Health

Summary

Ms A was removed from the practice's treatment list. She believed this was inappropriate, and complained to the practice. She remained dissatisfied when she received their response and her partner (Mr C) complained to us on her behalf.

When we investigated, we found that the practice had not met the requirements of the relevant regulations for the removal of a patient from a treatment list. We upheld Mr C's complaint that Ms A's removal from the practice list had been inappropriate, and made recommendations to address this.

Recommendations

We recommended that the practice:

• apologise directly to Ms A that she was inappropriately removed from their treatment list; and
• review their procedures on the removal of patients from their treatment list to ensure that they comply with the relevant regulations, guidelines and guidance.

Summary

Mrs C complained that the care and treatment provided to her sister (Ms A) was unreasonable. Ms A had a history of chronic obstructive pulmonary disease (a long-term lung condition), osteoporosis (thinning of the bones) and heart problems. A GP from the medical practice visited and, after examining her, prescribed antibiotics and steroids (drugs commonly used to fight infections) in tablet form. Ms A had trouble taking these as she was normally unable to swallow tablets and usually had medication in liquid or powder form. Her condition did not improve.

A second GP visited the next day and again examined Ms A but was unable to take her temperature as his thermometer was broken. The GP prescribed a different antibiotic, again in tablet form. Neither GP considered that Ms A's condition warranted emergency admission to hospital and the second GP said that Ms A had specifically told him that she did not want to go to hospital. Ms A's condition continued to deteriorate and Mrs C called NHS 24 (a national advice helpline) later that evening. Ms A was taken by ambulance to hospital where she was found to be suffering from sepsis (serious infection) and hypothermia (where the body temperature falls below the normal range). She was admitted, but died shortly afterwards.

We did not uphold any of Mrs C's complaints. Our investigation, which included taking independent advice from a medical adviser, concluded that the examinations and management plan for Ms A had been reasonable. In particular, the adviser said that in light of Ms A's reluctance to go to hospital it was appropriate to take her views into consideration and to manage her condition at home. The family disputed that Ms A did not want to go to hospital, but the records showed that the ambulance paramedics had recorded her reluctance to go there. The practice acknowledged that Ms A had medication in liquid form, but there was nothing specific in her notes to highlight that she had difficulty in swallowing tablets. In any event, the second GP did not have access to the notes on his visit as he had been passed the call while out of the practice doing other home visits. There was also no clear evidence that Ms A or the family specifically told either GP that Ms A could not swallow tablets.

Summary

Mrs A was an 87-year-old nursing home resident. She had Alzheimer's disease and a history of breast cancer and heart disease.

Mrs A was admitted to hospital after being found in the early hours of the morning on her bedroom floor after a fall. She was found to have fractured her hip. She had surgery in hospital the next day, and was discharged back to the nursing home two days later. Mrs A fell again in hospital on the morning of her discharge, but was medically assessed as uninjured.

Mrs A's daughter (Mrs C) believed that, despite providing one-to-one nursing to the best of their ability, staff at the nursing home struggled to manage her mother's care after her discharge because of her medical condition, impaired mobility and deteriorating cognitive function (the ability to think, concentrate, formulate ideas, reason and remember).

Mrs A fell again, from a chair, six days after being discharged from hospital. She had fractured her arm and was readmitted to hospital. Several days later, she was transferred to another hospital for palliative care (care to prevent or relieve suffering) and died shortly after.

Mrs C said that hospital staff failed to assess her mother's cognitive impairment and individualise her care and treatment, particularly in relation to falls prevention.

Mrs C held welfare power of attorney for her mother and believed that staff failed to communicate with her as they should have, about Mrs A's discharge. As a result of this, Mrs C said that Mrs A was improperly discharged and the board failed to ensure that adequate arrangements for later support were in place. Mrs C also said that they failed to implement an effective falls care plan for her mother, and failed to fully take into account her high falls risk on discharge. As a result, Mrs C believed that Mrs A's fall from the chair, which caused her severe suffering and proved fatal, was avoidable. Finally, Mrs C believed that the board misrepresented the findings of a visit by the Healthcare Inspectorate, a regulatory body. In responding to her complaint, the board said that it was found that ‘a high standard of care was being delivered to elderly patients with cognitive impairment’.

