Health

Summary

Mr C's mother (Mrs A) collapsed at home, and was taken to hospital as an emergency. She was transferred to a ward at 15:50 and was assessed at 23:00. Early the next morning there was a marked deterioration in Mrs A's condition, and she was suspected to have suffered a stroke. Mrs A's condition continued to decline and she died that evening.

Mr C complained about his mother's care and treatment and questioned whether she was given any treatment when she was initially admitted to hospital. He was unhappy that she was not properly assessed until late at night by which time, he said, her condition had deteriorated and she had become confused. He was concerned that her anticoagulant medication (used to prevent blood from clotting) had been stopped and considered that this could have led to her stroke. Mr C was also concerned that in responding to his complaint, the board said that cancer could have been a contributing cause to Mrs A's death. He complained that this possibility had never been raised with him before.

Our investigation took account of all the available information, including the complaints correspondence and the relevant clinical records. We also obtained independent medical advice from a consultant in acute medicine for older people. We found that the board had maintained that they had treated Mrs A reasonably and had discussed the possibility of an underlying diagnosis of cancer with Mr C. However, on reviewing the case notes, the adviser was concerned that Mrs A was not provided with treatment until some ten hours after her admission. He said that the treatment, when provided, was reasonable but it had not been timely. He noted, however, that even if Mrs A had been treated earlier it was unlikely that her condition and prognosis would have changed. He also said that stopping her anticoagulants had been the correct thing to do in the circumstances. With regard to the underlying diagnosis of cancer, the adviser said that a discussion with Mr C was recorded in the notes but this was unclear about the precise language used, and whether or not the term 'malignancy' had been understood.

The advice received during the investigation confirmed that Mrs A's treatment had been reasonable. However, for it to be appropriate it would have to be both reasonable and timely. As it was not, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the delay which occurred; and
• review the guidelines published by the Society of Acute Medicine, particularly section AF-505, to ensure that more timely assessment of acute admissions occurs in the future.

Summary

Mr A had several consultations at the practice over four months, complaining of ongoing and increasing pain in his hip and knee. Mr A was then admitted to hospital and was diagnosed with lung cancer that had spread to his liver and bones. Mr A died a month after being admitted.

Mr A's wife (Mrs C) complained that if her husband been diagnosed sooner, he could have lived longer and had better pain relief.

As part of our investigation, we took independent advice from a medical adviser. The adviser said that the practice had carried out and arranged for appropriate investigations in an attempt to establish the reasons for Mr A's pain. They arranged chest and hip x-rays at an early stage, but these did not show any signs of cancer. The practice had prescribed stronger pain relief and referred Mr A to an orthopaedic specialist when the pain continued. Although the practice did not re-check a slightly abnormal blood test result within the specified period of a week, the adviser did not consider that the actual delay of ten days was unreasonable. The practice acted promptly when this was identified and we did not consider that the ten day delay would have affected what happened to Mr A. In addition, we could not say whether re-checking this sooner would have resulted in Mr A receiving more adequate pain relief or being admitted to hospital more quickly.

Summary
Mrs C had been a patient of a dentist at the practice for 20 years. She visited him complaining of toothache and a history of loosening teeth, and he referred her for a specialist assessment, mainly to discuss an implant and bridge. The specialist she attended told Mrs C that she had chronic adult periodontal disease (a condition involving infections of the gums and bone that surround and support the teeth). This had resulted in significant bone loss, and she also had a chronic infection. The specialist suggested a number of options for dealing with the problem but warned that the damage done would be difficult to address.

Mrs C complained that her dentist did not identify or treat her for periodontal disease and that, as a consequence, her teeth and gums had deteriorated to the extent that it would be difficult to maintain her remaining teeth or deal with the problem with which she had been left.

As part of our investigation, we obtained independent advice from one of our dental advisers. Our adviser confirmed that the dental records made by Mrs C's dentist were minimal and that there was no explicit diagnosis or treatment plan. There was no evidence that he had told her that she had serious periodontal disease or that she had been given any preventative advice. Given Mrs C's symptoms, we found that the dentist should have at least carried out a basic periodontal examination and taken x-rays, but he did not do so.

Recommendations
We recommended that the dentist:
• apologise to Mrs C for his failure in this matter; and
• discuss this matter at his next professional appraisal and provide evidence that he has done so.

