Health

Summary

Mr C's young daughter (Miss C) suffers from a number of medical conditions and has serious mobility problems. She uses either a wheelchair or a gait trainer, both of which need a lot of space for turning. After a number of years during which the family waited for a suitable house, a housing association, in conjunction with the local council, agreed to provide a new house. In relation to this, an occupational therapist from the health board assessed Miss C's housing needs and liaised with the housing association. Mr C complained that the occupational therapist did not properly assess Miss C and ensure that the house being built met her needs. He alleged that when he complained to the board about the situation, they did not properly investigate it.

Our investigation found that the procurement process for the house being built to meet Miss C's needs was not straightforward. There were a number of agencies and organisations involved and the role of the occupational therapist was to assess Miss C's needs in order to properly facilitate them in the development of the properly. The occupational therapist provided her professional opinion of what these needs were. However, during the complicated construction and development, the housing association contacted the occupational therapist about a number of design changes, which she agreed without speaking to Mr C. If followed through, one of these changes would have had serious repercussions for Miss C's mobility. We also found that Mr C had first complained to the council, who passed him on to the health board, but then the board took too long to reply to him. We, therefore, upheld his complaints about these matters, but not about the assessment of his daughter's needs, in which nothing had gone wrong.

Recommendations

We recommended that the board:

• apologise to Mr C for the errors identified, and for the delay in responding to his complaint.

Summary

Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when he attended the practice while experiencing heart symptoms, he was seen by a nurse and then sent home after discussing his condition with a doctor, having been told he might have shingles. He said that when he returned home, he was so ill that he required an emergency ambulance to take him to hospital.

To investigate the complaint, we obtained independent advice from one of our medical advisers, and took this into account with all the available information, including the complaint correspondence and relevant clinical records. We upheld the complaint, as our adviser identified a number of problems in handling Mr C's blood samples. They also said that when Mr C went to the practice he appeared to be suffering from a number of symptoms indicating the likelihood of a heart attack, which should have been addressed differently. In accordance with relevant guidance he should have received a detailed assessment by a doctor and been treated with glyceryl trinitrate spray to relieve pain.

Recommendations

We recommended that the practice:

• review their transport procedures after blood samples are taken from patients;
• carry out a review of their system and submit the results to their Community Health and Care Partnership lead for an external review;
• review their management and procedures of 'walk in patients' and clarify and review their Practice Nurse/Advanced Practice Nurse competencies/ autonomy;
• discuss Mr C's case as part of the GP appraisal process;
• carry out a significant event analysis; and
• note the 'identification and management of acute myocardial infarction' within their appraisal learning needs and review SIGN Guidance 93 (guidance for dealing with such matters).

Summary

Mr C, an advocate, complained on behalf of Mrs A that there was avoidable delay in her medical practice diagnosing that she had unknowingly contracted a sexually transmitted disease (STD). She had been attending her medical practice for more than two years with the symptoms but it was not until she was referred to an STD clinic that this was diagnosed. When Mr C complained to us, Mrs A was still undergoing treatment for the condition.

After taking independent advice from one of our medical advisers, we upheld this complaint. Our investigation found that an opportunity to diagnose the STD in August 2009 was missed. The adviser was critical of a lack of detail in the clinical notes, which made it difficult to assess whether or not the condition could have been diagnosed even earlier than that. They said that delay in diagnosing STDs can have serious consequences, as the presence of one can indicate the presence of others, some of which can have serious health effects. Undiagnosed STDs can also be passed on to new or different partners. The adviser also said that the delayed diagnosis probably contributed to the length of Mrs A's treatment.

Recommendations

We recommended that the practice:

• apologise for the failings identified during our investigation;
• conduct a significant event audit of this matter and share the outcome with Mrs A and Mr C; and
• conduct an audit of a selection of medical notes across the practice to ensure that the standards set by the General Medical Council are being met, and if any failings are identified ensure that appropriate training and discussion at annual appraisal(s) takes place.

Summary

Mr C's late mother (Mrs A) died in February 2012. Mr C complained that GPs at her medical practice failed to fully explore her symptoms and treat them appropriately. In particular, he was aggrieved that GPs accepted that his mother was suffering from terminal cancer and failed to take into account numerous occasions when she was prescribed antibiotics that produced an improvement in her condition. Mr C said said that this indicated that they failed to consider an alternative diagnosis.

To investigate the complaint, we obtained independent advice from one of our medical advisers. This confirmed that the GPs had taken appropriate action and, although a chest x-ray had indicated likely cancer, they had sought further confirmation that this was indeed the case. Confirmation was given by Mrs A's consultant, who also said that further tests were required to be absolutely sure. However, Mrs A had refused these. In the circumstances, we took the view that there was little more that the GPs could have done.

