Health

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.

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.