Health

Summary

Mr C complained about the care that his late mother (Mrs A) received from doctors and nurses at her medical practice. Mrs A's overall health had been deteriorating for some time. She was admitted to hospital with advanced lung disease and died shortly after admission. Mr C was concerned about the condition of his mother's legs and felt in particular that the doctors and nurses had failed to treat ulcers.

Our investigation found that the care provided to Mrs A was good, and that there was clear evidence that an ulcer was identified and treated appropriately until it healed. We noted that Mrs A's legs had changed colour towards the end of her life due to poor circulation, but we received independent medical advice that this did not reflect unreasonable care. Although we did not uphold the complaint, we did make a recommendation in relation to the practice's complaints handling.

Recommendations

We recommended that the practice:

• provide evidence to the Ombudsman that staff receive advice and/or training in relation to responding to complaints from recently bereaved individuals.

Summary

Mr C fell from his bicycle at speed and landed on his head. His GP was concerned that he might have suffered a spinal injury and arranged for him to go to hospital. Mr C was x-rayed, and discharged with a diagnosis of a soft tissue neck injury. Three days later, the hospital contacted Mr C, saying that, following a re-examination of his x-ray, it was possible that he had a cracked rib. Mr C went back to the hospital where he was given scans that confirmed the cracked rib and also identified cracked vertebrae. Mr C was fitted with a neck collar.

Mr C complained that there was a failure to carry out an appropriate assessment at the hospital when he first attended and that he was discharged home without a neck support. He also complained that when he next attended the hospital there was a delay in providing him with a neck collar once the fractured vertebrae had been confirmed. Having looked at the medical records and taken independent advice from our medical adviser, we found that the cracked rib should have been identified from the x-ray when Mr C first attended hospital. We upheld that complaint and made recommendations to address this. However, we did not uphold his other complaint, as our investigation found that the remainder of his care and treatment was appropriate.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to identify his rib fracture; and
• review the arrangements in place for assessing x-rays and remind relevant staff that attention must be paid to all information on the film including information outside the focus of the subject of the x-ray.

Summary

Mrs C complained on behalf of her son (Mr A), who was admitted to hospital on a voluntary basis to try to address his obsessive-compulsive disorder (OCD - an anxiety disorder where a person has obsessive thoughts and displays compulsive behaviour). Among other things, Mr A found it very difficult to share toilet facilities with other people, including his family. He was admitted to a mixed-sex dormitory-style ward, where there were only a few single rooms with private toilets. These rooms were allocated on the basis of clinical necessity. Although at times one or more of these rooms was vacant while Mr A was on the ward he was not allocated one, despite his and his mother's requests. Mr A became dissatisfied with his care and treatment, and discharged himself against medical advice. Mrs C later complained that her son did not receive appropriate care and treatment while he was on the ward. She said that he was not allocated a single room with private facilities, so instead he used bedpans, which were not emptied frequently enough; a doctor did not listen to Mr A during a review; and, when Mr A discharged himself, he was told that he would not get his medication.

When we investigated, the board told us that they decided to place Mr A on the ward on the basis of a clinical assessment that providing him with access to private facilities would not help him address his OCD. Our investigation, which included taking independent advice from one of our medical advisers, found that this was a reasonable decision. However, the adviser considered that allowing Mr A unlimited and unsupervised access to bedpans was in fact counter-productive. We found no evidence that the disposable bedpans used were not regularly disposed of, but noted that the board also said that Mr A sometimes hid used bedpans or would only accept assistance to dispose of them from certain staff and would wait until they were on duty.

Similarly, we found no evidence that the doctor involved in the review talked over, or would not listen to, Mr A. Where versions of events differ, and without truly independent evidence to support either version, we cannot prefer one version over another. We did find evidence that Mr A was very keen to discuss certain issues, mainly to do with dissatisfaction with some staff members, but that the doctor did not pursue these. It is possible that Mr A may have perceived this as not being listened to or being talked over. On the matter of medication, a series of appointments with a psychologist had been made, the first of which was to be on the day after Mr A discharged himself. He was issued with only 24 hours worth of his regular medication, in the hope that this would encourage him to keep the appointment. Unfortunately, he did not. Our adviser considered, however, that it was reasonable to only dispense a limited amount of medication in these circumstances. There was no evidence that Mr A was refused medication or only proved with medication on condition that he signed the discharge form.

