Health

Summary

Mrs C complained about the care and treatment a medical practice provided to her father (Mr A). Mrs C raised concern that the GP had not carried out a physical examination of Mr A when she first raised concern that he was confused. Mrs C said that despite her father living alone and having mobility problems, a phone discussion had only taken place where the GP prescribed antibiotics for a suspected urinary tract infection.

Mrs C continued to raise concerns with the medical practice about Mr A’s confusion. The GP then visited Mr A at home and thereafter referred him to a specialist for further assessment as she suspected he was suffering from the onset of dementia. Mrs C remained concerned about Mr A's health and contacted NHS 24. Mr A was subsequently taken to hospital by ambulance and further tests identified that he had suffered a stroke.

As part of our investigation we obtained independent advice from a medical adviser. We concluded that the initial phone consultation carried out by the GP was insufficient. We found that the GP, who was in fact a doctor in training, should have organised a home visit when Mrs C first reported her father's symptoms so that he could be fully assessed and his future management discussed with Mrs C.

Recommendations

We recommended that the practice:

• apologise for the failings identified;
• carry out a significant event analysis of Mr A's case; and
• draw our findings to the attention of the GP in training.

Summary

Mr C's mother (Mrs A), who suffered from Parkinson's disease, was admitted to hospital where she stayed for almost three months. After three weeks, she was transferred to a long-term ward before being discharged to a care home. Mr C said he was told that Mrs A was being transferred due to pressure on beds and would now be under the care of another consultant. He believed, however, that the consultant did not see Mrs A at all during her five week stay in that ward. He also believed that staff failed to ensure that Mrs A took her medication. Mr C also noted there was no walking frame in the ward and was told there was no rehabilitation or occupational therapy there. He had noticed that Mrs A's left hand had become rigid, and believed this was down to a lack of mobility opportunities and failure to provide medication. He also complained about one of the doctors, and that when his mother was discharged she had an injury about which he believed staff had lied to him.

As part of our investigation we took independent advice from two advisers - one specialising in nursing and one in medical care of the elderly. We upheld both of Mr C's complaints. In relation to the overall medical management of Mrs A's Parkinson's disease, the advice we accepted was that in the main the care and treatment provided to Mrs A was reasonable. However, the medical adviser said that there was no evidence that the consultant reviewed Mrs A, and we can only reach a judgement based on the evidence available to us. In this case the evidence indicates that the consultant did not see and review Mrs A as they should have done. Referring to the nursing care provided, the advice we accepted was that while aspects of this were reasonable, there were failures relating to prescribed medication. Although there was no evidence that missing the medication had caused Mrs A harm, we considered that the failure to record why it was not dispensed or to note other actions (such as informing medical staff) was significant.

Recommendations

We recommended that the board:

• bring our medical adviser's comments about the doctor to their attention and ensure that the doctor reviews the clinical care of their patients as per their duty of care towards them and fully records this;
• bring the failures in record-keeping in relation to prescribed medication to the attention of relevant staff;
• amend their policy to outline procedures to be followed when prescribed medicines are not dispensed; and
• apologise to Mr C for the failures identified.

Summary

Mr C's son (Mr A) attended a hospital accident and emergency department (A&E) complaining of left-hand rib pain, and pain in his elbows, right hip and shoulder, left wrist and lower back. An A&E junior doctor arranged for him to have a chest x-ray and reported that there was evidence of a lytic lesion (an area of bone damage, which can be caused by cancer) on one of Mr A's ribs. The doctor made an urgent referral for Mr A to be seen at the chest clinic. The x-ray was later reviewed and formally reported by a senior trainee radiologist. They did not identify a lytic lesion and did not mention it on the formal x-ray report. Based on the x-ray report, the consultant respiratory surgeon at the chest clinic contacted Mr A's GP and advised that there was nothing to be concerned about. He arranged for repeat x-rays in six weeks and did not see Mr A in his clinic. Mr A's condition deteriorated and he was ultimately diagnosed with advanced cancer, probably gastric in origin, which had spread to his bones. Mr C complained that radiology staff provided conflicting interpretations of the x-rays, causing a delay to Mr A's diagnosis.

