Health

Summary

Mr C complained that the board did not reasonably investigate his complaint in which he raised concerns about the quality of service his mother received during a visit to an eye clinic. As after six months the board had not sent a final response to Mr C about his complaint, he contacted us.

Our investigation established that the response was delayed because of a combination of human error and failures in the complaints handling process. The board have now updated their process in an effort to prevent a repeat occurrence, along with taking steps to increase staff awareness.

Recommendations

We recommended that the board:

• provide Mr C and his mother with an apology for the failings which have been identified in dealing with his complaint;
• apologise to Mr C for providing him with incorrect information as to the reasons why his mother was not seen on a certain date in March; and
• remind their service providers to provide timely responses to the feedback service in order that timescales can be met.

Summary

Mrs C complained that the medical practice had unreasonably removed her name from the list of patients who were entitled to receive the flu vaccination. She said she had been told to wait in the chance there was a surplus of flu vaccinations. Mrs C, who has a medical history of non-hodgkin’s lymphoma (a cancer which affects certain cells in the lymphatic system) was in remission but had received the flu vaccination for many years previously. Mrs C then purchased the vaccination privately. She also contacted her haematologist (a specialist concerned with the study of blood and blood-related disorders) who wrote to the practice. As a result, Mrs C was reinstated to the list of patients entitled to receive the vaccination.

The practice explained that Mrs C's condition was stable in 2011. She was not receiving immunosuppressant therapy (treatment to suppress immune response) and did not satisfy the criteria for groups who require the vaccination. Mrs C's records did not contain a marker that would have highlighted her eligibility for the vaccination and the GP who was reviewing patients on the list had used her clinical judgement and decided not to allow Mrs C the vaccination.

We upheld Mrs C's complaint. Our investigation found that the GP was entitled to decide whether individual patients satisfied the criteria for the vaccination and had used her clinical judgement. Our medical adviser explained, however, that although Mrs C was not on immunosuppressant therapy at the time, her past history of lymphoma made it likely that she would be prone to infections. The adviser felt that most GPs would cover such patients using immunisations such as the flu vaccination. We found that the practice could have taken a more proactive role when they told Mrs C that she was not going to have the vaccine. They could also have made contact with the haematologist themselves when Mrs C reported her concerns or have offered her a face-to-face meeting to discuss the matter in more detail.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failure to take her circumstances fully into account; and
• consider holding a significant event analysis in order to establish if there were any missed learning opportunities.

Summary

Mrs C complained that delays in the investigation and treatment of her late husband's cancer hastened his death. She also complained about a lack of nursing and personal care provided to him, including pain relief; inappropriate discussions about resuscitation; a shortage of beds in the specialist respiratory ward and the hospice; delays in giving her access to her late husband's medical records; and that the board delayed in dealing with her complaints.

Our investigation found that Mr C had been investigated for pain, stiffness and swelling in his legs and ankles, which was attributed to a rheumatic condition. However, as this condition can also affect the lungs, a chest x-ray was taken in January 2011. The x-ray was reported to be normal and Mr C's treatment and monitoring of the rheumatic condition continued. In February 2011 Mr C's condition had deteriorated, and he had lost weight. He returned to the rheumatology clinic for further investigations. Various investigations including computer tomography (CT – a special investigative scan) and positron emission tomography (PET – a special investigative scan) were undertaken and Mr C was diagnosed with lung cancer in March 2011. The cancer was an aggressive one and by the time of diagnosis it had already spread and was considered to be inoperable. Despite treatment, including chemotherapy, Mr C died in June 2011.

We took independent advice from three of our medical advisers - a respiratory physician (lung specialist), an oncologist (cancer specialist) and a senior nurse. The respiratory physician was critical that the January x-ray was reported as normal as there was what he felt to be 'unequivocal', if fairly subtle, indications of abnormality on the x-ray. However, he and the oncologist agreed that even had this x-ray been correctly reported and a referral to the chest clinic made in January 2011 the outcome and duration of Mr C's life would have been the same. They also agreed that Mr C’s management was otherwise appropriate and timely. The nursing adviser was, however, critical of the lack of assessment, monitoring and review of Mr C’s pain; the standard of the notes; and the lack of personal care, including washing, provided to him.

