Health

Summary

Mr C's wife (Mrs C) became unwell and visited her GP who arranged for tests, which showed she had kidney stones. Mrs A continued to suffer abdominal pain but a CT scan (a special scan using a computer to produce an image of the body) and various other gastrointestinal investigations (investigations of the stomach and intestine) did not show any significant abnormality. Mrs C's GP referred her to a hospital accident and emergency unit (A&E) surgical team for further assessment. An urgent out-patient CT scan was requested and she was discharged the same day.

Nine days later, Mrs C went to A&E again because she continued to suffer severe pain, and was reviewed by the medical and surgical teams. Further tests were carried out and although she could have been admitted at this time, Mrs C preferred to go home and prepare herself for being admitted in two days' time. However, as Mrs C could no longer tolerate the pain, she returned to A&E the next day and was admitted to hospital. A CT scan and biopsies (tissue samples) confirmed that Mrs C had cancer of the pancreas that had spread to her liver, and she died a few weeks later.

Mr C complained that the consultant did not examine his wife and that she was only prescribed painkillers and advised to take laxatives. We took independent advice from one of our medical advisers, who said that Mrs C was appropriately assessed and examined by the junior A&E doctor and that although laxatives had been recommended, there was evidence that the staff were also considering other causes of the pain. We also noted that relevant tests were organised, including x-rays and blood tests and Mrs A was appropriately given morphine for pain relief.

However, we upheld Mr C's complaint, as we identified that it would have been reasonable and appropriate for the consultant, as the senior A&E doctor in attendance, to have examined Mrs C to confirm the junior doctor's assessment and findings. In doing so, we noted our adviser's view that such an examination was unlikely to have resulted in an earlier diagnosis of cancer. We also considered that the consultant should have pro-actively consulted with the surgical team, rather than having done so at Mrs C's request. Finally, we were critical that the consultant did not document his consultation with Mrs C. The General Medical Council provides guidance, which says that it is good medical practice to make such a record.

Recommendations

We recommended that the board:

• inform the consultant of our findings in relation to matters related to Mrs C's examination and the documenting of his consultation.

When it was originally published on 27 March 2013, this case was wrongly categorised as ‘not upheld’. The correct category is ‘upheld’ and it was amended on 8 May 2013.

Summary

Mr C complained about the care and treatment that his late wife (Mrs C) received at the medical practice over a three month period. Mr C was unhappy that the practice did not carry out relevant investigations of Mrs C's persistent and severe abdominal pain. He told us that he felt that doctors at the practice did not listen to their concerns, and that there was a lack of support. After Mrs C was admitted to hospital, further investigations showed that she had pancreatic cancer, and Mrs C died a few weeks later.

We did not, however, uphold Mr C's complaint. Our investigation found clear evidence to show that the practice had carried out appropriate and reasonable investigations to try to diagnose the cause of Mrs C's ongoing pain. They had also referred Mrs C to a specialist for further investigation. We noted that a CT scan (a special scan using a computer to produce an image of the body) had been carried out two months before her diagnosis, but had not shown any abnormalities. Our independent medical adviser also explained that pancreatic cancer tends to present late, often with non-specific symptoms, and has some of the lowest survival rates of all cancers.

Summary

Mr C had a left knee and hip replacement several years ago. He attended the hospital's orthopaedic clinic (clinic for conditions involving the musculoskeletal system) around a year ago because he continued to have pain in his left leg and difficulty walking. He was discharged from the clinic, but was diagnosed around a year later with neuro-sarcoidosis (a chronic disease of unknown origin characterised by the enlargement of lymph nodes in many parts of the body along with nerve tissue dysfunction). Mr C complained that, despite his ongoing pain and difficulty walking, the orthopaedic consultant discharged him from the clinic without referring him to a neurologist (a specialist in the science of the nerves and the nervous system, especially of the diseases affecting them).

After taking independent advice from one of our medical advisers, we found that there was evidence that the consultant carried out appropriate assessments to test Mr C's reflexes and there was no clear indication of a neurological abnormality. Referral to a neurologist would not, therefore, have been necessary at that time. In addition, we considered that it was reasonable for them to have discharged Mr C, as it was not unusual for a man of Mr C's age to experience unsteadiness following knee and hip operations.

