Health

Summary

Mr C complained that he was prescribed the wrong dosage of his medication and that clear instructions were not given as to how many tablets he could take at a time. The practice provided us with copies of their records, clearly showing the appropriate dosage and instructions attaching to Mr C's prescription. We found no documentary evidence to support Mr C's account of events and we did not uphold the complaint. Mr C also said that he mistakenly received a letter from the practice about test results and complained that the practice had not explained why this had been sent. The practice confirmed that the letter was not intended for Mr C but, for data protection reasons, they could not offer an explanation to him. However, they provided us with sufficient information to satisfy us that there had been no administrative error and we did not uphold the complaint.

Mr C also complained that a meeting was set up for him to discuss his complaint with the practice manager and one of the doctors. He said that when he turned up the doctor did not know why he was there and the practice manager was not in attendance. Upon reviewing the records, we noted that the practice manager had documented that she set up this consultation for Mr C to discuss his medication with the doctor. It, therefore, appeared that both parties had differing recollections of the purpose of the meeting. We had no way of reconciling these different interpretations and we did not uphold the complaint. Finally, Mr C complained about the practice's handling of his complaint. We found that they failed to respond to him within the timeframe set out in their complaints procedure. We acknowledged that this may not always be possible but considered that Mr C should have been kept up to date. This did not happen and we, therefore, upheld the complaint.

Recommendations

We recommended that the practice:

• review their complaints procedure in order to ensure that, where complaint investigations are likely to take longer than their published timescales, they notify complainants of this and provide a revised target response date.

Summary

Mrs C complained that the care and treatment given to her young son (Master A) by his medical practice was inadequate. Master A had become increasingly unwell over the Christmas holiday period of 2011/12. He was eventually seen at hospital, but Mrs C complained that GPs in the medical practice had failed to diagnose her son properly and that it was largely due to luck that the second GP he saw referred him to hospital.

We investigated the complaint and took all the relevant documentation into account. We obtained independent advice from one of our medical advisers and reviewed Master A's clinical notes. We did not, however, uphold the complaint. The advice received was that the progression of Master A's illness had been slow and insidious. However, in the face of his presenting symptoms, his care and treatment had been satisfactory and appropriate.

Summary

Mrs C complained about the care and treatment given to her son (Master A) by out-of-hours GPs. Master A became increasingly unwell over the Christmas holiday period of 2011/12. He was twice seen by out-of-hours GPs in hospital but Mrs C said that he was not diagnosed properly or quickly enough, as a consequence of which he became severely ill. She also said that the board failed to properly deal with her complaint about this.

We investigated the complaint and took all the relevant documentation into account. We obtained independent advice from one of our medical advisers and reviewed Master A's clinical notes. We did not, however, uphold the complaint. Our adviser said that Master A's situation was a rare one and that most children with his symptoms would have recovered without hospital intervention. However, both out-of-hours doctors had responded appropriately and treated him satisfactorily.

Summary

Mrs C had rectal cancer. She underwent radiotherapy and chemotherapy before being admitted to hospital for an operation to remove the tumour. After surgery, Mrs C complained of abdominal pain and became very unwell. A scan showed that she had a leak in her bowel and she underwent an emergency operation. She was admitted to the intensive care unit and then transferred to the high dependency unit. A few days later, she was moved from the high dependency unit to a general surgical ward. The surgeon noted in her medical records that medical input was not sought before this move. She was discharged from hospital several weeks later, after which she received care at home from nurses and had an out-patient appointment.

Mrs C complained about communication with her and her family about the first operation. She said that they were unprepared for the nature and scale of the operation and that staff failed to identify post-operative complication within a reasonable time. She was also concerned about her move from the high dependency unit to a general ward, where staff appeared unable to cope with her serious condition. Finally, she complained about her post-operative care generally, the care she received from a nurse specialist at home following her discharge from hospital and confusion over the follow-up appointment at the hospital.

