Health

Summary

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke.

We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s complaint.

We did not uphold Mr C's third complaint as our investigation did not find evidence that doctors had ignored reported symptoms of slurred speech. The notes provided clearly detailed the symptoms and signs that Mrs C had when she was assessed at the hospital.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified in Mrs C's care;
• review the processes governing referral to the on-call neurology team when a patient presents with symptoms consistent with hemiplegic migraine, to ensure an appropriate management plan is agreed and documented, with reference to the SIGN guidance; and
• provide evidence that they have reviewed the procedures within the accident and emergency department for the identification of stroke and the appropriate point for involving a stroke physician in light of the failings identified in this complaint.
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Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.

Summary

Mrs C's daughter (Miss A) fractured her forearm and received treatment under anaesthetic at the hospital to manipulate the bone back into position. A cast was placed on Miss A's arm and she was reviewed on four occasions by a consultant surgeon. As Mrs C had concerns about the treatment the consultant provided, Miss A was referred to a second consultant. Miss A then had further surgery as the forearm fracture had become displaced. Mrs C complained that the first consultant had not taken corrective action when he became aware that the fracture had moved. She was unhappy because her daughter sustained permanent scarring and may not regain the full movement of her arm.

Our investigation found that Miss A had corrective surgery five months after her injury. After taking independent advice from one of our medical advisers, we considered that the treatment provided by the first consultant was reasonable. We also found that there was a possibility that corrective surgery was carried out too early because the bone might have corrected itself over the course of six to eighteen months. Our adviser said that fractures in children heal very fast, and as a child grows there is great remodeling capacity as long as there is about 18 months growth left. Miss A was eight years old at the time of her injury. We did not uphold Mrs C's complaint, as we concluded that there was no unreasonable delay in Miss A's treatment.

Summary

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach.

Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer.

After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the apparent lack of consideration of Mrs C's shrunken kidney, and upheld Mr C's complaint that this was not investigated quickly enough. Investigations concentrated on the biliary tree but found no significant abnormalities other than gallstones. Mrs C's pain was located in the area of her shrunken kidney, which was highlighted in June 2010 and showed again in the November 2011 CT scan. It was established in December 2011 that the biliary tree abnormalities were not the source of the pain. We concluded that there was sufficient cause to refer Mrs C to a urologist at an early stage, rather than to concentrate investigations on the biliary tree abnormalities. We did not uphold Mr C's complaints about how details of his wife's condition were explained in a letter to her and about medication prescribed.

Recommendations

We recommended that the board:

• share our findings with the clinical team so that they may consider reviewing how referrals are managed for patients requiring multi-disciplinary investigations.

Summary

Mrs C's late sister (Mrs A) suffered from dementia and lived in sheltered housing. Mrs C held welfare power of attorney for her. When Mrs A first joined the medical practice, she was on regular medications for a number of conditions, including dementia, and was under the care of her GP and a community psychiatric nurse. She was prescribed an antidepressant and medication for her dementia. Care staff, however, became increasingly concerned about her challenging behaviour. After visiting Mrs A in response to a phone call from care staff , her GP prescribed diazepam on an ‘as required’ basis. Several days later, Mrs C contacted the GP expressing concern about the prescription and the fact that the GP had not consulted Mrs C about it, given that she held welfare power of attorney for her sister. Mrs C also believed that the GP prescribed the diazepam on the basis of a phone call with staff, and did not see Mrs A in person. Mrs C said that during a meeting with the community psychiatric nurse the day before the prescription, they had agreed to continue to monitor Mrs A's progress on the antidepressant.

Mrs C complained that care staff may be trained to administer medication, but they are not qualified to make medical decisions about when the medication is required and that the practice failed to ensure there was an appropriate system for administering the drugs. Mrs C said that within days of Mrs A moving to another practice, the GP said she needed a full assessment and admitted her to hospital where her medication was reduced and where she stayed for three months before moving to a nursing home.

Several days after the prescription of diazepam, Mrs C phoned the GP to discuss her concerns. She followed this up by letter. She did not hear from the practice and approached the health board with a complaint three weeks later. The health board forwarded her written complaint to the practice who responded in writing two weeks later. Mrs C was unhappy with the practice's complaints handling.

After taking independent advice from one of our medical advisers, we upheld only two of Mrs C's six complaints. We found that the prescription of diazepam was reasonable in relation to both the prescription and the system to administer the drugs. We also found that the GP's assessment of Mrs A's medication and care needs was reasonable. However, we found that the GP's communication with Mrs C was unreasonable, given that under the Adults with Incapacity (Scotland) Act 2000 Mrs C should have been consulted about the prescription of diazepam, and that there were shortcomings in the way the practice dealt with her complaint. As result of Mrs C's complaint, the GP and the practice took action that we considered appropriate, therefore, we did not find it necessary to make recommendations.

