Health

Summary

Mr C, who is a prisoner, complained that he was not seen by the prison dental hygienist after being advised that he would be seen again in three months. He was also unhappy that it took nearly four months for him to see the dentist after he reported that a tooth had broken, causing him pain and increasing difficulty in eating and sleeping.

The board told us that when they took over responsibility for providing NHS care for prisons in their area in April 2012, there were no guidelines in place aimed specifically at the treatment of prisoners but this was now underway. They also said that since Mr C complained, the prison had audited its practice against the board's new dental services standard statement.

Although we recognised that the prison's dental resources were going through a transitional period, we were unable to clearly identify why Mr C's hygienist appointment did not go ahead until 11 months after it was recommended he be seen again. We took independent advice from our dental adviser, who said that from the evidence in the dental records it would have been reasonable for Mr C to see the hygienist around every three months. We, therefore, took the view that the delay was likely to have affected the progression of Mr C's gum disease, which the records show got worse during the months he was waiting to be seen. In addition, we found that the time it took before Mr C saw the dentist was unreasonable and not in accordance with the guidance in place at the time, or the draft guidance due to be published. We were concerned that the board did not identify this while investigating his complaint. We found that the delay was likely to have contributed to his tooth decay and the possibility that he may lose a tooth.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay he experienced in being seen by the hygienist and the dentist; and
• provide the Ombudsman with evidence to show that the prison has audited their practice against the board's dental services standard statement.

Summary

Mrs C complained about an out-of-hours hospital consultation with a trainee doctor, which she attended with her four-year-old daughter, Miss A. The appointment was made after Mrs C called NHS 24 to report that Miss A had been unwell for several days and that her condition was worsening. She complained that the doctor did not examine her daughter, and inaccurately concluded that Miss A was suffering from a viral infection. She also complained that he was patronising and condescending. She said she left the examination room and went to the accident and emergency department at another hospital, where Miss A was quickly diagnosed with scarlet fever.

In responding to the complaint, the board explained that the doctor was at the beginning of his second year as a general practice registrar and that a fully qualified GP trainer had been on the premises to supervise him. They said it was unfortunate that Mrs C had chosen to leave the premises before the supervisor could intervene. However, they acknowledged that the incident had thrown up a number of training issues that they needed to address with the doctor before he could complete his training and demonstrate his competence as a qualified GP. In particular, they said this would cover the recognition of scarlet fever.

In bringing her complaint to us, Mrs C acknowledged that the board had identified training gaps and had undertaken to address these. However, she also felt that the incident had highlighted gaps in the supervision of trainee doctors. She noted that she had been in the examination room for up to ten minutes and considered this too long for a trainee to be left unsupervised.

We discussed the case with one of our independent clinical advisers and he had no concerns about the doctor having been left unsupervised for this period of time. He said this was perfectly reasonable for a doctor at this stage of training. We, therefore, did not uphold the complaint. However, we did make recommendations as our adviser had concerns about the adequacy of the proposed action to address the identified training gaps. He noted that the board said the issues needed to be addressed before the doctor could complete his four year training programme, but he considered that they should be addressed much sooner than this. He highlighted that hospital out-of-hours clinics, with the requirement to work with sick children, were one of the more challenging aspects of general practice. Our recommendations on the case, therefore, reflect our adviser's concerns.

Recommendations

We recommended that the board:

• put an action plan in place to ensure that the issues arising from this incident are addressed within three months;
• make arrangements for the doctor's next two sessions to be directly supervised by a GP trainer to ensure that he is competent in this setting; and
• make the doctor's educational supervisors aware of this incident, which should be included in his training record.

Summary

Ms C, who is a claims assessor for an insurance company, contacted us on behalf of her client (Mr A). Mr A was concerned that an operation to fix a fracture to his upper leg had failed and he was left with a shortened leg as a result. He thought that this was because a junior doctor was allowed to complete the operation unsupervised, and said that follow-up physiotherapy had only caused him additional concerns when the fracture re-opened. Mr A also believed he suffered a morphine overdose at the time of surgery which left his health additionally compromised and contributed to a post-operative problem with blood clots.

We took independent advice on this complaint from three of our medical advisers – specialists in orthopaedics, anaesthetics and physiotherapy. The orthopaedic adviser said that the surgery was not performed to an adequate standard, although not because of a lack of supervision. The adviser noted that during the operation there had been difficulty inserting screws to fix the fracture, and ultimately these had not been placed correctly. This was a recognised complication, but one he felt should have been identified at the time. He was concerned that there was no record showing that the possibility of the leg being left shortened was discussed with Mr C beforehand. The dosage of morphine was not considered to be unreasonable in the circumstances of the trauma Mr C had suffered, although it was clear that he had suffered a recognised side-effect from it. The physiotherapy problems were considered to be an inevitable consequence of the failed surgery, but not unreasonable in all the circumstances. We upheld the complaint about the standard of surgery but not those about supervision or physiotherapy.

Recommendations

We recommended that the board:

• provide evidence that their new consent form is now routinely used and includes space for noting all risks discussed; and
• remind surgical staff of the need to make a comprehensive note of operations, particularly where adverse technical problems have arisen, so that subsequent review is possible.

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.