Overall, however, as we found little evidence of the type of structured, supportive and focused care plan that we would have expected to address Mr A's complex condition and behaviours, we upheld Mrs C's complaint and made recommendations to address the failings our investigation found.

Recommendations

We recommended that the board:

• provide appropriate training to enable multi-disciplinary team working to be supported by cohesive and structured care plans that are appropriately recorded in a patient's notes;
• monitor the implementation of the 'Ten essential shared capabilities for mental health practice' training to ensure that relevant rights-based and recovery-focused care is being provided; and
• apologise for the failings identifed.

Summary

Ms C complained about the length of time that it took to provide a diagnosis for her father (Mr A), who was eventually diagnosed with pancreatic cancer. Mr A initially attended his medical practice complaining of abdominal pain, weight loss and vomiting. He was prescribed medication, blood samples were taken, and he was referred for an endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside). This found a hiatus hernia (where part of the stomach pushes up into the lower chest) and gastritis (inflammation of the lining of the stomach), for which Mr A had already been given medication. The blood tests, however, showed abnormalities, and Mr A's GP remained concerned. She referred Mr A for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body). This came back normal, but the head of Mr A's pancreas was not visible. The GP remained concerned, so she referred Mr A for an urgent CT scan (a special scan using a computer to produce an image of the body) through an urgent suspected upper gastro-intestinal cancer pathway (a route into further treatments not available to GPs directly).

We took independent advice from our medical adviser, which indicated that the steps taken by the GP in reaching a diagnosis were appropriate. The adviser noted that pancreatic cancer is difficult to diagnose. The diagnostic path required several tests, but there was no evidence of any delays within the practice in either making referrals or passing on test results. Our investigation also found no evidence of delays in providing test results.

Summary

Ms C complained about the treatment her daughter (Miss A) had received from the Child and Adolescent Mental Health Service (CAMHS). She said that they had not responded soon enough when she and her daughter had expressed concerns about Miss A. Miss A experienced a significant deterioration in her eating behaviour, which coincided with a planned break from treatment, and a change in treatment staff. Ms C told us that she was concerned about her daughter's behaviour and weight loss, and while the staff did respond, by the time Miss A was referred to a specialist unit, she had to be hospitalised for re-feeding before she could receive treatment for her eating disorder. She felt that this significant deterioration in her daughter's health could have been avoided.

As part of our investigation, we sought independent advice from one of our medical advisers. Having taken this advice, we upheld Ms C's complaint on the basis that, while community-based approaches to eating disorders can be effective, they require a strong working relationship between family and staff. This should be in place before the situation becomes critical. Given the absence of such a relationship, the community-based approach was unlikely to be effective in Miss A's case. The absence of a risk assessment also meant that there was less scope for staff to correctly assess the situation when it became critical, and act accordingly. The family had to wait for over a month before Miss A was referred to a specialist unit, and during this time her weight loss continued and her condition deteriorated. We agreed that this could have been avoided if an eating disorder risk assessment had been in place.

Recommendations

We recommended that the board:

• develop a clear CAMHS protocol about the risk assessment of eating disorders;
• consider developing clear CAMHS guidelines on what situations merit priority and specialist referral; and
• provide information which will assure the Ombudsman that systems are in place within the CAMHS team to ensure that handover (including risk assessment) between health professionals is robust and documented to the standards required.

