Health

Summary

Miss C's mother (Mrs A) was admitted to an island hospital with pancreatitis (inflammation of the pancreas), where her condition deteriorated overnight. The next day, it was identified that she was developing organ failure, as a complication of the pancreatitis. She was transferred to a mainland hospital in another health board area. Mrs A died around sixteen days later from multiple organ failure.

Miss C complained about the care and treatment provided to her mother in the island hospital in the two days before she was transferred. After taking independent advice from one of our medical advisers, we found that a prompt and appropriate detailed medical assessment was completed when Mrs A was admitted. There was clear documentation of her vital signs, current drug treatment, physical examination and initial blood tests. The initial diagnosis of acute pancreatitis was correct and was made within a very short time. We also found that the later care and treatment provided to Mrs A was reasonable and appropriate, as was the attention to her pain relief. The deterioration in Mrs A's condition was due to the development of increasingly severe pancreatitis, complicated by early organ failure, rather than inadequate medical care. We did not consider that there were any clinical failings that impacted adversely on Mrs A, and our adviser said that no other specific treatment could have been offered at that time that might have changed the course of events.

Miss C also complained that the board failed to provide her and her sibling (who were both teenagers) with sufficient support when their mother was transferred to the mainland hospital. Miss C decided not to travel with Mrs A when she was transferred by ambulance, and said that when she and her sibling later went to visit their mother, they had to stay in a bed and breakfast without any support.

We found that although it would not have been appropriate for the board to pay their costs, they should have provided Mrs C’s children with advice on how to try to get help with these. We also found that Miss C was not given enough information about her mother’s prognosis to make an informed decision about whether to travel with her in the ambulance. Having carefully considered this matter, we upheld the complaint that the board had not provided Mrs A's children with adequate support when it was decided that she should be transferred.

Recommendations

We recommended that the board:

• issue a written apology to Miss C for the failure to provide her with adequate information about her mother's prognosis and for failing to provide her with adequate advice on how to try to obtain further support with travel costs; and
• take steps to ensure that relatives are given adequate information about how to try to get help with the costs of visiting patients who are transferred to hospital on the mainland.

Summary

Mr C was being treated for HIV (Human immunodeficiency virus - the virus that causes acquired immunodeficiency syndrome (AIDS)). He was unhappy because the board sent his medication to a family member's home, rather than to his medical practice as requested. A family member opened the package and became aware of Mr C's HIV status. Mr C had not discussed this with his family, and it caused him and his family a great deal of upset and difficulty.

He complained to the board, who investigated and found that when he had asked for his medication be sent to his practice (which was in another board's area) the board's pharmacy services had said that they could not send medication to a GP outwith their board's area. Nursing staff had then contacted Mr C's consultant for advice, who said that the medication should be sent to Mr C's home address. However, pharmacy services unfortunately had the address of a family member on their database rather than Mr C's own address. They did not contact Mr C to check that the address was correct or that he was happy for the medication to be posted directly to him. As a result of these failings, the board upheld his complaint, apologised to him, and advised that they had introduced procedural changes to prevent this happening again.

Mr C remained unhappy and brought the complaint to us. We investigated and found that the board's explanation of what went wrong was correct. As they failed to check Mr C's address details or seek his consent to send the medication to his home address, we upheld his complaint. We also obtained details of the safeguards introduced to ensure that this does not happen again, and were satisfied that these were appropriate. For this reason, and because they had already apologised to Mr C for the significant distress this matter had caused, we made no recommendations for further action.

Summary

Ms C is a transgender woman undergoing gender reassigment (a process of changing from man to a woman). She complained that the assessment process for acceptance for gender reassignment surgery took too long and was unreasonably delayed. She started going to the relevant clinic, attending regularly over the following three years. She was referred for a range of additional treatments including hormone therapy, plastic surgery and speech therapy. She sometimes presented at the clinic as a man and sometimes as a woman, but consistently said she was keen to seek gender reassignment surgery.

After three years Ms C was given a referral for gender reassignment surgery in the UK. Ms C then said she preferred to have this abroad, asked for a referral, and withdrew from the service.

In considering this complaint, we took independent advice from our psychiatric adviser, who reviewed all the consultations that Ms C had as she progressed towards referral for surgery. While he acknowledged that it had taken some time for Ms C to gain her referral, he did not identify any specific delays on the part of the board. The timescales involved were partly due to referrals to other services and partly due to inconsistencies in the way Ms C was presenting at the clinic.

Ms C also complained that the board unreasonably refused to refer her for surgery abroad. She said that the criteria for referral were the same, and she would be paying for the surgery. The board said that the decision not to refer Ms C was taken on policy grounds, as international referrals are only made when specialist skills are not available in the UK. Our adviser noted that it would have been appropriate to make an exception to policy on this occasion, given that payment for surgery was not an issue, and we upheld the complaint. However, we noted that before gaining a new referral, Ms C would need to provide evidence that she was ready for surgery now, as she does not currently meet the referral criteria because she withdrew from the service.

