Health

Summary

Miss C complained about the care and treatment provided by her former dentist, together with the way in which her complaint was handled. During the course of our enquiries, the dentist acknowledged that there were failings in Miss C's follow-up treatment and the handling of her complaint. In order to address these issues, the dentist agreed to apologise to Miss C and reimburse her for the cost of her treatment. Miss C was satisfied with the proposed action and so we considered her complaints resolved.

Summary

After she was diagnosed with osteoarthritis (the most common form of arthritis), Mrs C had hip replacement surgery. She went back to see the surgeon because she had pain in her hip. He thought that her symptoms suggested trochanteric bursitis (a condition that causes pain over the outside of the upper thigh, usually due to inflammation or injury to some of the tissues that lie over the top of the thighbone). He injected the tender area with a local anaesthetic and steroid on a number of occasions and arranged for her to attend physiotherapy.

When the problems persisted, Mrs C was referred to another surgeon. He said that the pre-operative x-ray showed minimal osteoarthritic change, and thought that the diagnosis of trochanteric bursitis was improbable. He said that the pain might be related to infection or mechanical loosening and organised a bone scan and then an MRI scan, although these did not show any abnormality. The surgeon decided that there were some problems with the hip replacement and that there was enough evidence to support replacing it with a different type. He then carried out this operation.

Mrs C complained to us that the board had failed to carry out appropriate hip replacement surgery in the first operation. After taking independent advice from one of our medical advisers, however, our investigation found that it was reasonable and appropriate to carry out a total hip replacement and that the surgery was carried out to a reasonable standard. Although the first operation failed to achieve the aim of the surgery, which was pain relief, the operation note was clear and did not indicate any problems. A small number of patients have significant pain following hip replacement and we were unable to say what had caused Mrs C's pain. There were no identifiable technical errors and we found that the initial surgery was carried out to an acceptable standard.

Summary

Mr C had been diagnosed with a retroperitoneal liposarcoma (a malignant soft-tissue tumour) which was removed. Two years later, a CT scan (a special scan using a computer to produce an image of the body) showed that the tumour had grown back, and it was decided that scans should be carried out to monitor its growth. The scans showed that the affected area had grown and so it was decided to surgically remove the tumour. When the operation was carried out, it was not possible to remove the tumour completely. The right ureter (the tube that carries urine from the kidney to the bladder) was also involved in the tumour and it was divided and closed off.

Mr C complained that the surgeon failed to obtain an up to date CT scan of the affected area before he carried out the operation. After taking independent advice from one of our medical advisers, we found that such a scan was not needed as it would not have changed the need for or prevented the surgery on Mr C's ureter. We also found that all the required investigations were performed and documented before Mr C had the operation.

We did, however, uphold his other complaints. Mr C complained that the surgeon had failed to obtain informed consent from him for the operation. He said that he thought that only the tumour would be removed and had never been told that surgery on other tissue or organs might be required. The board's consent policy clearly says that it is essential for health professionals to clearly document both a patient's agreement to treatment and the discussions that led to that agreement. The policy says that this will be done either using a consent form that the patient signs, or by documenting in the patient's case record that they have given verbal consent. We found that the clinical decisions and surgical treatment were correct and in line with the accepted standard of practice for this operation. However, there was no documented evidence that Mr C was given sufficient information before the surgery about possible loss of kidney function. Consequently, we found that that there was no evidence that the board had communicated with Mr C effectively during the consent process.

Several weeks after Mr C was discharged from hospital, he was admitted to another hospital with hydronephrosis in his right kidney (a condition where one or both kidneys become stretched and swollen because of a build-up of urine). Mr C said that he and the staff in the other hospital were initially unaware that his right ureter had been intentionally closed off. Because of this he was initially diagnosed with a possible kidney stone, before it was identified that the problem was related to the surgery on his ureter.

We found that it was not possible to say whether Mr C was given sufficient information after the operation, as there was no written documentation of the discussions on ward rounds. The board said that he was told what had been done. However, it was clear that after the operation Mr C was not fully aware of the extent of the surgery he had. We could not say whether this was because he was told, but did not retain the information, or because this information was not given to him. However, important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes and there was no evidence in Mr C's notes that staff had effectively communicated details of the operation to him.

Recommendations

We recommended that the board:

• consider if their consent form should be reviewed in order that there is a section to record possible risks and complications; and
• remind the relevant staff involved in Mr C's care and treatment that important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes.

