Health

Summary

Mr C complained that when he made a request to the practice for a copy of his late mother's GP clinical records he was not provided with a full copy of her records for the previous ten years. He also had concerns that since 2005 his mother had visited the practice with recurrent ear infections, but it was not until late 2010 that she was referred to an ear nose and throat consultant, who diagnosed a tumour in her ear.

We did not uphold Mr C's complaints. Our investigation found that the practice had provided a full copy of his late mother's records and had explained that they initially kept paper records before moving to electronic records. We also found that although Mr C's mother had reported ear infections intermittently since 2005, these had cleared with treatment. By 2010 the ear problem with which she presented to the practice was different.

Summary

Mr C complained about the care and treatment that his brother (Mr A) received from the board in the month before his death. Mr A was admitted to hospital suffering from pains in his chest, upper abdomen and down his right arm, and an initial diagnosis of heart attack was made. While Mr A was in hospital it also became apparent that he had a pneumonic chest infection (lung infection). This became the leading diagnosis, with an underlying diagnosis of heart disease, with evidence that Mr C had suffered a previous heart attack. Treatment was based on this assessment, and once Mr A was considered to be well enough, he was discharged. He was not referred for an angiogram (an image of the blood flow through the heart) while in hospital, and Mr C complained specifically about this. Mr A was referred for a follow-up echo-cardiogram test (ECG - a test to measure heart activity) and was given medication to reduce the risk and possible complications of a further heart attack, but he died five days after being discharged.

Shortly after Mr A died, Mr C complained to the hospital about his brother's care and treatment. He waited over two months for the board's response, and when he received it, Mr C was still unhappy about their decision. The board commissioned an independent review of the case, to determine whether there was any fault that they had not identified in Mr A's care and treatment. The report did not identify any failings, and was followed up by a further, final response from the board to Mr C. Mr C then complained to us about his brother's care and treatment and about the way the board handled his complaint.

We obtained independent advice on this complaint from a medical adviser. Their advice indicated that Mr A's symptoms were hard to diagnose, particularly at the early stages, as his symptoms were not typical and related to the interaction of two conditions - chest infection and heart disease. However, the adviser said that Mr A's treatment was reasonable and in line with the Scottish Intercollegiate Guidelines Network (SIGN) guidelines on acute coronary syndromes. In particular, the advice indicated that it was appropriate to delay the angiogram until after discharge, once the chest infection had resolved.

In relation to the handling of Mr C’s complaint, we found that the board had failed to provide a timely response. As the board had already acknowledged this failing, taken action and apologised, we did not make a recommendation.

Summary

Mr C had a history of abdominal pain, diarrhoea and constipation. He was referred to hospital and was seen by two gastroenterologists (clinicians specialising in the treatment of conditions affecting the liver, intestine and pancreas) at various out-patient appointments. He was diagnosed as having irritable bowel syndrome (IBS) and bile salt diarrhoea. Mr C complained about the board's investigation of his symptoms, suggesting that the two gastroenterologists gave conflicting opinions as to their cause. However, he was also specifically concerned about a hospital admission when he said he was left for several days without being seen by a gastroenterologist. Once the gastroenterologist attended, he was dissatisfied with the extent of their examination and their findings.

Our investigation included taking independent advice from a medical adviser. We did not find any evidence to suggest that Mr C had been misdiagnosed or that the two gastroenterologists reached conflicting views about his treatment, and we were generally satisfied that the overall treatment of Mr C's condition was reasonable. However, we found that Mr C was not seen by a gastroenterologist for eight days during the hospital admission. There was clear evidence that staff on the ward identified a need for him to be seen by a gastroenterologist at an early stage in his admission. However, despite reassurances that someone from gastroenterology would attend, this did not happen. There was insufficient evidence to say whether this was because the ward staff failed to contact gastroenterology as planned, or because gastroenterology failed to act on requests from the ward. The end result, however, was that Mr C's treatment fell below an acceptable standard. We accepted advice that this would not have had a significant long term impact on his physical condition, but we noted that IBS has a recognised psychological component, and symptoms can be made worse by stress and anxiety. We considered that the delay in being seen by a gastroenterologist would not have helped Mr C's recovery.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in him being seen by a gastroenterologist during his hospital admission; and
• draw our findings to the attention of the staff involved with a view to identifying any improvements that can be made to communication between the wards and the gastroenterology unit.

