Health

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A's late husband (Mr A) before he committed suicide. Mr A had a history of depressive illness. He was referred to a community psychiatric nurse (CPN). He saw both the CPN and the board's mental health assessment service before he was admitted to hospital after presenting with suicidal thoughts. He took his own life two days after being discharged from hospital.

In considering this complaint, we took independent advice from our psychiatric adviser, after which we upheld only one of Ms C's four complaints. Ms C had complained that the CPN delayed in referring Mr A to hospital. Our investigation found, however, that the CPN had not delayed in referring him to a consultant psychiatrist at the hospital. We were also satisfied that there were reasonable attempts to manage Mr A with other treatments, and noted that there was contact with other parts of psychiatric services at an early stage.

Ms C also complained that the board failed to make a reasonable diagnosis or offer reasonable treatment and medication to Mr A when he was admitted to hospital. Our investigation found that Mr A's case was complex and he had diagnoses of personality disorder and depression. The risks he presented were considered and assessed, but it was concluded that he did not meet the criteria for detention. We found that attempts had been made to manage his case with appropriate drug and psychological treatments and our adviser said that his treatment and medication were reasonable.

Ms C also complained that the board failed to carry out an appropriate risk assessment. She said that they failed to properly assess the risk of suicide and child protection issues. She also said that they had failed to involve Mrs A when deciding to discharge Mr A. We found that the hospital had carried out frequent risk assessments on Mr A in a satisfactory manner. He did not show impaired decision-making and so could not be detained in hospital. We also found that Mrs A was involved as far as possible in her husband's care, and that child protection issues were taken into account. However, we upheld the complaint about the assessment of risk, as we found that Mr A had been discharged to his brother's home. We considered that the hospital should have asked Mr A for consent to contact his brother in order to involve him in the discharge plan, and to check if there were children at his address. We noted that the standard documentation around discharge had not been completed and had this been done, it could have acted as a prompt to contact Mr A's brother.

Recommendations

We recommended that the board:

• make the staff involved in Mr A's care and treatment aware of our findings.

Summary

Ms C complained about a delay by her GPs in diagnosing that she was pregnant. She initially went to the practice to report a missed period, and was advised to take a further pregnancy test, which was negative. She attended the practice five months later saying that she had bloating and constipation. The GP thought she was constipated and prescribed a laxative. Ms C then went on holiday where she participated in various activities. She returned to the practice and it was then diagnosed that she was pregnant. The practice apologised for the missed diagnosis of pregnancy, but said that the GPs had dealt with the symptoms that she reported and had focused on the history of bloating and constipation. They also said that Ms C's complaint would be included in the appraisal folder and discussed at appraisals later in the year, where lessons learned are shared with colleagues.

We obtained independent advice on the complaint from one of our medical advisers, who considered Ms C's medical records in detail. Their advice was that the actions of the GPs were appropriate, although the diagnosis of pregnancy was missed. In such cases, as long as the clinicians involved took reasonable action based on the symptoms that were presented, we have no grounds to criticise their actions. Our adviser had no concerns about the GP's actions and prescription, and noted that the GP had told Ms C to return for re-evaluation if the symptoms did not settle.

Summary

Mrs C's mother (Mrs A) suffered a stroke after undergoing surgery for a fractured hip. Mrs C complained that the operation had taken too long and that her mother was not provided with a reasonable level of care during and after the surgery. She also believed that her mother did not receive adequate treatment after the stroke was diagnosed, as she did not receive a scan to confirm the diagnosis and was not moved onto a stroke ward.

After taking independent advice from one of our medical advisers, we upheld the first complaint as we found that the operation to repair Mrs A's broken hip did not follow best practice. She was not operated on within the 24-hour time limit set out in Scottish Intercollegiate Guidance Notes (SIGN), and the fit of the artificial hip was not properly checked, which meant the operation took 45 minutes longer than planned and unnecessarily increased the risks to Mrs A during surgery. We found that the board had not acknowledged or investigated these failings sufficiently in their investigation of Mrs C's complaint.

We did not uphold Mrs C's other complaints as we found no evidence to show that Mrs A was inappropriately discharged from the recovery room to a ward when she failed to recover from the anaesthetic, nor that her treatment was not reasonably managed when it was realised that she had suffered a stroke.

Recommendations

We recommended that the board:

• provide evidence that staff have been reminded about the importance of using trial stems prior to the insertion of cement during arthoplasties (a surgical procedure that restores the function of a joint);
• remind all staff of the importance of the 24-hour safe period set out in SIGN guideline 111;
• remind all staff of the importance of making clear, accurate notes for all clinical decisions; and
• apologise in writing for the failings identified in our investigation.

Summary

Mr C had taken his late wife (Mrs C) to her medical practice as she had suffered from vomiting, diarrhoea and dizziness for two days, following a surgical procedure. Mrs C had a history of systemic lupus erythematosus (an inflammatory, multi-system autoimmune disease) and Mr C was concerned that due to his wife's medical history she should have been admitted to hospital. The GP who assessed Mrs C had diagnosed possible infective gastroenteritis, recommended medication and fluids and to seek a further medical review if there was no improvement. Mrs C deteriorated overnight and was admitted to hospital the next day where she continued to deteriorate and died a few days later. Mr C was concerned that his wife might have had a better chance had she been admitted earlier, and complained that the GP had not assessed her properly and had failed to arrange a hospital admission for her.

