Health

Summary

Mr C complained about his former medical practice. He said that he worked as a self-employed plasterer and for some time had suffered from tennis elbow which affected his ability to work. He said that after he had physiotherapy he returned to the practice as requested, but was refused a further sick line. Mr C complained that the doctor concerned would not listen to him and, despite the fact that he was not fit to work, would not give him a sick line.

To investigate the complaint, we looked at all the available information, including the complaints correspondence and Mr C's medical records. After also obtaining independent advice from one of our medical advisers, we did not uphold Mr C's complaint. The adviser said that the responsibility for sickness notification was a statutory one. GPs issue sick notes after assessing the patient, which includes taking an occupational history and conducting an examination. In Mr C's case, the examination showed no abnormality and the GP recommended that he go back to work but should return to the practice if the problem recurred. As the GP did not think Mr C was unfit for work, she did not provide a sick line. The adviser said that in all the circumstances, this was in order.

Summary

Miss C, who has a complex eye condition requiring regular ophthalmology (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) interventions, complained about the process for accessing these services. Her condition can flare up at short notice requiring her to seek an urgent ophthalmology appointment.

The board's previous process for seeing an ophthalmologist involved attending an eye casualty service which was very busy and could involve waiting the full day to be seen. In order to improve this service, and try to filter out patients whose conditions could be treated by a GP or optometrist (at a community optician practice), the board changed the system. Patients are now required to attend either their GP or optometrist for initial examination and onward ophthalmology referral if required. This should still lead to an ophthalmology appointment within 24 to 48 hours. Miss C complained that she has to re-start this process from the beginning each time, despite her flare ups being regular and onward referral to ophthalmology being inevitable. In responding, the board indicated that, where required, Miss C could obtain repeat appointments by contacting her consultant’s secretary. However, Miss C said that this only applies during normal weekday working hours and only while she was under a specific consultant.

Our enquiries revealed that the old eye casualty service was open seven days a week from 09:00 to 16:30. The new clinic hours are the same but it is not open on a Sunday. As prior referral to this clinic is required, this means that Miss C has no direct access to the clinic at weekends when her consultant’s secretary is unavailable. We acknowledged that this might be frustrating for her but noted that the provisions in place will still result in Miss C being seen within the 48 hour target timescale. We also noted that emergency intervention at weekends could still be sought via NHS 24 or direct presentation at an accident and emergency department. As such, we did not uphold the complaint. However, we noted that when Miss C complained to the board, she expressed concern that she might lose her eyesight if she did not receive immediate treatment. Although the board appeared to have noted this while considering the complaint, they did not respond to it. We were critical of them for this and made a recommendation about it.

Recommendations

We recommended that the board:

• respond to Miss C's concerns about the long-term effect of the condition on her eyesight should she not receive immediate treatment.

Summary

Mrs C complained about the care and treatment a medical practice provided to her father (Mr A). Mrs C raised concern that the GP had not carried out a physical examination of Mr A when she first raised concern that he was confused. Mrs C said that despite her father living alone and having mobility problems, a phone discussion had only taken place where the GP prescribed antibiotics for a suspected urinary tract infection.

Mrs C continued to raise concerns with the medical practice about Mr A’s confusion. The GP then visited Mr A at home and thereafter referred him to a specialist for further assessment as she suspected he was suffering from the onset of dementia. Mrs C remained concerned about Mr A's health and contacted NHS 24. Mr A was subsequently taken to hospital by ambulance and further tests identified that he had suffered a stroke.

As part of our investigation we obtained independent advice from a medical adviser. We concluded that the initial phone consultation carried out by the GP was insufficient. We found that the GP, who was in fact a doctor in training, should have organised a home visit when Mrs C first reported her father's symptoms so that he could be fully assessed and his future management discussed with Mrs C.

Recommendations

We recommended that the practice:

• apologise for the failings identified;
• carry out a significant event analysis of Mr A's case; and
• draw our findings to the attention of the GP in training.

Summary

Mr C's mother (Mrs A), who suffered from Parkinson's disease, was admitted to hospital where she stayed for almost three months. After three weeks, she was transferred to a long-term ward before being discharged to a care home. Mr C said he was told that Mrs A was being transferred due to pressure on beds and would now be under the care of another consultant. He believed, however, that the consultant did not see Mrs A at all during her five week stay in that ward. He also believed that staff failed to ensure that Mrs A took her medication. Mr C also noted there was no walking frame in the ward and was told there was no rehabilitation or occupational therapy there. He had noticed that Mrs A's left hand had become rigid, and believed this was down to a lack of mobility opportunities and failure to provide medication. He also complained about one of the doctors, and that when his mother was discharged she had an injury about which he believed staff had lied to him.

As part of our investigation we took independent advice from two advisers - one specialising in nursing and one in medical care of the elderly. We upheld both of Mr C's complaints. In relation to the overall medical management of Mrs A's Parkinson's disease, the advice we accepted was that in the main the care and treatment provided to Mrs A was reasonable. However, the medical adviser said that there was no evidence that the consultant reviewed Mrs A, and we can only reach a judgement based on the evidence available to us. In this case the evidence indicates that the consultant did not see and review Mrs A as they should have done. Referring to the nursing care provided, the advice we accepted was that while aspects of this were reasonable, there were failures relating to prescribed medication. Although there was no evidence that missing the medication had caused Mrs A harm, we considered that the failure to record why it was not dispensed or to note other actions (such as informing medical staff) was significant.

