Health

Summary

Mr C complained about various aspects of his treatment by reception staff and the practice manager when he attended the practice on two occasions.

Our investigation found that there had been shortcomings in a number of areas and because of this we upheld the complaint. However, we also noted that the practice had already reviewed what had happened and had identified a number of areas where they could have handled things better. They had taken adequate action to put things right and help prevent these problems from happening again. We did not, therefore, find it necessary to make any recommendations.

Summary

Ms C's daughter (Ms A) suffers from chronic back pain following an accident some years ago. Ms C complained on behalf of her daughter that the medical practice failed to do enough to provide her with appropriate treatment.

As part of our investigation, we took independent advice from a medical adviser. He considered Ms A's medical records, her medical history and the care and treatment provided by the practice. He said that the practice had provided an appropriate level of care and treatment, including tests and treatment options. Although Ms A's pain has not been resolved, the adviser took the view that the practice have taken appropriate steps to try and identify the underlying problem and to provide on-going treatment in order to minimise the pain Ms A is suffering.

Summary

Mr C had been prescribed nitrofurantoin (an antibiotic drug used to treat bacterial infection) for a number of years for a recurring infection. He was then diagnosed with pulmonary fibrosis (a rare condition causing scarring of the lungs), which is a known side effect of nitrofurantoin and the drug was stopped. He complained that his medical practice failed to review his long-term prescriptions of nitrofurantoin appropriately.

The British National Formulary (BNF) provides national guidance for healthcare professionals about the prescribing of medicines. The BNF entry for nitrofurantoin says that lung and liver function should be monitored where someone had been prescribed this long-term. In addition, the General Medical Council (GMC) provide prescribing guidance, which says doctors should ensure that they are familiar with the BNF guidance for medicines they prescribe.

Our investigation found that during medication reviews the practice should have consulted the BNF to look up the long-term effects of the drug that they were prescribing. They should also have asked Mr C if he was having any problems with his breathing and recorded his response to this in the medical records. There was no evidence in Mr C's medical records that they had done so. Mr C also complained that the practice failed to consider the possible implications when he presented several times with breathing or chest problems. We obtained independent medical advice on this and found that the practice had acted reasonably in response to the symptoms Mr C presented with. However, in view of the fact that the practice had failed to consult the BNF about nitrofurantoin, they were not aware of the possible implications of taking the drug on a long-term basis. We, therefore, upheld both complaints.

Recommendations

We recommended that the practice:

• apologise Mr C for the failure to consult the BNF during medication reviews or at any other time to look up the long-term effects of nitrofurantoin.

Summary

Mr C had been prescribed nitrofurantoin (an antibiotic drug used to treat bacterial infection) for a number of years for a recurring infection. He was then diagnosed with pulmonary fibrosis (a rare condition causing scarring of the lungs), which is a known side effect of nitrofurantoin and the drug was stopped. He complained that his former medical practice failed to review his long-term prescriptions of nitrofurantoin appropriately.

The British National Formulary (BNF) provides national guidance for healthcare professionals about the prescribing of medicines. The BNF entry for nitrofurantoin says that lung and liver function should be monitored where someone had been prescribed this long-term. In addition, the General Medical Council (GMC) provide prescribing guidance, which says doctors should ensure that they are familiar with the BNF guidance for medicines they prescribe.

We considered that the practice should have asked Mr C if he was having any problems with his breathing when they were reviewing his medication and that they should have recorded his response to this in the medical records. As there was no evidence in Mr C's medical records that they had done so, we upheld his complaint.

Recommendations

We recommended that the practice:

• apologise to Mr C for failing to record whether they had asked if he was having any problems with his breathing when they reviewed his medication.

Summary

Mrs C complained that the board failed to provide her with appropriate care and treatment when she attended a hospital accident and emergency department (A&E). Mrs C said she had gone to hospital a number of weeks after injuring her ankle. She said she was told that she had a bad sprain, but that she did not need an x-ray as the pain would ease itself. A week later Mrs C went back to hospital in severe pain. A number of x-rays were taken and she was told that her foot was fractured. Mrs C complained that the staff nurse who dealt with her on her first visit to hospital did not check on her while she was waiting and treated her with contempt, as if she should not have been there.