Summary

Mrs C was treated in hospital for a sub-arachnoid haemorrhage (bleeding into the area between the brain and the thin tissues that cover it) that required emergency surgery. She complained that during her stay in hospital, she contracted bacterial meningitis (inflammation of the protective membranes covering the brain and spinal cord) as a result of an external ventricular drain (a device used in neurosurgery) that was inserted to control an abnormal build-up of cerebrospinal fluid (a clear colourless fluid produced in part of the brain). Mrs C was treated with antibiotic therapy administered intravenously (into a vein) and intrathecally (into the spinal subarachnoid space - the compartment within the spinal column which contains the cerebrospinal fluid). Her condition stabilised and she was later discharged home.

Mrs C told us that she continued to suffer a number of debilitating symptoms including no sense of smell or taste, frequent headaches, and lack of

co-ordination and concentration; and said that she has been unable to return to work. She attributes this to receiving inadequate care and treatment during her stay at the hospital. Mrs C also complained about matters related to the patient's charter, prescribed medication, her visitor allocation, treatment by staff and the response to her complaint.

As part of our investigation, we obtained independent advice from two medical advisers, who considered all aspects of Mrs C's care. We took account of their advice alongside all the documents provided by Mrs C and the board. Our investigation found no evidence of any failure in the care and treatment Mrs C received, either in relation to the fact that she contracted bacterial meningitis, or with her medication, visitors or treatment by staff. We did uphold her complaints about the patient's charter and the board's complaint response, but did not find it necessary to make any recommendations.

Summary

Ms C and Mr C are sister and brother. Their elderly father (Mr A) was admitted to a hospital as an emergency with a suspected urinary tract infection, and was discharged home five days later. Ms C was unhappy that although she held a power of attorney for her father, no senior member of staff contacted her to discuss Mr A's care, in particular the changes that were made to his heart medication. The hospital clinician's view was that Mr A suffered from several illnesses and his admission was precipitated by increasing confusion and reduced mobility. The clinician said that the medicine changes made in hospital took account of Mr A's condition at the time of his first admission. Mr A was readmitted to the hospital about four weeks later and tests confirmed he had suffered a heart attack. He died there three days later. Both Ms C and Mr C said that the hospital withdrew Mr A's life supporting medication during his first admission and they made several complaints linked to this.

We took independent advice from one of our medical advisers, who considered all the clinical aspects of the case. We took account of his advice along with the documentation provided by Ms C and Mr C and the board. The adviser said that life supporting medication was not withdrawn, and that Mr A's age, frailty and his other illnesses had to be taken into account. However, the adviser also said that consideration should have been given to Mr A's future symptom control when he was discharged home after his first admission, so we made recommendations to the board about this. The adviser also said that there was no evidence that a review by a doctor was not independent. Although, therefore, we did not uphold the complaints about Mr A's clinical treatment, we considered that the board had offered unsatisfactory explanations to Ms C and Mr C when they complained and we upheld this aspect of the complaint.

Recommendations

We recommended that the board:

• feedback the learning from this complaint to all staff;
• ensure that when changes in medicine(s) are made to patients with diminished capacity, such changes are discussed with their carers;
• ensure that, when medicines are changed prior to a patient's discharge home, consideration is given for appropriate follow-up or monitoring of the patient;
• ensure that information entered in case records is an accurate reflection of events;
• apologise to Ms C and Mr C for the failures identified in this case; and
• ensure that the rationale for changes in medication is clearly documented.

Summary

Mrs C's late mother (Mrs A) was prescribed methotrexate (a disease-modifying anti-rheumatic drug) from October 2008 for rheumatoid arthritis. She was monitored on a four-weekly basis, her GP practice took blood tests and she was seen regularly by the rheumatoid clinic at the hospital. In April 2012, however, Mrs A was admitted to hospital where she was diagnosed with pancreatic cancer. She died the following month.

Mrs C complained that her mother should have been taken off the medication because her immune system started to deteriorate and because she had a sore stomach around mid-2011. She also complained that the practice failed to reasonably treat her mother's stomach pain, which Mrs C believed was an indicator that her mother had pancreatic cancer. Finally, Mrs C said that in October 2011 a blood test was carried out showing high levels of inflammation, which she believed indicated cancer, but the practice then failed to carry out any further tests.

After taking independent advice from one of our medical advisers, we found that the practice had properly monitored Mrs A while she was prescribed methotrexate. Moreover, there were no specific entries in Mrs A's medical records in 2011 showing that she attended the practice complaining of a sore stomach. We were, therefore, satisfied that there was no evidence that the care and treatment Mrs A received fell below a reasonable standard.

