Summary
Mr C complained to us about advice given to him by the board's out-of-hours service. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix we were unable to take this complaint further and closed our file.
Summary
Mr C, who is a prisoner, complained about the prison health centre's complaints handling. Mr C had submitted a formal complaint about the health care and treatment he had received. However, the health centre responded to the complaint under the feedback procedure, not the complaints procedure. The board said that this was in accordance with the approach for all informal complaints, which should be dealt with by local response. They said that any further complaints or feedback forms would be dealt with through the formal complaints procedure. They also commented that, where possible, complaints are addressed at the point of contact, unless the complainant wished to pursue their complaint through the formal complaints procedure.
We considered that as Mr C had submitted a formal complaint, it should have dealt with as such. We were concerned that the board were using the feedback procedure as an additional level to the NHS complaints procedure. This is restricting, and over-complicates prisoners' access to the NHS complaints procedure. It is clear that Scottish Government guidance does not require NHS users to complete the feedback procedure before accessing the complaints procedure. This should also apply to people receiving NHS care and treatment whilst in prison.
Mr C went on to make a further formal complaint to the health centre. However, he said that they returned the complaint form to him, and explained that it was not answered, along with several others, due to the fact that they met him to see if the issues could be dealt with. They said that during the meeting, Mr C withdrew the complaint after agreeing that the problems were resolved. However, we found no records to support this in the evidence we received from the board.
Mr C then submitted a further complaint to the health centre, but did not receive a response. The health centre should have sent this complaint to the board for response. Mr C contacted the board, who advised that they had not received it from the health centre. The board could provide no explanation as to why this complaint and the previous complaint were not submitted to them in line with their complaints procedure. In view of these failings, we upheld Mr C's complaint.
Recommendations
We recommended that the board:
Summary
Ms C is an advocate for the sister of the late Mr A. Ms C complained that the care and treatment that two medical practices provided to Mr A was unreasonable.
Mr A had attended the first practice until March 2010, when he changed his registration to the second practice. At the time of the events complained about, the practices were independent of each other. The second practice has since taken over management of the first practice.
Mr A began to attend his GP at the first practice in July 2009, reporting recurring bouts of diarrhoea. Blood tests suggested that he had an infection of helicobacter pylori (a bacteria commonly found in the stomachs of middle-aged people which has been linked to ulcers and some stomach cancers). Mr A was treated with three different types of antibiotics and was advised to eat a bland diet. He continued to report symptoms of altered bowel habit, and then weight loss, as his food and drink options became more limited.
Mr A was eventually referred to hospital in February 2010, and was diagnosed the following month with Mantle Cell Lymphoma (MCL - a cancer of the white blood cells). He was treated by both his local NHS board and the specialist team at another board. In June 2011, he was told that his test results were clear.
In August 2011, however, Mr A's symptoms returned and he again visited a GP, this time at the second practice. Tests initially suggested that the MCL had returned. However, after a liver biopsy (where a sample of tissue is taken for examination in the laboratory), Mr A was told that he had a second type of cancer, incurable small cell lung cancer. This had already spread to his liver. Mr A died some three weeks later.
As part of our investigation, we took independent advice from a medical adviser. We found that in July 2009 the North East Scotland Cancer Co-ordinating and Advisory Group had issued guidance for GPs on the action to take and when to take it, when patients reported symptoms suspicious of cancer. A symptom that should have triggered an urgent referral to a specialist colorectal surgeon (a specialist in disorders of the stomach and bowel) was where a patient reported altered bowel habit for more than six weeks. Mr A had reported his symptoms for some seven months before he was referred. Even then, he was given only a routine referral to a general surgeon, rather than the urgent specialist referral described in the guidance. We upheld Ms C's complaint and made recommendations to address these failings.
Recommendations
We recommended that the practice:
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:
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:
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:
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.