Health

Summary

Mr C complained about root canal treatment that he had received. He told us that after it he was left with periodic pain for two years, and that he had to pay for corrective work to be carried out by a new dentist.

After taking independent advice from a dental adviser, we upheld Mr C's complaint. Our investigation found that the standard of treatment he received was inadequate. The adviser said that an x-ray taken after the treatment showed that the dentist had not completely filled the root canal, leaving space that could then act as a possible further source of infection, and that led to Mr C's problems. We also found that there was a lack of information in the dental records and no record of any discussion with Mr C of the options, risks or warnings given in advance of treatment. In addition, there was no evidence that x-rays taken had been graded or that any report on the x-rays was written.

Recommendations
We recommended that the dentist:

• apologise to Mr C for the failings identified in this case;
• refund the cost of treatment required by Mr C from another dental practice;
• ensure that dental records are in accordance with General Dental Council standards; and
• provide the Ombudsman with an undertaking that she would address the concerns raised in this complaint through her continuing professional development.

Summary

Miss C was detained in hospital under mental health legislation for nine days, and was assessed by a mental health team in the community after she was discharged. Miss C complained that while in the hospital, she was very bored, and had nothing to do. She said that she started to smoke just to pass the time. She also complained that the board failed to offer or provide the help that she needed after she was discharged, including accommodation away from her family home.

We upheld Miss C's complaint about her stay in hospital. Our investigation found that, while there was evidence that the hospital provided a programme of ward activities for patients, there was no evidence that Miss C was invited to participate, or that she was invited but declined to participate. Nor was there evidence that she had any planned one-to-one sessions with staff as she should have. In relation to the help provided after her discharge, we found that medical staff acted reasonably and in accordance with her wishes. We did not uphold this complaint, as we were not persuaded that there was an unreasonable lack of help.

Recommendations

We recommended that the board:

• ensure that staff encourage patients to participate in available ward activities, to record in a patient's records when this has occurred and whether the patient accepted or declined the invitation to participate; and
• ensure that staff are made aware of the need to provide patients with access to planned one-to-one sessions with staff, for the frequency and duration of these sessions to be negotiated and agreed and for this information to be clearly recorded in the patient’s careplan.

Summary

Mrs C complained that the GPs treating her late mother (Mrs A) failed to fully investigate her symptoms and take timely and appropriate action. She also complained that one of the GPs refused to refer Mrs A to the gastroenterology clinic (a clinic specialising in medicine of the digestive system) for further investigation.

Mrs A was a long-term sufferer of coeliac disease (a condition in which the small intestine fails to absorb and digest food) and was reviewed on an annual basis at a gastroenterology clinic. She also had a skin condition which was linked to the disease, and suffered long-standing back pain. Although Mrs A was prone to constipation because of the medication she took for her conditions, from mid-2010 she had told the practice that she had increasingly severe constipation, sometimes for four to five days. The advice she received from the practice was to increase her laxatives (medication taken to cause or encourage bowel movements). Blood tests taken in early April 2011 returned abnormal results, which the practice attributed to the infective skin condition Mrs A had at the time. They referred Mrs A urgently to the dermatology department (the department dealing with skin conditions). In early May, the department told the GPs that they should seek a further opinion on Mrs A's condition. Mrs A was referred to the gastroenterology clinic that month, where tests revealed that she had inoperable bowel cancer. Mrs A died the following month.

We upheld two out of three of Mrs C's complaints. Our investigation, which included taking independent advice from one of our medical advisers, found that there were delays in fully investigating Mrs A's symptoms and making timely and appropriate referrals for specialist advice. Mrs A had a long-term medical condition, and was taking medication that affected her bowels. Our adviser said that her initial symptoms in 2010 should not, therefore, have triggered a specialist referral. However, when these symptoms continued, and increased in severity despite a significant increase in her laxative medication, this should have triggered action from the GPs. The adviser was of the view that while it was reasonable for the GPs to address the issue of the infective skin condition, they appeared to do so to the exclusion of any other possible underlying condition and did not take a proactive and holistic approach. Although the adviser noted that, even if they had acted more urgently, the outcome for Mrs A was likely to have been the same, we upheld this complaint as we found that there was unreasonable delay in referring Mrs A to a specialist.

