Health

Summary

Ms C complained about the care and treatment that her late brother (Mr A) received from a medical practice. She was very unhappy with the GP's long-term use of antibiotics in treating Mr A's skin problems. Mr A found it very difficult to leave home, and Ms C said that for almost eighteen months, the GP prescribed Mr A a large amount of antibiotics, mainly during home visits or phone consultations. Mr A had later died from cancer of the pancreas (which was unrelated to this complaint).

We took independent advice from one of our medical advisers, and reviewed Mr A's medical records, as well as the documentation provided by Ms C. While we acknowledged that the GP had considerable difficulties in managing Mr A's condition, our adviser said that it was clear that an inappropriate amount of antibiotics was prescribed over a long period, and that Mr A's condition might have been managed better by involving district nurses. We accepted this advice, upheld the complaint and made two recommendations.

Recommendations

We recommended that the practice:

• conduct a significant events review; and
• apologise to Ms C for the failures identified.

Summary

Mr C fell and injured his foot while on holiday. Upon returning home, he went to a hospital accident and emergency department (A&E) where his foot was x-rayed. He was told that this showed no problems, but he continued to experience severe pain in the following months. Some six months later, Mr C's GP referred him for further x-rays, which showed that he had a dislocated toe. He was told that, because of the amount of time that had passed, this could not be corrected without surgery. Mr C complained that staff failed to identify the dislocation when reviewing the earlier x-rays.

When investigating Mr C's complaint, the board asked a panel of six consultant radiologists (specialists in analysing images of the body) to review the x-rays. They concluded that the dislocation was not evident on the original x-rays and that Mr C's toe joint must have separated between then and the referral, when the dislocation was obvious. Mr C's consultant orthopaedic surgeon (a specialist in conditions involving the musculoskeletal system) also reviewed the x-rays. He concluded that a slight abnormality was evident on the original x-rays, but did not feel that it was reasonable to expect staff to have diagnosed a dislocation from this at the time, as it was only apparent when comparing the image to the March 2012 x-ray.

We took independent advice from two medical advisers. The first, a consultant radiologist, said that the original x-rays showed a subtle but definite abnormality, which should have led to the dislocation being diagnosed, or to further specialist opinion being sought. However, the second adviser, a consultant orthopaedic surgeon, disagreed and did not consider that staff could reasonably have been expected to diagnose the dislocation at the earlier time.

We did not uphold Mr C's complaint. We found it likely that Mr C's toe had a dislocation when he went to A&E. However, it was clear from the conclusions reached by a number of professional medical personnel that this was not easy to diagnose from the initial x-rays. Although, with the benefit of hindsight and the later x-ray, it was possible to determine that there were abnormalities in the initial x-rays, we considered that the original conclusions reached were reasonable, based on the evidence available at the time.

Summary

Mr C was unhappy about a delay in reporting the result of a test carried out on a blood sample from his late mother. He said that by the time the board contacted the GP with the result of the test, his mother had deteriorated and required hospital admission. He complained to us that the board's investigation of his complaint was inadequate.

We took independent advice from one of our medical advisers. In considering the complaint we noted that the board had apologised for the delay in reporting the result. They explained that this was caused by human error, and that they had reminded the staff member of their responsibilities. When the error was discovered, urgent action was taken to contact Mr C's mother's GP. Our medical adviser said that the time taken to report on the blood sample was in fact reasonable, but that the member of staff had missed an opportunity to report it sooner. We did not uphold the complaint as we found that the board had carried out a thorough investigation, and had taken appropriate action to prevent this happening again.