Summary

Mr C complained that a filling that had come loose from one of his front teeth had not been adequately restored, resulting in it having to be replaced several times. He also complained that during the attempts at restoration, healthy tooth tissue was drilled away.

Our investigation, which included taking independent advice from a dental adviser, found no evidence of inadequate treatment or that healthy tooth tissue had been drilled away. The adviser said that there are two approaches to this type of restoration, either of which would be considered reasonable. The adviser commented that the position of the tooth and the nature of the restoration would have made this treatment challenging and problematic. The dentist chose one of the two accepted methods and there was no evidence that the treatment provided was not of a reasonable standard.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) when she was admitted to hospital. Mrs A suffered from cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember) and had difficulty settling. Although Mr C's sister offered to come in to help her go to sleep, staff refused the offer. Mr C said that, when he visited on the evening of her admission, he found his mother 'trapped' in a chair behind a desk at the nursing station. She was cold, with no blanket, socks or slippers. Mr C said that throughout her stay in hospital his mother received only basic care and, although she was diagnosed as having gastric cancer at the end of her stay, she was discharged the next day without a care plan in place and with only a box of paracetamol.

Mr C said that the board did not deal with his family reasonably on the day his mother was admitted to hospital, nor did they make reasonable arrangements for Mrs A's discharge. Mr C was also unhappy with the way in which the board responded to his subsequent complaint.

Our investigation took all the relevant information into account, including the complaints correspondence and Mrs A's clinical notes. We also obtained independent nursing advice. The adviser said that while it was not clear why Mrs A was in the chair on the evening of her admission, she had been there too long. The adviser also said that the offer of assistance should perhaps have been accepted, and that communication with Mr C and his family that day was poor. Because of this, on balance we upheld the complaints about communication and Mrs A's overall care and treatment, although we found that her medical care was reasonable. We found that a discharge plan was available for Mrs A, but there was no evidence that it had been communicated adequately to her family or her GP and so, although we did not uphold this complaint, we made a recommendation. Our investigation found that the board had reasonably dealt with Mr C's complaint.

Recommendations

We recommended that the board:

• formally remind staff on the ward of the professionalism required of them;
• remind appropriate staff of the necessity of completing patients' records properly and fully; and
• advise the Ombudsman of the action since taken to prevent such a situation recurring, and if no action has been taken, advise what is proposed.

Summary

Mr C complained about issues arising when his late wife (Mrs C) was admitted to hospital. He said that at first it was believed that Mrs C was suffering from pneumonia and had suffered a slight heart attack. This was confirmed by a heart scan. However, during her stay in hospital, Mrs C began to show symptoms of confusion. A psychiatric opinion was obtained which confirmed that she was suffering from fluctuating delirium (confusion). Despite Mr C's concerns about his wife's mental health, he said he was told that she was not detainable in hospital and was subsequently discharged. Mr C said that at this time she was in a very confused state.

A few days later, Mrs C was readmitted to hospital as an emergency. Mr C said he was advised that his wife had not suffered another heart attack and that no procedures would be carried out. He was told that he could go home, which he did. However, after short time, Mrs C died without her family beside her.

Mr C complained that his wife was discharged from hospital despite being in a very confused state. He also alleged that the board failed to explain the seriousness of Mrs C's condition to him and said that she had not suffered a heart attack.

As part of our investigation we obtained independent clinical opinions from two of our medical advisers, who are consultants in geriatric medicine and forensic psychiatry. Having considered her medical records, they confirmed that Mrs C's state of mental health was not such that the board could detain her, and concluded that she was not unreasonably discharged from hospital. We did not uphold this complaint. However, we found that the notes taken at the time of Mrs C's final admission were insufficiently clear to confirm what Mr C was told about her condition. It was clear, though, that his wife had in fact suffered a very serious heart attack from which she was unlikely to recover. It was, therefore, arguable whether Mr C was given appropriate information from which he could make an informed decision about whether to leave the hospital. We upheld Mr C's complaint about the information provided.

Recommendations

We recommended that the board:

• make a formal apology for the circumstances on the night of Mrs C's death; and
• remind staff in Accident and Emergency and the Coronary Care Unit of their obligation to properly record the information given to families about the condition of their relatives who have suffered a heart attack.

Summary

Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her lung. Mrs A was found to have a chest infection and pneumonia. The family were reassured that she would be discharged home within a few days. During her admission, however, Mrs A had a fall and a number of seizures. She also developed confusion. Her breathing difficulties persisted and she died nine days after admission.

