Health

Summary

When Mrs C 's mother (Mrs A) became unwell, Mrs A's carer contacted Mrs C, who went to her mother's house, and a doctor from NHS 24 (the out-of-hours service) visited. He examined Mrs A and wanted to admit her to hospital but his notes recorded that she strongly refused. He prescribed an antibiotic (a drug used to treat bacterial infection) after asking Mrs C if she knew if her mother had any drug allergies. He also advised Mrs C to get in touch again if her mother's condition deteriorated. He later discovered that she was allergic to the drug he had prescribed, and contacted Mrs C to arrange an alternative. Mrs A, however, died during the night. Mrs C disagreed that her mother had refused hospital admission and felt that the doctor should have known of Mrs A's previous experience of the drug.

Our investigation found that the doctor could not have known of Mrs A's allergy as he did not have access to her emergency care summary. This consists of basic information about a patient (including allergic reactions) and is available in the out-of-hours centre but not in the out-of-hours doctors' vehicles. The doctor was in his vehicle when asked to attend Mrs A. It was clear he took prompt and appropriate action to check her summary when he reached the out-of-hours centre, and to then arrange alternative medication. We took independent medical advice from one of our advisers, who said that the doctor's other actions, such as his examination of Mrs A, were also appropriate. We could not say for sure whether Mrs A had refused to go to hospital, as the accounts were so different. However, we did not uphold the complaint, as we found no grounds to suggest that the doctor's care and treatment (including his decision not to admit Mrs A to hospital) were unreasonable.

Summary

Mr C, who is a prisoner, suffers from irritable bowel syndrome (IBS) - a condition that can cause stomach cramps, bloating, diarrhoea and constipation. He told us that he spent a short period of time in one prison, where he received a gluten free diet to help his symptoms. However, when he transferred to the prison where he was to spend the majority of his sentence, he only received a gluten free diet for around three weeks. It was then stopped while the board awaited the results of blood tests. When the results came back, they showed that Mr C was not gluten intolerant, and he was told he would not receive a gluten free diet in future.

We did not uphold Mr C's complaint as we found that the decision not to provide him with a gluten free diet was clinically appropriate. However, we were critical of the board for the apparent inconsistency in approach, as Mr C apparently initially received a gluten free diet, which raised his expectations about what he should receive. We drew this to the board's attention.

Summary

Miss C complained that during treatment a dentist handled her five-year-old daughter (Miss A) with excessive force, and shouted at her. While the dentist was attempting to fill one of Miss A's teeth, she became distressed and moved in the chair. In trying to adjust Miss A's position in the chair, Miss C complained that the dentist handled Miss A roughly, causing bruising to her arm.

The dentist indicated that, as Miss A had slid down the chair, he lifted her under the arms to put her back in the correct position. He said he did not use any force and he could not understand the bruising allegation. He also said that he was required to raise his voice to give instructions to his nurse and be heard over Miss A's crying. He said he did not shout at Miss A. In investigating the complaint, we obtained a statement from the nurse which supported the dentist's position. In the absence of any evidence to support Miss C's version of events, we did not uphold the complaint.

Summary

Mrs C said that her husband (Mr C) was involved in an accident in which he fell from height, and was airlifted to hospital. She said that following various CT scans (special scans that use a computer to produce an image of the inside of the body), Mr C was diagnosed with a spinal fracture. He was transferred to another hospital nearer to where they lived, but suffered a major stroke that resulted in him having severe communication difficulties. After Mr C had the stroke, it was diagnosed that Mr C's carotid artery was dissected (the layers of the artery wall supplying oxygen-bearing blood to the head and brain became separated). Mrs C complained that the hospital did not provide clarity about the treatment Mr C had received from them and that her complaint about this was not adequately addressed.

