Health

Summary

Mrs C, an advocacy worker, complained on behalf of Mrs A. Mrs A had given birth to her third child twelve days after the date on which the baby was expected. The board said that before the birth, Mrs A had only minor problems and so she was on a low risk pathway. The plan was for the baby to be born with the use of an epidural (spinal pain relief) but as labour progressed, the baby began to show significant distress and so was delivered by caesarean section under general anaesthetic. Within a few minutes, Mrs A began to suffer heavy bleeding, and needed a hysterectomy (surgery to remove the womb) to control this. Unfortunately, during this procedure Mrs A suffered damage to her urinary system, which needed further surgery. She had a slow recovery and was not discharged home for several weeks. Mrs C said that Mrs A suffered psychologically because of these events and that not enough was done to prevent them from happening.

Our investigation took into account all the available information, including the complaints correspondence and the relevant clinical and nursing records. We obtained independent advice from relevant consultants in all the areas relating to Mrs A's concerns, and from a senior matron in a maternity unit.

The board had sympathised with the difficult time Mrs A experienced and had apologised that aspects of her care had caused her concern. They acknowledged that the events of the delivery and what had happened after it had been difficult for Mrs A, but said they were of the view that everything that had been done had been in the best interests of her and her baby.

We did not uphold Mrs A's complaints about her care and treatment before and during the birth. We found that the clinicians involved in Mrs A's case had done nothing that contributed to her serious and life threatening condition. Our advisers said that all the procedures carried out were reasonable and had been appropriately administered. Although Mrs A felt that her husband had not been properly updated about her condition we concluded that this was reasonable, as the clinician's first responsibility had been to save Mrs A's life.

Overall, we found that Mrs A's care was generally reasonable. However, one of our advisers said that, once Mrs A was returned to a ward, it would have been appropriate to reassess her situation with regard to transferring her to a single room, particularly in view of her prolonged stay in hospital. The adviser also noted that an error was made with an injection and that Mrs A had been discussed publicly. These things should not have happened. We, therefore, upheld her complaint about the care she later received in the maternity ward and made recommendations to address this.

Recommendations

We recommended that the board:

• apologise to Mrs A for their shortcomings in this matter;
• emphasise to staff the importance of ensuring that discussions between professionals about an individual's care needs are kept private; and
• remind nursing staff to take account of individual patients' needs when allocating single rooms.

Summary

Mr C fractured his leg in several places. He was admitted to hospital and had an operation. The consultant reviewed Mr C the next day. Mr C had a change of plaster cast and was advised not to put weight on his leg. Mr C's medical records noted the following day that he was not complying with the non-weight bearing instructions. He was discharged several days later.

Mr C's first out-patient appointment early the next month was cancelled and he was seen towards the end of that month. An x-ray taken at that appointment showed that the tibia (large bone in the leg) was misaligned. The board told Mr C that the consultant's opinion was that the misalignment was likely to have been the result of Mr C bearing weight on his leg contrary to advice. Mr C told us that this unreasonably blamed him for problems with his leg. Mr C sought an acknowledgement that things went wrong during his operation and an apology from the board. He said that as a result of the board’s failures, he will suffer pain permanently.

Our investigation included taking independent advice from one of our medical advisers. We found that the operation was performed to a reasonable standard and that it was likely that a number of factors, including the severity of the fracture, led to the misalignment. Mr C was concerned about the misalignment, but the advice we received and accepted is that it was within reasonable limits. We also found evidence in Mr C's medical records that he was not complying with the advice to put weight on his leg, and we were satisfied that the board's response reflected what was in these records. We appreciated why Mr C was unhappy with the way in which the board's first response was worded, but found that they had later assured him that they were not accusing him of wrongdoing but, rather, had recognised that he could not comply fully.

Summary

Mr C raised a complaint about how a dental practice had handled his representations about treatment that he had received by a dentist at the practice. Although it was difficult to establish the exact sequence of events after Mr C complained, our investigation found that the practice had not handled his complaint in line with their complaints procedure and we upheld his complaint.