Summary

Mr A's late wife (Mrs A) was in hospital, and had developed symptoms that suggested she might be infected with legionella (the bacterium that causes legionnaire's disease). Blood tests were taken, but Mrs A died the next day, before the results were known. The hospital issued a death certificate and Mr A organised his wife's funeral. However, when the undertaker tried to collect Mrs A's body the day before the funeral, the hospital would not release it. This was because the legionella tests had come back positive and the procurator fiscal had been informed. Mr A was left not knowing when he would be able to hold his wife's funeral, and said that he did not receive a clear explanation of the reasons for the delay or what would happen if the tests were positive. Because of the delay, the family had to cancel the funeral which both caused extreme distress and inconvenienced them, as family members were travelling from other parts of the UK.

The further tests, however, showed that the first result had been a 'false positive' and Mrs A did not have a legionella infection. An advocacy worker (Ms C) complained to us on Mr A's behalf about the board's administration and communication. She said that the board had issued the death certificate prematurely and delayed in deciding not to release Mrs A's body. She also said that their communication was unreasonable in that they delayed in telling the appropriate people that Mrs A's body was not to be released, provided an inadequate reason for not releasing Mrs A's body, and failed to provide reasonable information about what would happen if the test results were positive or about when Mrs A's body would be released.

We did not uphold the complaint that the board's administration of matters was unreasonable, as we found no evidence of delay in deciding to release Mrs A's body. Our investigation found that the decisions about this were taken as quickly as they could have been. We also found that it was reasonable for them to issue a death certificate, as the main causes of death were appropriately recorded.

However, we did uphold the complaint that the board's communication was unreasonable. Although a doctor had contacted Mr A at the right time to explain why Mrs A's body could not be released, we found no evidence that the doctor explained to him the implications of a positive test result. Although we acknowledged that normally the chance of a positive test was small, we found that Mr A and his family should have been told of the possible implications in order that they could make informed choices about important matters such as funeral arrangements.

Recommendations

We recommended that the board:

• take steps to ensure that, where similar circumstances arise, medical staff make relatives aware of the potential impact of a positive test result.

Summary

Mrs C complained about the care given to her mother (Mrs A) by the practice GPs. Mrs A had rheumatoid arthritis (an inflammatory condition that mainly affects flexible joints) and osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break). She injured her ankle, which caused her severe pain, and she could not put weight on her foot. Mrs A's medical practice did not arrange for this to be x-rayed, and it was some time later that an out-of-hours doctor sent her for an x-ray, which identified a fractured tibia (shin bone) and fibula (bone on the outside of the lower leg). Mrs C complained that the practice unreasonably failed to arrange for Mrs A to be x-rayed.

Our investigation found that, over a two week period after the injury, the GPs twice visited Mrs A at home as well as having a phone consultation, yet did not arrange an x-ray. They instead diagnosed a flare up of arthritis and prescribed pain relief, with increased dosages when the pain did not subside (and indeed worsened). We found that the GPs should have arranged for an x-ray to be taken, particularly as Mrs A had osteoporosis and taking into account her age, frailty and the fact that she could not put weight on her foot. We also upheld the complaint that a phone consultation was inappropriate after the two home visits. We found that further action should have been taken at this time and that the decision to simply increase pain medication during a phone consultation was unreasonable.

Recommendations

We recommended that the practice:

• provide a formal written apology for the failure in service Mrs A experienced; and
• provide evidence to the Ombudsman that a significant event analysis has been carried out and of any service improvements that are identified following it.

Summary

Mrs C was referred to a hospital gynaecology clinic with a vaginal prolapse (a condition when one or more of the pelvic organs slips down from its normal position). After she was first seen, she was given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and given a follow-up appointment for five months after that. A couple of months before the follow-up appointment was due, however, she developed post-menopausal bleeding (PMB - vaginal bleeding occurring over twelve months after the menopause). Treatment of her prolapse was postponed while this was investigated. Mrs C had biopsies (tissue samples) taken on three separate occasions before having a hysterectomy (surgery to remove the womb) some seven months after reporting the bleeding. Mrs C complained about the length of time between her initial GP referral and her surgery. She also complained about the number of biopsies she had to have and the length of time taken between each biopsy. She felt that her treatment was delayed as a result of failed biopsies.