Two of our independent medical advisers considered all aspects of this case. We took account of their advice along with all the documentation provided by Mrs C and the board. We did not uphold Mrs C's complaints about treatment and complaints handling. The advisers said that Mr C had been correctly assessed and investigated at the hospital, in accordance with standard UK practice, and that appropriate diagnostic imaging techniques were used. They also said that clinicians diagnosed Mr C correctly and he had received a reasonable level of care. Our investigation found that the board had appropriately investigated and responded to Mrs C's complaint. However, we considered that they had failed to respond as agreed to Mrs C's enquiry about the board's protocol for image scanning, and we upheld that aspect of Mrs C's complaint.

Recommendations

We recommended that the board:

• feed back the learning from this complaint to all staff to ensure such an evolving communication failure will not recur; and
• apologise to Mrs C for this failure and the upset it has caused.

Summary

When Mr C was admitted to hospital, medical staff decided that, due to his severe lung disease, he should not be resuscitated in the event of heart or breathing failure. They, therefore, placed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order on his medical notes. Mr C was dismayed when he later found this out and expressed his disagreement with the decision. In responding to Mr C, the board indicated that the decision was one that medical staff were empowered to make. However, they acknowledged that this should have been discussed with Mr C and/or his family. They apologised for their failure to do so and also agreed to clearly record Mr C's wishes on the front of his medical notes.

Mr C was not satisfied that the remedial steps taken by the board would prevent a similar thing happening to someone else and he approached us. We noted that the NHS Scotland policy on DNACPR says that resuscitation should not be offered as a treatment option where, in the opinion of medical staff, it would fail. We were, therefore, satisfied that it was appropriate for staff to exercise their judgment and take the decision. However, because of the failure to tell Mr C about this, which the board had already acknowledged, we upheld the complaint. The board have demonstrated to us that they learned from this failing. They implemented a quality improvement plan including provision to ensure that patients or their relatives are in future informed of requests for DNACPR, and said they would carry out random audits of patient case notes to ensure that this was being adhered to.

Recommendations

We recommended that the board:

• inform the Ombudsman of the outcome of the audit of patient case notes used as a measure of effectiveness in their quality improvement plan.

Summary

Mr C's mother (Mrs A) collapsed at home, and was taken to hospital as an emergency. She was transferred to a ward at 15:50 and was assessed at 23:00. Early the next morning there was a marked deterioration in Mrs A's condition, and she was suspected to have suffered a stroke. Mrs A's condition continued to decline and she died that evening.

Mr C complained about his mother's care and treatment and questioned whether she was given any treatment when she was initially admitted to hospital. He was unhappy that she was not properly assessed until late at night by which time, he said, her condition had deteriorated and she had become confused. He was concerned that her anticoagulant medication (used to prevent blood from clotting) had been stopped and considered that this could have led to her stroke. Mr C was also concerned that in responding to his complaint, the board said that cancer could have been a contributing cause to Mrs A's death. He complained that this possibility had never been raised with him before.

Our investigation took account of all the available information, including the complaints correspondence and the relevant clinical records. We also obtained independent medical advice from a consultant in acute medicine for older people. We found that the board had maintained that they had treated Mrs A reasonably and had discussed the possibility of an underlying diagnosis of cancer with Mr C. However, on reviewing the case notes, the adviser was concerned that Mrs A was not provided with treatment until some ten hours after her admission. He said that the treatment, when provided, was reasonable but it had not been timely. He noted, however, that even if Mrs A had been treated earlier it was unlikely that her condition and prognosis would have changed. He also said that stopping her anticoagulants had been the correct thing to do in the circumstances. With regard to the underlying diagnosis of cancer, the adviser said that a discussion with Mr C was recorded in the notes but this was unclear about the precise language used, and whether or not the term 'malignancy' had been understood.

The advice received during the investigation confirmed that Mrs A's treatment had been reasonable. However, for it to be appropriate it would have to be both reasonable and timely. As it was not, we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise for the delay which occurred; and
• review the guidelines published by the Society of Acute Medicine, particularly section AF-505, to ensure that more timely assessment of acute admissions occurs in the future.

Summary

Mr A had several consultations at the practice over four months, complaining of ongoing and increasing pain in his hip and knee. Mr A was then admitted to hospital and was diagnosed with lung cancer that had spread to his liver and bones. Mr A died a month after being admitted.