Summary

Mrs C was admitted to hospital, suffering from increased confusion and needing more and more pain relief. She was also on a high dose of steroids for giant cell arteritis (GCA - inflammation of the blood vessels, usually in the head, which can cause blindness). She was transferred to another hospital nearly four weeks later, then back to the first hospital around three months after that. Mrs C's husband (Mr C) complained that she fell while in both hospitals and was concerned that these events had not been properly investigated. He also said that his wife's medication was not properly monitored, that the nursing care in relation to her deteriorating condition and pressure ulcer was inadequate and that his complaints were inadequately handled.

As part of our investigation we took independent advice from a medical adviser. They said that Mrs C had a complicated medical history, but that she had an unacceptable number of falls in the first hospital, and that the assessment of her being at risk of falling was inadequate. In line with national guidance, staff should have done more to prevent Mrs C from falling, and so we upheld the complaint that she was not properly monitored or assessed for this. However, we did not uphold Mr C's other complaints about his wife’s care. Our investigation found that after each of the falls both hospitals treated Mrs C's symptoms appropriately. We also found evidence showing that Mrs C was appropriately monitored and assessed for the medications she was prescribed. She received good personal care from nursing staff, and an appropriate care plan was implemented for a pressure ulcer that developed on her heel. This was dressed regularly but we noted that there was no wound chart for it - to have one would have demonstrated good practice in wound care management.

We also upheld Mr C's complaint about complaints handling. Our investigation found that, although the board's responses to the complaints addressed the issues concerned and explained the reasoning behind treatment decisions, they should have tried to address the underlying issues when responding to Mr C. In addition, the length of time it took the board to respond to the complaint was unreasonable, only occurring after we had started to investigate the complaint, some nine months later.

Recommendations

We recommended that the board:

• provide Mr and Mrs C with a full apology for the failings identified;
• ensure all relevant staff at the first hospital are aware of and implement appropriate falls prevention measures, including when to seek the advice of a falls specialist, in line with national guidance;
• remind relevant staff that when prescribing off-label (prescribing drugs in unusual circumstances or doses) the relevant protocol should be followed to ensure there is a proper record and the patient or, where appropriate, their family, is fully informed;
• take steps to acknowledge and address any clear underlying issue causing distress to the complainant as far as possible in complaint responses; and
• ensure that responses to complaints are sent out in a timely manner within the appropriate NHS complaints timescale.

Summary

Mr C's wife (Mrs C) visited a medical practice on a number of occasions complaining of stomach pain. Mr C complained that the practice unreasonably delayed in diagnosing his wife's illness. The practice initially gave Mrs C painkillers. When the pain did not go away the practice took blood tests to rule out cancer. Mrs C then started to complain of weight loss as well as pain. When these symptoms occurred together the doctor referred her to general surgeons at the local hospital, where Mrs C was diagnosed with mesenteric ischemia (a condition that reduces blood flow to the bowel).

To investigate the complaint we took independent advice from one of our medical advisers. He explained that this diagnosis was difficult to make, and would need to be made at a hospital as it required detailed investigations to confirm it. The adviser was satisfied that the practice had referred Mrs C appropriately when she started to have increasing pain and weight loss. The adviser confirmed that there was no evidence of an unreasonable delay in diagnosis.

Summary

Ms C has type 2 diabetes. In July and August 2012 she attended, or was admitted to, hospital five times with swollen, painful legs. Deep venous thrombosis (DVT - a blood clot in a vein) was discounted and she was ultimately diagnosed as having cellulitis with some pitting oedema (an indentation on the skin that persists for some time after the release of pressure). After her last discharge, her GP advised her to stop taking the medication she had been prescribed, as she had neither DVT or cellulitis. He prescribed diuretic tablets (drugs that enable the body to get rid of excess fluid) which, Ms C said, remedied the problem. Ms C complained that the board failed properly to diagnose her condition and that she had been wrongly treated for cellulitis. She said that if the correct diagnosis had been made earlier, she would have improved sooner and spared unnecessary pain.

As part of our investigation, we obtained independent advice from one of our medical advisers. We carefully considered all the complaints correspondence and Ms C's relevant clinical records. The adviser said that, while the treatment given to Ms C was not unreasonable, overall there appeared to be a lack of clinical awareness. He said that although, throughout, she had pitting oedema, which indicated that diuretic therapy should be tried, it was not. The adviser said that if this had been tried earlier, it would likely have resolved Ms C's problem.