We took independent advice from a medical adviser, who said that the prolapse was not clinically urgent, but that PMB could be indicative of cancer and needed urgent investigation. A hysterectomy was required to deal with the prolapse, and treatment for PMB would also require a hysterectomy. However, if cancer was found in the PMB treatment, it might also be necessary to remove the ovaries and lymph nodes within the abdomen. With this in mind, we found that while the PMB was being investigated it was appropriate to postpone the prolapse hysterectomy, so that she did not have to undergo two separate operations should cancer be found.

We also found that the biopsies that were taken were inconclusive rather than incomplete. Each biopsy was necessary and completed and reported in a reasonable timescale. Ultimately, the biopsies showed no signs of cancer. We were generally satisfied with the investigation and management of Mrs C's PMB.

That said, from December 2011, the board were required to work in accordance with the national waiting time target of 18 weeks from GP referral to treatment. Although Mrs C was referred before then, we considered that the board should have been working towards the target by the time of her referral. It took 35 weeks for Mrs C to be offered treatment after her referral, and her PMB began 31 weeks after referral. As the biopsies showed that Mrs C did not have cancer, we concluded that, had the board carried out the hysterectomy to address her prolapse in line with the 18 week target, Mrs C would not have developed PMB, and as such would not have required the biopsies and other investigations that she underwent. We, therefore, upheld her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation; and
• ensure that their general gynaecology clinic have systems in place to provide treatment in line with national referral to treatment targets.

Summary

Mr C complained that his medical practice failed to provide appropriate care and treatment when he had an eye infection and unreasonably refused to allow him to see a GP.

Mr C developed an eye infection, and called his practice on a Friday to request an appointment. He was told that there were no appointments available and that he should call again on Monday. By Monday his eyes had not improved, and he contacted NHS 24 (a national phone helpline service for advice on health matters). They advised him to see his GP. His workplace occupational health team also advised him not to work, and to see his GP. When Mr C contacted the practice again, he was told that when he first called he should have been referred to the LENS service (a service set up by the regional NHS board, providing direct access to treatment for minor eye conditions). The receptionist he spoke to on this occasion apologised that he was not told this when he first called, and advised him to contact a local optician, a participant in the LENS scheme.

Mr C was treated with various eye drops but his condition was slow to resolve. He contacted the practice several times over the next two weeks asking to see a GP. Although he twice saw a nurse from the practice, he was never able to see a GP. As he was unable to see a GP, Mr C continued with the treatment provided by the LENS service and was discharged the next month with the infection resolved.

Our investigation, which included taking independent advice from a medical adviser, concluded that it was reasonable that Mr C should have been referred to and treated by the LENS service. We, therefore, did not uphold the complaint about his initial treatment. The adviser said that the care and treatment provided by the service was reasonable and appropriate, and would not have been different from the treatment provided by a GP. However, we did find that when his condition was slow to resolve, it was unreasonable that Mr C was not given the opportunity to discuss his condition with a GP and be reassured that the treatment being provided by the LENS service was appropriate. Because of this, we upheld his complaint that he was refused access to a GP during that time.

Recommendations

We recommended that the practice:

• apologise for the failings identified; and
• review their policy and procedures for the allocation of GP appointments where patients have been referred to another service, and ensure that staff are considerate of the possible need for the reassurance provided by discussion with a GP when a condition is not resolving within a reasonable time.

Summary

Miss C complained that, when she visited her GP as a new patient, he refused to prescribe her Zopiclone (a drug used to treat sleeping problems). She said she had been unable to sleep because she had been in a hypomanic stage (a period of mild over-active, excited behaviour) of her bipolar disorder (a condition that affects a person's mood) for the last two months. From previous use, she said she knew that Zopiclone would help. She told the GP that her former GP and her psychiatrist found this acceptable.