After taking independent advice from two medical advisers, our investigation found that the lesion was present on the original x-ray but was not reported by the senior trainee radiologist. We acknowledged that the lesion was not clear and that it was not necessarily unreasonable that the radiologist did not identify it at that time. However, clearer abnormalities were missed by radiology staff on further x-rays taken the following month. We were also concerned that the consultant made a definitive decision about Mr A's condition based only on the x-ray report, when there was evidence that he had seen the A&E doctor's conclusions and had possibly reviewed the x-ray films himself. We considered that, based on the information available to him, the consultant should have seen Mr A in his clinic. We found that Mr A's diagnosis was delayed as a result of this. Although we recognised that this would not have affected his prognosis, he could have entered palliative care sooner and his pain could have been managed more effectively.

Recommendations

We recommended that the board:

• apologise to Mr C and his family for the failings that led to the delay to diagnosing Mr A's cancer;
• ask their radiology and respiratory staff to reflect on this case with a view to identifying points of learning for the future; and
• conduct a serious incident review of Mr A's case.

Summary

Mr C's son (Mr A) attended his then medical practice in June 2011 complaining of left hand rib pain and pain in his elbows, right hip and shoulder, left wrist and lower back. He was examined by the GP, blood tests were taken and he was prescribed pain medication. Mr A's pain worsened and he had a further phone consultation with his GP. Advice was given, and Mr A was encouraged to join a different practice closer to home, as he no longer lived in his current GP's area.

Mr A transferred to a new medical practice. Before his first consultation there, Mr A's pain worsened again and he attended a hospital accident and emergency department (A&E) where x-rays were taken, showing evidence of possible cancer. He was referred to the hospital chest clinic, but the chest physician reviewed the information and decided that he did not need to see Mr A. When Mr A attended his first consultation at the new medical practice, his health records had not yet arrived from the previous practice. Because of the time it took to add Mr A's information to the computer system, important results from A&E were not available at his next appointment. Before Mr A had his second consultation at the practice, the chest physician from the hospital contacted them and advised that Mr A had nothing to be concerned about. Mr A was treated with pain killers on the understanding that he had a cracked rib.

Mr C complained that the new practice did not ensure they had all of Mr A's records and test results to hand when examining him, and that the GPs who examined him did not conduct thorough examinations, preferring to prescribe stronger pain medication to alleviate his symptoms. Having taken independent advice from one of our medical advisers, our investigation found that the initial lack of records during the first consultation was outwith the practice's control. The call from the chest physician then reassured them that there was nothing sinister in Mr A's chest x-ray. We considered that, once the records arrived, they could have been made available to the GPs before they were added to the computer system. Given, however, the advice provided by the chest physician, we took the view that it was very unlikely that the treatment offered to Mr A would have been any different had his x-ray results and other records been available. We noted that the practice have since changed their procedures to ensure that GPs are made aware of any patient information that has not yet been added to the computer system.

Summary

Mr C, who is a prisoner, was told by a prison officer that he was to attend an appointment at the prison health centre. The doctor wanted to review Mr C's 'medically unfit' status. Mr C said that he was not well enough to go to the appointment and asked the prison officer to tell the health centre. After this, Mr C complained that he had to pass information about his health to the prison officer, which he felt was inappropriate.

During our investigation, the health board explained to us that prison staff are responsible for the movement of prisoners around the different areas of the prison. That includes taking prisoners to the health centre for appointments. In addition, the board confirmed that prisoners are required to let prison staff know when they feel unwell. They advised that prisoners do not need to explain to staff why they are unwell.

In light of the information provided, we were satisfied that what happened in Mr C's case was appropriate and we did not uphold his complaint.

Summary

Mr C, who is a prisoner, complained that the board had refused his requests to see the prison doctor. Mr C had attended the prison's health centre regularly with approximately two to three consultations every month over a six-year period. He made several requests to see a doctor in 2012. However, he received reply slips either asking for more information or advising that his current medication was sufficient and that a consultation with the doctor was not required. Mr C said that because of this his condition had gone undiagnosed and was effectively untreated.