One of the complaints referred specifically to how quickly the GPs dealt with blood test results. The adviser was of the view that the results were dealt with in a timely manner, although the referral which followed was to the wrong specialism. Therefore, on balance we did not uphold that complaint. Another complaint was that one of the GPs refused to refer Mrs A to the gastroenterology specialist. Our investigation found no evidence that the GP actually refused to refer Mrs A to this specialist. However, we found that the fact that all the GPs focussed their attention on the skin condition had the same effect, and so we also, on balance, upheld this complaint.

Recommendations

We recommended that the practice:

• issue a written apology for the failings identified;
• conduct a significant event audit of this case, with any findings and recommendations to be discussed at the GPs' next annual appraisals; and
• undertake a review of a sample of patient records to ensure that clinical note taking complies with the standards set by the General Medical Council's 'Good Medical Practice: Providing good clinical care'.

Summary

Mr C had suffered from abdominal and chest pain for several years. He complained that the board were unable to find out what was causing this. Mr C was under the care of a pain specialist at a hospital and was reviewed by surgeons, chest physicans, and gastroenterologists (specialists in the treatment of conditions affecting the liver, intestine and pancreas). He also complained that the pain specialist unreasonably refused him a specialised diagnostic scan and that he was not reviewed at regular intervals.

After taking independent advice from one of our medical advisers, our investigation found that thorough and appropriate assessments and investigations, including various specialised diagnostic scans, had been carried out. We also found that Mr C was reviewed at regular intervals and given appropriate pain relief in an attempt to address his pain.

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. About 15 months after being diagnosed with cancer, Mr A was given the all-clear. However, within two months, his symptoms had returned. Tests at first suggested that the original cancer had come back, but following a liver biopsy (where a sample of tissue is taken for examination in the laboratory), he was told that he had 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 two medical advisers, a consultant haematologist (a specialist in disorders of the blood) and a consultant oncologist (cancer specialist), found that once Mr A had been referred to the board, the investigation of his condition and his care and treatment were 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 both the board's specialist team and by another NHS board in his home area. The advisers 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 advisers said that his treatment complied with these standards and was, therefore, reasonable. They also considered that overall the care and treatment provided by the board was reasonable and timely.

Summary
Mrs C complained about the care and treatment that her father (Mr A) received from the board during the four months it took to provide a definitive diagnosis of pancreatic cancer (cancer of the pancreas - a gland in the digestive system). Mr A had been attending his medical practice, and they referred him to hospital for a range of tests. When the test results indicated the possibility of pancreatic cancer, Mr A was referred on an urgent suspected cancer pathway (a route into further treatments which are not available to GPs directly) for a scan. Following this, his case was discussed at a team meeting, and he was referred on for another specialist scan. The results of this test were reviewed at further team meetings, which identified a need for a specialist form of endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). Mr A had to wait four weeks for this test, and was given a final diagnosis of pancreatic cancer four months after he first attended his GP. During his hospital visits, he was seen by a clinical nurse specialist three times, but never had a clinic appointment with a consultant.

We obtained independent advice on this complaint from two medical advisers. Their advice indicated that pancreatic cancer is difficult to diagnose, so it took several tests to get a diagnosis. In Mr A's case, there were no significant delays in delivering the tests or results. However, we upheld Mrs C's complaint as our investigation found that the lack of contact with a consultant indicated a lack of good patient care. Mr A's needs and concerns were not kept at the heart of the process, and this made it more difficult for him and his family to accept the apparently slow progress in reaching a diagnosis.

Recommendations
We recommended that the board:

• conduct a significant event analysis around the substance of this complaint, particularly in relation to the conduct and role of doctors and specialist nurse practitioner in the delivery of diagnostic service, taking into account our advisers' concerns on this issue;
• ensure that the findings of this complaint become a significant part of the relevant consultant's next appraisal; and
• issue an apology to Mr A for failing to provide him with appropriate care and attention while he was undergoing diagnostic tests.

