Health

Summary

Mr C complained about the care and treatment that his father (Mr A) received during his stay in hospital, and particularly during the final three days of his life. Mr A was diagnosed with myasthenia gravis (a medical condition where muscles become easily tired and weak) while he was on a neurology ward (for disorders of nerves and the nervous system) and was then transferred to a cardiology ward (for heart disorders) due to the deterioration of a long standing heart condition. While he was in the cardiology ward, the consultant neurologist remained in contact and reviewed him regularly. When Mr A was about to be discharged, he contracted a norovirus (winter vomiting) infection, and was not well enough to leave. His family asked for assurances that the consultant neurologist was consulted about the delayed discharge, but medical notes indicate that he was not told about the delay until late on the third day after. He then reviewed Mr A promptly.

That night Mr A's heart condition deteriorated, and he became weak and tired. He had difficulty swallowing his pills the next morning, and his family said that he choked on his food at lunchtime, although the board did not provide any information about that incident. After lunch, Mr A's condition deteriorated rapidly. A chest x-ray indicated that he had an infection, with possible signs of aspiration (when material from the stomach or throat is taken into the lungs), and although staff tried to stabilise his condition, Mr A died.

We obtained independent advice on this complaint from a medical adviser. They said that the neurologist should have been told earlier about Mr A's delayed discharge. They also said that Mr A should have been given a swallowing assessment to ensure he would not choke on food. They concluded that there was evidence that aspiration had led to an infection (pneumonia), which contributed to Mr A's deterioration, although this evidence was not completely conclusive. We upheld Mr C's complaint about his father's care and treatment, on the basis that communication between specialist teams was inadequate and that a swallowing assessment should have been conducted.

Mr C also complained about the board's handling of his complaint. Our investigation found that the board had given Mr C conflicting information. We also found evidence that their initial investigation was not sufficiently robust. We upheld this complaint, and highlighted that it took a full eight months for Mr C to get a final response to all the issues he raised, which was far too long.

Recommendations

We recommended that the board:

• ensure that, where a review is requested from another specialist, adequate notes are taken in enough detail for staff to carry out appropriate tests and monitoring;
• raise staff awareness to ensure that all complaints are handled in line with their complaints procedure, and in particular, that investigations are thorough and responses adequately address all the issues raised; and
• apologise to the family of Mr A for the failures identified.

Summary

In 2007, Ms C had her right breast removed because of cancer. In 2012, her left breast was also removed as a preventative measure and at the same time, she underwent reconstructive surgery (breast implants). She was discharged from hospital but was re-admitted about a week later, and had to have necrotic (dead) skin removed, as well as her breast implants. She was discharged on the day that the presence of a bacterial infection was identified. Ms C's recovery has been slow and she complained that, in the circumstances of her case, she was discharged inappropriately.

The complaint was investigated, taking into account all the relevant information, including the complaints correspondence, and Ms C's medical records. We also obtained independent medical advice. We did not uphold Ms C's complaint as our investigation found that on both occasions it had been appropriate to discharge her. On the day of her first discharge, she was noted to be doing well and her wound was satisfactory. On the next occasion, there was no suggestion in the records that she had infection. She had already completed a course of antibiotics and was discharged with more. While it was noted that the circumstances experienced by Ms C were distressing in that she did suffer infection, lost her implants and suffered the trauma of poor wound healing, the advice received was that it had been appropriate to discharge her.

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received from the medical practice during two days when she was at home between being discharged from hospital and going into a hospice. When Mrs A was discharged, hospital staff requested a GP home visit for the following day. However, this request was missed, and it was not until Mrs C phoned the practice that a home visit was arranged. The following day, a hospice nurse visited Mrs A and found that her pain was severe and that she needed to be in the hospice for this to be managed effectively. The nurse phoned the practice for another home visit, so that Mrs A could be given further pain relief before she was transferred to the hospice. However, this request was not identified as urgent, and it took a further call to the practice to prompt the visit. When the GP arrived she did not have appropriate medication with her and had to go to a pharmacist to get some.

We obtained independent advice on this complaint from one of our medical advisers. They confirmed that there were delays in providing a home visit the day after Mrs A came out of hospital. This was because the practice did not pick up the request from Mrs A's discharge letter or from a call from staff at the hospital. The adviser considered that the GP attending on the second day should have had appropriate pain relief with her when she came to the house, as she was aware of the reason for the visit. She also said that the GP had not administered appropriate pain relief. We upheld Mrs C's complaints as there was evidence that the practice had not responded appropriately to calls for home visits and had not provided appropriate pain relief to a patient in severe pain. We did, however, note that they had already identified some of these failings and had put in place systems for improving communication in relation to home visits.