Summary

Miss C was diagnosed with chronic kidney disease (CKD) in 2007. She complained that a GP at her medical practice incorrectly advised her to stop taking high blood pressure medication after she reported experiencing side effects. The GP had prescribed the medication for Miss C in 2008 because her blood pressure was elevated and this could have affected her kidney function. Miss C also complained that her kidney function continued to decrease but nothing was done to address this. In addition, she was unhappy that the GP did not properly investigate pain she had reported having in her side.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. Our investigation found no evidence that the GP had advised Miss C to discontinue the blood pressure medication. We considered that this was unlikely to have affected the progression of her CKD because she was managed in accordance with the national guidelines for the condition. Had Miss C been diagnosed with high blood pressure and had a significant amount of protein in her urine then it would have been appropriate for her to have remained on the medication. We also considered that there was no indication that the GP needed to make an urgent referral in relation to the backache Miss A had reported and that appropriate pain relief and a referral to physiotherapy was made.

Summary

Mrs C's mother-in-law (Mrs A), who lives overseas, was visiting her family when she became unwell with stomach pain and anaemia. The family GP referred her to hospital, where she was treated for severe liver disease complicated by fluid retention (an excessive build up of water in the body) for about five weeks. She was then discharged, with the intention that she should come back later for further treatment. However, when she was seen as an out-patient a few weeks later, she was urgently readmitted because of fluid retention. Mrs C complained about Mrs A's care and treatment. She said that Mrs A's experience in hospital was unpleasant; that because an interpreter was not provided, a family member had to stay with her; and that the family were asked to pay a large bill for Mrs A's treatment. She also complained that the board did not respond reasonably to her complaints.

We took independent advice from three of our medical advisers. After considering the advice, we upheld both of Mrs C's complaints. The hospital investigations had showed that Mrs A had cirrhosis of the liver (scarring of the liver as a result of continuous, long-term damage), with complications of fluid retention, and indicated that this was because of infection with hepatitis C (a virus that can infect and damage the liver, and can be transmitted to others through contact with infected blood). The advisers agreed that there was no evidence of inadequate care by nursing staff or clinicians, nor did they consider that there was an unreasonable delay in providing a bed for her, which was one of Mrs C's concerns. Similarly, there was no evidence of unreasonable communication by nursing staff and clinicians with Mrs C and her family about Mrs A's care and treatment. We noted, however, that it was not confirmed to anyone that Mrs A was suffering from hepatitis C, and that there was no evidence in the records that Mrs A or her family received appropriate counselling about the implications of this. In addition, the board’s policy clearly says that interpretation services should be offered. If these were declined, then the board should have considered an appropriate way of obtaining Mrs A's consent to using family members to translate, and this did not appear to happen. We were critical of the board about these points and, although we recognised that a number of aspects of Mrs A's care and treatment were reasonable, on balance we upheld Mrs C's complaint.

In terms of the board's response, we noted that Mrs C felt that the family should not have to pay for Mrs A's treatment, and that this was still in dispute when we investigated the complaint. We found that the Scottish Governmentprovide guidance in their document of April 2010 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services'. This specifically excludes viral hepatitis from the services and treatment that attract a charge. We also noted that the board's complaints response was relatively brief and did not provide a full summary of Mrs A’s medical problems. Had it done so, and in particular had it mentioned that she had hepatitis C, the board could then have considered the financial implication of the diagnosis under the guidance. Although, therefore, we would not normally become involved in the issue of such charges, we considered this to be relevant in this case and upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• take steps to offer the appropriate counselling to Mrs C's family (including Mrs A);
• ensure that all patients (and, where appropriate, family members) receive counselling in respect of the implications of chronic hepatitis C infection and that these discussions are recorded in the clinical record;
• advise the Ombudsman of the counselling arrangements that are in place for patients diagnosed with hepatitis;
• ensure staff are aware of and follow their policy on communication and support for patients where English is not their first or preferred language;
• ensure that full and appropriate clinical information is included in complaints response letters;
• review this case for payment in view of the guidance 'Overseas Visitors' Liability to Pay Charges for NHS Care and Services' (April 2010) and advise Mrs C and the Ombudsman of the outcome; and
• apologise to Mrs C and Mrs A for the upset this matter has caused.

Summary

Mr C complained about the care given to his wife (Mrs C) in an accident and emergency department on two occasions, and said that she was displaying clear symptoms of stroke on both. He also complained that Mrs C was discharged from hospital on her second visit, even though she was unable to speak without slurring. He told us he pointed this out to the doctors, but was ignored. Mrs C's GP referred her urgently to the hospital the following day, where she was found to have suffered a stroke.

We took independent advice on this case from one of our medical advisers. Our investigation found that on the first occasion Mrs C was diagnosed as suffering from migraine (an extreme type of headache which can cause disturbances to speech and vision). We found that it was reasonable to attribute Mrs C's symptoms on this occasion to migraine, but that her case should have been discussed with the on-call neurologist (a specialist in diseases of the nerves and the nervous system) and a management plan agreed. We, therefore, upheld the complaint that her treatment and diagnosis was not reasonable and made a recommendation referring to the relevant guidelines from the Scottish Intercollegiate Guidelines Network (SIGN).