Ms C also complained about the standard of plastic surgery on her jaw. She said that it had left her jaw heavier on one side, and that this was deliberate on the part of the surgeon. We took independent advice on this from a facial surgery adviser, who found that the technique used during surgery was appropriate and that the results were of an acceptable standard. He noted that all faces are asymmetric and that patients who have had plastic surgery are much more aware of their appearance after surgery than they were before.

Finally, Ms C complained that there were factual inaccuracies in the board’s response to her complaints. We reviewed the correspondence, and found that there appeared to be some confusion around the use of the word ‘ambivalence’, which was used by Ms C’s psychiatrist to describe her approach to her gender reassignment when she was not consistently presenting as female. However, our psychiatric adviser considered these assessments to be appropriate. We also found some inconsistency around the information presented in relation to her attendance at appointments and some confusion caused by a statement from the board’s plastic surgeon. However, we could not find any significant inaccuracies in the board’s correspondence, and did not uphold this complaint.

Recommendations

We recommended that the board:

• ensure that all patients attending/receiving the services of the clinic are, at their first appointment, given verbal and written information of the policies and procedures followed there in relation to gender reassignment surgery; and
• apologise for not referring Ms C for surgery abroad when it would have been appropriate to do so.

Summary

Mr C complained about the care and treatment the board provided after he went to their accident and emergency department (A&E). He said that they failed to appropriately examine and assess his symptoms of severe abdominal pain with urinary and bowel problems. He also said that they inappropriately discharged him at 05:30 in the morning without considering whether he had the means or ability to return safely home. Mr C said that after seeking further medical assistance elsewhere, he was admitted to hospital the next day with an obstructed bowel and was kept in for assessment and treatment.

We took independent advice on this case from one of our medical advisers. The adviser said that the assessment and examination in A&E were of a reasonable standard and that the treatment Mr C received elsewhere the next day did not indicate otherwise, so we did not uphold his complaint about care and treatment. However, the adviser was critical of the board for failing to have adequate discussions with Mr C about treatment for constipation and failing to give him laxatives to take home with him. The adviser also said that they failed to discuss practical arrangements for Mr C's discharge to ensure that he could return home safely. We upheld the complaint about discharge and made recommendations accordingly.

Recommendations

We recommended that the board:

• provide Mr C with a written apology for the failings identified;
• feed back our adviser's comments on the treatment of Mr C's constipation to the staff who examined him in A&E; and
• remind relevant nursing staff of the need to discuss and make appropriate discharge arrangements for patients in A&E and record this information in the clinical notes.
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Summary

Mr C sustained head injuries in a road traffic accident. He went to hospital where his wound was dressed and he was advised to take painkillers. He attended his medical practice the following day for a change of dressing. Several days later he saw another GP who arranged for a nurse to rebandage his wound. He said that it was found to be dirty with glass fragments left in it. Mr C complained about the way his GPs managed his wound. He was also concerned about how one of the GPs managed his subsequent headaches and said he should have been referred for further investigation earlier. Finally, Mr C said that the follow-up by nursing staff, rather than his GP, was not reasonable.

We took independent advice from one of our medical advisers. They said that wound management is a nursing responsibility and that the management and follow-up was appropriate for this type of injury. In relation to the glass fragments, the adviser said these were unlikely to have caused complications and would have worked their way to the surface. It was, therefore, reasonable to allow this to happen and to treat Mr C with antibiotics rather than try to remove fragments, which might have damaged the healing process. In relation to how the practice managed Mr C's headaches, the advice was that further investigations and treatment were provided within a reasonable time, although the GP did not record information about one of the consultations. Having said that, we found that the care and treatment provided overall was of a reasonable standard.

Summary

Mrs C complained that her medical practice failed to diagnose the symptoms of kidney damage after surgery. She said that this meant she had to undergo further surgery and led to a permanent loss of kidney function. Mrs C also complained that after the surgery the practice had failed to take adequate follow-up action.

After taking independent advice from one of our medical advisers, our investigation found that the practice had acted appropriately on the symptoms Mrs C presented with after her first operation. They had monitored her situation and referred her to a specialist when it was clear that she was not recovering. We also found that the practice acted appropriately and in a timely way in trying to support Mrs C, even though they were not advised of Mrs C's discharge, nor about the specialist type of dressing that she had been fitted with. In the circumstances, we found that the practice had provided her with a reasonable level of care.

Summary

Mrs A was diagnosed a number of years ago with early onset dementia. She was admitted to a specialist psychiatric and mental health unit for assessment because of problems with her sleep pattern. During her stay she fell on the ward, breaking her left thigh, and needed a hip replacement in another hospital. Mrs A returned to the unit nine days later and a further 11 days after this fell again, after another patient pushed her. This time she broke her right hip, which also had to be replaced in the other hospital. Mrs A was discharged from there to a nursing home where she is now living. Her daughter (Miss C) complained that Mrs A was provided with inadequate care and supervision while she was being assessed. Miss C also complained that the board's responses to her complaints was inadequate.

