Health

Summary

Mr and Mrs C were unhappy with the advice and information that they received from their medical practice. These included that the practice unreasonably gave Mrs C the impression she had breast cancer; failed to advise Mr C to return if his skin condition changed; handled their request for a home visit for their son inappropriately; and failed to communicate their son’s death appropriately within the practice.

In our investigation, we reviewed the correspondence that Mr and Mrs C provided and the practice’s complaint file. We also obtained independent advice on the appropriate medical records from one of our medical advisers (who is a GP).

In terms of the first two complaints, the adviser said that, where a GP suspects cancer, they should generally frame matters in such a way as to minimise alarm. The adviser noted that Mr C’s notes stated ‘and review’ (indicating that the GP intended Mr C to return). On the third complaint, the adviser noted that Mr and Mrs C’s son had a mental health condition, and that the practice made a distinction between physical and mental conditions for house calls. However, this was not considered unreasonable. Finally, the adviser indicated that a medical practice would not generally know that a patient had died until they were told by another source. Depending on the circumstances, this could involve a hospital, the Procurator Fiscal or the police. The adviser said that from the notes, it did not look as though the practice had been told that Mr and Mrs C's son had died.

While we recognised how significant these complaints were for Mr and Mrs C – they had been patients of their practice for over 30 years and had also recently lost their son - the privacy of medical consultations limited the evidence available. In the evidence that we did see, in combination with the advice we received, we found nothing to indicate that the practice had acted unreasonably.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment that Mrs A’s husband (Mr A) received from the medical practice. Ms C said the practice failed to take appropriate steps to lead to an earlier diagnosis of Mr A’s cancer and assured the couple that Mr A's 'bloods' had been checked when they had not. She also said that one GP unreasonably failed to follow up on blood tests and a second GP failed to deal with Mrs A in an appropriate manner when she went to the practice for support.

We took independent advice from one of our medical advisers on this case. Our adviser said that the practice had tried to care for Mr A in this very difficult situation. He said that the care and treatment they provided was appropriate and there was no evidence to suggest that they should have referred Mr A to hospital earlier or made a diagnosis of cancer themselves. The adviser said the evidence in the records did not suggest that the practice failed to take appropriate steps to lead to an earlier diagnosis.

We upheld the complaint about the assurance given to Mrs A about 'bloods'. We found that both parties agreed that the first GP at the practice indicated that she had ‘checked Mr A’s bloods'. However, we took the view that when the GP spoke to Mrs A, a layperson, it was reasonable for Mrs A to interpret this as meaning that the GP had checked Mr A’s blood test results and not simply that she had taken blood samples for testing, which is what the GP suggested she meant. Given the language used, we considered that, on balance, the centre did tell Mrs A that Mr A’s bloods had been checked when they had not.

On the matter of follow-up, the first GP had said that she went online to see where Mr A’s blood test results were. She found that the results were not there and Mr A had been admitted to hospital. Our adviser indicated that this seemed reasonable, as from the point at which the first GP discovered that Mr A was in hospital, there would no longer have been any need for her to follow up on blood test results. We accepted the adviser’s views and did not find that the practice unreasonably failed to follow up the blood tests.

On Mrs A’s appointment with the second GP, the notes the GP made at the time did not contain any information that supported Mrs A’s account of what had happened, and we could not uphold this complaint. It was Mrs A’s word against the GP’s and there were no independent witnesses or other means for us to verify whose version of events was correct.

Recommendations

We recommended that the practice:

• provide Mrs A with a written apology for not explaining clearly what had happened to Mr A's blood samples;
• feed back our views on the communication and record-keeping to the staff involved in this case;
• take steps to ensure that in future, clear language is used when communicating with patients and summaries of phone calls are recorded in patients’ medical records;
• feed back our adviser’s comments on significant event analysis/audit to the staff involved in this case; and
• amend their procedures to include a requirement for significant event analysis/audit in future instances of this type.

Summary

Mr C complained that when he made a request to the practice for a copy of his late mother's GP clinical records he was not provided with a full copy of her records for the previous ten years. He also had concerns that since 2005 his mother had visited the practice with recurrent ear infections, but it was not until late 2010 that she was referred to an ear nose and throat consultant, who diagnosed a tumour in her ear.

We did not uphold Mr C's complaints. Our investigation found that the practice had provided a full copy of his late mother's records and had explained that they initially kept paper records before moving to electronic records. We also found that although Mr C's mother had reported ear infections intermittently since 2005, these had cleared with treatment. By 2010 the ear problem with which she presented to the practice was different.