In their response to our enquiries, the board said that requests to see the doctor are through a nurse referral. They said that in Mr C's case, his requests and care were discussed with the doctor. The doctor decided that he did not need to see Mr C and asked that advice was given to him instead.

Our investigation found no evidence in the medical records that Mr C's condition had gone undiagnosed or that the treatment provided to him was inappropriate. However, we noted that although Mr C was eventually given an appointment with a doctor, this was nearly five months after he first asked for one. We found it is reasonable for a nurse to triage (assess) the need for an appointment with the doctor. However, if a patient insists on seeing the doctor and considers that there has been a change in their condition or requirements, it would not be reasonable to repeatedly block access. We took the view that it would be more productive for the doctor to discuss with the patient the most appropriate way to access health care services in the future; why they had been triaged; how the triage system works; and why the doctor was satisfied that the current arrangements were appropriate. We considered that when Mr C continued to request an appointment with the doctor, he should have been given this earlier so that such a discussion could take place.

Recommendations

We recommended that the board:

• make health centre staff aware of our findings on this matter.

Summary

Mrs C's late father (Mr A) was admitted to hospital in late 2011 with recurrent abscesses. In October 2011, he was transferred to another hospital for audiology (hearing) tests. He was transferred without an escort and wearing only pyjamas and a cardigan. Mr A was doubly incontinent during the journey and also suffered a fall.

In November 2011, Mr A was referred to a specialist colorectal (bowel) surgeon and a loop colostomy (a procedure whereby the loop of the bowel is pulled through the thickness of the abdomen wall) was planned. Mr A had bowel surgery several days later. During the operation, Mr A’s bowel suffered a trauma, which the board said the surgical team did not know about at the time. He returned to the ward with a temperature which was treated by antibiotics (drugs to treat bacterial infection). His condition deteriorated and he started to show signs of sepsis (blood infection). Further investigations (chest x-ray, ECG, blood tests and blood cultures) were carried out and he was prescribed a strong antibiotic intravenously. Just over an hour later, staff noted that Mr A might be showing signs of sepsis, and an abdominal examination showed tenderness. An anaesthetic review noted that surgical emphysema (formation of bubbles of air in the soft tissues) was present. He was taken back to the operating theatre, where the surgeon discovered that Mr A’s bowel had been perforated and this had caused peritonitis (inflammation of the tissue lining the abdomen). Mr A needed further operations, and was transferred to intensive care, but his condition deteriorated and he passed away several weeks later. The cause of his death was recorded as acute peritonitis and perforation of colon (bowel) during colostomy operation.

Mrs C complained about Mr A’s care and treatment at the hospital including aspects of his transfer to the other hospital. In particular, she complained about the surgeon's failure to detect that Mr A’s bowel had perforated during the original operation and that the post-operative complications were not recognised and treated within a reasonable time. Mrs C also complained that the board failed to handle her complaint within a reasonable time and failed to respond to her questions reasonably. After taking independent advice from two of our advisers - a surgeon and a nurse, we upheld two of Mrs C's complaints. Our investigation found that the board failed to provide adequate nursing care for Mr A during his transfer and that he should have had an escort and a blanket or outdoor clothes on. We also found that there was a significant delay of five months by the board in responding fully to Mrs C's complaints. As, however, the board had taken steps to address most of the shortcomings identified in these complaints we made only one recommendation. We did not uphold Mrs C's complaint about the operation and after-care, as we found no evidence that the surgical team failed to perform the operation in a reasonable way and we were satisfied that the post-operative complications were identified and dealt with appropriately within a reasonable time.

Recommendations

We recommended that the board:

• bring the shortcomings in record-keeping to the attention of staff concerned.

Summary

Mr C complained that his medication for anxiety had been stopped as it was no longer on the list of approved medication compiled by the Scottish Medicines Consortium. He said that when he went to his medical practice for assistance, a GP told him to return home and arranged for an ambulance to call at Mr C's home and take him to hospital for an assessment by mental health services. Mr C said that he did not receive appropriate and timely medical treatment, and believed that he should have been allowed to wait at the practice for the ambulance. He was also concerned at the time it took to arrive.