We also found that on her second visit to hospital, it was unreasonable for Mrs C to have been diagnosed as suffering from migraine. There was no record of either a FAST (Face, Arm, Speech, Time of Event) assessment, or of a ROSIER (Record of Stroke in Emergency Room) review. Our adviser said that had either of these been carried out, then the result would have been positive. There was no record of discussion between emergency department doctors about Mrs C's unusual symptoms, and her case should have been discussed with a neurologist or stroke physician and a CT scan (a type of scan using x-rays to create a detailed picture of the inside of the human body), should have been requested. The board had not recognised this failing in their response to Mr C’s complaint.

We did not uphold Mr C's third complaint as our investigation did not find evidence that doctors had ignored reported symptoms of slurred speech. The notes provided clearly detailed the symptoms and signs that Mrs C had when she was assessed at the hospital.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified in Mrs C's care;
• review the processes governing referral to the on-call neurology team when a patient presents with symptoms consistent with hemiplegic migraine, to ensure an appropriate management plan is agreed and documented, with reference to the SIGN guidance; and
• provide evidence that they have reviewed the procedures within the accident and emergency department for the identification of stroke and the appropriate point for involving a stroke physician in light of the failings identified in this complaint.
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Summary

Miss C had a history of occasional minor back pain over a number of years, and was diagnosed with sciatica and a prolapsed disc. In November 2011, Miss C developed pain in her lower back and pelvis, which made walking very painful. The pain moved to her right hip, leg and buttock and she began to experience numbness and muscle weakness. In early January 2012, the pain moved again to her lower back and upper left leg. The pain was severe and affected her mobility. Miss C phoned NHS 24, having not been able to contact her own GP. Miss C's GP was asked to visit her at home. He prescribed pain medication and advised her to monitor her condition and to contact NHS 24 again should the pain worsen when the practice was closed. Miss C contacted NHS 24 again late that night. It was suggested that she attend an accident and emergency unit, but due to the pain she experienced when sitting, standing or walking, she did not feel able to do so. NHS 24 then arranged for an out-of-hours (OOH) GP to conduct a consultation by phone. The OOH GP concluded that Miss C's condition was improving and that she likely had a urinary infection. She was told that she should continue to self-monitor overnight. Miss C's condition deteriorated further the following day and, after another call to NHS 24, she was admitted to hospital where she underwent emergency surgery. She was diagnosed with cauda equina syndrome, where a lesion, or prolapsed disc, presses on the nerves at the base of the spinal cord, causing pain, numbness, weakness and/or urinary disturbance or faecal incontinence.

Miss C raised a number of concerns about the OOH GP's assessment of her condition and his failure to visit her at home or to arrange an ambulance to take her to hospital that night. She was left with persistent numbness after her surgery and felt that, had the OOH GP recognised the red-flag symptoms (symptoms that are especially likely to indicate a particular serious illness) of cauda equina, and arranged for her to be admitted to hospital earlier, this might have been prevented.

We found that Miss C had described recognised red-flag symptoms of cauda equina to NHS 24 and the OOH GP. These included numbness in the area between the legs and urinary problems. We accepted independent medical advice that these should have prompted a home visit from the OOH GP. Although we acknowledged that Miss C's symptoms and mobility appeared to be improving between the time of her discussions with NHS 24 and the OOH GP, this is not uncommon for patients with cauda equina and the fact that red-flag symptoms had been described should have been the primary consideration. We considered that, by failing to carry out a home visit, the OOH GP did not put himself in a position to properly diagnose or rule out cauda equina syndrome.

Recommendations

We recommended that the board:

• share our findings with the OOH GP and consider whether additional training should be provided to him on the identification of, and response to, red flag symptoms; and
• apologise to Miss C for failing to provide a home visit.

Summary

Mrs C's daughter (Miss A) fractured her forearm and received treatment under anaesthetic at the hospital to manipulate the bone back into position. A cast was placed on Miss A's arm and she was reviewed on four occasions by a consultant surgeon. As Mrs C had concerns about the treatment the consultant provided, Miss A was referred to a second consultant. Miss A then had further surgery as the forearm fracture had become displaced. Mrs C complained that the first consultant had not taken corrective action when he became aware that the fracture had moved. She was unhappy because her daughter sustained permanent scarring and may not regain the full movement of her arm.

Our investigation found that Miss A had corrective surgery five months after her injury. After taking independent advice from one of our medical advisers, we considered that the treatment provided by the first consultant was reasonable. We also found that there was a possibility that corrective surgery was carried out too early because the bone might have corrected itself over the course of six to eighteen months. Our adviser said that fractures in children heal very fast, and as a child grows there is great remodeling capacity as long as there is about 18 months growth left. Miss A was eight years old at the time of her injury. We did not uphold Mrs C's complaint, as we concluded that there was no unreasonable delay in Miss A's treatment.