As part of our investigation, we took independent advice from one of our medical advisers. After studying Mrs C's medical records, our adviser concluded that this was a tragic case of a rapid deterioration in a person with an extremely rare condition, and she did not see any evidence in Mrs C's records to suggest that the GP could have foreseen or prevented this. We did not uphold the complaint, as our adviser said that the GP provided appropriate clinical treatment and had no concerns about their actions.

Summary

Mr C attended a hospital emergency department, with a badly cut hand. He was assessed by an emergency nurse practitioner. Following an examination, the nurse noted that he had superficial cuts to the second, third and fourth knuckles which were treated with steri-strips (adhesive strips that can be used to close small wounds). Mr C was referred to a consultant orthopaedic surgeon three weeks later as he noticed that he had poor extension (straightening) of his middle finger. The consultant and a specialist orthopaedic registrar reviewed Mr C and said that the function of the finger was recovering. They did not arrange a further review, but some eight months later, Mr C was reviewed again at his request. The consultant suggested a night resting splint for six months, and discharged him back to the care of his GP. Mr C was only able to use the splinting for a month because he found it uncomfortable, and the GP referred him again for a further assessment. Mr C was reviewed some six months later, when again the consultant discharged him back to the GP saying that he was happy to see Mr C again if he wanted to talk things over further or reconsider the outcome of their discussion.

Mr C told us that he now has a bend in his finger, which is very sore. He complained that the nurse should have conducted a more thorough assessment or asked a doctor for advice. He was also concerned about the follow-up treatment he received.

After taking independent advice from a surgical adviser and a nursing adviser, we found that the record-keeping of the initial assessment was not of a reasonable standard. It did not show that the nurse carried out a full and extensive examination of the injury including, significantly, movement and wound base of the cuts. We also found that there were failures in discharge planning. Our nursing adviser said that it was difficult to know from the records if there was evidence of a further injury that would have meant he should have been referred to a specialist. However, as we have to reach a decision based on the evidence available, we upheld Mr C's complaint about his treatment after the injury occurred, given the failures in record-keeping in relation to the assessment and discharge plan.

In relation to the follow-up treatment the advice we were given, which we accepted, was that this was reasonable. We were satisfied that he was seen appropriately on three occasions, and our medical adviser explained that the treatment plans and discharge arrangements for these consultations were reasonable.

Recommendations

We recommended that the board:

• ensure that the findings of this complaint are discussed with the nurse and that it is used as a learning tool in terms of their professional development for carrying out examinations of this nature;
• bring the failures in record-keeping to the attention of the nurse; and
• apologise for the failures identified.

Summary

Mr C, who is a prisoner, complained because he said the prison health centre unreasonably stopped the medication used to treat his opiate addiction. The board explained to Mr C that, after giving him his tablets, he was asked to sit in another room to be observed whilst the tablets dissolved. After a short time, Mr C indicated the tablets had dissolved, although this normally took around five to ten minutes. Because of that, Mr C was searched and he was found to have a piece of cling film in his pocket which had a strong smell of lemon (with which the tablets are flavoured). As a result of this, Mr C was referred to the doctor to have his medication reviewed and it was decided to stop his prescription. He was also offered an alternative, which he accepted.

During our investigation, we took independent advice from one of our medical advisers, who said that the prison doctor's decision was reasonable, given that the health centre suspected that Mr C was not taking the medication appropriately. We also noted that the alternative was suitable. In light of this, we were satisfied the prison health centre's decision to stop Mr C's prescription was reasonable and we did not uphold the complaint.

Summary

Mr C, who is a prisoner, complained that the prison health centre unreasonably stopped his pain medication. He said he was prescribed the medication whilst he was in the community and it was the only type that helped his pain. The health centre had checked with Mr C's community doctor who confirmed he was being prescribed the medication. However, they then decided Mr C did not need the medication and prescribed him something else for his pain. Mr C told us he had tried many other types of medication but none of them helped.

We took independent advice on Mr C's complaint from one of our medical advisers. He felt that the prison health centre did not appear to have undertaken a detailed assessment of Mr C's circumstances. In his opinion, the information available suggested Mr C had tried various types of reasonable pain relief but they had been unsuitable. In addition, our adviser noted that the medication the health centre were refusing to prescribe was likely to be suitable for the type of pain Mr C was experiencing. In light of the information available to us, and having accepted this advice, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• undertake an appropriate review of Mr C's clinical need for the pain relief he requested.

Summary

Ms C said she had suffered back pain since about 2006 but had only managed to get her GP (with whom she had been since 2008) to send her for a bone scan in 2013. She said she could not be specific about dates as she could not remember them exactly but about three years ago she had collapsed in the street, and had difficulty walking. She said she was in considerable pain and asked to have her back x-rayed, but the GP refused. When Ms C was later referred for a bone scan she was very upset to be told that she had four fractures in her back.