Recommendations

We recommended that the practice:

• review their procedures to ensure they deal with complaints in accordance with the NHS complaints procedure; and
• apologise to Mr C for their handling of this complaint.

Summary

Mrs C complained on behalf of her brother (Mr A) that his hip replacement operation was unreasonably delayed. Mr A's consultant put him on the waiting list for surgery. Mr A waited 13 weeks before receiving a phone call offering him an appointment for surgery in the Greater Glasgow and Clyde health board area. As Mr A had not discussed this option with his consultant, and as he had significant difficulty in mobilising, he said he would prefer to wait for a local appointment. Mr A and Mrs C then wrote to the board asking for all further communication about Mr A's care to be via Mrs C. Unfortunately, the board did not receive this before they called Mr A again and offered him an appointment in the Tayside health board area. Again, Mr A refused this and said he would rather wait for a local appointment.

Mrs C complained that Mr A's treatment was unreasonably delayed. We upheld her complaint, as there was no evidence that Mr A was told or had any discussion with his consultant about the possibility of having to travel for treatment. On this basis, we took the view that it was unreasonable to offer him treatment outside his local health board area. He was, therefore, not provided with any reasonable offers of treatment within the 18 week target time. Mr A's surgery was eventually carried out 26 weeks after he went on the waiting list, and we did not consider this to be reasonable.

Since Mr A's treatment, there have been several changes in local and national policy and practice, including the implementation of new legislation relating to waiting times. As these changes have addressed many of the shortcomings that led to this complaint, we did not make any recommendations.

Summary

Mr C complained about a range of issues related to his late wife’s (Mrs C) medical and nursing care and treatment while she was in hospital. Mrs C became terminally ill and died shortly afterwards, having been admitted to another hospital for palliative care.

Our investigation established that it would not be possible to prove the facts in relation to a number of Mr C's complaints because he and the board disputed what had happened, or what had been said, and Mrs C's clinical records did not cast any light on this. In cases where it is very unlikely that we would be able to establish enough facts to reach a robust conclusion, it is not our practice to look further into a complaint.

In respect of other parts of Mr C's complaint, we considered that the board's responses (which were given in two letters, at two meetings and through a number of phone conversations and emails) showed that their investigation had been reasonable and they had made significant efforts to give him a large volume of detailed information. They had taken his complaints seriously and took action to improve various areas of their practice, even where they had been unable to prove his allegations. Overall, however, we could not reach a finding on Mr C's complaint because of a lack of evidence.

Summary

When Mrs C 's mother (Mrs A) became unwell, Mrs A's carer contacted Mrs C, who went to her mother's house, and a doctor from NHS 24 (the out-of-hours service) visited. He examined Mrs A and wanted to admit her to hospital but his notes recorded that she strongly refused. He prescribed an antibiotic (a drug used to treat bacterial infection) after asking Mrs C if she knew if her mother had any drug allergies. He also advised Mrs C to get in touch again if her mother's condition deteriorated. He later discovered that she was allergic to the drug he had prescribed, and contacted Mrs C to arrange an alternative. Mrs A, however, died during the night. Mrs C disagreed that her mother had refused hospital admission and felt that the doctor should have known of Mrs A's previous experience of the drug.

Our investigation found that the doctor could not have known of Mrs A's allergy as he did not have access to her emergency care summary. This consists of basic information about a patient (including allergic reactions) and is available in the out-of-hours centre but not in the out-of-hours doctors' vehicles. The doctor was in his vehicle when asked to attend Mrs A. It was clear he took prompt and appropriate action to check her summary when he reached the out-of-hours centre, and to then arrange alternative medication. We took independent medical advice from one of our advisers, who said that the doctor's other actions, such as his examination of Mrs A, were also appropriate. We could not say for sure whether Mrs A had refused to go to hospital, as the accounts were so different. However, we did not uphold the complaint, as we found no grounds to suggest that the doctor's care and treatment (including his decision not to admit Mrs A to hospital) were unreasonable.

