Health

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.

Summary

Mr C complained to the medical practice about the level of treatment he had received there over a period of a few years. They responded, acknowledging that there had been communication difficulties with Mr C, and that actions of and comments from the GPs had been made with the best of intentions.

It was their view that Mr C had misinterpreted these. However, as a result of the complaint, the practice said that they had learned that they should be more sensitive and vigilant towards any patient who is dissatisfied or unhappy with any member of staff.

Our investigation found that the medical records confirmed the information in the practice's response to Mr C, and that they had carried out a thorough investigation into his complaint.

Summary

Mrs C complained about the care and treatment her husband (Mr C) received in hospital during two separate admissions. Mrs C was dissatisfied that her husband was discharged from the hospital despite being advised that he would be undergoing further tests at a second hospital while an inpatient. She was also dissatisfied with the care Mr C received during a second admission because she said there were communication problems between two doctors about arrangements for Mr C to have a coronary artery bypass graft (CABG - a surgical procedure to treat coronary heart disease) at the second hospital. Mrs C said that in response to the complaint, the board acknowledged her frustration at the length of time Mr C waited for the CABG but advised that they did not consider there had been any mismanagement by the first doctor.

Our investigation found that there was evidence to support that the first doctor provided appropriate care during Mr C's first admission and made reasonable attempts during the second admission to transfer Mr C to the second hospital with a view to having a CABG carried out. We also established that the second doctor had to ensure that Mr C was fit to undertake major cardiac surgery, because of a number of underlying health conditions. Although we did not uphold the complaint, we made a recommendation to address the issue of joined-up care between hospitals.

Recommendations

We recommended that the board:

• review how they share information about a patient's management plan between hospitals to ensure timely care and treatment.

Summary

Mr and Mrs C complained about care that the board provided to their son (Mr A). Mr A was placed in foster care in an area away from the family home. The doctor who had been treating Mr A at home referred him to the new area's child and adolescent mental health services team (CAMHS). Mrs C complained that she and Mr C were not involved in the subsequent process.

We upheld this complaint. Our investigation found that there was no opportunity for Mr and Mrs C to express their views to the team despite the fact they maintained parental rights. We also found that CAMHS did not communicate with Mr and Mrs C until a third party prompted them to do so. We also upheld a complaint that mental health care arrangements for Mr A were not reasonable. We found that, although the board had attempted initial unsuccessful engagement with Mr A, his views had not been clearly sought at any stage. We noted that, during a meeting, those involved considered that Mr A was 'reluctant' to engage with CAMHS, but did not initiate a follow-up plan (which should have included obtaining Mr A's views clearly). Five months passed before Mr A was contacted again with the offer of an appointment, which he accepted.

We did not uphold a complaint that staff unreasonably failed to contact Mr and Mrs C when Mr A was admitted to hospital, as we found that they had acted reasonably by accepting that Mr A's foster parents, who had attended hospital with him, were acting as the responsible adults. Mrs C said that Mr A had been asking for her and Mr C, but we found no evidence that staff at the hospital were aware of this, as this information came from Mr A's foster carers rather than the medical records.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for not involving them in Mr A's transfer to CAMHS;
• review the procedures within CAMHS following referrals, to ensure parents have the opportunity to exercise their parental rights, where appropriate, and that parents are advised of outcomes and communicated with appropriately;
• ensure all the staff concerned, and the CAMHS team as a whole, are reminded of the need to maintain detailed minutes during professionals' meetings and to ensure the terms of a referral are considered fully; and
• review CAMHS processes to ensure that the views of the child or young person concerned are taken into account in a timely way.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr C), who had heart problems, during three admissions to hospital. Mr C was to have an operation to improve the blood flow to his heart. Mrs C said that, over the three admissions, her husband's transfer to a second hospital for the procedure was cancelled five times. He was eventually transferred, but died late the following evening. Mrs C also complained that it was unreasonable that she was referred to the second hospital for information about the cancellations, and that the board's response to her complaint glossed over the reasons for one of Mr C's discharges from hospital and was not consistent with the response from the second hospital.

Our investigation, which included taking independent advice from a medical adviser who is a consultant cardiologist (heart specialist), found that the reasons for the multiple cancellations of Mr C's transfer were all medically based. The adviser was of the view that each of the cancellations was reasonable, based on his clinical condition at the time. They also said that the procedure he was to undergo was designed to relieve chest pain. However, because of his other serious medical conditions, even if the procedure had been carried out during Mr C's first admission to hospital it would have been unlikely to have changed the eventual outcome or to have prolonged his life. This is because Mr C's eventual condition would not have been cured, altered or improved by the procedure.