We took independent advice from one of our medical advisers, who considered Ms C's medical records, and said that the GPs in the practice had made reasonable assessments of her back pain when she went to the surgery. Although we did not uphold her complaint about delay in referring her for a scan, our adviser also said that it was possible for a GP to order a lumbar spine x-ray if a worrying cause of back pain is suspected, and that the GP had misinterpreted the findings of the bone scan, so we made recommendations.

Recommendations

We recommended that the practice:

• ensure that all GPs note that it is possible for a GP to order a lumbar spine x-ray if a worrying cause of back pain is suspected;
• update Ms C's records to accurately reflect that she has four osteoporotic fractures in her spine and take the opportunity to re-evaluate her pain management given this information; and
• apologise to Ms C for the misinformation concerning whether or not she has four fractures and that a GP cannot refer a patient directly for a spinal x-ray.

Summary

Mrs C, who is an advice worker, complained on behalf of Mr and Mrs B about the care and treatment of their late son (Mr A). Mr A had an aggressive form of leukaemia (cancer of the white blood cells), and received a transplant of stem cells (cells made in the bone marrow, which can produce other cells). However, after the transplant it became apparent that the donor had developed an immunity to a virus called cytomegalovirus (CMV, a member of the herpes virus family) after he was accepted as a donor. This was evident in a blood test that the board received shortly before the transplant, but the change was not identified until after the transplant. Mr and Mrs B were concerned that this should have been identified, and that they were left not knowing what would have happened if it had been identified and acted on earlier.

Mr A became unwell after the transplant, and showed signs of very low levels of CMV in his blood, which was treated with medication. However, he had problems with his lungs, and his condition deteriorated further. Mr and Mrs B expressed concerns that this was worsened by the presence of CMV. His condition continued to deteriorate, despite a reduction in his level of CMV, and six weeks after his transplant, he died.

The board accepted that an error was made in not identifying the change in the donor's CMV status. However, there was no policy or procedure in place at the time to ensure this unusual event was identified. They also said that although this was discussed with the family at the time, the focus on his treatment meant that the discussions about CMV were not as detailed as they could have been.

As part of our investigation, we took independent advice from a specialist medical adviser, who said that the care and treatment given to Mr A was reasonable. She said that this was a most unusual problem. We noted that as there was no procedure in place at the time for checking for changes in blood tests, there was no failure of procedure, and also that as this was such a rare occurrence it was not surprising that this was not catered for. Our adviser also said that there was an urgent need for Mr A to have a transplant, and that the donor was still the most appropriate match, despite the change in his CMV status, as the risks associated with CMV were much less than those of not having a transplant at all. She said that Mr A's CMV level was reducing before his death, and that she was of the view his death was due to complications resulting from his transplant, and not the CMV. She noted that there was a lack of information in the records of discussions with the family in relation to their son's CMV status and the change in donor's status.

We did not uphold Mrs C's complaints, as we found that the board had followed their procedures in so far as they covered such a situation. We noted that they had now introduced procedures to ensure checks are made in future. We did consider whether Mr A in fact gave informed consent to the procedure as he did not know about the donor's status, but accepted our adviser’s view that it was very difficult to provide fully informed consent given all the variables involved. We also acknowledged that the reason that Mr A was not told about the change in status was because the team did not know about it, not because they did not tell him. Based on the advice we received, it appears that Mr A died of other complications, and the change in the donor's CMV donor status did not appear to have caused his death.

Recommendations

We recommended that the board:

• review the consent form and consider including reference to CMV risks and update the list of immunosuppressants used in the procedure; and
• remind staff of the need to ensure that appropriate records are kept of all discussions in relation to the giving of test results, particularly those where consent is required, and of subsequent meetings with family members.

Summary

Mr C was admitted to hospital for a hip replacement. Shortly after his operation, he said that he was in severe pain. Mr C said that he reported this to a nurse who told him that she could not divert from the anaesthetist's pain management plan until she discussed this with him when he was available later that day. The anaesthetist reviewed Mr C several hours later and prescribed a fast-acting morphine tablet. He also prescribed other pain relief, including a slow acting morphine tablet. However, Mr C complained that over the next few days, nursing staff refused a number of requests for pain relief. When his pain levels subsided several days later he decided to make no further requests for this. Mr C also complained that nursing staff failed to accurately record his reported levels of pain and the drugs administered.

We sought independent advice from our nursing adviser. The adviser said that the board's account of the drugs administered after surgery was evidenced by the medical records, although she recognised that pain was subjective and that it can be difficult in some instances to eliminate all pain. The board had also acknowledged this in their replies. We noted that the level of pain Mr C said he experienced was not reflected in the medical records. Having considered the matter carefully, we were unable to reconcile the different accounts of the level of pain experienced, and we did not uphold his complaint. We found that appropriate pain relief was administered in accordance with board policy and the level of pain recorded in Mr C's notes at the time. In addition, we noted our adviser's comments that a balance had to be struck between relieving pain and ensuring a patient was not over-sedated.