Summary

Mr C, who has type 1 diabetes, complained that he was not offered a meal over a period of several hours while waiting to leave hospital. He did say that a nurse had offered him something, which he had declined. The board said that the staff nurse recalled a nurse offering food three times, although Mr C said this was not true. Our investigation found that Mr C had been in hospital overnight in relation to a condition other than his diabetes, and nursing staff were satisfied he knew how to manage the diabetes himself. He was administering his insulin himself while in the hospital. This meant that his food intake did not need to be recorded, which also meant we were unable to establish whether he was offered something to eat at a suitable time. There were, therefore, no grounds to uphold this part of Mr C's complaint.

Mr C also complained that the patient discharge sheet referred to him as female. When he complained to the board, they apologised, explained that this had been human error and told him what action they were taking to help prevent a recurrence. We also noted that the writer of the discharge sheet had referred to Mr C as 'Mr' on the following line, which was an indication that the gender error had been a human error, rather than a deliberate attempt to humiliate Mr C. We also considered the board's explanations and actions were reasonable.

Mr C was also unhappy with the board's complaints handling, which he said took too long and did not address the issues. We found that the board had taken the complaint seriously, investigated the various issues robustly and tried hard to respond to the key issues raised and many of Mr C's other points. There were delays, but we also noted that the NHS complaints procedure only gives timescale guidelines in respect of the first complaint reply, not in respect of follow-up correspondence, such as Mr C's follow-up letter. We took the view that the board should have kept in contact with Mr C about the delays but did not consider it would be proportionate to make any recommendation for action by the board as, on balance, their complaints handling was generally good.

Summary

Mr C complained about the time the board took to provide him with tests, referrals and a diagnosis. He was concerned that every time he was referred for tests or treatment he was placed back on the waiting list. He was of the view that the board failed to meet their obligations in terms of the required waiting times.

We found that the board's initial referral exceeded, by a few days, the 18 week NHS 'treatment to referral time' standard. A subsequent referral for an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) also exceeded this timescale, so we upheld the complaint. As the board had, however, already apologised to Mr C for the delay and taken steps to try and avoid similar future failures, we did not make any recommendations.

Summary

Mrs C complained about her late husband (Mr C)'s care and treatment by the board. She said there was an avoidable delay in the diagnosis of Mr C's cancer and that following chemotherapy in March 2012, it was unreasonable to have scheduled a follow-up CT scan (a special scan using a computer to produce an image of the body) for six months later – Mrs C thought it should have been sooner.

We obtained independent advice on this case from one of our medical advisers, a consultant clinical oncologist (a specialist in treating patients who have cancer). The adviser explained that Mr C had a rare aggressive duodenal (in the first part of the small intestine) cancer which the board promptly diagnosed and treated by surgery and chemotherapy. He said the clinical care and treatment Mr C received was both appropriate and to a high standard.

The adviser said there was no evidence in Mr C’s medical notes that the board told Mr and Mrs C when the next CT scan would be carried out. A letter from the board to Mr C’s GP said only that Mr C had a further appointment for three months’ time. According to the board, they planned to carry out a further scan in September 2012, six months after the completion of chemotherapy. Therefore, while it appeared that the board planned to carry out a further scan at a future date, we were unable, due to the conflicting evidence, to reach a definite conclusion on what the board told Mr and Mrs C about the time frame. However, our adviser explained that CT scans are usually only carried out if a patient has symptoms that suggest the cancer may have come back, and this was not the situation when Mr C was seen in March 2012. Therefore, the board’s apparent plan to carry out a further CT scan was, according to the adviser, above standard care and would not, irrespective of the timescale, be deemed unreasonable. We accepted the adviser’s view, and did not uphold Mrs C's complaints.

Summary

Mr C complained to the medical practice about the treatment that his late wife (Mrs C) received for gout. A GP had prescribed tranquilisers instead of painkillers. After two weeks Mrs C started losing skin on her hands and the GP reduced the medication. Mrs C was later admitted to hospital, where she died, with the cause of death stated as kidney failure and diabetes. Mr C said that his wife should have been admitted to hospital sooner, as she was passing blood.

Although we noted that this was a complex medical case, we upheld Mr C's complaint. After taking independent advice from one of our medical advisers, our investigation found that there was a lack of documentation in the GP records about Mrs C's deterioration in the weeks before she was admitted to hospital. There was also a failure to check her kidney function in view of medication that had been prescribed, and the practice should have referred Mrs C for a specialist opinion or hospital admission sooner.

Recommendations

We recommended that :

• conduct a significant event audit to see if lessons can be learned from this complaint;
• apologise to Mr C for the failings identified in our report; and
• ensure that the GP concerned revises the presentation of acute renal failure and management of hypertension and discusses the case at his next appraisal.