Summary

Miss C complained that there was a lack of continuity in the midwifery care she received during her pregnancy, and that she had ongoing symptoms after being incorrectly given a general anaesthetic. Miss C was also unhappy that the board did not acknowledge her concerns about these symptoms, which included headaches, loss of vision, vomiting and dizziness.

Miss C told us that she was concerned that blood samples had been lost, that she had to repeat herself every time she saw a new midwife, and that she did not get advice when she needed it. She said that her phone messages were not returned and there was a lack of information about antenatal classes (classes for new parents before a baby's birth) and induction of labour (treatment given to bring on the onset of birth).

Our investigation found that Miss C saw three different midwives during her pregnancy, because a member of staff was off sick. However, but we did not find evidence that her overall care was inconsistent or unreasonable, and we did not uphold this complaint. The clinical records were of a good standard and there was evidence that that antenatal matters and induction of labour were discussed with Miss C. The board did acknowledge that a blood sample had been lost, but had apologised for this.

Miss C also complained that she continued to experience symptoms after an error with anaesthetic. We found that Miss C was appropriately given a spinal block (an injection of a small volume of anaesthetic into the lower spine) during a caesarean section (a surgical procedure used to deliver a baby). However, the anaesthetist then made a mistake and gave her a general anaesthetic instead of antibiotics. This resulted in Miss C losing consciousness. Although there can be an association between headaches and spinal blocks, our adviser said that Miss C's symptoms did not suggest that they were a result of anaesthetic complications. We accepted this advice and did not uphold Miss C's complaint that the board failed to recognise the long-term effects of the anaesthetic.

However, we found that the board had not provided a response to Miss C's concerns about this. Had they done so, it might have provided Miss C with some reassurance, and we upheld her complaint about the board's complaints handling.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to respond to her concerns about the potential long term effects from the anaesthetic; and
• reflect on this case and consider offering a debrief to patients shortly after significant events.

Summary

Mrs C complained about the care and treatment she received during a three-week hospital admission. Mrs C was admitted for an endoscopic retrograde cholangiopancreatogram (ERCP - a procedure where a flexible tube is passed into the small intestine) and believed that she would be discharged the same day. She said that she had to change for her surgery in a supply room, and that nursing staff were unaware of her whereabouts when the theatre porter came to take her to surgery. She also said that there was no pre-operative discussion or explanation of her impending surgery, no consultation about possible complications and risk factors, no explanation of the forthcoming surgical procedure, and no formal introduction to the surgeon or the surgical team. The procedure was difficult and a significant complication developed which meant that Mrs C remained in hospital for three weeks. The procedure proved difficult because of the narrow opening of her bile duct. She also underwent a sphincterectomy (her sphincter muscles were cut). She developed pancreatitis (inflammation of the pancreas) which caused her severe pain. Mrs C's condition deteriorated and she said that staff failed to recognise this and that her family had to alert them to her deteriorating condition. She was transferred to a high dependency unit seven days after the procedure. She also complained that staff failed to provide appropriate or effective pain control until she was prescribed a morphine pump (a medical device used to deliver pain relief into the spine) nearly two weeks after the procedure, and that the board made inaccurate statements in relation to pain relief and communicating the risks of the procedure.

After taking independent advice from one of our medical advisers, we upheld three of Mrs C's four complaints. Our investigation found that Mrs C was asked to change in a treatment room (not a supply room) and that this should not be normal practice. We noted that the board acknowledged the distress this caused Mrs C and took steps to ensure it did not happen again. We also found no evidence that Mrs C was made aware that pancreatitis is a common complication of ERCP and sphincterectomy, which is unacceptable. We did not uphold the complaint about the standard of post-operative care and treatment Mrs C received, as we found that this was reasonable, including the pain relief regime that was in place. We found that the board had correctly said that while it had been difficult to control the pain in Mrs C's case, appropriate and reasonable pain relief was provided. During our investigation, the board acknowledged that they had misinterpreted the level of discussion between the consultant and Mrs C about the risks of the procedure, and we found that they had inaccurately stated in their response to her complaint that Mrs C was informed about the risks.