Mr C raised a number of concerns about the treatment and nursing care provided during Mrs A's admission. He also complained about the level of communication with the family.

We took independent advice from two of our advisers, one a specialist in the care of older people, and the other an experienced nurse. Our investigation found that, although Mrs A was initially assessed as being at a low risk of falling, she was not reassessed in line with the board's policy after she fell, and so we upheld the complaint about this. That said, we were satisfied with the level and type of investigations that the board carried out to assess whether she had incurred any injuries or whether her condition had changed. We did not uphold the other complaints, as generally we found the nursing care to be adequate, although we highlighted some issues that could have made Mrs A's stay in hospital more comfortable. Mrs A's family had found the communication from staff to be poor and the information contradictory on some occasions. Based on the clinical records, however, we were satisfied that the family were given full details of the nature and severity of Mrs A's condition. We recognised that there may have been additional conversations not documented in the notes, but felt that, overall, the communication was sufficiently frequent and detailed.

Recommendations

We recommended that the board:

• remind staff of the post-fall protocol outlined in the in-patient falls resource pack and the need to properly record all action taken; and
• provide the Ombudsman with evidence of the additional training provided to nursing staff.

Summary

Mrs C complained about the care given to her late husband (Mr C) while he was in hospital. She said that he was moved three times but only on the last occasion was it suitable for his condition. She alleged that he was not comfortable or properly looked after and that his clinical care was poor. In particular, she said that he endured terrible pain when his chest drains were being replaced. Overall, Mrs C believed that the lack of proper care hastened Mr C's death. She further complained that she was not kept informed by staff about his condition.

In investigating this complaint, we obtained independent advice from medical and nursing advisers. We also took into account all the information provided by Mrs C and by the board (including the relevant correspondence and clinical records). The board had said that the clinical care and treatment given to Mr C were appropriate. However, our medical adviser said that Mr C should have been referred earlier to a thoracic surgeon and should not have undergone four attempts to insert chest drains, particularly without appropriate sedation. There were also failings in Mr C's nursing care, in that his dignity and privacy were not always protected. We, therefore, upheld Mrs C's complaints about her husband's care and treatment, although we did not uphold the complaint that she was not kept informed, as the evidence showed that good attempts were made to let her know what was happening.

Recommendations

We recommended that the board:

• make a formal apology to Mrs C for the shortcomings in the clinical care given to her husband;
• train doctors, as insertion care appears to be less than adequate, to ensure that drains are properly inserted and secured properly;
• review their protocol for Intercostal Chest Drain to ensure that it is sufficiently comprehensive and includes how to deal with recurrent pneumothoraces;
• make a formal apology to Mrs C for failings in the nursing care given to her husband; and
• provide the Ombudsman with evidence confirming that systems are in place (and regularly monitored) to address the failures identified.

Summary

Mrs C complained about the care and treatment the board provided to her son (Master C) after he was admitted to hospital with a perforated appendix. His appendix was removed but he later had to be re-admitted to hospital because of infections, and twice had further unplanned abdominal surgery to release fluid. It was almost a month before he recovered. Mrs C complained that the board failed to diagnose and correct her son's problem; failed to identify a leakage from the stump of the appendix which she felt suggested that the initial surgery had failed; denied her request for the attendance of a surgeon; and failed to provide appropriate nursing care for her son when his condition deteriorated. She also complained that the board did not respond to her complaint appropriately, by failing to answer her question about her son being transferred to a major paediatric surgical centre for treatment.

We took independent advice on this case from one of our medical advisers, who is a paediatric surgeon, and a nursing adviser. Our medical adviser said that the protracted course of events was more likely to be related to the advanced stage of the appendicitis when Master C reached hospital, rather than the care he received there. He explained that the leak was unlikely to have been caused by the initial surgery, but more likely to be associated with the severity of the underlying diagnosis. He was of the view that the board did not unreasonably deny Mrs C's request for a surgeon, that the timing of surgical review was reasonable and the review itself appeared to have been appropriate. Our nursing adviser indicated that staff took appropriate action in response to Mrs C's concerns about her son's deteriorating health and that they requested review as appropriate. We accepted the views of both our advisers.

Although we deemed the board's care and treatment of Master C to be reasonable we did, however, draw their attention to our medical adviser's view that that, given Master C's unplanned further operations, it would be reasonable for the board to discuss his case at a departmental meeting. On the matter of the response to Mrs C's complaint, we considered that the board did answer the question about why they decided to transfer Master C to another hospital and explained why they were unable to continue to treat him where he was.