Recommendations

We recommended that the board:

• bring our medical adviser's comments about the doctor to their attention and ensure that the doctor reviews the clinical care of their patients as per their duty of care towards them and fully records this;
• bring the failures in record-keeping in relation to prescribed medication to the attention of relevant staff;
• amend their policy to outline procedures to be followed when prescribed medicines are not dispensed; and
• apologise to Mr C for the failures identified.

Summary

Mr C's son (Mr A) attended a hospital accident and emergency department (A&E) complaining of left-hand rib pain, and pain in his elbows, right hip and shoulder, left wrist and lower back. An A&E junior doctor arranged for him to have a chest x-ray and reported that there was evidence of a lytic lesion (an area of bone damage, which can be caused by cancer) on one of Mr A's ribs. The doctor made an urgent referral for Mr A to be seen at the chest clinic. The x-ray was later reviewed and formally reported by a senior trainee radiologist. They did not identify a lytic lesion and did not mention it on the formal x-ray report. Based on the x-ray report, the consultant respiratory surgeon at the chest clinic contacted Mr A's GP and advised that there was nothing to be concerned about. He arranged for repeat x-rays in six weeks and did not see Mr A in his clinic. Mr A's condition deteriorated and he was ultimately diagnosed with advanced cancer, probably gastric in origin, which had spread to his bones. Mr C complained that radiology staff provided conflicting interpretations of the x-rays, causing a delay to Mr A's diagnosis.

After taking independent advice from two medical advisers, our investigation found that the lesion was present on the original x-ray but was not reported by the senior trainee radiologist. We acknowledged that the lesion was not clear and that it was not necessarily unreasonable that the radiologist did not identify it at that time. However, clearer abnormalities were missed by radiology staff on further x-rays taken the following month. We were also concerned that the consultant made a definitive decision about Mr A's condition based only on the x-ray report, when there was evidence that he had seen the A&E doctor's conclusions and had possibly reviewed the x-ray films himself. We considered that, based on the information available to him, the consultant should have seen Mr A in his clinic. We found that Mr A's diagnosis was delayed as a result of this. Although we recognised that this would not have affected his prognosis, he could have entered palliative care sooner and his pain could have been managed more effectively.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failings that led to the delay to diagnosing Mr A's cancer;
• ask their radiology and respiratory staff to reflect on this case with a view to identifying points of learning for the future; and
• conduct a serious incident review of Mr A's case.

Summary

Mr C's son (Mr A) attended his then medical practice in June 2011 complaining of left hand rib pain and pain in his elbows, right hip and shoulder, left wrist and lower back. He was examined by the GP, blood tests were taken and he was prescribed pain medication. Mr A's pain worsened and he had a further phone consultation with his GP. Advice was given, and Mr A was encouraged to join a different practice closer to home, as he no longer lived in his current GP's area.

Mr A transferred to a new medical practice. Before his first consultation there, Mr A's pain worsened again and he attended a hospital accident and emergency department (A&E) where x-rays were taken, showing evidence of possible cancer. He was referred to the hospital chest clinic, but the chest physician reviewed the information and decided that he did not need to see Mr A. When Mr A attended his first consultation at the new medical practice, his health records had not yet arrived from the previous practice. Because of the time it took to add Mr A's information to the computer system, important results from A&E were not available at his next appointment. Before Mr A had his second consultation at the practice, the chest physician from the hospital contacted them and advised that Mr A had nothing to be concerned about. Mr A was treated with pain killers on the understanding that he had a cracked rib.

Mr C complained that the new practice did not ensure they had all of Mr A's records and test results to hand when examining him, and that the GPs who examined him did not conduct thorough examinations, preferring to prescribe stronger pain medication to alleviate his symptoms. Having taken independent advice from one of our medical advisers, our investigation found that the initial lack of records during the first consultation was outwith the practice's control. The call from the chest physician then reassured them that there was nothing sinister in Mr A's chest x-ray. We considered that, once the records arrived, they could have been made available to the GPs before they were added to the computer system. Given, however, the advice provided by the chest physician, we took the view that it was very unlikely that the treatment offered to Mr A would have been any different had his x-ray results and other records been available. We noted that the practice have since changed their procedures to ensure that GPs are made aware of any patient information that has not yet been added to the computer system.

Summary

Mr C, who is a prisoner, was told by a prison officer that he was to attend an appointment at the prison health centre. The doctor wanted to review Mr C's 'medically unfit' status. Mr C said that he was not well enough to go to the appointment and asked the prison officer to tell the health centre. After this, Mr C complained that he had to pass information about his health to the prison officer, which he felt was inappropriate.