Our investigation found that the GP had been right to be cautious as Zopiclone is a drug that must be prescribed with care. For example, it is a drug that is open to abuse as a so-called street drug. Also, Miss C's medical records had not yet arrived, so the GP's knowledge of her was very limited. He did prescribe alternative medication, so there is no question that she was given nothing to help with her condition. The GP then contacted her former GP and her psychiatrist and, having been reassured by some of the information from them, prescribed the Zopiclone the next day. Our independent medical adviser considered that this was a very reasonable approach and we did not uphold Miss C's complaint.

Summary

Mr C complained that GPs at the practice failed to take appropriate action after he repeatedly went there with back pain. The practice gave him pain relief, and offered physiotherapy. After he was admitted to a hospital accident and emergency department, magnetic resonance imaging (MRI scan - used to diagnose health conditions that affect organs, tissue and bone) was carried out, the result of which suggested an abnormality. On further investigation Mr C was found to be suffering from miliary tuberculosis (a form of bacterial lung infection which has spread to other organs).

We reviewed all Mr C's correspondence and obtained background correspondence and a copy of medical records from the practice. We also took independent advice from one of our medical advisers. He found that the practice's actions had been appropriate. The adviser confirmed the practice had followed guidelines in relation to the management and treatment of Mr C's back pain. He also explained that the diagnosis was rare and it was reasonable that the practice had not diagnosed it.

Summary

Mr C complained that the board provided inadequate treatment to his adult daughter (Miss A) in a hospital accident and emergency department (A&E) after a fall. Miss A had been taken there after a neighbour found her with a head injury. The doctor who saw Miss A recorded that she was intoxicated with alcohol and had abdominal and chest pain. She noted that Miss A had drunk a bottle of wine, and was difficult to assess and quite uncooperative with questioning. Miss A was initially unwilling to say how she had hurt herself, but eventually said she had fallen in her flat and had gone to the foyer to get help. However, the doctor was not convinced by this.

The doctor noted that Miss A said that the abdominal/chest pain started before she fell and was due to an existing kidney disorder. Miss A refused to have the head injury stitched, so it was cleaned and glued. The doctor arranged for a chest x-ray and routine blood tests. She gave Miss A painkillers and re-examined her after two hours, by which time, the chest and abdominal pain had improved. The doctor recorded that she thought that Miss A had likely suffered a muscular chest injury, and discharged her. Miss A was advised to see her GP in two days to get her bloods rechecked, and to return to hospital if there were any problems. Miss A declined to contact her parents for help to get home.

Miss A returned to A&E later that day, and this time told staff that she had in fact fallen off a balcony. She was admitted and was in hospital for three weeks. A CT scan (a special scan using a computer to produce an image of the body) and x-rays showed that she had suffered a number of injuries.

We obtained independent medical advice on the complaint, and found that, in general, the care provided to Miss A was reasonable. The doctor assessed Miss A in the context of the description she gave of a minor fall, and Miss A had to take responsibility for not saying what had actually happened. If the examining doctor had been aware of how the injury happened, Miss A would have been immobilised and a CT scan would have been requested, which would have shown the extent of her injuries much earlier.

However, our adviser also said that there were a few lapses in the standard of care. There was inadequate questioning about the significance of the head injury, particularly in the context of there being a four centimetre laceration to the head. If the doctor had asked about loss of consciousness, persistent headache, vomiting or amnesia memory loss, then responses might have indicated a need for a CT scan. The adviser also said that it was unlikely that a more senior doctor would have discharged Miss A, and there were a few subtle clues missed. These included a mildly raised respiratory rate, the chest and abdominal pain and a raised white cell count.

Although we upheld the complaint this was a decision taken on balance, in view of the fact that the overall care provided to Miss A was reasonable and the doctor was clearly not assisted by the fact that she was given inaccurate information about how Miss A sustained her injury.

Recommendations

We recommended that the board:

• issue an apology to Miss A for the failings identified; and
• make the doctor aware of our findings.