Summary

Mr C complained about the care and treatment of his late wife (Mrs C). Mrs C had developed a cough and, when it persisted, she visited her GP. She was given a range of medication over the next six weeks. When the cough did not clear up, the GP referred her for a chest x-ray, which was reported as normal, and she was referred to a respiratory consultant. While Mrs C awaited this appointment, her symptoms persisted and she developed a pain in her hip. She was given painkillers and referred for an x-ray of her pelvis. This was also reported as normal. When the pain continued and Mrs C also developed numbness in her shoulder, she was given an urgent referral to orthopaedic services. The hospital changed this to a normal referral. When this was identified, the GP changed the referral back to urgent. By this time, Mrs C had seen the respiratory consultant, who diagnosed her with a viral infection. When Mrs C had still not been seen by orthopaedic services a week later, her GP sent her to the hospital with an urgent referral. Mrs C was admitted, and was diagnosed with lung cancer.

Mr C complained that the medical practice failed to diagnose lung cancer for several months. Our investigation reviewed the NHS guidance on suspected cancer, and we took independent advice from one of our medical advisers. We did not, however, uphold Mr C's complaint. The advice we received was that the medical practice acted appropriately, based on the information they had. Mrs C was at low risk of lung cancer, and chest x-rays are the standard initial diagnostic tool. The lack of evidence of lung cancer was borne out by the chest physician's diagnosis of a viral infection. We also found that the medical practice referred Mrs C appropriately for x-rays and specialist opinion.

Summary
Miss C had gastric band surgery (surgery to fit a band around the top of the stomach to help weight loss) some years ago, but was not offered supporting lifestyle therapy sessions at the time and did not achieve the weight-loss that had been expected. After moving to another area, Miss C sought further surgery through her new health board. As the board did not have a bariatric (obesity) service at that time, she was referred to another health board, and funding was approved for surgery and supporting therapy sessions. Surgery was agreed pending completion of the therapy sessions, but the specialist left and Miss C was referred back to her local board, who by that time had the facility to provide the required treatment.
 
Miss C was again identified as a suitable candidate for surgery, which was to happen when she completed the therapy sessions. However, the lack of a suitable dietician meant that the therapy sessions could not be completed, and so surgery could not go ahead. Miss C complained that the board referred her for surgery without ensuring that all the necessary services were in place.

We accepted that surgery could not go ahead without a fully funded multi-disciplinary service being in place, consisting of surgical staff, psychology and dietetics. Initially, Miss C was referred to a board that had such a service, but was referred back to her own board when the service was disbanded.

Our investigation found that Miss C was accepted there as a candidate for surgery and that, although there was still no bariatric service in place, a surgical place was allocated to her from an allocation set aside for patients on a pilot diabetes project. The board gave three separate reasons as to why Miss C did not receive her surgery: she failed to attend therapy sessions; there was no suitably qualified dietician available; and there was no fully-funded multi-disciplinary unit. We found that the board had agreed to allow Miss C another chance to take the therapy sessions and that there was a dietician in place, although they were not funded to work as part of a multi-disciplinary team. With regard to the lack of a multi-disciplinary team, we found that the board were able to provide this service to patients on the diabetes project, but not to those requiring surgery outwith that project. We considered that the board failed to look at Miss C's case by taking all her needs into account. Having agreed that she was suitable for the therapy sessions and surgery and that funding would be made available for this, they should have followed through on their agreement and funded the dietetic input that was required. We concluded that this was an administrative failing, which meant that Miss C could not access the support services that would have completed the assessment of her suitability for surgery.
 

Recommendations
We recommended that the board:

• prioritise the completion of Miss C's assessment and therapy sessions in line with the National Planning Forum's guidance;
• ensure that full multi-disciplinary funding is made available for the completion of Miss C's therapy sessions and any surgical treatment that she may subsequently be approved for in line with the clinical advisory panel's approval;
• apologise to Miss C for the delay in progressing her case; and
• provide the Ombudsman with details of how they intend to meet the requirements for multi-disciplinary assessment and treatment of patients in line with the National Planning Forum's guidance.