Summary

Mrs C complained about the care and treatment given to her late mother (Mrs A) in hospital over a two day period. Mrs A was elderly, had been unwell and was deteriorating. Mrs C said she had spoken to her mother by phone late on the afternoon of the first day, and she had sounded well. However, Mrs C received a call the next morning to say that Mrs A had deteriorated rapidly and that she should come to the hospital. Mrs C then spoke over the phone with an out-of-hours GP who was treating Mrs A. The GP advised Mrs A that he felt it would not be appropriate to transfer Mrs A to an acute unit, and that ensuring her comfort and dignity was the priority at that stage. Mrs C complained to us that she felt an opportunity to provide Mrs A with further treatment was missed. She said that though she understood Mrs A was nearing the end of her life, she was concerned that there was a lack of appropriate care and treatment over the two days.

We obtained independent medical, nursing and GP advice from our medical advisers in order to reach a decision on Mrs C's complaint. We found that, although it may have been reasonable to reduce the number of observations carried out on Mrs A due to the type of care she was receiving, this was not recorded in her care plan, nor was there evidence of this having been discussed with Mrs A or her family. We noted that clinical observations taken a couple of days before were inappropriately recorded as 'low', and there was then a

60-hour period during which no observations were made. We took the view that the Modified Early Warning Score (MEWS - a guide used to quickly determine the degree of illness of a patient) had not been used correctly and, although there was no suggestion that the eventual outcome for Mrs A would have been different, we found that her care in this regard was not reasonable.

We did find that the care provided by the GP following the discovery of Mrs A in an unresponsive state was appropriate, reasonable and patient-centred. Mrs C had felt it was inappropriate and distressing that he had discussed these matters over the phone, although the board said that they had phoned Mrs A earlier to advise her to attend the hospital immediately. Mrs C disputed this. We could not reach a definitive conclusion about this, although we noted that in the circumstances there did not appear to have been any alternative and that the GP handled a difficult situation well. On balance, however, giving regard to our findings in relation to the lack of observations, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C in writing for the failures identified in Mrs A's care; and
• consider adopting a weighted scoring system to identify patient deterioration in place of the 'as required' use of the MEWS system, as detailed in National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS.

Summary

Mr C's brother (Mr A) was in hospital for two months before being discharged to a care home. Mr C's other brother (Mr B) had welfare and continuing power of attorney for Mr A. Mr C complained that staff failed to take into account Mr A's communication problems related to his cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and his rapid deterioration while he was in hospital. Staff also failed to notice his legs were swollen or that he had injured his eye. Mr C asked to see a doctor who knew Mr A but as that person was unavailable, the family had to speak with another doctor who was not familiar with him. The doctor suggested an assessment. Mr C said that when this was carried out, Mr A's dementia and inability to recognise threats and dangers to his own safety were obvious. Mr C was also unhappy that nursing staff put items of lightly and heavily soiled clothing in the same bags for taking home to launder.

As part of the arrangements to discharge Mr A from hospital, an occupational therapist and social worker visited his home. Mr C did not agree with their findings, or that the proposed adjustments to the house would enable his brother to live there. The family were, therefore, concerned about Mr A's planned discharge home. The hospital consultant phoned Mr C at home to explain why Mr A was being discharged, but the family were not told exactly when this would happen. On arriving at visiting time one day, Mr B found an ambulance crew taking Mr A to be discharged home. The family said this was not acceptable, and Mr A was returned to the ward. He was eventually transferred to a care home. Again, Mr C said that the family and Mr A's social worker were not told about this in advance and only learned of it in a phone message left on an answering machine. Mr C complained about Mr A’s care and treatment at the hospital. In particular, he complained about the lack of clinical treatment which was provided; a lack of co-ordination by health and social work staff; a failure to properly assess Mr A's needs and a failure to communicate with Mr C and his other brother about Mr A’s welfare and eventual discharge.

After taking independent advice from one of our medical advisers, we upheld Mr C's complaints about care and treatment and about communication with Mr A's family. We found that while the care and treatment provided in relation to Mr A’s physical health, including medication, was reasonable, there were failures in relation to his mental health care needs. These included fully assessing his capacity for decision-making, which was of considerable concern to us. While we found evidence in the medical records of communication by nursing staff with Mr A's family about his discharge planning, the medical consultant's communication with them was limited to one phone call. This was below a reasonable standard, as the communication failed to meet the needs of Mr A or his family in relation to Mr A’s welfare given the complexity of his condition. We found, however, that the assessment and planning for discharge was reasonable. We found evidence that Mr A's family were involved and we were satisfied that the arrangements themselves were reasonable.

Recommendations

We recommended that the board:

• ensure that failings identified in relation to communication and documentation are brought to the consultant's attention and reviewed as part of the consultant's annual appraisal;
• apologise to Mr C for the failures identified;
• bring our adviser's comments about the review of Mr A’s prostate medication to the attention of relevant staff;
• provide evidence of how they are implementing Scotland's National Dementia Strategy with particular reference to communication with the families and carers of patients with cognitive impairment; and
• introduce a policy to ensure that the cognitive function of elderly patients is assessed and, if this is impaired, that capacity for decision-making is also assessed.