Health

Summary

Ms C is an advocate for the sister of the late Mr A. Ms C complained that the care and treatment provided by the board to Mr A was unreasonable. Around 15 months after being diagnosed with cancer, Mr A was given the all-clear. However, within two months, his symptoms had returned. Initially, tests suggested that the original cancer had returned, but following a liver biopsy (where a sample of tissue is taken for examination in the laboratory), Mr A was found to have a second type of cancer, incurable small cell lung cancer, which had already spread to his liver. Mr A died some three weeks later.

Our investigation, which included taking independent advice from a medical adviser who is a consultant haematologist (a specialist in disorders of the blood), found that once Mr A had been referred to the board his care and treatment had been reasonable. Mr A had a rare form of cancer - Mantle Cell Lymphoma (MCL - cancer of the white cells that help the body fight infection). Mr A was treated for MCL by the board and by a specialist team in another NHS board area.

The adviser reviewed Mr A's treatment against guidelines issued by the British Committee for Standards in Haematology which were published in 2012. Although this guidance was provided after Mr A's treatment, the adviser said that his treatment complied with these standards and was, therefore, reasonable. The adviser considered that overall, the care and treatment provided to Mr A by the board was reasonable and timely.

Summary

Ms C's dentist referred her to the board's dental institute for treatment to remove the roots of a broken wisdom tooth. Ms C complained that there was unacceptable delay in providing an appointment at the institute; and that the lack of communication about the waiting time was unreasonable.

After investigating, we did not uphold Ms C's complaints. The dentist referred her to the dental institute as a routine referral, to have the roots of her tooth removed under sedation. Our investigation found that she was offered an appointment there ten weeks after the referral was received, and we were satisfied that this was within the national target timescales. We were also satisfied that the waiting time for an initial appointment was appropriately communicated to Ms C from the start, and that it was clearly explained to her why it was not possible to say before the initial consultation how long it would be before she received treatment.

Summary

Miss C's mother (Mrs A) was admitted to hospital. She was very frail and had significant leg ulcers, and needed more care than could be provided at home. After a couple of weeks, Miss C had spoken with a healthcare professional about her mother's planned return home. However, Mrs A was then diagnosed with aspirational pneumonia (inflammation of the lungs and airways from breathing in foreign material). She was reviewed by a speech and language therapist, who considered that Mrs A's swallowing was unsafe and so she was given a modified diet. A doctor then reviewed Mrs A, and said that she had further deteriorated. She reassessed Mrs A's medication and decided that she should not be given normal quantities of food or drink by mouth ('nil by mouth') because of her difficulty in swallowing. Mrs A died of pneumonia a few days later.

Miss C complained to us that communication from staff was poor; that Mrs A went on to develop a urine and chest infection and that the doctor had, unreasonably, given instructions that should her intravenous antibiotic drip become detached, it was not to be re-fixed. Miss C said that when the drip became dislodged, despite repeated requests, it was not reinserted and Mrs A's medication was withheld. Miss C also said that, while her mother was in hospital, she had emphasised to staff that they needed to ensure that her mother received enough to drink as she knew it was critical that Mrs A did not develop an infection. Miss C said that her mother had been in great discomfort before her death, as she had not been receiving medication and had in fact developed a urine infection that had served to weaken her condition further.

After taking independent advice from a medical adviser, however, we did not uphold Miss C's complaints about her mother's care and treatment. Our investigation found that the care and treatment provided was reasonable, as was staff communication with Miss C, although they could have explained the meaning of 'nil by mouth' better. Our adviser said the records showed that Mrs A's leg wounds were appropriately treated, and her pain managed, and that there had been care from a multi-disciplinary team including physiotherapy, occupational therapy, dieticians, medical and nursing staff. The records were of a good standard and contained daily entries of the care and treatment given. We did, however, identify some shortcomings in the way the board dealt with Miss C's complaint in that there were a number of inaccuracies in their response.

Recommendations

We recommended that the board:

• satisfy themselves that when a patient is to be 'nil by mouth', the situation is clearly explained to, and understood by, those concerned; and
• emphasise to all their staff the importance of responding to complaints in accordance with their stated policy.

Summary

Mr C complained that there was an unreasonable delay in diagnosing his wife (Mrs C)'s cancer. Mr C said that tests dating back to 2005 contained suspicious results that the hospital should have acted upon. He said that he had specifically asked if there was a possibility that his wife had cancer and had been told there was not. He also questioned why, after his wife had been assessed as unfit to have a biopsy, one was undertaken about five months later, when her health had deteriorated.