Summary

Mrs C visited her GP after having had a cough for three months, and was prescribed antibiotics. Mrs C returned a few weeks later. She said she told the GP that she was unable to climb 20 stairs and that the GP noted Mrs C's breathlessness when talking to her. Soon after that, Mrs C visited the medical practice again, saying her cough was no longer a problem but that she was still breathless even when exerting herself very little. At a further consultation about a month later, Mrs C said she told the GP she could no longer climb the stairs, was using the lift at work and her inhaler was not working. The GP then prescribed steroids, referred Mrs C for a blood test and discussed referring her to a chest physician.

About a week after that, Mrs C said she attended the practice for blood tests but asked to see a GP. Mrs C said that the steroids were not helping and she was unable to walk the few metres into the consulting room without stopping. The GP agreed to refer Mrs C to a private consultant to speed up diagnosis. Later that month, however, Mrs C was taken to a hospital accident and emergency department with an acute attack of breathlessness, where she was quickly diagnosed with a pulmonary embolism (a clot in the blood vessel that transports blood from the heart to the lungs) that needed immediate treatment. Mrs C complained that her GP did not recognise the worsening symptoms or treat them with any sense of urgency, and did not adequately record the problem with breathlessness. She believed the delay in diagnosis caused a chronic (long-term) condition and that a potentially life-threatening situation could have been avoided.

As part of our investigation we took independent advice from a medical adviser, who studied Mrs C's medical records. The adviser said this was a complicated matter as, in his view, it involved two diagnoses, one related to the ongoing symptoms and the other to the acute symptoms. The adviser said that he considered that the early symptoms that Mrs C described were the result of pulmonary hypertension (raised blood pressure in the blood vessels that supply the lungs) and that later symptoms could have been caused by either this or the pulmonary embolism. He concluded that Mrs C had developed a progressive disease (pulmonary hypertension), but that the actions of the GPs had not changed the long term outlook. We did not uphold the complaint, noting that pulmonary embolism is difficult to diagnose and that the practice had throughout actively managed Mrs C's worsening symptoms and provided her with a reasonable standard of care and treatment.

Summary

Mr C made three complaints about the treatment that the board's mental health service gave his brother (Mr A). Mr A had long term mental health difficulties including paranoid schizophrenia (a condition that may cause hallucinations, delusions and muddled thoughts and behaviours). He lived independently and had been prescribed Modecate (an antipsychotic medication administered by injection) for many years. Mr C said this had resulted in severe physical impairment for Mr A including paralysis and locked muscles. He also felt it had been detrimental to Mr A's mental health and was inappropriate because he had suffered a head injury at a young age.

We did not uphold any of Mr C's complaints. We took independent advice from one of our medical advisers, and found that in order to manage this condition, it was often necessary to prescribe medication on a long term basis. We found that in Mr A's case, consideration had been given to the side effects of the drug, which had been balanced against the benefits of managing his psychiatric condition. We also noted that Mr A had been prescribed other medication to combat the side effects. We also found that the doctors treating Mr A had taken into account his head injury when deciding what medication he should be prescribed.

Mr C had also complained that Modecate was inappropriately stopped suddenly, and replaced with Olanzapine (an oral medication). We found that this was done appropriately. Olanzapine had less side effects than Modecate, and the change was made because Mr A was going to receive increased home support. This meant that he could be supervised in taking oral medication. We also noted that the change happened while Mr A was in hospital on a long term basis, and so the transitional period could be monitored.

Finally, Mr C had said that a doctor had suggested that he apply for a power of attorney in respect of Mr A, but had then carried out an assessment that found that Mr A did not have the capacity to make a decision about that. Our investigation found no evidence that the board had unreasonably suggested Mr C apply for this and also found that the general assessment of Mr A's capacity was conducted appropriately. However, as we noted that Mr A had not been assessed specifically on his capacity to consent to medical treatment, we made a recommendation about this.

Recommendations

We recommended that the board:

• conduct an assessment of Mr A's capacity to consent to treatment and ensure the results inform his treatment plan.