his daughter's symptoms. He also complained that Mrs A was left alone in a cubicle and that he and his wife were not allowed to sit with her.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaints. We found that Mrs A was seen by a nurse immediately on arrival at the hospital. However, she asked to use the toilet and was allowed to do so, which delayed triage (the process of deciding which patients should be treated first based on how sick or seriously injured they are) by around 30 minutes. Mrs A was triaged by a nurse and was prioritised as 'urgent', meaning she would be seen by a doctor within one hour. Our adviser said that Mrs A's symptoms were sufficiently abnormal to merit being prioritised as 'very urgent', which should have resulted in a doctor seeing her within ten minutes. Mrs A collapsed around twenty minutes after triage. We were satisfied that Mrs A was treated appropriately following her collapse, but we criticised the board for failing to identify the seriousness of her condition. Although we found it appropriate for Mrs A to be given privacy to use the toilet, we were also critical that Mrs A’s parents were not allowed to sit with her in the cubicle, or that staff did not ask Mrs A whether she wished to be visited.

Recommendations

We recommended that the board:

• apologise to Mrs A's family for the issues highlighted in our investigation;
• share this decision with staff carrying out triage in A&E with a view to ensuring an appropriate combination of tool-based prioritisation and professional judgement;
• take steps to ensure that the Fife Early Warning system (a system based on observation, and used to monitor changes in the patient’s condition) is being properly implemented and understood by staff in A&E;
• take steps to ensure that the triage process and decisions reached regarding treatment priority are properly documented; and
• remind nursing staff of the Nursing and Midwifery Council guidance on standard of conduct, performance and ethics 2008.

Summary

Mr C was referred for hospital physiotherapy treatment but, as he had not received an appointment after two months, he complained to the board. In their response, the board acknowledged that their waiting list for routine physiotherapy appointments was much longer than they would like it to be. They apologised to Mr C and explained the steps they were taking to try to reduce the waiting list. They also confirmed that they had sent him a separate letter offering him an appointment. However, as Mr C did not receive this, he was unable to respond to the offer, and because of this he was removed from the waiting list and discharged. When he contacted the board to ask why he had not heard anything, he found out he had been discharged and brought his complaint to us.

Our investigation found that although the board do not keep copies of appointment letters, they had recorded on their system that a letter had been sent to Mr C and the date it was sent. They also provided us with evidence that they had notified Mr C’s GP of his discharge. We obtained independent advice from our medical adviser, who is a GP. The adviser confirmed that this was reasonable and that the onus was then on Mr C to get in touch. We noted that, despite having been told by the board that an appointment letter had been sent, he waited over six months to get in touch with them to tell them he had not received it. When he did get in touch, the physiotherapy service phoned him to explore the possibility of reinstating his referral but Mr C indicated that he no longer wished an appointment.

As we considered the board’s response to the initial complaint to have been reasonable, and as Mr C himself appeared to have delayed in querying why he had not received the appointment letter, we did not uphold the complaint.

Summary

Mrs C attended the medical practice as she had a swollen, discoloured and painful varicose vein in her right leg. She was initially seen by the practice nurse, who prescribed antibiotics (drugs to treat bacterial infection) and anti-inflammatory medication after consulting one of the practice doctors. The following day, as Mrs C’s leg continued to be very painful, she again phoned the practice and was advised by one of the doctors that she had not allowed enough time for the medication to work. Over the next 12 days, Mrs C was visited at home twice, as she felt she was not improving. On the afternoon of the second home visit, the doctor who visited Mrs C arranged for her to be seen by a vascular specialist at hospital. Mrs C requested an ambulance to take her there. She was offered a non-emergency ambulance but due to the possibility she might wait a number of hours for it and miss the appointment, the practice told her that she might wish to make her own travel arrangements, which she did. At the hospital, an ultrasound scan of Mrs C's right leg revealed a blood clot from the ankle to the groin, and she required emergency surgery. Mrs C was admitted to hospital the same day and discharged several days later.

Mrs C complained that the practice failed to appropriately assess and treat her symptoms, and that she should not have had to make her own way to the hospital. She was dissatisfied with the explanations provided by the practice and the way in which they dealt with her concerns and complained to us, saying that she had no faith in them.