During our investigation, we took independent advice from a medical adviser. He explained that the treatment Mrs C received when she first went to A&E was appropriate, and in accordance with internationally validated and recognised clinical guidelines. He said it was clearly recorded that there was no evidence of bone pain and that Mrs C was able to put weight on her foot. He explained that the absence of bone pain suggested that an x-ray was not required. We did not, therefore, uphold Mrs C's complaint about her care and treatment.

On the matter of the nurse’s conduct, although the board said they had discussed this with her during their investigation of the complaint, they had not recorded what was said, and had taken no statement from her. In response to our enquiries, they obtained an account from the nurse in which they said she accepted that her conduct towards Mrs C had been inappropriate. Although it would have been more appropriate for a statement to have been taken at the time rather than eleven months later, we upheld this element of Mrs C's complaint, as the evidence supported her view that the nurse did not deal with her appropriately.

Recommendations

We recommended that the board:

• apologise to Mrs C for the staff nurse’s conduct towards her; and
• provide the Ombudsman with a copy of the change to their procedure for investigation of complaints.

Summary

Mr C complained on behalf of Mr A about the care and treatment he received at a hospital. Mr A had attended the hospital's accident and emergency department (A&E), complaining of dehydration, frequent urination, vomiting and lack of energy. Mr A had also said that his eyesight was blurry and he had a dry mouth. After tests, Mr A was diagnosed with a virus and a low salt count, and discharged. Two days later, Mr A became ill during a journey and was taken to hospital where he was immediately diagnosed as having type 1 diabetes. He was in hospital for about a week. Mr C complained that Mr A was not properly diagnosed during his initial hospital visit.

Our investigation took account of all the available information, including the complaints correspondence and Mr A's medical records. We also obtained independent medical advice. We found that not all the tests that should have been carried out were carried out. This meant that Mr A's condition was not properly diagnosed and he was discharged from A&E too early. Our investigations also showed that the board had not addressed all the complaints Mr C put to them on behalf of Mr A.

Recommendations

We recommended that the board:

• apologise to Mr A for their failure to carry out appropriate diagnostic testing;
• apologise for failing to correctly diagnose Mr A and for discharging him prematurely;
• confirm that the GP specialist trainee raised this case as a significant event at her appraisal;
• confirm to the Ombudsman that they are satisfied that the systems failure that allowed a patient to be discharged from A&E before test results were reviewed has been remedied;
• apologise to Mr C and Mr A for failing to admit when responding to the complaint that there had been faults with regard to Mr A's care and treatment; and
• apologise for their failure to respond to the complaint about the way in which Mr A was spoken to.

Summary

When Mr and Ms C's young daughter became ill, they took her to their medical practice. She was examined by a GP, who said that she was suffering from a yeast infection and nappy rash. Later that day Mr and Ms C's daughter’s condition deteriorated and she was taken to hospital, where she was diagnosed with scarlet fever. Mr and Ms C complained to the practice that the GP did not diagnose their daughter correctly. The practice responded but Mr and Ms C felt that the response was inaccurate and did not deal with the complaint.

As part of our investigation, we took independent advice from a medical adviser. He explained that the diagnosis of scarlet fever is rare, and that there was evidence that the GP had taken appropriate steps to diagnose Mr and Mrs C's daughter's condition. Taking this into account we did not uphold the complaint.

When investigating the complaint about the practice's complaints handling, we looked at the practice's complaints procedure and response. We found that the practice had not followed their complaints process. We also found that the GP had not written detailed medical notes which meant that the practice's response was incomplete. We, therefore, upheld this complaint and made recommendations to address these failings.

Recommendations

We recommended that the practice:

• ensure that all relevant members of staff reacquaint themselves with the practice complaints procedure and ensure that they follow it; and
• ensure that the GP concerned is aware of the General Medical Council guidance on record-keeping.

Summary

Mr C was on holiday when he was taken ill while on a moored boat. He called 999 but was told that as his condition was not life-threatening he should call NHS 24. When he did so, they said they would ask an out-of-hours doctor at a local hospital to call Mr C within an hour. Mr C complained that the out-of-hours doctor would not arrange an ambulance to take him to hospital, and instead gave him the number of local GP surgeries he could contact. Mr C said that he was in great pain and could not walk, but with assistance managed to get back to his holiday home. When he got there, an ambulance was called and Mr C was taken to hospital. Mr C felt the out-of-hours doctor should have arranged an ambulance to take him to hospital in the first instance.