The board acknowledged that their failure to ensure that Mrs C and her family had a full understanding of the magnitude of the initial surgery and how it was to be carried out had caused considerable distress. This should have taken place at the pre-assessment stage through discussion with the clinical team and provision of written information leaflets. The board said it was also clear that Mrs C and her family had not been properly prepared for the immediate post-operative period. They apologised for these failings and set out an action plan to address them. They also agreed that they had failed in respect of the provision of specialist nursing after Mrs C returned home, and had since initiated a comprehensive and robust action plan.

After taking independent advice from our medical advisers, our investigation found that although Mrs C signed a consent form at an out-patient appointment the day before the operation, the notes on the form did not mention any complications or facts relating to the procedure. We, therefore, found that the board failed to record any discussions about the procedure and its complications or to provide written information before the operation took place. We also found that they failed to provide counselling from a specialist nurse in relation to the surgery, contrary to the relevant guidelines. Although Mrs C was moved from the high dependency unit to a ward that could attend to the monitoring that she needed at the time, this was only ascertained after the event and no medical input was sought before the move. Finally, although we found that the post-operative care was reasonable in all aspects except the lack of involvement of a specialist nurse, this was a significant failing. As the board had already taken significant steps to address most of the failings identified, we only found it necessary to make one recommendation.

Recommendations

We recommended that the board:

• ensure that the patient is formally assessed as being clinically appropriate to move from the high dependency unit in a similar situation.

Summary

Mrs C complained about the care and treatment her late husband (Mr C) received in hospital. Mrs C said that a locum (temporary) assistant had not carried out the correct procedure for referring Mr C to a specialist chest consultant at the hospital; that records from another patient were found in Mr C’s notes and that an occupational therapist (OT) had conducted an assessment on Mr C using water from a tap with a blocked sink.

We took independent advice from a medical adviser, who considered all aspects of Mrs C’s complaint and Mr C’s care at the hospital. He said that the board had failed to ensure that an abnormality on Mr C’s chest x-ray was appropriately investigated after it was noted by the radiologist (a medical specialist that uses imaging to diagnose and treat disease). The board had acknowledged and addressed this, and apologised to Mrs C before the complaint was brought to us. We, therefore, upheld this complaint. Mr C subsequently died of cancer, but our adviser said that it was not possible to say whether the outcome for Mr C would have been different had a diagnosis been made earlier.

Although our investigation found no evidence that another patient’s records were included in Mr C’s notes, we acknowledged that such an event can occasionally occur and noted that the board had expressed regret about this. We upheld the complaint.

We found no evidence that water from a blocked sink had been used in the OT assessment and so we did not uphold this complaint.

Recommendations

We recommended that the board:

• provide an update on the implementation of their protocol, with specific reference to how results of investigations undertaken whilst a patient is an in-patient are reconciled with their case notes after discharge.

Summary

Mr C complained that an optometrist used incorrect optical notes when undertaking his consultation and did not realise his mistake until Mr C pointed it out to him. The optometrist explained that he picks up the optical records for the next patient in the queue before entering the waiting room and calling their name. He said he followed the standard process on this occasion. He explained that it became clear during the consultation that Mr C's optical history and examination results did not correspond with the optical records he held. He then checked the name and established from Mr C that he was not the patient called. He explained that he called for a different patient in the waiting room but Mr C came forward.

Our investigation found that Mr C suffered no ill effects from this consultation. In addition, there were no witnesses to the consultation itself and we did not consider it proportionate to try and trace other patients who were in the waiting room and who may have witnessed the optometrist calling for the appointment. As we could not reasonably obtain sufficient evidence to allow us to reach a clear conclusion on what happened that day, we did not uphold Mr C's complaint.

Summary

A nurse working for the board's child and adolescent mental health services wrote to the local social work department about Ms C's teenage son, who lived in a children's home. Ms C considered the letter to be one-sided and unfair, and said that the nurse should not have written an assessment of her son without having met him.

Our investigation found that the nurse had been asked to assess Ms C's son. She had written the letter at the request of the social work department, and it was intended solely to represent the views that the nurse had obtained in discussion with the manager of the children's home. The discussion with the manager had been the starting point of the assessment that the nurse was asked to make, and he had also arranged to have two meetings with Ms C's son as part of his detailed assessment. We were satisfied that the letter was accurately based on the nurse's clinical record of his discussion with the manager, that it accurately explained the purpose of the letter and the context of the information in it and that it was appropriate for such a letter to be written.