Our investigation identified several areas of concern and we upheld five of the six complaints. The only complaint we did not uphold was that about the lack of beds in the respiratory ward and hospice. We found that the only reason Mr C was not transferred was because there was a particularly high demand for beds at that time. Mr C was transferred to the respiratory ward as soon as a bed was available, but died before a bed was available in the hospice.

Recommendations

We recommended that the board:

• issue a written apology;
• review a sample of x-ray reports to ensure that no others have been mis-reported;
• review the process of reporting on x-rays to ensure timely reporting;
• ensures that all relevant information is recorded on the multi-disciplinary team meeting forms;
• reviews the policy on ordering PET scans in line with SIGN (Scottish Intercollegiate Guidelines Network);
• review training on the discussion, decision making, review and recording of 'do not resuscitate' decisions;
• ensure that all nursing staff are aware of and implement national and local guidance on assessment, management and review of patients' pain;
• ensure that all nurses are aware of the need to provide regular and appropriate personal care where patients require assistance;
• ensure that all nurses are aware of and implement national guidance on record-keeping issued by the Royal College of Nursing; and
• report on the remedial action taken to prevent a recurrence of delays on access to copy medical notes.

Summary

Mrs C complained that the medical practice did not provide reasonable care and treatment to her husband (Mr C). Mr C had gone to the practice complaining of back and neck pains; pins and needles in his fingers, and difficulty walking and working. After several appointments, he saw Doctor 1, who recorded that he told Mr C that the problem was probably related to his spine and nerve entrapment. Doctor 1 also recorded that he had referred Mr C to physiotherapy and neurology (which deals with problems of the nervous system). He later completed a referral to physiotherapy, but there is no evidence that he completed a referral to neurology at that time.

Mr C saw another GP, Doctor 2, several days later. Doctor 2 recorded that Mr C had worsening pain in his arms, spine and back and some muscle spasms in the lumbar region. He also recorded that Mr C had weakness and numbness in his hands and was awaiting a neurology appointment. Mr C then saw Doctor 1 again. This was nearly three weeks after Doctor 1 had agreed to refer him to physiotherapy and neurology. Doctor 1 recorded that the pain was increasing despite analgesia (pain relief). He also completed a letter for urgent referral to neurology, as there was no sign of a referral being completed after the earlier visit. Mr C went to the accident and emergency department of a hospital (A&E) two days later. He was transferred to another hospital and an MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) led to a diagnosis of a serious back condition. Mr and Mrs C considered that this condition could have been prevented had the practice acted sooner.

After taking independent advice from one of our medical advisers, we found that the practice's general care and treatment of Mr C was reasonable, apart from the delay in sending the neurology referral letter. That said, Doctor 1 referred him to neurology urgently when it became clear that the initial (non-urgent) referral had not been done. In addition, he was transferred to another hospital for urgent treatment after attending A&E. In view of this, it is unlikely that the failure to complete the initial neurology referral had any significant impact on Mr C’s subsequent care and treatment.

Mrs C also complained that the practice’s response to Mr C’s complaint unreasonably contained inaccuracies. However, we found that the comments in the practice’s response were confirmed by Mr C’s medical records.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failure to send the referral letter.

Summary

Mr C, who is a prisoner, complained that the health board inappropriately failed to conduct an adequate occupational therapy assessment to inform his needs and requirements as a disabled prisoner. However, he was freed from prison whilst we were investigating his complaint and did not provide us with a contact address. We were unable to obtain a contact address for Mr C and we had no option but to close our file on his case.

Summary

Ms C complained that her medical practice had not provided her with reasonable care and treatment. She said that they had stopped prescribing medication that she had been on long term, asked her to attend for reviews at the practice and had not supplied her with a neck collar to address the symptoms of her dystonia (a condition which causes shaking, in Ms C's case of the neck muscles). She further complained that they had not re-referred her to the dystonia clinic and declined to issue a certificate to excuse her from appearing in court.

Our investigation, which included taking independent advice from a medical adviser who is a GP, found that the actions of the practice had been reasonable, and we did not uphold Ms C's complaints. We found that Ms C had been taking a high dose of Hormone Replacement Therapy (HRT) since a hysterectomy (surgical removal of the uterus) a number of years ago. Medical opinion is that long-term use of HRT carries serious health risks and our adviser thought it was reasonable for the practice to encourage Ms C to reduce the HRT with a view to stopping eventually. When she declined to do so and also declined to attend the practice for health reviews, we considered it reasonable for them to refuse to continue to prescribe the HRT.