Summary

Mr C complained about the care and treatment that his brother (Mr A) received from the board in the month before his death. Mr A was admitted to hospital suffering from pains in his chest, upper abdomen and down his right arm, and an initial diagnosis of heart attack was made. While Mr A was in hospital it also became apparent that he had a pneumonic chest infection (lung infection). This became the leading diagnosis, with an underlying diagnosis of heart disease, with evidence that Mr C had suffered a previous heart attack. Treatment was based on this assessment, and once Mr A was considered to be well enough, he was discharged. He was not referred for an angiogram (an image of the blood flow through the heart) while in hospital, and Mr C complained specifically about this. Mr A was referred for a follow-up echo-cardiogram test (ECG - a test to measure heart activity) and was given medication to reduce the risk and possible complications of a further heart attack, but he died five days after being discharged.

Shortly after Mr A died, Mr C complained to the hospital about his brother's care and treatment. He waited over two months for the board's response, and when he received it, Mr C was still unhappy about their decision. The board commissioned an independent review of the case, to determine whether there was any fault that they had not identified in Mr A's care and treatment. The report did not identify any failings, and was followed up by a further, final response from the board to Mr C. Mr C then complained to us about his brother's care and treatment and about the way the board handled his complaint.

We obtained independent advice on this complaint from a medical adviser. Their advice indicated that Mr A's symptoms were hard to diagnose, particularly at the early stages, as his symptoms were not typical and related to the interaction of two conditions - chest infection and heart disease. However, the adviser said that Mr A's treatment was reasonable and in line with the Scottish Intercollegiate Guidelines Network (SIGN) guidelines on acute coronary syndromes. In particular, the advice indicated that it was appropriate to delay the angiogram until after discharge, once the chest infection had resolved.

In relation to the handling of Mr C’s complaint, we found that the board had failed to provide a timely response. As the board had already acknowledged this failing, taken action and apologised, we did not make a recommendation.

Summary

Mr C had a history of abdominal pain, diarrhoea and constipation. He was referred to hospital and was seen by two gastroenterologists (clinicians specialising in the treatment of conditions affecting the liver, intestine and pancreas) at various out-patient appointments. He was diagnosed as having irritable bowel syndrome (IBS) and bile salt diarrhoea. Mr C complained about the board's investigation of his symptoms, suggesting that the two gastroenterologists gave conflicting opinions as to their cause. However, he was also specifically concerned about a hospital admission when he said he was left for several days without being seen by a gastroenterologist. Once the gastroenterologist attended, he was dissatisfied with the extent of their examination and their findings.

Our investigation included taking independent advice from a medical adviser. We did not find any evidence to suggest that Mr C had been misdiagnosed or that the two gastroenterologists reached conflicting views about his treatment, and we were generally satisfied that the overall treatment of Mr C's condition was reasonable. However, we found that Mr C was not seen by a gastroenterologist for eight days during the hospital admission. There was clear evidence that staff on the ward identified a need for him to be seen by a gastroenterologist at an early stage in his admission. However, despite reassurances that someone from gastroenterology would attend, this did not happen. There was insufficient evidence to say whether this was because the ward staff failed to contact gastroenterology as planned, or because gastroenterology failed to act on requests from the ward. The end result, however, was that Mr C's treatment fell below an acceptable standard. We accepted advice that this would not have had a significant long term impact on his physical condition, but we noted that IBS has a recognised psychological component, and symptoms can be made worse by stress and anxiety. We considered that the delay in being seen by a gastroenterologist would not have helped Mr C's recovery.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in him being seen by a gastroenterologist during his hospital admission; and
• draw our findings to the attention of the staff involved with a view to identifying any improvements that can be made to communication between the wards and the gastroenterology unit.

Summary

Miss C was diagnosed with chronic kidney disease (CKD) in 2007. She complained that a GP at her medical practice incorrectly advised her to stop taking high blood pressure medication after she reported experiencing side effects. The GP had prescribed the medication for Miss C in 2008 because her blood pressure was elevated and this could have affected her kidney function. Miss C also complained that her kidney function continued to decrease but nothing was done to address this. In addition, she was unhappy that the GP did not properly investigate pain she had reported having in her side.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our investigation found no evidence that the GP had advised Miss C to discontinue the blood pressure medication. We considered that this was unlikely to have affected the progression of her CKD because she was managed in accordance with the national guidelines for the condition. Had Miss C been diagnosed with high blood pressure and had a significant amount of protein in her urine then it would have been appropriate for her to have remained on the medication. We also considered that there was no indication that the GP needed to make an urgent referral in relation to the backache Miss A had reported and that appropriate pain relief and a referral to physiotherapy was made.