We took independent advice on this case from one of our medical advisers. The advice, which we accepted, was that the practice had not failed in their care of Mrs C. Indeed, the adviser considered the prompt referral of Mrs C to a vascular surgeon was evidence of excellent practice. The adviser also said that Mrs C did not need an emergency ambulance to take her to hospital and the reason that she was given as to why she might wish to make her own way there was reasonable. However, we also accepted that the practice may not have given Mrs C clear explanations and reassurance about her diagnosis and treatment. In addition, while there were clearly conflicting views about the reasons for the breakdown in Mrs C‘s relationship with the practice, we took the view that they should reflect on whether they had fully considered the reasons for Mrs C’s dissatisfaction and loss of faith, and how these could be resolved, particularly as she remains a patient there.

Recommendations

We recommended that the practice:

• review the way they communicate with their patients; and
• invite Mrs C to a meeting to discuss her concerns.

Summary

Mrs C complained about the care and treatment that the board provided to her late mother (Mrs A) before she committed suicide. Mrs A had been admitted to hospital with low mood and worsening anxiety. She had a diagnosis of recurrent depressive disorder and a history of drug overdoses dating back a number of years. When it was initially proposed that Mrs A would be discharged from hospital, both she and Mrs C had concerns that she was being discharged too early. After taking independent advice from one of our medical advisers, we found that that staff had taken these concerns on board and had postponed the discharge by five days, which we found showed evidence of reasonable patient and carer involvement. We found that Mrs A's subsequent discharge was appropriately planned and phased. Risk assessments had been carried out and she had three successful overnight passes before her discharge. In view of all of this, we considered that it had been reasonable for the board to discharge Mrs A.

Mrs C also complained that staff had failed to ensure that there was an adequate support package in place when Mrs A was discharged. It had been agreed that she would be followed up by a community psychiatric nurse (CPN) and would attend an out-patient psychiatric clinic. We found that the planned follow-up care at the time of Mrs A's discharge was reasonable, in that it was adequate to meet her needs and her level of assessed risk. However, Mrs A's consultant in hospital had recorded that she would receive CPN input for as long as was indicated after she was discharged, and in the weeks after her first appointment with a CPN, Mrs A's anxiety levels had increased. Mrs C, Mrs A and her GP had all contacted the board to say that she was struggling with increased anxiety. Despite this, after a second CPN visit, it was decided that the visits would stop. Although it was decided that she would be referred to a mental health day service, Mrs A had concerns about this. The CPN also told Mrs A that she was moving to another job. We found that, on balance, in view of Mrs A's increased anxiety it was unreasonable to discontinue the CPN follow-up after only two visits and so we upheld this complaint. We did, however, consider that it was appropriate for the CPN to tell Mrs A that she was moving to another job. Mrs A took her own life just two days after the second appointment. Had the CPN input been continued, the next visit would probably not have been for another few weeks. We took the view that it would, therefore, be unreasonable to say that the withdrawal of CPN support was a significant factor in Mrs A's decision to take her own life.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the premature decision that Mrs A no longer needed to see a CPN; and
• make the relevant staff aware of our finding on this complaint.

Summary

Mr C complained on behalf of his partner (Ms B) that the care and treatment provided to her late mother (Mrs A) was inappropriate. Mrs A, who lived in a care home, was admitted to hospital where she was diagnosed with pneumonia and treated with intravenous antibiotics (drugs to fight a bacterial infection, delivered straight to the patient's vein). Mrs A was discharged to her care home three days later with antibiotic tablets, but died suddenly in the early hours of the following morning.

Our investigation included taking independent advice from two of our advisers, a medical adviser and a nursing adviser. The medical adviser said that Mrs A's condition had improved while she was in hospital. Because she was returning to a care home, it was reasonable for the hospital to consider discharging her. However, there was clearly a lack of discussion with the family and the care home about Mrs A's ongoing care. Ms B was not aware that her mother had been in hospital until the care home phoned to tell her that Mrs A had died. The medical adviser was also concerned that there was a lack of communication with Mrs A about her treatment, including a medical decision not to attempt resuscitation if her heart or breathing stopped (DNACPR). There was also no evidence that Mrs A's mental capacity had been appropriately assessed. The nursing adviser said that there was a lack of communication between nursing staff and Mrs A's family and her carers in planning for her discharge, and a general lack of detail in the nursing notes.

Recommendations

We recommended that the board:

• ensure that relevant staff reflect on the medical adviser's comments in relation to the assessment of patients who lack mental capacity to make complex decisions about their care and treatment;
• issue a reminder to relevant staff of the requirement to keep clear, accurate and legible records;
• ensure that relevant staff reflect on the medical adviser's comments in relation to the completion of the DNACPR form;
• provide evidence that relevant staff have reflected on the specific reasons why there was a failure to communicate with the patient and her family; and
• apologise to Mr C and his partner for the failures identified during this investigation.