Ms C was also taking diazepam (a tranquiliser) to treat her dystonia. Diazepam is an addictive drug and the practice tried to encourage Ms C to attend for reviews of her long-term use of it. Again Ms C was reluctant to do so and at times the practice, therefore, prescribed a reduced amount of it until she was reviewed. This also happened when her son abused her supply. Again we considered the actions of the practice to be reasonable.

On the matter of the neck collar, our adviser said that current medical opinion is that neck collars cause the muscles to weaken and waste away which is the opposite to what is required in a patient with dystonia. Ms C had been seen twice at the dystonia clinic, where the only treatment they were able to offer her was botox injections, which she had declined. The practice invited Ms C to come in and discuss this but she declined to attend. We took the view that in the circumstances it was reasonable for the practice not to supply a collar or to re-refer Ms C to the clinic.

Ms C had not been seen in person at the practice for some six months when she asked one of the GPs by phone to write her a certificate to excuse her from attending court. The GP said that he could not do so without seeing her but Ms C said she did not want to visit the practice. We found that it was, therefore, reasonable for them not to provide the certificate.

Summary

Mrs C cancelled an appointment for a scale and polish (dental cleaning) and x-rays that her dentist had advised her to have. The dentist wrote to her explaining why he recommended the treatment. He said that she had excess tartar (dental plaque) accumulation and that x-rays of her back teeth would help determine if there were underlying problems. He also said that in most cases where patients suffer from sensitive teeth, he uses a local anaesthetic, which helps to decrease sensitivity during cleaning. He acknowledged that a patient can choose whether to continue with treatment but went on to say that if she did not have it, her teeth would require extensive scaling which might cost more. Without x-rays, he also could not guarantee that there were no undiagnosed areas of decay etc. When Mrs C attended an appointment with the dentist some eight months after the cancelled appointment, she asked for a standard clean and polish with no anaesthetic. She said that the dentist refused to treat her and when she asked to speak to the practice manager she was told to put her complaint in writing. She was removed from the dentist's practice list and not allowed to transfer to another dentist within the practice.

Mrs C was concerned about the insistence of using anaesthetic to proceed with the clean and polish and failure to provide an adequate explanation regarding why anaesthetic was required. Mrs C was also concerned about the dentist's attitude, saying he was condescending and unprofessional. She was unhappy at being removed from his list and not being allowed to transfer to another dentist within the practice. In relation to the complaints handling, Mrs C complained that she could not speak to the practice manager and that there was no attempt at informal resolution, that the dentist's response failed to answer some of her points and that the matter was investigated and responded to by the person she was complaining about. As a result, she said that she suffered anguish and upset and that she was left without NHS dental provision when she lost half a tooth which had previously been treated by the dentist.

We accepted the independent advice of one of our medical advisers that the use of anaesthetic in these circumstances is reasonable and that the dentist provided a reasonable explanation about this. We did not find evidence to support Mrs C's complaint about the dentist's attitude and we found that her removal from the list and not transferring her to another dentist in the practice to be reasonable. On complaints handling, we found that arrangements should have been made for Mrs C to talk to the practice manager but that on the whole the complaint was handled properly - Mrs C's complaint was fully considered and addressed, and she received a written response to her complaint from the dentist.

Summary

A consultant psychologist working for the board diagnosed Ms C with a histrionic personality disorder (a condition in which people act in a very emotional and dramatic way that draws attention to them). Ms C was known to frequently appear at the local accident and emergency (A&E) department and at her medical practice, and the consultant wrote to those services advising that they should manage her behaviour carefully and that they should not entertain threats of self-harm or suicide.

In his letters, the consultant noted that Ms C might become aggressive toward staff and suggested that the police could be called should this happen. Ms C complained that the consultant's advice to these services meant that she was prevented from receiving treatment for other conditions, in particular, for nerve pain in her legs. She also complained that the consultant did not make her aware of her diagnosis or of the fact that he had written to other healthcare services about her behaviour.