We took independent advice about this complaint from a medical adviser, who is a GP. The adviser said that it was appropriate for the GP to have arranged for the mental health assessment and that the assessment result confirmed there was no clinical need for an urgent referral to hospital by emergency ambulance. We did not uphold the complaint as there was no evidence that the GP acted incorrectly.

Summary

Mr and Mrs C were unhappy with the advice and information that they received from their medical practice. These included that the practice unreasonably gave Mrs C the impression she had breast cancer; failed to advise Mr C to return if his skin condition changed; handled their request for a home visit for their son inappropriately; and failed to communicate their son’s death appropriately within the practice.

In our investigation, we reviewed the correspondence that Mr and Mrs C provided and the practice’s complaint file. We also obtained independent advice on the appropriate medical records from one of our medical advisers (who is a GP).

In terms of the first two complaints, the adviser said that, where a GP suspects cancer, they should generally frame matters in such a way as to minimise alarm. The adviser noted that Mr C’s notes stated ‘and review’ (indicating that the GP intended Mr C to return). On the third complaint, the adviser noted that Mr and Mrs C’s son had a mental health condition, and that the practice made a distinction between physical and mental conditions for house calls. However, this was not considered unreasonable. Finally, the adviser indicated that a medical practice would not generally know that a patient had died until they were told by another source. Depending on the circumstances, this could involve a hospital, the Procurator Fiscal or the police. The adviser said that from the notes, it did not look as though the practice had been told that Mr and Mrs C's son had died.

While we recognised how significant these complaints were for Mr and Mrs C – they had been patients of their practice for over 30 years and had also recently lost their son - the privacy of medical consultations limited the evidence available. In the evidence that we did see, in combination with the advice we received, we found nothing to indicate that the practice had acted unreasonably.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment that Mrs A’s husband (Mr A) received from the medical practice. Ms C said the practice failed to take appropriate steps to lead to an earlier diagnosis of Mr A’s cancer and assured the couple that Mr A's 'bloods' had been checked when they had not. She also said that one GP unreasonably failed to follow up on blood tests and a second GP failed to deal with Mrs A in an appropriate manner when she went to the practice for support.

We took independent advice from one of our medical advisers on this case. Our adviser said that the practice had tried to care for Mr A in this very difficult situation. He said that the care and treatment they provided was appropriate and there was no evidence to suggest that they should have referred Mr A to hospital earlier or made a diagnosis of cancer themselves. The adviser said the evidence in the records did not suggest that the practice failed to take appropriate steps to lead to an earlier diagnosis.

We upheld the complaint about the assurance given to Mrs A about 'bloods'. We found that both parties agreed that the first GP at the practice indicated that she had ‘checked Mr A’s bloods'. However, we took the view that when the GP spoke to Mrs A, a layperson, it was reasonable for Mrs A to interpret this as meaning that the GP had checked Mr A’s blood test results and not simply that she had taken blood samples for testing, which is what the GP suggested she meant. Given the language used, we considered that, on balance, the centre did tell Mrs A that Mr A’s bloods had been checked when they had not.

On the matter of follow-up, the first GP had said that she went online to see where Mr A’s blood test results were. She found that the results were not there and Mr A had been admitted to hospital. Our adviser indicated that this seemed reasonable, as from the point at which the first GP discovered that Mr A was in hospital, there would no longer have been any need for her to follow up on blood test results. We accepted the adviser’s views and did not find that the practice unreasonably failed to follow up the blood tests.

On Mrs A’s appointment with the second GP, the notes the GP made at the time did not contain any information that supported Mrs A’s account of what had happened, and we could not uphold this complaint. It was Mrs A’s word against the GP’s and there were no independent witnesses or other means for us to verify whose version of events was correct.

Recommendations

We recommended that the practice:

• provide Mrs A with a written apology for not explaining clearly what had happened to Mr A's blood samples;
• feed back our views on the communication and record-keeping to the staff involved in this case;
• take steps to ensure that in future, clear language is used when communicating with patients and summaries of phone calls are recorded in patients’ medical records;
• feed back our adviser’s comments on significant event analysis/audit to the staff involved in this case; and
• amend their procedures to include a requirement for significant event analysis/audit in future instances of this type.