Health

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.

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.