Recommendations

We recommended that the practice:

• put in place a system that ensures that actions identified in patient discharge letters are carried out;
• ensure that they are familiar with, and take account of, Scottish Intercollegiate Guidelines Network Guidance 106: control of pain in adults with cancer to ensure appropriate pain relief is used;
• ensure that where a home visit is required for pain relief for palliative care, the doctor attending has access to the appropriate pain relief prior to attending; and
• apologise to Mrs C for the additional distress caused by the failings identified in our investigation.

Summary

Mrs C complained about the care that her husband (Mr C) received in hospital after a catheter (a tube used to drain urine) was inserted into his bladder. Mrs C also complained about poor record-keeping in relation to the catheter's removal and that the board's correspondence to her contained inaccurate information.

Mrs C said that a member of the nursing staff told her that Mr C had pulled the catheter out, but it did not need replacing as he was passing urine normally. After Mr C was discharged from hospital, he suffered recurrent urinary tract infections for approximately six months. He was referred to a specialist and tests showed that a 20 centimetre section of the catheter had been found in Mr C's bladder, which caused Mr C severe pain.

We considered that it was likely Mr C had pulled part of his catheter out due to episodes of confusion and agitation while in hospital. We took independent advice from one of our medical advisers, who said that this was a very unusual case, and that it was good practice for nursing staff to record when a catheter had been removed. We found that there was no evidence to show that nursing staff had ensured that Mr C's catheter had been removed safely or had monitored him in line with the board's guidelines for urinary catheter care. Our investigation also found that whilst the board had apologised to Mrs C verbally for inaccuracies in their correspondence, including referring to her husband by the wrong name and suggesting that he had passed away, we considered that it would have been appropriate for them to have apologised to her in writing, as she had requested.

Recommendations

We recommended that the board:

• review their guidelines on urinary catheter care and care plans, with a view to including a requirement to record the due date and the date when a catheter is removed in order to ensure continuity of care;
• apologise to Mr and Mrs C for the failings identified; and
• draw our findings to the attention of relevant staff, to ensure appropriate written responses and apologies are given where relevant.

Summary

Miss C complained about aspects of the care she received during the birth of her son. She was unhappy with the time taken to allocate her a midwife on admission and to give her pain relief. She was also concerned about the attitude of staff in the labour ward, which she felt was dismissive and unprofessional at times. Miss C had a forceps delivery (where the baby is delivered using a surgical instrument resembling a pair of tongs). She complained that the care provided by the labour ward doctor and the surgeon in the theatre during the procedure was abrupt and overly forceful. In particular she was concerned about the physical damage that she and her son sustained during the birth.

We took independent advice on Ms C's complaint from two medical advisers. We upheld her complaints about delays and about unprofessional behaviour on the ward, noting that the board had already apologised for these, although we concluded that her overall treatment was reasonable in the circumstances. We did not uphold the complaint about the staff in the operating theatre, as we found no evidence of failures there, although in relation to this complaint we identified a concern with the quality and accuracy of the board's investigation it, and made recommendations accordingly.

Recommendations

We recommended that the board:

• review the consent form for operative vaginal delivery, to consider including all the common risks given in the Royal College of Gynaecologists Consent Advice No 11 (Operative Vaginal Delivery) July 2010;
• apologise to Miss C for the failure to adequately investigate her concerns and provide her with an accurate response to her complaint; and
• provide the Ombudsman with the outcome and details of any actions arising from their investigation into the failures of their original investigation into this complaint.

Summary

Mrs C complained that her former GP did not investigate the symptoms she was reporting, and that this led to a delay in a spinal problem being diagnosed and treated. Mrs C had a complex medical history with various symptoms which she reported at various consultations at the medical practice, as well as during home visits and phone consultations. She was being treated for various medical conditions, some of which had symptoms that related to her spinal problem.

Our investigation, which included taking independent advice from one of our medical advisers, found that it was reasonable that the practice did not specifically investigate the possibility of a spinal problem. The adviser was of the view that many NHS GPs would have had difficulty in identifying or suspecting a spinal problem in the midst of the many and complex conditions from which Mrs C suffered. The adviser also noted that the first mention of a symptom that could specifically have related to a spinal problem, and which could have been followed-up, took place at a consultation at the practice in April 2012, which lasted for an hour. During the consultation, Mrs C had taken exception to a suggestion by the GP for a referral to another specialist, unrelated to the spinal problem. She had left the consultation and four days later made a formal complaint to the practice. In her letter she indicated that she and her husband no longer wished to be patients there.

The practice had reviewed Mrs C's complaint letter, and as they felt that the doctor/patient relationship had broken down, had applied to the local health board to have Mr and Mrs C allocated to another practice, which happened in early May. By the middle of June, Mrs C's new GP had ordered a MRI (a specialist type of imaging) scan, which revealed the spinal problem. Our investigation found that, in the circumstances, it was not unreasonable that the original practice did not follow up the specific symptom reported in April 2012.