Recommendations

We recommended that the board:

• ensure that staff properly inform patients of risks when they are obtaining consent for treatment and that record-keeping reflects this; and
• apologise to Mrs C for the failings identified.

Summary

Mrs C said that her husband (Mr C), who had terminal cancer, had fallen from his bed which was in a side room in the hospital, and died later that day. Mrs C felt that staff should have kept a better watch on her husband as he had lain on the floor for some time. She felt that the level of investigation of her complaint was inadequate.

In response to Mrs C's complaint, the board had apologised that the level of observation carried out on Mr C overnight was inadequate, and said that they had reminded staff of their responsibilities. They also explained that Mr C was assessed as at low risk of falling and when he was discovered on the floor he was examined by a doctor and put back to bed. Mr C had been placed in the side room for privacy, and to allow the family flexibility in visiting. Our investigation noted that it was good practice for the board to have placed Mr C in the side room for privacy reasons. We did not uphold the complaint, as we found that the board had properly investigated Mrs C's concerns.

Summary

Ms C complained that a medical practice she was registered with failed to properly assess her or her children with regard to their symptoms. Ms C was unhappy with the practice's assessment of her thyroid (a gland in the front inside area of the neck) and matters related to a parasite (an organism that lives on or in the body (host) from which it feeds) that she believed she and her family were suffering from.

We noted that Ms C was registered with the practice for approximately three months and within that period, tests were carried out on both Ms C and her two children. We considered that the practice had carried out reasonable and appropriate investigations and that there was no evidence of parasites.

Summary

Ms C complained that a medical practice she was registered with failed to carry out adequate assessments or arrange appropriate investigations to diagnose the symptoms she presented with. Ms C was mainly concerned that the practice had not monitored her thyroid (a gland in the inside front area of the neck) or recognised the positive impact of a particular drug on her condition.

We noted that Ms C might have received more consistent care had she not seen so many different doctors there over the course of two years. However, we considered that overall the medical practice carried out reasonable investigations and made appropriate specialist referrals in response to Ms C's ongoing symptoms. The practice have since provided evidence to show that their use of locum (temporary) doctors has reduced.

Summary

Mr C complained that it took too long to deal with a treatment plan proposed by his dentist. Mr C thought that the treatment time guarantee applied and had been exceeded. However, we found that at the time of Mr C's complaint the treatment time guarantee was not in force and did not apply. We also found that his treatment plan was progressed within a reasonable timescale.

Mr C also complained that a phone call was poorly handled. We upheld this complaint because the board had acknowledged and apologised for providing incorrect information during the phone call.

Summary

Miss C had been attending her GP for a number of months with a suspected prolapsed disc (ruptured disc in the spine). Before her scheduled orthopaedic (medicine of the orthoskeletal system including the spine) appointment, her condition deteriorated suddenly. She experienced severe pain and numbness in her legs.

Due to a lack of response from her medical practice, Miss C contacted NHS 24 for advice. NHS 24 contacted the medical practice and arranged a home visit. Miss C was then advised to attend her hospital appointment, but she continued to be in severe pain. She called NHS 24 again and arrangements were made for an out-of-hours GP to contact her. The GP contacted Miss C and discussed her symptoms, which had worsened and included numbness, pain when urinating and burning sensations in her legs. The GP did not visit her or suggest a hospital attendance. Miss C was advised to self-assess her condition overnight.

The following afternoon, Miss C was admitted to hospital where she was diagnosed with cauda equina (a disorder that affects the nerves). Miss C complained that NHS 24 did not provide full details of her symptoms to the out-of-hours GP, resulting in a delay to diagnosis which has left her with nerve damage that may be permanent.

Upon reflection, after submitting her complaint to us, Miss C decided that she was satisfied that NHS 24 had in fact provided full information to the GP. She accepted NHS 24 's apology for other incorrect information provided by their staff, as well as their reassurance that steps would be taken to prevent similar issues in the future. She withdrew her complaint, and so we did not reach a finding on it.