Health

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.

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.