During our investigation, the health board explained to us that prison staff are responsible for the movement of prisoners around the different areas of the prison. That includes taking prisoners to the health centre for appointments. In addition, the board confirmed that prisoners are required to let prison staff know when they feel unwell. They advised that prisoners do not need to explain to staff why they are unwell.

In light of the information provided, we were satisfied that what happened in Mr C's case was appropriate and we did not uphold his complaint.

Summary

Mr C, who is a prisoner, complained that the board had refused his requests to see the prison doctor. Mr C had attended the prison's health centre regularly with approximately two to three consultations every month over a six-year period. He made several requests to see a doctor in 2012. However, he received reply slips either asking for more information or advising that his current medication was sufficient and that a consultation with the doctor was not required. Mr C said that because of this his condition had gone undiagnosed and was effectively untreated.

In their response to our enquiries, the board said that requests to see the doctor are through a nurse referral. They said that in Mr C's case, his requests and care were discussed with the doctor. The doctor decided that he did not need to see Mr C and asked that advice was given to him instead.

Our investigation found no evidence in the medical records that Mr C's condition had gone undiagnosed or that the treatment provided to him was inappropriate. However, we noted that although Mr C was eventually given an appointment with a doctor, this was nearly five months after he first asked for one. We found it is reasonable for a nurse to triage (assess) the need for an appointment with the doctor. However, if a patient insists on seeing the doctor and considers that there has been a change in their condition or requirements, it would not be reasonable to repeatedly block access. We took the view that it would be more productive for the doctor to discuss with the patient the most appropriate way to access health care services in the future; why they had been triaged; how the triage system works; and why the doctor was satisfied that the current arrangements were appropriate. We considered that when Mr C continued to request an appointment with the doctor, he should have been given this earlier so that such a discussion could take place.

Recommendations

We recommended that the board:

• make health centre staff aware of our findings on this matter.

Summary

Mrs C's late father (Mr A) was admitted to hospital in late 2011 with recurrent abscesses. In October 2011, he was transferred to another hospital for audiology (hearing) tests. He was transferred without an escort and wearing only pyjamas and a cardigan. Mr A was doubly incontinent during the journey and also suffered a fall.

In November 2011, Mr A was referred to a specialist colorectal (bowel) surgeon and a loop colostomy (a procedure whereby the loop of the bowel is pulled through the thickness of the abdomen wall) was planned. Mr A had bowel surgery several days later. During the operation, Mr A’s bowel suffered a trauma, which the board said the surgical team did not know about at the time. He returned to the ward with a temperature which was treated by antibiotics (drugs to treat bacterial infection). His condition deteriorated and he started to show signs of sepsis (blood infection). Further investigations (chest x-ray, ECG, blood tests and blood cultures) were carried out and he was prescribed a strong antibiotic intravenously. Just over an hour later, staff noted that Mr A might be showing signs of sepsis, and an abdominal examination showed tenderness. An anaesthetic review noted that surgical emphysema (formation of bubbles of air in the soft tissues) was present. He was taken back to the operating theatre, where the surgeon discovered that Mr A’s bowel had been perforated and this had caused peritonitis (inflammation of the tissue lining the abdomen). Mr A needed further operations, and was transferred to intensive care, but his condition deteriorated and he passed away several weeks later. The cause of his death was recorded as acute peritonitis and perforation of colon (bowel) during colostomy operation.

Mrs C complained about Mr A’s care and treatment at the hospital including aspects of his transfer to the other hospital. In particular, she complained about the surgeon's failure to detect that Mr A’s bowel had perforated during the original operation and that the post-operative complications were not recognised and treated within a reasonable time. Mrs C also complained that the board failed to handle her complaint within a reasonable time and failed to respond to her questions reasonably. After taking independent advice from two of our advisers - a surgeon and a nurse, we upheld two of Mrs C's complaints. Our investigation found that the board failed to provide adequate nursing care for Mr A during his transfer and that he should have had an escort and a blanket or outdoor clothes on. We also found that there was a significant delay of five months by the board in responding fully to Mrs C's complaints. As, however, the board had taken steps to address most of the shortcomings identified in these complaints we made only one recommendation. We did not uphold Mrs C's complaint about the operation and after-care, as we found no evidence that the surgical team failed to perform the operation in a reasonable way and we were satisfied that the post-operative complications were identified and dealt with appropriately within a reasonable time.

Recommendations

We recommended that the board:

• bring the shortcomings in record-keeping to the attention of staff concerned.

Summary

Mr C complained that his medication for anxiety had been stopped as it was no longer on the list of approved medication compiled by the Scottish Medicines Consortium. He said that when he went to his medical practice for assistance, a GP told him to return home and arranged for an ambulance to call at Mr C's home and take him to hospital for an assessment by mental health services. Mr C said that he did not receive appropriate and timely medical treatment, and believed that he should have been allowed to wait at the practice for the ambulance. He was also concerned at the time it took to arrive.

We took independent advice about this complaint from a medical adviser, who is a GP. The adviser said that it was appropriate for the GP to have arranged for the mental health assessment and that the assessment result confirmed there was no clinical need for an urgent referral to hospital by emergency ambulance. We did not uphold the complaint as there was no evidence that the GP acted incorrectly.