Our investigation found that there was a difference of opinion between the out-of-hours doctor and Mr C about his ability to get off the boat, but the information in the records did not help us resolve this. We took independent advice from one of our medical advisers, who said that there was no evidence to suggest an emergency ambulance was required, and that the out-of-hours doctor had provided appropriate advice. This was that, should Mr C's condition worsen, he should contact the emergency service again. It was also appropriate for the out-of-hours doctor to suggest that Mr C should contact a general practitioner who might have been willing to visit him on the boat.

Summary

Mr C hurt his foot while gardening. He complained that the board did not diagnose that it was fractured despite two visits to a hospital accident and emergency department (A&E). When he first attended A&E, Mr C was recorded as limping but able to bear weight on his injured foot. The records showed that his foot was sore but with a good range of movement. A bad sprain was diagnosed and Mr C was given advice on how to care for his foot.

Mr C then went on holiday for two weeks. His foot had not improved so on the way home he went to another A&E. Again the foot was recorded as having a good range of movement and Mr C was able to put weight on it. A rash was also recorded but was put down to a sweat rash, and it was noted that Mr C told staff that he had done a lot of walking on his holiday. Again a bad sprain was diagnosed. Mr C's foot was not x-rayed during either visit to hospital.

Mr C then went to see his GP as he was still having trouble with his foot and now felt it was mis-shapen. The GP arranged an x-ray which revealed that Mr C's foot was fractured. He was referred to an orthopaedic specialist (a specialist in medicine of the musculoskeletal system) who diagnosed that four of the five bones in Mr C's foot had been displaced. Mr C now has to wear orthotic footwear (special footwear available on NHS prescription) to accommodate his mis-shapen foot. Mr C was also unhappy that the board would only provide two pairs of footwear and would not provide specialist footwear such as Wellington boots; gardening boots; or sandals.

Our investigation, which included taking advice from an independent adviser specialising in emergency medicine, concluded that it was reasonable that

x-rays were not taken and that the fracture went un-diagnosed. The adviser pointed out that there should always be clear clinical indications of the need for examination by x-ray. In Mr C's case no such clear indications were present - he was able to bear weight and although his foot was painful and swollen, it had a good range of movement. The adviser commented that this type of dislocation is a relatively rare injury and so, in the circumstances, it was not unreasonable that it was not diagnosed at the time. On the matter of the orthotic footwear, we found that the board’s guidance reflects national guidance issued by the NHS in Scotland, and that it was reasonable for them not to provide more than two pairs.

Summary

Mr and Mrs C's son was admitted to hospital for surgery to correct a squint. He was discharged the same day but had to be re-admitted three days later as his eye had become infected. Mr and Mrs C were unhappy that their son has since had to endure the pain and trauma of five further operations, and that despite these, the prognosis for his eye remains poor.

Mr and Mrs C were critical of the care and treatment given to their son both during and after the operation. They said that his eye should have been patched immediately afterwards, which would have prevented infection. They also maintained that as the infection was so rare, medical staff involved were uncertain about treatment and had been unable to predict any degree of success for any of the procedures undertaken.

Our investigation took into account all the relevant information, including complaints correspondence and the relevant clinical records. We also took independent advice from a medical specialist in paediatric ophthalmology (the anatomy, physiology and diseases of the eye in children).

Our adviser said that the decision to operate was correct, that all the procedures undertaken were reasonable and appropriate, and that the care and treatment provided were satisfactory. He did not consider that the lack of an eye patch had had any effect. However, he said that Mr and Mrs C could have been given a more detailed explanation about how the infection had occurred. He said it was unclear from the records what had or had not been discussed with them, and that the consent forms used did not provide space to record the aims or possible risks or complications of an operation. We did not, therefore, uphold Mr and Mrs C's concerns about their son's treatment, although we did uphold their complaint that the explanation given was not reasonable.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for failing to provide a full explanation; and
• satisfy themselves that their consent forms are adequately formatted to allow the recording of information about the aims and risks of surgery.