Mr A's wife (Mrs C) complained that if her husband been diagnosed sooner, he could have lived longer and had better pain relief.

As part of our investigation, we took independent advice from a medical adviser. The adviser said that the practice had carried out and arranged for appropriate investigations in an attempt to establish the reasons for Mr A's pain. They arranged chest and hip x-rays at an early stage, but these did not show any signs of cancer. The practice had prescribed stronger pain relief and referred Mr A to an orthopaedic specialist when the pain continued. Although the practice did not re-check a slightly abnormal blood test result within the specified period of a week, the adviser did not consider that the actual delay of ten days was unreasonable. The practice acted promptly when this was identified and we did not consider that the ten day delay would have affected what happened to Mr A. In addition, we could not say whether re-checking this sooner would have resulted in Mr A receiving more adequate pain relief or being admitted to hospital more quickly.

Summary
Mrs C had been a patient of a dentist at the practice for 20 years. She visited him complaining of toothache and a history of loosening teeth, and he referred her for a specialist assessment, mainly to discuss an implant and bridge. The specialist she attended told Mrs C that she had chronic adult periodontal disease (a condition involving infections of the gums and bone that surround and support the teeth). This had resulted in significant bone loss, and she also had a chronic infection. The specialist suggested a number of options for dealing with the problem but warned that the damage done would be difficult to address.

Mrs C complained that her dentist did not identify or treat her for periodontal disease and that, as a consequence, her teeth and gums had deteriorated to the extent that it would be difficult to maintain her remaining teeth or deal with the problem with which she had been left.

As part of our investigation, we obtained independent advice from one of our dental advisers. Our adviser confirmed that the dental records made by Mrs C's dentist were minimal and that there was no explicit diagnosis or treatment plan. There was no evidence that he had told her that she had serious periodontal disease or that she had been given any preventative advice. Given Mrs C's symptoms, we found that the dentist should have at least carried out a basic periodontal examination and taken x-rays, but he did not do so.

Recommendations
We recommended that the dentist:
• apologise to Mrs C for his failure in this matter; and
• discuss this matter at his next professional appraisal and provide evidence that he has done so.

When this report was first published on 27 March 2013, it was incorrectly categorised as being about Greater Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 9 April 2013, and for which we apologise.

Summary

Ms C has a clinical need for a hysterectomy (surgery to remove the womb), and was to be referred to hospital for treatment. Her social and domestic circumstances meant that she did not wish to be treated at the local hospital. She discussed this with her GP and her GP requested she be referred outwith the board's area for her operation. The medical director reviewed the request, but declined it on the basis that the procedure could be carried out locally. Ms C appealed, and the chief executive reviewed the decision and also declined it as he agreed with the medical director's decision.

As part of our investigation, we asked to see the protocol that the board use to consider extra-contractual referral (ECR - where a person is referred for treatment elsewhere). We found that the protocol did not say that the medical director could decline an ECR - rather, an ECR panel should have considered and decided on Ms C's request. We upheld Ms C's complaint, as we found that her request had not been reasonably considered by the board in line with their protocol, which was that such requests should initially be considered by an ECR panel.

Recommendations

We recommended that the board:

• ensure that relevant staff clearly understand and follow the process for considering extra-contractual referrals; and
• consider Ms C's request at an extra-contractual referral panel, as a matter of urgency.
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Summary

Mrs C complained about the professionalism of an ambulance crew who had attended her late husband about a year before. She said that the crew refused to allow her husband to take a case with him in the ambulance or to allow a family member to travel with him. The family was also told to wait an hour before attending the hospital.

The board explained that due to the time that had elapsed since the incident, the crew could not recall what was actually said. The board, however, accepted that there must have been a failing in the way the crew communicated to the family. As a result the crew had been reminded of their responsibilities and that their actions could be interpreted differently from what they intended. We found that the board had conducted a thorough investigation, including interviewing appropriate staff, and we took the view that it was unlikely that further consideration of the matter would achieve more for Mrs C.