We found that it was reasonable for the consultant to send letters to the medical practice and A&E, as both services had an ongoing involvement with Ms C. Generally we were satisfied that the content of his letters was appropriate and represented advice rather than instruction. However, in one of his letters to Ms C's GP, the consultant made what we felt was a clear instruction that threats of suicide should not be tolerated. As good practice guidance says that all threats of suicide should be taken seriously and investigated, we did not find this instruction to be appropriate. Comments from the board and our mental health adviser suggested that it was likely that Ms C would have been told her diagnosis. However, there was no written record of such a discussion and nothing to suggest that she was made aware of the letters that were being sent to other healthcare services. It is an underpinning principle of mental health care that patients are involved in decisions about their care and treatment. We considered that the board had failed to involve Ms C in her care or to record her involvement, and upheld her complaints.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted; and
• draw the consultant's attention to our adviser's comments about the letter.

Summary

Mr C, who is paralysed from the neck down, complained that the board unreasonably and without prior consultation proposed to change some elements of the nursing care they provide.

Our investigation, which included taking independent nursing advice, found that Mr C had been cared for by the same two nurses for much of the last 20 years. During this time their practices had changed little, which meant they were not in keeping with current good practice. Our nursing adviser, therefore, felt it was reasonable for the board to have taken the opportunity to review Mr C's care package when one of the long standing nurses retired and the team leader changed. The team leader had phoned Mr C to discuss the proposed changes, but the conversation did not go well. Mr C, therefore, felt that, rather than a discussion with him about his future care, the changes were imposed upon him. The board acknowledged that it would have been better for this conversation to have taken place face-to-face and have put this change into place for such discussions in the future.

After this, following 'moving and handling' training for the staff, it was apparent that no moving and handling assessment had taken place for a number of years. During a routine visit by two staff Mr C took exception to the way that they wanted to use a 'sliding sheet' (used to ease the moving of a patient from bed). He became upset and asked the staff to leave before the procedure he was to receive was completed. A moving and handling assessment was arranged but again this did not go well and Mr C asked the staff to leave his home. He has not received nursing care from the board since the end of September 2011.

We did not uphold Mr C's complaints, as our investigation found that the actions of the board and their staff had been reasonable. We noted that in responding to the complaints, the board offered Mr C a meeting with their associate nurse director to discuss his future care. Although at the time Mr C did not feel able to take up this offer, it remains open and we have encouraged him to take this up when he feels able to do so.

Summary

Ms C's medical practice referred her to a consultant surgeon at the hospital because she had rectal bleeding and loose stools. Tests were carried out and an inital diagnosis of proctitis (the mildest form of colitis, which is inflammation affecting the lining of the bowel causing diarrhoea and rectal bleeding).

As Ms C's symptoms did not improve with the medication that she was prescribed, she was referred to a consultant gastroenterologist (a medical professional specialising in the treatment of conditions affecting the liver, intestine and pancreas). Ms C attended several clinic appointments between March 2010 and June 2011 and had various investigative procedures carried out in response to her ongoing symptoms of fatigue and passing blood. Ms C's condition worsened in October 2011 and she was admitted to a different hospital where she underwent an emergency colectomy (an operation to remove the large bowel).

Ms C complained that the consultant gastroenterologist had failed to diagnose the severity of her condition. She felt that earlier diagnosis would have allowed alternative drug therapy to be tried which might have avoided the need for the colectomy and a stoma (a surgically made pouch on the outside of the body). Ms C was unhappy that the consultant gastroenterologist had not clearly told her that she had ulcerative colitis and that he had said at an appointment in June 2011 that there was nothing seriously wrong.

We did not uphold Ms C's complaint. After taking independent advice from one of our medical advisers, we found that Ms C was correctly referred to the consultant gastroenterologist and reviewed with a frequency appropriate to her condition and symptoms. In addition, Ms C was prescribed appropriate medication although it was identified that she had an intolerance to one of the drugs. Our adviser explained that flare-ups in ulcerative colitis can happen unpredictably and that Ms C's severe episode that led to the colectomy could not have been predicted or prevented. We found evidence that the consultant gastroenterologist clearly explained at an early stage the results of the investigative procedures and Ms C's diagnosis. However, we could not say exactly how much information they shared with Ms C about her condition, as there was a lack of documented information about this. Although we did not uphold Ms C's complaint, we drew the board's attention to the lack of information and to the relevant guidance about keeping records.