After taking independent advice from a medical adviser, who specialises in mental health issues, we upheld all of Mrs C's complaints. We found that the board's communication with Mrs A's family was unreasonable both in relation to the Adults with Incapacity (Scotland) Act 2000 and to discharge. We considered that a lack of meaningful consultation with Mrs C and the nursing home led to a significant personal injustice to Mrs A, as her discharge was ineffectively planned and coordinated and failed to ensure that her needs were met. We were also extremely concerned about the overall failures in communication, given the importance of meeting the needs of patients with dementia in every aspect of care, treatment and clinical management.

We found that the board failed to comply with their falls prevention policy in a number of important respects. This was unacceptable. The risks of falling cannot be completely eliminated, but can be minimised by careful assessment and clinical management. Some measures were implemented for Mrs A, but additional measures should have been taken to further reduce the risks, given the potentially significant and severe consequences of a fall injury to an elderly person with dementia.

We found that there were a number of significant failures by the board in addressing Mrs A's mental health care needs. We were particularly concerned that Mrs A’s cognitive function was not formally tested during her stay in hospital. Finally, we drew to the board’s attention our finding that the Healthcare Inspectorate report had in fact highlighted the need for improvements in the areas of assessment and care-planning.

Recommendations

We recommended that the board:

• audit staff awareness of the board's policy on falls prevention and the knowledge and skills of staff relevant to its effective implementation, and take action to address any knowledge and skill gaps identified by the audit;
• review the fractured neck of femur care pathway to ensure it meets the needs of patients with dementia, in particular around assessment of cognitive functioning, pain assessment and communication under the Adults with Incapacity Act; and
• inform the Ombudsman of progress in implementing the action plan arising from the Healthcare Inspectorate report and how related clinical practice will be monitored and assessed.

Summary

Ms C's daughter (Miss A) was diagnosed with throat cancer and was admitted to hospital for chemotherapy and radiotherapy. She was found to have chest and urinary infections, so her chemotherapy and radiotherapy were postponed until these were treated. When her condition improved, Miss A received chemotherapy. After a second course of chemotherapy, she became neutropenic (the blood cells that fight infection had reduced) and was taken to another hospital, where she died.

Ms C complained that her daughter's condition was not properly monitored. In particular, she noted that blood tests were not taken daily, as had happened with another family member with cancer. Ms C felt that, had Miss A's blood results been closely monitored, she could have been treated and her prognosis might have been better. Ms C also complained about staff communication with the family. She was told after Miss A's death that the tumour was one of the largest the consultant had seen. She said that had she known this earlier, she might have decided to keep Miss A at home during her final days.

We took independent advice from one of our medical advisers, who confirmed that blood tests are not carried out daily following chemotherapy. This is because it will already be known that the treatment makes the patient neutropenic. Neutropenia is only an issue if the patient develops sepsis (a severe blood or tissue infection), and this is not diagnosed through blood tests, but from the patient's physical symptoms. If there is evidence of sepsis, then blood tests would be carried out. We found that Miss A’s treatment and monitoring was in line with the board's protocol for treating patients with head and neck cancers.

The evidence also suggested that communication with the family was good, although we were unable to establish whether specific information was provided about the size of the tumour. It was, however, clear from the records that both Miss A and her sister were told the tumour was extensive; and that Miss A continued with hospital treatment in full knowledge of this.

Summary

Mrs C complained that when she was admitted to hospital with a broken ankle, staff administered an unreasonable level of morphine, resulting in a severe reaction. She also complained that when she raised her concerns about this with the board, they failed to provide her with a sufficiently detailed response, and failed to respond within a reasonable timescale.

We investigated Mrs C's concerns, and sought independent advice from one of our medical advisers. Our adviser noted that Mrs C was given a fairly high dose of morphine, both orally and by injection, and suffered a subsequent reaction (opiate toxicity). However, we did not uphold this complaint as the adviser said that the levels prescribed were not unreasonable, given Mrs C's condition and the fact that she was about to undergo a plaster replacement on her ankle which would have resulted in an increase in pain.

We also reviewed the board's complaints correspondence and were satisfied that they provided a reasonable response to Mrs C's concerns. However, to the extent that there was at one stage a delay in responding to Mrs C's correspondence, we upheld this complaint, although we did not find it necessary to make any recommendation.