Summary

Mrs C's mother-in-law (Mrs A), who lives overseas, was visiting her family when she became unwell with stomach pain and anaemia. The family GP referred her to hospital, where she was treated for severe liver disease complicated by fluid retention (an excessive build up of water in the body) for about five weeks. She was then discharged, with the intention that she should come back later for further treatment. However, when she was seen as an out-patient a few weeks later, she was urgently readmitted because of fluid retention. Mrs C complained about Mrs A's care and treatment. She said that Mrs A's experience in hospital was unpleasant; that because an interpreter was not provided, a family member had to stay with her; and that the family were asked to pay a large bill for Mrs A's treatment. She also complained that the board did not respond reasonably to her complaints.

We took independent advice from three of our medical advisers. After considering the advice, we upheld both of Mrs C's complaints. The hospital investigations had showed that Mrs A had cirrhosis of the liver (scarring of the liver as a result of continuous, long-term damage), with complications of fluid retention, and indicated that this was because of infection with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood). The advisers agreed that there was no evidence of inadequate care by nursing staff or clinicians, nor did they consider that there was an unreasonable delay in providing a bed for her, which was one of Mrs C's concerns. Similarly, there was no evidence of unreasonable communication by nursing staff and clinicians with Mrs C and her family about Mrs A's care and treatment. We noted, however, that it was not confirmed to anyone that Mrs A was suffering from hepatitis C, and that there was no evidence in the records that Mrs A or her family received appropriate counselling about the implications of this. In addition, the board’s policy clearly says that interpretation services should be offered. If these were declined, then the board should have considered an appropriate way of obtaining Mrs A's consent to using family members to translate, and this did not appear to happen. We were critical of the board about these points and, although we recognised that a number of aspects of Mrs A's care and treatment were reasonable, on balance we upheld Mrs C's complaint.

In terms of the board's response, we noted that Mrs C felt that the family should not have to pay for Mrs A's treatment, and that this was still in dispute when we investigated the complaint. We found that the Scottish Governmentprovide guidance in their document of April 2010 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services'. This specifically excludes viral hepatitis from the services and treatment that attract a charge. We also noted that the board's complaints response was relatively brief and did not provide a full summary of Mrs A’s medical problems. Had it done so, and in particular had it mentioned that she had hepatitis C, the board could then have considered the financial implication of the diagnosis under the guidance. Although, therefore, we would not normally become involved in the issue of such charges, we considered this to be relevant in this case and upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• take steps to offer the appropriate counselling to Mrs C's family (including Mrs A);
• ensure that all patients (and, where appropriate, family members) receive counselling in respect of the implications of chronic hepatitis C infection and that these discussions are recorded in the clinical record;
• advise the Ombudsman of the counselling arrangements that are in place for patients diagnosed with hepatitis;
• ensure staff are aware of and follow their policy on communication and support for patients where English is not their first or preferred language;
• ensure that full and appropriate clinical information is included in complaints response letters;
• review this case for payment in view of the guidance 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services' (April 2010) and advise Mrs C and the Ombudsman of the outcome; and
• apologise to Mrs C and Mrs A for the upset this matter has caused.

Summary

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke.

We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s complaint.

We did not uphold Mr C's third complaint as our investigation did not find evidence that doctors had ignored reported symptoms of slurred speech. The notes provided clearly detailed the symptoms and signs that Mrs C had when she was assessed at the hospital.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified in Mrs C's care;
• review the processes governing referral to the on-call neurology team when a patient presents with symptoms consistent with hemiplegic migraine, to ensure an appropriate management plan is agreed and documented, with reference to the SIGN guidance; and
• provide evidence that they have reviewed the procedures within the accident and emergency department for the identification of stroke and the appropriate point for involving a stroke physician in light of the failings identified in this complaint.
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Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.

Summary

Mrs C's daughter (Miss A) fractured her forearm and received treatment under anaesthetic at the hospital to manipulate the bone back into position. A cast was placed on Miss A's arm and she was reviewed on four occasions by a consultant surgeon. As Mrs C had concerns about the treatment the consultant provided, Miss A was referred to a second consultant. Miss A then had further surgery as the forearm fracture had become displaced. Mrs C complained that the first consultant had not taken corrective action when he became aware that the fracture had moved. She was unhappy because her daughter sustained permanent scarring and may not regain the full movement of her arm.

Our investigation found that Miss A had corrective surgery five months after her injury. After taking independent advice from one of our medical advisers, we considered that the treatment provided by the first consultant was reasonable. We also found that there was a possibility that corrective surgery was carried out too early because the bone might have corrected itself over the course of six to eighteen months. Our adviser said that fractures in children heal very fast, and as a child grows there is great remodeling capacity as long as there is about 18 months growth left. Miss A was eight years old at the time of her injury. We did not uphold Mrs C's complaint, as we concluded that there was no unreasonable delay in Miss A's treatment.