After taking independent advice from a medical adviser, we did not uphold Mr C's complaint. The adviser noted that his wife had other serious health conditions, including tuberculosis (a bacterial infection mainly affecting the lungs) and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). The adviser also noted that it was likely that the cause of the mass that Mr C thought was indicative of cancer in 2005 was likely to have been caused by Mrs C's tuberculosis. Our investigation, therefore, found that the actions of the hospital were, therefore, reasonable and appropriate. Although we did not uphold the complaint, we noted that the clinical team at the hospital did not seem to have been able to effectively communicate the seriousness of Mrs C's health problems to the couple.

Summary

Mrs C's elderly mother (Mrs A) suffered from angina (heart pain) and high blood pressure. She fell at home and was taken to hospital. Although doctors found no bony injuries from her fall, they decided to keep Mrs A in hospital until her mobility improved. When visiting their mother a few days later, Mrs C and her brother found her in a deep sleep and unresponsive. It was suggested that Mrs A had had a stroke. However, when a consultant reviewed her, he suggested she might be having an adverse reaction to pain medication (tramadol - an opiate drug) that she had been prescribed. Mrs A was given another drug to reverse the effects of the tramadol. Although Mrs A's condition initially improved, she developed heart arrhythmia (abnormal heart rhythm) and collapsed and died thirteen days after being admitted to hospital. Mrs C complained that it was inappropriate for her mother to be prescribed tramadol and that the board's staff failed to take timely action when it was evident that she was sensitive to this medication.

During our investigation we took independent advice from a medical adviser. We did not uphold the complaint that the medication prescribed was inappropriate. The adviser explained that elderly, frail, patients can be at risk of chest infections, and opiates such as tramadol relieve rib pain and allow patients to cough properly, decreasing the risk of infection. However, they can also increase sedation and depress breathing. The risks are lower with tramadol than with other such drugs, however, and we found that it was appropriate for this to be prescribed, particularly as Mrs A was not known to have a sensitivity to the drug. Our investigation found, however, that Mrs A's deterioration was caused by a reaction to the tramadol, which could have been identified earlier. We were not critical of a junior on-call doctor who had investigated the cause of Mrs A's symptoms and had sought advice from two senior colleagues. However, we considered that the initial presumption that Mrs A had had a stroke may have led to some lack of consideration of other causes, such as tramadol sensitivity, and we upheld Mrs C's complaint that the board did not act quickly enough in this respect. We found that the subsequent twelve-hour delay before diagnosis would not have had any long-term impact on Mrs A's health, and that there was no link between the prescription of tramadol and her death. However, we recognised that the delay in identifying this issue caused additional distress to Mrs A and her family.

Recommendations

We recommended that the board:

• ask the clinical team to review Mrs A's case and our comments with a view to identifying any points of learning.

Summary

Mrs C was unhappy with care and treatment she had received from a doctor at the medical practice, and had tried to avoid consulting him. However, she had to see him for a medication review. She was unhappy about this and raised concerns about the treatment she received from him when she attended the review. In particular, she complained that he changed her medication. To investigate the complaint, we took independent advice from a medical adviser. Their advice was that it was entirely appropriate for the practice to have made arrangements to review Mrs C's medication, and that the decision to change her medication was reasonable. We, therefore, did not uphold this complaint. We noted that the practice said that they had asked Mrs C to attend for review several times before an appointment was eventually arranged, but Mrs C said she did not receive such requests. As the practice had not kept records of the requests, we made a recommendation about this.

Mrs C also complained about a further consultation with the doctor when she was taken ill and had to arrange an urgent appointment. She said the doctor failed to examine her, instead passing her on to the practice nurse, and that he had panicked her by discussing the possibility of norovirus (winter vomiting virus). The doctor said that he did examine Mrs C, with the assistance of the practice nurse, and that he diagnosed a chest infection and made arrangements to have her admitted to hospital. Mrs C disputed this, maintaining that she was not examined and that a chest infection was not mentioned. The advice we received was that the records suggested an appropriately managed chest infection. This did not accord with Mrs C's account of events but we were unable to reconcile this account with the documentary evidence and we did not uphold her complaint.

Recommendations

We recommended that the practice:

• remind staff to ensure that all attempts to contact patients are appropriately recorded.

Summary

Mr C's young daughter is in the care of his former partner. He complained to the board that a health visitor did not take appropriate action to protect his daughter when he raised concerns about her welfare.