Summary

Mr C’s wife (Mrs C) was diagnosed with breast cancer in June 2009. In early 2010, she developed problems going to the toilet. Mr C said this became an ongoing problem that caused his wife extreme pain and discomfort. Mrs C’s GP referred her to hospital for x-rays of her spine and pelvis which were carried out in July 2010 and showed no significant abnormality. In view of Mrs C’s history of breast cancer, the radiologist recommended a bone scan which was performed in August 2010. Although the bone scan findings noted ‘increased uptake’ (an abnormality) in both sacro-iliac joints (joints in the lower back next to the pelvic region), the opinion was that this could be due to mechanical reasons in the joints, as Mrs C had undergone hip operations 15 years previously.

Mrs C's GP then referred her to a different hospital for further investigation as she was having difficulty walking. An MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) was carried out in September 2010 which identified extensive cancer and Mrs C passed away in April 2011. Mr C complained to the board that he felt that something might have been missed on his wife’s x-ray and that she should have been diagnosed earlier, sparing her a lot of pain, and possibly prolonging her life.

After taking advice from two of our medical advisers, including a cancer specialist, we found that reasonable investigations were carried out after Mrs C's GP referred her for further investigation. There was no clear evidence of cancer from the earlier blood tests, x-rays and bone scans. We also found that the description given and findings reached on the x-rays and bone scan were accurate and that only two weeks had passed between the bone scan and the MRI scan being undertaken. We could not, therefore, conclude that there had been a delay in Mrs C being diagnosed.

Summary

Ms C complained that the treatment provided by an orthopaedic (dealing with conditions of the musculoskeletal system) department was not of an acceptable standard. Ms C was unhappy with the treatment she received in relation to her deformities in her feet as a result of bunions and thought that mistakes had been made.

After taking independent advice from one of our medical advisers, a consultant orthopaedic surgeon, we did not uphold her complaint. We recognised that this had been and continued to be, a difficult time for Ms C and that she had undergone three operations. However, we found no evidence that the treatment provided was not of a reasonable standard. The surgery initially carried out did have complications, and as a result of those complications there was a need for two more operations, however, this was not due to any fault in the treatment provided.

Summary

Mr C complained to us about the eye treatment that he received in hospital. Mr C is registered partially sighted and felt that his glaucoma (abnormally high fluid pressure in the eye) became considerably worse while under the care of the hospital. He was concerned that they treated him without obtaining a copy of his previous medical records from a hospital in England. As he remained unhappy with the treatment, his GP referred him to another hospital. Mr C also complained that information in his medical records had been crossed out and that the board’s response to his complaint contained errors and omissions.

After taking independent advice from one of our medical advisers, we considered that Mr C had been reviewed at reasonable intervals and noted that his eyesight had not deteriorated during the time he was seen at the hospital. However, we upheld his complaint about treatment as we found that the hospital did not act quickly enough in obtaining a copy of his medical records from the hospital in England. Had this information been sought at his first clinic appointment, the clinicians would have known a reasonable target pressure for which to aim in Mr C's case. In addition, the hospital did not take an image of his optic nerves or measure the central corneal (transparent part of the external coat of the eye covering the iris and the pupil) thickness in order to ensure his eye pressure levels were accurate as possible in line with National Institute of Clinical Excellence (NICE) guidelines. We also considered that it would have been reasonable for Mr C to have been offered treatment at his third appointment. We did not identify any concerns with the information that had been crossed out in Mr C's medical records but upheld the complaint about complaints handling as we noted that the board had apologised for providing incorrect information about an appointment in their complaint response.

Recommendations

We recommended that the board:

• remind relevant staff involved in Mr C's care that a summary of a patient’s previous eye treatment for glaucoma should be requested from the previous healthcare providers at the time of their initial clinic appointment; and
• ensure that as part of the initial assessment, optic nerve head imaging and central corneal thickness measurements are carried out in line with NICE guidelines.