Recommendations

We recommended that the board:

• apologise to Ms C for failing to appropriately assess and treat her; and
• conduct a critical incident review into the circumstances in this case.

Summary

Mr C suffers from ulcerative colitis (a disease where inflammation develops in the large intestine). When he became unwell, his GP advised him to go to the accident and emergency department. Mr C was admitted to hospital and given an intravenous steroid (a drug used to treat inflammation, introduced directly into a vein) while awaiting a gastroenterology (digestive system and its disorders) review. After the review, because Mr C was eating and drinking, the doctor who reviewed him prescribed the steroid in oral form (to be taken by mouth). After a discussion with the hospital pharmacist, the doctor noted that before Mr C was admitted to hospital, he had been taking a different oral steroid. The doctor, therefore, changed the prescription and put Mr C back on the steroid he had been taking before admission. Mr C was unhappy with this, as he felt that steroid had not been helping him, and he discharged himself from the hospital.

As part of our investigation we took independent advice from a medical adviser. The advice we received indicated that it was appropriate to give intravenous medication after admission to hospital, until tests are carried out and it is established that the patient can tolerate oral medication. The adviser also confirmed that the decision to re-prescribe the steroid that Mr C had been taking prior to admission was reasonable, as the effects of both steroids were similar.

Summary

Mr C's daughter (Miss A) who was three years old, was taken to her medical practice because she was vomiting. Mr C complained that GPs there failed to appropriately investigate Miss A's symptoms and that this led to a delayed diagnosis of a brain tumour. Miss A's parents had taken her back three days after the first visit, and further vomiting was reported. The GP recorded that a referral to a paediatrician should be considered if the current pattern of vomiting continued. Miss A's parents brought her to the practice again three months later. It was recorded that she had a viral infection and that she had had a few episodes of vomiting. She returned to the practice again nearly eight weeks later. It was recorded that the vomiting had continued for a number of months and that she vomited approximately every two weeks. The GP prescribed medication for stomach problems.

Miss A was taken to the practice again ten days later, which was her fifth visit about vomiting. It was recorded that she was vomiting as before and this had been for a few months on and off. She was prescribed further medication. It was recorded that her parents should call the practice if this was not working and she would then be referred to a paediatrician. Two weeks later, Miss A was referred to a paediatrician in view of the unexplained vomiting. This was noted as a routine (not an urgent) referral.

Miss A attended the practice again two weeks later, before she had seen a paediatrician. It was recorded that the vomiting was on-going and that she had been tired lately and had a bradycardia (slow heart rate) when lying down. A referral was made to a private paediatrician, as her parents had private health insurance. Mr C's wife phoned the practice later that afternoon, however, as Miss A's condition had worsened and she was now more drowsy. It was arranged that Miss A would be taken to hospital for assessment, where she was admitted. The next day, another hospital phoned the practice to tell them Miss A had been admitted there, as she had a brain tumour that required urgent neurosurgery.

Our investigation found that the practice carried out a significant event analysis to assess why their GPs did not refer Miss A for a specialist opinion earlier. They considered the National Institute for Health and Care Excellence (NICE) referral guidelines for suspected cancer, which say that when a child presents with the same symptoms several times, but there is no clear diagnosis, they should be referred to hospital urgently. The practice acknowledged that under these guidelines Miss A's referral could have been made earlier, as an urgent case. In addition, the GP who saw Miss A at her second visit had recorded that referral to a paediatrician should be considered if the current pattern of vomiting continued. Despite the fact that Miss A did continue to vomit and attended the practice a further three times, she was not initially referred to a paediatrician. When the referral was eventually done, it was marked as routine rather than urgent. This was a balanced decision, but having carefully considered the matter, we upheld Mr C's complaint. In view of the action taken by the practice as part of the significant event analysis, however, we did not find it necessary to make any recommendations.