Health

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.

Summary

Mrs C complained to the board about the care and treatment that her late husband (Mr A) received in hospital when he attended the emergency department. Mr A was discharged home but around two months later he was admitted to the hospital again where it was identified that he had terminal lung cancer that had spread to his liver and bones. Mrs C said that her husband had been suffering agonising pain in his leg over a few months and had been frequently attending his medical practice.

After taking independent advice from one of our medical advisers, we did not uphold Mrs C's complaint. Her husband had presented at the emergency department with pleuritic chest pain (pain associated with the lungs). Our investigation found that the hospital carried out appropriate assessments and investigations at this time. In addition, a chest x-ray and blood tests had given no indication of pneumonia or malignancy.

Summary

Mr A was an elderly man who was admitted by ambulance to a hospital accident and emergency department after complaining of chest pains. His son (Mr C) complained that the board failed to carry out appropriate investigation, diagnosis and management of Mr A's condition before deciding to discharge him from the hospital, and unreasonably failed to place Mr A in isolation. Mr C also complained that the board failed to provide an appropriate response to his complaint.

We did not uphold Mr C's complaints. After looking at Mr A's hospital records and taking independent advice from our medical and nursing advisers, our investigation found that the decision to discharge Mr A was reasonable and was taken after appropriate investigation, diagnosis and management were carried out. Mr A's chest pain was investigated through observation, an electrocardiogram (a test that records the electrical activity of the heart) and a blood test. Mr A had taken aspirin before going to hospital, and so we found it was reasonable that other medicines were not administered. We also found that Mr A did not meet the criteria for isolation, in that he was not considered to have a diagnosis of infectious diarrhoea or diarrhoea associated with recent antibiotic use, or both. Nor was there any need to place Mr A in a single room and the decision not to initially place Mr A in one was reasonable. The board's response to Mr C's complaint was reasonable in light of the medical and nursing care provided and Mr A's hospital records, and we concluded that it addressed all the issues Mr C raised.

Summary

Mr C attended the hospital's accident and emergency department (A&E) during the night, as he was concerned that he might be experiencing a repeat of a chest condition he had had some years previously. After discussion with a nurse, he was shown to a phone and advised to speak to the person at the other end, who turned out to be from the out-of-hours GP service, NHS 24. NHS 24 advised him to return home, and that they would phone him within an hour to assess his condition. Mr C felt that his situation had not been taken seriously and he left. NHS 24 phoned him three times at home, but Mr C felt too distressed to answer their calls. In the morning, he saw his GP, who diagnosed a chest infection.

We explained to Mr C that it is NHS policy that someone should only attend A&E if they have an emergency and that, if they need to see a GP outside their practice's opening hours, they should phone NHS 24. NHS 24 then assess, by phone, whether the patient needs to see a GP and, if so, whether they should travel to the out-of-hours GP, or whether the out-of-hours GP should visit them at home. The papers we received from the board showed that, when Mr C arrived at A&E, the nurse considered whether he did need emergency care and spoke to a doctor, who decided that this was a matter for NHS 24, rather than A&E.

We did not uphold the complaint because the hospital appropriately established that Mr C needed to contact NHS 24, rather than themselves, then helped him contact them. We also noted that the board said that, because of Mr C's complaint, if someone arrived at A&E but needed to contact NHS 24, staff now made the phone call themselves, giving NHS 24 the relevant details. NHS 24 would then phone the patient back. They believed this would improve their service for patients, and we welcomed the board's use of a complaint as an opportunity for learning and improvement.

Summary

Mr C complained that there was an inadequate number of toilet facilities on his ward.

Our investigation found that patients spend only a limited time on the ward. In essence, the ward is used for little more than eating meals and making phone calls. Patients spend most of their waking time in other areas, which have ample toilet facilities. Sleeping areas are separate, and have en-suite toilet facilities. We also established that Mr C was able to move between areas to a reasonable extent. We considered this reasonable and we did not uphold the complaint.

Summary

Mrs C complained that when her husband (Mr C) was airlifted to hospital after a heart attack, there was unreasonable delay in transferring him from the air transport into the hospital and in assessing his condition.

We upheld both Mrs C's complaints. Our investigation found that there was no ambulance available to transfer Mr C into the hospital. The health board and Scottish Ambulance Service were in the process of finalising a protocol under which patients could be transferred on a trolley in such circumstances. However, when Mr C was taken ill the protocol had not been finally agreed or adopted although the equipment required - such as a trolley and protective clothing and equipment - was available.

Our investigation identified that responsibility for a patient remains with the service until the patient is received in hospital. The ambulance staff involved in transporting Mr C were paramedics and provided evidence that they had offered to take clinical responsibility for transferring Mr C on a trolley. However, this offer was declined by a nurse from the hospital who was also there. It was about 40 minutes before an ambulance was available to transfer Mr C. In view of the offer made by the paramedics, we considered that it was unreasonable for Mr C to have had to wait this long.

With regard to the assessment of Mr C's condition, our independent adviser noted that she would not necessarily expect to find notes of an assessment made while a patient was the responsibility of another body. However, although we noted that responsibility remained with the service until Mr C was received at the hospital, the board had in fact indicated in their response that the nurse had assessed Mr C's condition. We found no evidence, however, that any such assessment was made.

Recommendations

We recommended that the hospital:

• apologise for the distress caused by the failings identifed; and
• ensure that all staff are aware of the amended policy for manual transfer of patients when ambulances are not available, in order to expedite transfer, assessment and treatment of patients.

Summary

Mr C is unable to cut his own toenails, and complained that the board failed to provide him with an appropriate regular service for this. He explained that delays in having his toenails cut impacted on his mobility and caused him discomfort.

Our independent medical adviser noted that it was reasonable that times between appointments may be affected by staff resource and demand. As Mr C’s complaint was very similar to one that he had made before and the board had already explained the appointment system to him at that time, we did not uphold his complaint.

Summary

Mr C complained that, when he attended a hospital clinic appointment, the doctor carried out a procedure without Mr C's consent. He said that he told the doctor that he could look at the problem only, but not take any action. He said that the doctor ignored his wishes.

When we investigated this, the board explained that the doctor and the health care assistant who were present were of the opinion that Mr C had agreed to the procedure. We found, however, that the doctor had not strictly adhered to the board's informed consent policy and had not explained what the procedure entailed, or recorded that Mr C had agreed to the procedure. We upheld Mr C's complaint and made a recommendation about this.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to obtain his informed consent.