When this report was first published on 27 March 2013, it was incorrectly categorised as being about Greater Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 9 April 2013, and for which we apologise.

Summary

Ms C has a clinical need for a hysterectomy (surgery to remove the womb), and was to be referred to hospital for treatment. Her social and domestic circumstances meant that she did not wish to be treated at the local hospital. She discussed this with her GP and her GP requested she be referred outwith the board's area for her operation. The medical director reviewed the request, but declined it on the basis that the procedure could be carried out locally. Ms C appealed, and the chief executive reviewed the decision and also declined it as he agreed with the medical director's decision.

As part of our investigation, we asked to see the protocol that the board use to consider extra-contractual referral (ECR - where a person is referred for treatment elsewhere). We found that the protocol did not say that the medical director could decline an ECR - rather, an ECR panel should have considered and decided on Ms C's request. We upheld Ms C's complaint, as we found that her request had not been reasonably considered by the board in line with their protocol, which was that such requests should initially be considered by an ECR panel.

Recommendations

We recommended that the board:

• ensure that relevant staff clearly understand and follow the process for considering extra-contractual referrals; and
• consider Ms C's request at an extra-contractual referral panel, as a matter of urgency.
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Summary

Mrs C complained about the professionalism of an ambulance crew who had attended her late husband about a year before. She said that the crew refused to allow her husband to take a case with him in the ambulance or to allow a family member to travel with him. The family was also told to wait an hour before attending the hospital.

The board explained that due to the time that had elapsed since the incident, the crew could not recall what was actually said. The board, however, accepted that there must have been a failing in the way the crew communicated to the family. As a result the crew had been reminded of their responsibilities and that their actions could be interpreted differently from what they intended. We found that the board had conducted a thorough investigation, including interviewing appropriate staff, and we took the view that it was unlikely that further consideration of the matter would achieve more for Mrs C.

Summary

Miss C complained about the time that it took for an ambulance crew to attend to her late father, who had suffered a heart attack. The board explained that on receipt of an emergency 999 phone call, the nearest available ambulance was dispatched. However, when it was thought that the ambulance would be delayed due to road works, a second ambulance was dispatched and the first was stood down. The board then realised that the second ambulance had to negotiate the same road works and as a result arrived one minute after the time estimated for the first ambulance's arrival. The board explained that the first ambulance should not have been stood down and gave an assurance that lessons have been learned. We found that the board had taken the complaint seriously, and that the appropriate staff had been interviewed and reminded of their responsibilities. We took the view that further consideration of the complaint would not achieve more for Miss C.

Summary

In September 2011, the hospital introduced a new clinical model, which set up new hub and cluster units (a central point and areas for activities). Each of the four hubs supports a cluster of three 12-bedded wards, with various therapeutic, physical, creative and social activities taking place in the hub. There is a central unit where more formal therapies and educational activities are held.

Mr C, who is a patient in the hospital, complained that patients were unreasonably pressured to attend activities in the hub area and that alternatives to attending there were limited. Our investigation found that the board had already addressed staff recruitment and training issues and reviewed policies to allow a more flexible use of resources. This had allowed them to keep more wards open while still staffing the hubs, and they confirmed that in the last month Mr C's ward had not been closed. They also pointed out that sometimes they cannot keep all areas open because of staffing and safety issues.

The hospital provided details of Mr C's personal programme of activities. We noted the steps that have been taken to review and improve practices at the hospital. Independent advice received from our medical adviser on a previous similar case was that positive progress had been made. Our adviser also said that staff often have to find a balance between encouraging patients to engage with therapies and activities and making them feel pressurised.

We took the view that it was not unreasonable for patients from one area to move elsewhere when there are short term difficulties. The matter of deciding how patients should spend their time, and where, is one for the board to consider and decide upon and we found no evidence of anything having gone wrong in the process of deciding how to go about this. On the basis of the information provided and the advice previously received from our adviser, we did not uphold Mr C's complaint.

Summary

Mrs C made a number of complaints about the board's care and treatment of her husband (Mr C). Mr C had been diagnosed with rectal cancer (cancer of the lower part of the large bowel) and liver metastasis (cancer that spreads to other parts of the body).