Summary

Mr C complained that the board unreasonably delayed in diagnosing that his late wife (Mrs C) had mesenteric ischemia (reduced blood flow to the intestines). He also complained that they delayed in operating on Mrs C following her diagnosis and that this caused her death.

We took independent advice from one of our medical advisers, who explained that mesenteric ischemia is a very difficult condition to diagnose. It is usually diagnosed by excluding other causes and this can take some time. We were satisfied that the board carried out appropriate assessment and investigations to exclude other causes to diagnose Mrs C's condition. However, we found that the diagnosis of mesenteric ischemia should have been considered sooner in view of the fact that Mrs C was known to have vascular disease.

The board decided that operating on Mrs C would be very high-risk, and referred her to another board for advice. Although we found that this was in itself reasonable, there were delays in obtaining the advice. It was then decided that Mrs C required a major surgical operation, which would carry some significant risks to her health. The surgeon who had been managing Mrs C's care was due to leave the board at that time. He referred Mrs C to another board and asked that they take over her management. Again, given the circumstances, we found that this was reasonable. However, we found that the referral should have been more urgent and the board should have pursued this when no response was received from the other board.

Mrs C's condition deteriorated further before she was seen by the other board. She underwent an emergency surgical procedure and was admitted to intensive care. A second procedure was carried out to review her bowel. It was decided that the surgical options were limited, and the surgeon could not carry out a bowel resection (partial surgical removal). Mrs C subsequently passed away.

Our adviser said that Mrs C was a high-risk candidate for surgery and it was likely that this would have been unsuccessful. It could also have led to other parts of her system being compromised, even if it had been undertaken at an earlier opportunity. It would have been inappropriate to carry out surgery without obtaining advice from the other board. Although we upheld Mr C's complaints, as we found that there had been delays by the board, both before and after Mrs C was diagnosed with mesenteric ischemia, our adviser said that the outcome was unlikely to have been different if these delays had not occurred.

Recommendations

We recommended that the board:

• make the clinical staff involved in Mrs C's treatment aware of our finding on this matter; and
• review the management of Mrs C's case and consider how they can ensure continuity of care when a patient is referred to another board for treatment.

Summary

Mr C was under the care of a specialist pain physiotherapist in the board's pain clinic service. He was also referred to, and awaiting treatment from, a specialist pain psychologist there. However, the physiotherapist left her post and later, after two periods of sickness absence, the psychologist did likewise. Mr C complained about the delay in filling these posts and the resultant gap in service provision. During our investigation, we took independent advice from one of our medical advisers, who said that the board took reasonable steps to explain the position to Mr C, to make alternative treatment options available to him, and continue to provide a service in the face of challenging circumstances. We also saw evidence that Mr C had not always fully engaged with his treatment plan, and in the circumstances we did not uphold the complaint. However, although we acknowledged the difficulties the board faced in filling these specialist positions, we considered that they could have acted more promptly in advertising the physiotherapist post.

Mr C also complained about the way in which the board handled his complaint. In particular, he was unhappy that he was told that the psychologist would be returning to work, only to later find that she had resigned. We found that the information shared with Mr C was accurate when it was provided and we did not consider that the board could reasonably have foreseen that the post would later be vacated. We saw no evidence of a deliberate attempt to mislead Mr C, as he alleged. Mr C also complained that the board failed to respond to an email he sent them and to address all the complaint points he raised. The board accepted that an administrative error had led to a response not being sent and apologised for this. We also noted that the board had agreed four points of complaint for investigation with Mr C, but did not appear to have responded to all of them so, in the circumstances, we upheld Mr C's complaint about their complaints handling.

Recommendations

We recommended that the board:

• highlight to relevant staff the importance of timely recruitment to specialist posts in order to minimise disruption to patients’ therapeutic programmes; and
• remind complaints handling staff to ensure they respond to all complaint points that have been agreed with the complainant.

Summary

Mrs C complained about the care and treatment provided to her brother (Mr A) while he was both an out-patient and an in-patient in hospital. Mrs C also complained about the arrangements for discharging her brother from hospital, and of a lack of communication and/or consultation with Mr A's family.