Summary

Mr C complained about the care and treatment provided to his friend (Mr A) in the accident and emergency department of a hospital, and cardiac nurse follow-up after surgery.

After submitting his complaint, Mr C contacted us to say that Mr A was satisfied with the care he was now receiving and his recovery was progressing. Mr C also said that hospital staff had alleviated Mr A's concerns and reassured him that lessons had been learned. Because of this, Mr C withdrew his complaint and we closed our file, as no further action was needed.

Summary

Mr C complained that hospital staff failed to act on symptoms he developed after surgery and this led to a delayed diagnosis of ocular candidiasis (a fungal infection in the eyes). Mr C had been admitted to the urology ward (where patients with conditions relating to urinary function are treated) with a kidney infection. He also had kidney stones and it was decided that he should have a stent (a mesh tube) inserted, as a stone was causing an obstruction.

Mr C was treated for sepsis (blood infection), but it was then recorded that there was yeast in his blood cultures. He was examined by a microbiologist, who recommended that he was reviewed by an ophthalmologist (eye specialist), because fungal blood infections can sometimes spread to the back of the eye. This is very difficult to treat and can result in the loss of vision or of the eye. A referral was faxed to the ophthalmologist the following day. Mr C remained in the urology ward, receiving injections of anti-fungal medication for his blood infection.

Several days later, it was recorded in Mr C's notes that the vision in his left eye was blurred, which was discussed with ophthalmology the following day. It was noted that they would review Mr C the following week. However, the next day, it was recorded that Mr C's vision had worsened and an urgent ophthalmology review was needed. Mr C's family also raised concerns at that time. He was reviewed by an ophthalmologist that night, and ocular candidiasis was diagnosed. He was transferred to the care of an ophthalmologist two days later, but has lost most of the vision in his right eye and has reduced vision in his left eye.

After taking independent advice from a medical adviser, we found that the blood infection was identified appropriately, appropriate treatment was quickly started and a prompt referral was made for an ophthalmologist to review Mr C. However, our investigation found that the junior doctors in the urology ward failed to continue to monitor Mr C's eyes while they were waiting for the ophthalmology review, and we upheld his complaint. We considered that the microbiologist should have provided more information about the need for this. Because of this, there was a failure to assess Mr C by asking about his eye symptoms or examining his eyes. When Mr C started to display symptoms in his eyes, this should have prompted another opthalmology referral at an earlier stage, although we noted that this would not necessarily have improved the outcome for him.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to monitor his eyes; and
• make the relevant staff in the hospital aware of our findings.

Summary

Following a review of treatment room services, the board consulted on proposed changes to these. The changes included introducing a new full-time treatment room service at a new site. Mr C complained that the board failed to carry out a meaningful consultation about the changes and said that many GPs and elected officials were concerned about the consultation and the impact of the changes.

Our investigation considered whether there was any administrative fault in the way the board consulted about the changes, particularly in relation to Scottish guidance about consultation. This says that consultations should be proportionate, clear and meaningful. In reaching our decision on the complaint, we took into account advice explaining why the changes do not constitute a major service change. We also noted that key stakeholder groups, including a patient representative group and the democratically elected representative general practitioner body, were involved in the consultation process. After carrying out an equality impact assessment, the board also engaged with public transport services. We were, therefore, satisfied that the board undertook a thorough, transparent and proportionate consultation process seeking input from, amongst others, general practitioners, patients and elected officials and, in doing so, complied with the guidance.

Summary

Mrs C complained that the care and treatment provided to her late mother (Mrs A) was not reasonable. She particularly complained about lack of pain relief, inadequate palliative (end of life) care, and communication failures. Mrs A, who was 94, had been admitted to hospital after a fall at home. On examination she was found to have a tumour in her chest. She was treated for her pain and for urinary back-up (where urine passes back up into the kidneys) but otherwise her care was non-interventional. Mrs A's condition deteriorated and she died two days later.

During our investigation we took independent advice from two advisers, a medical and nursing adviser. Both advisers considered that the care and treatment provided to Mrs A was reasonable and that appropriate and timely actions had been taken to monitor, review and address her pain. Urinary back-up is a common symptom in elderly patients and Mrs A's treatment for her pain may also have contributed to this. The medical adviser was of the view that appropriate action was taken to address this problem, and we did not uphold Mrs C's complaints about care and treatment.

The board acknowledged and apologised for communication failures between staff and the family. They reviewed the provision of palliative care in their region and additional training, including communicating with patients and families, has either taken place or is on-going. In view of this, although we upheld this element of the complaint, we did not need to make a recommendation.