Summary

Mr C complained on behalf of his late wife (Mrs C) who developed severe abdominal (stomach) pain in November 2011. After initial tests, hospital doctors at first thought Mrs C had a urinary tract infection, then appendicitis. These diagnoses were ruled out after she was transferred to another hospital, where a CT scan (a special scan using a computer to produce an image of the body) showed that Mrs C had a shrunken right kidney. This had been identified the year before in an MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone), when Mrs C was told that the shrunken kidney was likely congenital (present from birth). The CT scan also showed that bile ducts within her liver were enlarged, but that her liver was functioning normally. Further tests led to a suspected diagnosis of primary sclerosing cholangitis (a disease causing inflammation and obstruction of the bile ducts). Mrs C was later referred to a consultant urologist (a clinician who treats disorders of the urinary tract) who reviewed her CT scan and identified that the abnormalities in her kidneys had in fact progressed since the previous year's scan, and that the shrunken right kidney contained a solid cancerous mass. The cancer later spread into Mrs C's lungs and stomach.

Mr C complained that Mrs C's shrunken kidney had been observed as early as June 2010, but she had repeatedly been assured that this was congenital. He thought that the board's failure to investigate the cause of this had contributed to a delay to the diagnosis of her cancer.

After taking independent advice from a medical adviser, who is a consultant surgeon, we considered the initial investigations into Ms C's abdominal pain, and the working diagnoses, to have been reasonable. Early ultrasound and CT scans highlighted abnormalities in Mrs C's biliary tree (the structures responsible for transporting bile) and it was appropriate for these to be investigated. That said, we were concerned by the apparent lack of consideration of Mrs C's shrunken kidney, and upheld Mr C's complaint that this was not investigated quickly enough. Investigations concentrated on the biliary tree but found no significant abnormalities other than gallstones. Mrs C's pain was located in the area of her shrunken kidney, which was highlighted in June 2010 and showed again in the November 2011 CT scan. It was established in December 2011 that the biliary tree abnormalities were not the source of the pain. We concluded that there was sufficient cause to refer Mrs C to a urologist at an early stage, rather than to concentrate investigations on the biliary tree abnormalities. We did not uphold Mr C's complaints about how details of his wife's condition were explained in a letter to her and about medication prescribed.

Recommendations

We recommended that the board:

• share our findings with the clinical team so that they may consider reviewing how referrals are managed for patients requiring multi-disciplinary investigations.

Summary

Mrs C's late sister (Mrs A) suffered from dementia and lived in sheltered housing. Mrs C held welfare power of attorney for her. When Mrs A first joined the medical practice, she was on regular medications for a number of conditions, including dementia, and was under the care of her GP and a community psychiatric nurse. She was prescribed an antidepressant and medication for her dementia. Care staff, however, became increasingly concerned about her challenging behaviour. After visiting Mrs A in response to a phone call from care staff , her GP prescribed diazepam on an ‘as required’ basis. Several days later, Mrs C contacted the GP expressing concern about the prescription and the fact that the GP had not consulted Mrs C about it, given that she held welfare power of attorney for her sister. Mrs C also believed that the GP prescribed the diazepam on the basis of a phone call with staff, and did not see Mrs A in person. Mrs C said that during a meeting with the community psychiatric nurse the day before the prescription, they had agreed to continue to monitor Mrs A's progress on the antidepressant.

Mrs C complained that care staff may be trained to administer medication, but they are not qualified to make medical decisions about when the medication is required and that the practice failed to ensure there was an appropriate system for administering the drugs. Mrs C said that within days of Mrs A moving to another practice, the GP said she needed a full assessment and admitted her to hospital where her medication was reduced and where she stayed for three months before moving to a nursing home.

Several days after the prescription of diazepam, Mrs C phoned the GP to discuss her concerns. She followed this up by letter. She did not hear from the practice and approached the health board with a complaint three weeks later. The health board forwarded her written complaint to the practice who responded in writing two weeks later. Mrs C was unhappy with the practice's complaints handling.

After taking independent advice from one of our medical advisers, we upheld only two of Mrs C's six complaints. We found that the prescription of diazepam was reasonable in relation to both the prescription and the system to administer the drugs. We also found that the GP's assessment of Mrs A's medication and care needs was reasonable. However, we found that the GP's communication with Mrs C was unreasonable, given that under the Adults with Incapacity (Scotland) Act 2000 Mrs C should have been consulted about the prescription of diazepam, and that there were shortcomings in the way the practice dealt with her complaint. As result of Mrs C's complaint, the GP and the practice took action that we considered appropriate, therefore, we did not find it necessary to make recommendations.