Mr A had severe learning difficulties, significant health problems, and had developed dementia, but lived in his own home with the assistance of carers. In early 2011 he developed a number of further health problems and was admitted to hospital. After Mr A had been in hospital for some time, Mrs C was told that he was dying and it was recommended that he be transferred to another hospital for end of life care. Mr A's family took steps to surrender the tenancy of his home and to dispose of some of his belongings. However, Mr A's condition improved and about three months later he was deemed fit enough to be discharged. Mrs C complained that because of what she had been told earlier, Mr A was now homeless and had to be discharged to a nursing home. Mr A became unwell again two months later and was readmitted to hospital. He was discharged again but died a few hours later at his nursing home. Mrs C was particularly concerned that, during his transfer to the nursing home on a very cold and snowy day, Mr A was not dressed in the warm clothing she had ensured was available.

Our investigation, which included taking independent advice from two of our medical advisers, found that the care and treatment provided to Mr A had been reasonable overall. There was no evidence to suggest that he had not been adequately assessed or that his nutrition was inadequate, as Mrs C had feared. However, the advisers raised some concerns over a lack of clarity on issues of Mr A's lack of capacity; the waiting times for out-patient investigations; and information for relatives on NHS continuing care provision. Although we did not uphold Mrs C's complaint, we made recommendations to address these points.

Recommendations

We recommended that the board:

• consider implementing guidelines or targets on timescales for the provision of out-patient investigations such as echocardiograph;
• consider reviewing relevant patient documentation to clarify, where a patient lacks capacity, whether a legally appointed Attorney or Guardian is in place; and
• consider reviewing their policy on informing relatives in relevant situations about the option of NHS continuing care, the assessment process and the appeal process.

Summary

Mr C went to the practice because he had lower back and left leg pain, together with numbness. After his second visit, he was referred for physiotherapy, and then to hospital for a consultant opinion and an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone). The hospital, however, returned the referral to the practice on the basis that there were no 'red flag' symptoms (symptoms indicating a possible serious condition).

Three days after being referred, Mr C went to a hospital accident and emergency department with increasing pain and numbness. He was ultimately given a scan that confirmed a central prolapsed disc (where the centre of a disc in the spine pushes out into the spinal column) which required emergency surgery. Mr C questioned the treatment he had been given by the practice, as he believed they should have done more. He claimed that as a consequence, his outcome was poorer than it would have been.

To investigate this complaint we considered all the available documentation and relevant clinical records. We also obtained independent advice from one of our medical advisers. We did not, however, uphold Mr C's complaint. Our adviser said that, overall, Mr C's care and treatment had been entirely appropriate and reasonable. The adviser also said that the practice had correctly identified red flag symptoms and made an appropriate, immediate referral, which the hospital had declined to accept.

Summary

Mr C visited a hospital accident and emergency department (A&E) with lower back and left leg pain and increasing periods of numbness. He was discharged with an appointment to see a consultant twelve days later. Within a short time of being discharged, however, Mr C returned to hospital as he was experiencing increasing pain and numbness. Examination showed that there had been some loss of sensation and Mr C was admitted. An MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) was carried out the next day, and showed a central prolapsed disc (when the centre of a disc in the spine pushes out into the spinal column) and Mr C was urgently transferred to a neurological unit at another hospital. The following day, a laminectomy (a surgical procedure to remove a portion of the vertebral bone called the lamina) and a discectomy (surgical removal of disc material that presses on a nerve root or spinal cord) were carried out.

Mr C complained that he should not have been sent home after he first attended A&E. He believed that if he had been kept in hospital the first time, his post-operative problems would have been reduced. We investigated the complaint and all the relevant documentation and clinical records were carefully considered. We obtained independent advice from a clinical adviser, which we also took into account. The adviser said that Mr C's first examination showed a decreased sensation in the area surrounding the anus and genitals and, so the diagnosis of partial or incomplete cauda equine syndrome (a very large disc prolapse that may cause pressure on the nerves supplying the bowel and bladder, leading to incontinence) should have been considered. Unless this is dealt with very quickly, within hours, the chances of recovery are low, and it was not considered. We upheld the complaint, noting that Mr C should have had an immediate MRI scan.

Recommendations

We recommended that the board:

• formally apologise to Mr C for their failure in this matter; and
• review their management pathway for suspected cauda equina syndrome and define the indications for an emergency MRI scan.