Mrs C said that her husband had cognitive defects (his understanding was limited) and the board did not take this into account when obtaining consent for surgical procedures carried out on him. She said that Mr C was not competent to give informed consent (consent for medical procedures to take place, with a proper understanding of what these involve) and that she stressed this to every health professional she came in contact with. Mrs C was both financial and welfare power of attorney for her husband (ie she could control decisions about most aspects of his life). However, when responding to her complaint, the board said that Mr C was not at any point considered to have been incapacitated to an extent where he could not sign his own consent forms.

We upheld Mrs C's complaints about Mr C's care and treatment and about the board's complaints handling, but not her other complaints. Our investigation found that, on balance, there was evidence in the case notes to show that Mr C had cognitive impairment that compromised his capacity to provide informed consent. The clinicians involved should have documented their own assessment of his capacity, but failed to do so. We, therefore, did not know what their views on this were, or how, if at all, they had assessed Mr C's capacity to consent to medical procedures. If they believed that Mr C lacked capacity, then the provisions of the Adults with Incapacity Act should have been used, which would have ensured Mrs C's involvement as power of attorney. Mrs C's involvement in major decisions relating to Mr C's care, including consent to undergo surgery, would also have been documented. On the other hand, had the clinicians believed that Mr C did have capacity for such decision making, they should have clearly documented this. In view of this, we found that the assessment and documentation of Mr C's cognitive function and capacity to consent was below a reasonable standard.

Mr C had had a ventriculoperitoneal shunt (a device to divert fluid from the brain) inserted several years before. A central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) had been placed in the same area during his treatment for cancer. Staff noted inflammation around the site of the central line and it became apparent that Mr C's confusion had worsened. Mr C's condition deteriorated and the central line was removed. A scan was then carried out, which found that there was more fluid in Mr C's brain than had previously been seen. Mr C was transferred to a neurosurgical ward (ward for surgery of the brain or other nerve tissue), but his condition continued to deteriorate and the shunt was removed. Mr C's neurosurgeon considered that his neurological deterioration was a direct result of the infected central line, although the surgical staff involved in fitting the central line disputed this. We found that the surgical staff should have avoided putting the central line in the same area as the shunt. However, there was insufficient evidence for us to decide that this caused an infection and led to Mr C's neurological deterioration. We found that the other treatment provided to Mr C was appropriate and in line with the current guidelines for the management of rectal cancer. We also found that it was reasonable to undertake keyhole surgery and that Mr C's consultant was reasonably involved in his care and treatment.

Mrs C also complained that the board did not reasonably provide information about Mr C's condition. Although this was a balanced decision, we found that the information provided had been reasonable. However, we found that the board had not responded to Mrs C's complaints within a reasonable timescale.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C; and
• consider how to raise awareness amongst medical and nursing staff of the need to: objectively assess cognitive function; assess and document capacity to consent; clearly document the existence of proxy decisionmakers such as a power of attorney; and, document the inclusion of the power of attorney in decision making processes more explicitly than occurred in this case.

Summary

Mrs C complained that a GP failed to physically examine her husband (Mr C) during a home visit and wrongly concentrated on his mental health problems. The practice explained that the GP believed that Mr C was depressed and that he required a psychiatric assessment, which she arranged on return to the practice.

Our investigation found that Mr C's medical records showed that the reason for the home visit was for mental health issues rather than a physical examination. Our medical adviser reviewed the records and felt they were appropriate in relation to a visit for mental health issues. We were unable to resolve the difference of opinion between Mrs C and the GP about what was actually said at the visit, but we were satisfied that the GP's actions in making a referral for psychiatric assessment were correct.

Summary

Mrs C's daughter (Miss A) attended a GP appointment with symptoms of depression. She was prescribed Prozac (an anti-depressant medication). Mrs C complained that this treatment was inappropriate. She felt that the GP had not tried to properly establish the cause of her daughter's depression and had unreasonably prescribed medication that could increase the risk of suicide in young people.

However, after taking independent advice from one of our medical advisers, we found that the GP's treatment of Miss A was reasonable. A review appointment had been made for a week later. We found that it was appropriate to prescribe such medication for Miss A's symptoms, particularly as the review appointment was in place to assess her reaction to, and mood level, whilst taking the medication.