On the matter of Mrs C being referred to the second hospital for further information on the cancellations, we found this was not unreasonable. Cancellation decisions were made jointly on the basis of her husband's clinical condition and the second hospital had the final say in whether or not he was fit to undergo the procedure. It was, therefore, reasonable that Mrs C should be referred to them for further information. Our investigation also found that the reasons for her husband's discharge were clear and had been made clear at the time. He was discharged so that another medical condition could be addressed to try to ensure that he was fit enough to undergo the surgical procedure, and we took the view that this was reasonable. Similarly, we found that there was no contradiction in the information provided in the complaint responses. Although we appreciated that this had been a very difficult time for Mrs C and her husband, we were satisfied that the overall care and treatment provided was reasonable.

Summary

Mr C has dementia. His wife (Mrs C) complained that the care and treatment provided to her husband by two hospitals was below a reasonable standard. She also said that when Mr C was reviewed by two doctors from an out-of-hours GP service they ignored her concerns that Mr C had a deep venous thrombosis (DVT – a blood clot in a vein). Mrs C also complained about a lack of communication from staff about Mr C's condition.

Mr C normally lived at home but in April 2011 he was in respite care when he became ill. His confusion increased and his mobility was affected. He was admitted to hospital but discharged three days later. Just over a week after he was discharged, Mrs C reported that Mr C was feeling terrible and had swollen legs and feet. He was seen on two consecutive days by GPs from the out-of-hours service. No definitive diagnosis was reached at either of these visits and Mrs C was given advice on managing Mr C's condition and to contact them again if his condition worsened. Mr C was, however, admitted to hospital again two days later, where DVT was diagnosed. He was transferred to another hospital, where he remained for three months before he was discharged.

We did not uphold Mrs C's complaints. Our investigation, which included taking independent medical and nursing advice, found no failings in the care and treatment provided to Mr C. Mrs C had been particularly concerned about two drugs given to her husband, an antipsychotic and a tranquiliser. Although more commonly used to treat mental illness, these drugs have been found to be useful, in low doses, for short periods under careful monitoring for those displaying the anxiety and agitation that can be a part of dementia. Our advisers were satisfied that the dosages were appropriate and that careful monitoring, dosage reduction and eventual withdrawal followed.

Our investigation found evidence of regular communication from staff to the family, in face to face or phone conversations. Mrs C complained that the family had had to seek out information and take the first steps in communicating with staff, but we found that it would be impractical and unreasonable to expect staff to always be proactive in communicating with patients' relatives. We found no evidence that the family were refused, or had any difficulty in obtaining, information about Mr C's condition.

Our investigation also found that the records showed that the out-of-hours GPs made appropriate and thorough examinations of Mr C. They considered DVT as a possible diagnosis but could make no definitive diagnosis at the time of the visits. Our medical adviser found no evidence of failure on the part of either GP.

Summary

Mrs C attended the board's dental service, as her dentures were loose and uncomfortable. She had a new lower denture fitted and her top denture relined. However, she found the new dentures uncomfortable from the outset and returned to the service. The dentist made her a new lower denture based on her original dentures. Mrs C was unable to eat with these dentures and they caused her pain. She went back to the dental service again and was referred to the dental hospital. She was told to wear her old dentures in the meantime, as they fitted better.

Mrs C saw a consultant at the hospital. He suggested replicating her old dentures, and adding a permanent soft lining material. He placed her on the waiting list for treatment by postgraduates at the hospital. However, at that time, they were reaching the end of their placements and were unable to offer treatment to new patients. Mrs C told us that due to the delay, she decided to get private treatment. She said that the dentist she saw privately was able to make her dentures without any difficulty.

Our investigation found that the board had failed to let Mrs C know that there would be a delay in her treatment because the postgraduates were unable to offer treatment to new patients at that time. Due to the delay that occurred as a result of this, the board failed to meet the 18 weeks referral to treatment target. Although the board's view was that the dentures made by the dental service were not defective, we found that they had accepted that the dentures were not fit for purpose by agreeing to make new ones.

Recommendations

We recommended that the board:

• consider how they can prevent delays for patients referred to postgraduates at the dental hospital for treatment; and
• refund the money Mrs C paid for dentures that she was unable to wear.

Summary

Mrs C's GP referred her to hospital because she suddenly lost the vision in her left eye. She was diagnosed with a blockage of the main artery supplying the retina (the inside lining of the eye), and her loss of vision was severe and permanent. Mrs C attended the hospital again a few days later with similar symptoms affecting her right eye. She was then given a high dose of steroids, as it was suspected she had giant cell arteritis (GCA - inflammation of the blood vessels, usually in the head, which can cause blindness).

Mrs C's husband (Mr C) complained to the board that Mrs C was not closely monitored after being prescribed such a large dose of steroids, but we did not uphold his complaints. After taking independent advice from one of our medical advisers, we found that the relevant consultant kept Mrs C under appropriate review, and there was a clear plan for the management of her steroids. We concluded that although Mrs C did suffer side effects, which were very distressing for her, these were properly assessed against the risk of her losing her eyesight permanently and having a stroke.