Summary

Mr C, who is a prisoner, suffers from irritable bowel syndrome (IBS) - a condition that can cause stomach cramps, bloating, diarrhoea and constipation. He told us that he spent a short period of time in one prison, where he received a gluten free diet to help his symptoms. However, when he transferred to the prison where he was to spend the majority of his sentence, he only received a gluten free diet for around three weeks. It was then stopped while the board awaited the results of blood tests. When the results came back, they showed that Mr C was not gluten intolerant, and he was told he would not receive a gluten free diet in future.

We did not uphold Mr C's complaint as we found that the decision not to provide him with a gluten free diet was clinically appropriate. However, we were critical of the board for the apparent inconsistency in approach, as Mr C apparently initially received a gluten free diet, which raised his expectations about what he should receive. We drew this to the board's attention.

Summary

Miss C complained that during treatment a dentist handled her five-year-old daughter (Miss A) with excessive force, and shouted at her. While the dentist was attempting to fill one of Miss A's teeth, she became distressed and moved in the chair. In trying to adjust Miss A's position in the chair, Miss C complained that the dentist handled Miss A roughly, causing bruising to her arm.

The dentist indicated that, as Miss A had slid down the chair, he lifted her under the arms to put her back in the correct position. He said he did not use any force and he could not understand the bruising allegation. He also said that he was required to raise his voice to give instructions to his nurse and be heard over Miss A's crying. He said he did not shout at Miss A. In investigating the complaint, we obtained a statement from the nurse which supported the dentist's position. In the absence of any evidence to support Miss C's version of events, we did not uphold the complaint.

Summary

Mrs C said that her husband (Mr C) was involved in an accident in which he fell from height, and was airlifted to hospital. She said that following various CT scans (special scans that use a computer to produce an image of the inside of the body), Mr C was diagnosed with a spinal fracture. He was transferred to another hospital nearer to where they lived, but suffered a major stroke that resulted in him having severe communication difficulties. After Mr C had the stroke, it was diagnosed that Mr C's carotid artery was dissected (the layers of the artery wall supplying oxygen-bearing blood to the head and brain became separated). Mrs C complained that the hospital did not provide clarity about the treatment Mr C had received from them and that her complaint about this was not adequately addressed.

Two of our independent medical advisers considered all aspects of this case. We took account of their advice along with all the documentation provided by Mrs C and the board. We did not uphold Mrs C's complaints about treatment and complaints handling. The advisers said that Mr C had been correctly assessed and investigated at the hospital, in accordance with standard UK practice, and that appropriate diagnostic imaging techniques were used. They also said that clinicians diagnosed Mr C correctly and he had received a reasonable level of care. Our investigation found that the board had appropriately investigated and responded to Mrs C's complaint. However, we considered that they had failed to respond as agreed to Mrs C's enquiry about the board's protocol for image scanning, and we upheld that aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the learning from this complaint to all staff to ensure such an evolving communication failure will not recur; and
• apologise to Mrs C for this failure and the upset it has caused.

Summary

When Mr C was admitted to hospital, medical staff decided that, due to his severe lung disease, he should not be resuscitated in the event of heart or breathing failure. They, therefore, placed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order on his medical notes. Mr C was dismayed when he later found this out and expressed his disagreement with the decision. In responding to Mr C, the board indicated that the decision was one that medical staff were empowered to make. However, they acknowledged that this should have been discussed with Mr C and/or his family. They apologised for their failure to do so and also agreed to clearly record Mr C's wishes on the front of his medical notes.

Mr C was not satisfied that the remedial steps taken by the board would prevent a similar thing happening to someone else and he approached us. We noted that the NHS Scotland policy on DNACPR says that resuscitation should not be offered as a treatment option where, in the opinion of medical staff, it would fail. We were, therefore, satisfied that it was appropriate for staff to exercise their judgment and take the decision. However, because of the failure to tell Mr C about this, which the board had already acknowledged, we upheld the complaint. The board have demonstrated to us that they learned from this failing. They implemented a quality improvement plan including provision to ensure that patients or their relatives are in future informed of requests for DNACPR, and said they would carry out random audits of patient case notes to ensure that this was being adhered to.

Recommendations

We recommended that the board:

• inform the Ombudsman of the outcome of the audit of patient case notes used as a measure of effectiveness in their quality improvement plan.