Our investigation included taking independent advice from a medical adviser, who is a senior and experienced nurse and health visitor. The adviser was satisfied that the actions taken by the health visitor and her predecessor were appropriate, reasonable and proportionate. We reviewed the documentation from the board and other relevant agencies and were satisfied that the health visitor's actions were reasonable and complied with relevant national and local guidance.

Summary

Mr C, who is a prisoner, complained because he felt the prison doctor unreasonably refused to prescribe him the medication he wanted. Mr C felt the medication was not sufficiently controlling the symptoms of his mental health problem. Because of that, Mr C said he was having difficulty sleeping and he asked to be prescribed a sedative to help with this. Mr C also suffers from a bone condition, and as he felt his body had become used to his existing pain relief medication he asked to be prescribed something stronger.

In investigating Mr C's complaint, we reviewed the board's response to it and sought independent advice from our medical adviser. We noted that the prison doctor had tried to meet with Mr C to discuss his pain and consider introducing anti-inflammatory medication but, because Mr C became abusive, the meeting was ended. In addition, the board advised Mr C that the sedative he wanted was normally only prescribed for short term use and because of that, the doctor decided not to prescribe it. The board also confirmed that two different psychiatrists had not recommended that prescription for Mr C.

Our adviser provided an opinion on Mr C's complaint. She said it was likely the prison doctor would have prescribed anti-inflammatory medication in addition to Mr C's pain medication and doing that would have been reasonable. She did not consider that the pain medication Mr C wanted to be prescribed was appropriate for his circumstances. In addition, our adviser noted that some medication that Mr C was taking for his mental health condition had sedative qualities, and said it would not be reasonable to prescribe a regular as well as those medications. In light of this advice, our view was that the prison doctor's decision not to prescribe Mr C the pain medication and sedative that he wanted was reasonable and appropriate.

Summary

Mrs C was diagnosed with breast cancer in 1998. Due to the severity of the disease and her young age, she was given yearly mammograms (a special

x-ray picture of the breast) which she was told were to continue until she was 50.

Around eleven years after diagnosis, Mrs C moved to Scotland. She was given a mammogram in 2010. The following year, it was explained to her that the policy was for mammograms to be given every two years.

After her routine mammogram in 2012, Mrs C was told she had cancer in her right breast. She alleged that if she had been given a mammogram in 2011 as she had expected, and as she had requested, she would have learned of her condition at an earlier stage and the outcome would have been better for her.

In investigating the complaint, we considered all the available information, including the complaints correspondence and Mrs C's relevant clinical records. We also took independent advice from a medical adviser. The adviser said that there was a difference between screening and follow-up treatment.

Mrs C was being followed-up after illness and treatment. In the adviser's view, Mrs C should have continued having annual follow-ups until she was 50. She also said that Mrs C was in a special category as she also had a family history of breast cancer. The adviser did not consider that Mrs C's personal circumstances were taken into account when she was being treated. She noted, however, that the hospital's policy of two year mammograms met minimum required standards, and that annual mammograms from the age of 30 to 50 would be an extreme risk. The adviser said that she would have offered MRI scans rather than mammography. We upheld the complaint but, because of this advice, made no recommendations.

Summary

Mr C complained about the care and treatment of his wife (Mrs C) while she was in hospital over a two-month period. Mrs C had, amongst other things, a history of diverticular disease (a disease affecting the colon). During the period concerned she was admitted three times and three surgical procedures were carried out. After the third operation, Mrs C's condition declined and she died. Mr C believed that not enough was done for his wife; that on her first admission she should have been x-rayed, and that some of the treatment provided made her condition worse. Mr C also questioned the timing of his wife's second operation and said that she was discharged despite continuing symptoms and the fact that she had an infection. He believed that she should have been given a scan before discharge. During her third operation, he said that a stoma (a surgically created pouch on the outside of the body for body waste) should have been created.

In investigating the complaint, we took into account all the available information provided by Mr C and by the board, including all the complaints correspondence and Mrs C's relevant clinical notes. We also obtained independent advice from a medical adviser. We did not, however, uphold Mr C's complaint.

The adviser said that the care and treatment given to Mrs C on her first two admissions was completely reasonable. However, they also said that on the third admission the treatment was difficult to explain insofar as it relied upon the findings during surgery, and the clinical opinion and judgment of the surgeon at the time. The adviser went on to say that, with the benefit of hindsight, the surgeon concerned might well have made a different decision. However, the adviser was clear that the action ultimately taken was entirely reasonable in the circumstances at the time.