We took independent advice from two of our medical advisers. They noted that at times, Mrs A had been on 'constant observations' (where staff were on hand with her at all times) but at other times she was not. The advisers said that Mrs A's mental health condition, falls risk, medication and physical condition were regularly and appropriately monitored and, where necessary, changes were made. Our investigation found that, although it was obviously very unfortunate that Mrs A sustained two fractures within 20 days, her care and supervision were reasonable and appropriate.

On the matter of the complaint responses, our investigation found that all acknowledgements and responses to Miss C's complaint letters were sent within the local and national target timescales. Full explanations were provided and the board acknowledged that this had been a distressing experience for Mrs A and all her family. The board also apologised that in the first response Miss C had not been made aware of the SPSO process. They had not apologised for what happened to Mrs A and Miss C had been concerned about this. We took the view that as we had found that what had happened was not the fault of the board, it was not unreasonable that they did not apologise for this.

Summary

Mrs C complained that a hospital made mistakes in the reporting of an x-ray that her late mother (Mrs A) had taken on 10 April 2012 after falling in her care home and injuring her left knee. Mrs A was discharged from hospital that day but was admitted to a second hospital three days later because she was in severe pain and unable to put weight on her left leg. She was eventually found to have fractured her knee. When the second hospital asked the first hospital to carry out another x-ray seven days after the first, the first hospital found that there had been an error in the reporting of the original x-ray.

Mrs C felt that the board had delayed in taking action to investigate whether there was a problem with the x-ray or arrange a follow-up, when Mrs A's symptoms did not resolve. Mrs C was also concerned that there was a failure to establish the reasons why the x-ray was wrongly interpreted. The board had explained that the likely cause of the error was a problem with their software system for viewing x-rays, which meant that a much older image of Mrs A's knee was superimposed on the new image. They advised that the error was a rare and unusual incident but that they had made relevant staff aware of the matter to ensure it did not happen again. However, our investigation identified that there was also an error with the reporting of the x-ray that was requested seven days after Mrs A fell, as it too was initially noted as showing no fracture. The board said of this that the x-ray image on 10 April 2012 had been displayed when trying to view the image taken seven days later.

We could not say for certain whether the errors in reporting the x-rays were as a result of a failure in the software system, or the wrong x-ray being opened, or if the correct x-ray images were viewed and the fracture was simply not identified. We concluded, however, that the board had not provided sufficient evidence that they had carried out a thorough investigation into both x-ray incidents. However, we noted that the first hospital had promptly arranged for Mrs A to return the following day for a second x-ray after the fracture was identified. We upheld Mrs C's complaints about interpretation of the x-rays, but not about their follow-up action.

Recommendations

We recommended that the board:

• undertake a significant event analysis into the reporting of the x-rays taken after Mrs A's fall, to establish clearly where the fault lay in order to reduce the likelihood of this happening again; and
• apologise to Mrs C for the failings identified.

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from the perinatal (period before and after birth) psychiatric service. In particular he complained that his wife was not adequately or correctly assessed; her medication might have contributed to her illness, she was allowed unsupervised leave with their daughter when she was an assessed risk to her daughter, she was subject to undue pressure to breastfeed and that a flawed decision was made to refer his daughter to social services as a child protection case.

Our investigation, which included taking independent advice from a clinical adviser, found that the care and treatment provided to Mrs C had been reasonable overall. There was no evidence to suggest that she had not been adequately or correctly assessed or that her medication was inappropriate. The adviser was satisfied that Mrs C was appropriately supervised and there was no evidence of undue pressure to breastfeed. However, the adviser raised some concerns over a lack of consultation with and involvement of, Mr C in his wife's care and we made recommendations to address these points.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failure to complete assessment documentation as required and to involve a carer in a manner consistent with the relevant care pathway documentation; and
• audit the use of completion of the care pathway documentation relevant to this case and consider what changes are needed to ensure documentation is properly completed and utilised.

Summary

Mr C complained that there was an excessive delay in carrying out surgery on his knee. He said that this delay had breached the target waiting times. The board's position was that he had received his treatment within the target waiting times.

We noted that although there was a gap between Mr C's first consultant appointment and the second appointment (at which the decision to proceed with surgery was made) this was due to tests being carried out to ascertain if surgery was the appropriate option. There was also an issue about the complexity of the operation, which involved the removal and replacement of an existing knee replacement. Due to bone loss around the original prosthesis, a specific orthopaedic surgeon was required. The waiting time target could, therefore, only be applied once it was certain that Mr C would progress to surgery. Once this decision had been made, the operation was carried out in three weeks. We did not uphold the complaint.