Summary

Mr C complained about the prison healthcare team making changes to medication he had been prescribed for chronic leg pain and migraines. He also complained about not being given medication for high blood pressure.

Mr C, however, withdrew his complaint before our investigation was completed.

Summary

Mr C complained that the board had failed to return his in-the-ear hearing aids to him after they were repaired and told him they must have been lost in the post. He said they then decided not to provide the same type as a replacement, and told him he would be given behind the ear aids instead. When Mr C complained about this, he said the board failed to fully evidence or explain why he could no longer have in-the-ear hearing aids.

We took independent advice from one of our medical advisers on this case and she said that the board's guidelines for hearing aid provision were arrived at properly, were ones they were entitled to apply and that the decision-making process was appropriate and in accordance with the guidance. She said that Mr C did not meet the criteria for in-the-ear hearing aids set out in the guidance.

In terms of their response to Mr C’s complaint, we considered that the board had provided a full and reasoned explanation of why Mr C no longer qualified for in-the-ear hearing aids, that their letters had been detailed and noted that they had offered to meet with Mr C to discuss his concerns.

However, we accepted that had Mr C’s original hearing aids not been lost in the post then he would not be in his current position. We also noted that he had said that the board had previously lost his hearing aids and moulds and we did not see any evidence that the board disputed this. Although, therefore, we did not uphold Mr C's complaints, we considered it reasonable that the board could and should have provided a more secure and reliable means of returning Mr C’s repaired hearing aids and because of this we made a recommendation.

Recommendations

We recommended that the board:

• provide Mr C with replacement in-the-ear hearing aids.

Summary

Mrs C's late husband (Mr C) was admitted to hospital, having been referred there by his GP for rectal bleeding and diarrhoea. His symptoms were attributed to his known history of diverticulitis (a common disease of the digestive system), but he was also found to have an abdominal aortic aneurysm (ballooning of part of the aorta, the body's largest artery). His symptoms settled and he was discharged after three days. However, a CT scan (a special scan using a computer to produce an image of the body) carried out during his admission showed that his aneurysm required urgent treatment and he was readmitted within two weeks for surgery, in which a graft was used to repair the aneurysm.

Mr C recovered well and was discharged six days later with arrangements for him to be reviewed in another six weeks. Around five weeks after his surgery, however, Mr C began coughing up blood. He attended the accident and emergency department, and was readmitted to hospital. Tests were carried out to check for a blood clot in his lungs or a chest infection, and he was treated for a presumed chest infection. Mr C's kidney function was also impaired and he became septic (with infection in the bloodstream), but the cause of the sepsis was unclear. He was referred for review by a surgeon who arranged another CT scan. This showed evidence of air pockets around the graft that had been used during his aneurysm repair. Mr C was treated with antibiotics, then had further surgery to remove and replace his infected graft. After the operation,

Mr C was taken to the intensive care unit (ICU) and high dependency unit (HDU), but was transferred back to the main ward three days after his operation. He developed oedema (swelling) and kidney failure. He was transferred back to the ICU, but suffered two heart attacks and died three weeks after the surgery.

Mrs C complained that the board discharged Mr C too soon after his initial operation. She also felt they failed to identify the source of his infection, despite his recent operation wound being a likely site and that the vascular surgeon who carried out his operation was not informed of his re-admission soon enough. Mrs C also complained that Mr C was transferred out of the ICU/HDU too soon.

After taking independent advice from our medical advisers, we upheld Mrs C's complaints about her husband's first discharge from hospital, and the move out of ICU/HDU, but not her other complaints. We found that the board failed to follow their own discharge planning policy properly and, although there was no clear evidence to suggest that Mr C was not fit for discharge after the first operation, a lack of records meant we were unable to be certain of this. We noted that the board took appropriate action when Mr C developed a rash over his entire body, but we criticised the decision to transfer him back to the main ward after his last operation. Our adviser said that his fluid balance was poorly managed and that staff on the main ward would not have been qualified to provide the close monitoring and treatment that he required. We were, however, satisfied that the board took reasonable steps to identify the source of Mr C's infection. As he initially presented with respiratory symptoms, there was no cause to involve the vascular surgeon or to investigate his operation site as the source of infection. However, as potential sources were ruled out, the vascular surgeon was contacted for his view.

Recommendations

We recommended that the board:

• audit their performance in relation to their discharge from acute care policy with particular emphasis on record-keeping and ensuring patients are reviewed daily;
• apologise to Mr C's family for the additional discomfort caused by his premature discharge to the main ward; and
• arrange for their ICU and HDU staff to review Mr C's case with specific reference to fluid balance management to identify any points of learning.