Health

Summary
Mrs C complained that she received poor care in hospital after undergoing a procedure to remove a gallstone from her bile duct, which resulted in her bowel being perforated. Mrs C also raised specific concerns that the risk of perforation was not explained to her; there was a lack of information given to her about what happened during the procedure, and she had not been aware of a tube having being inserted during the procedure.

The board said that the procedure was appropriate as not removing the gallstone could have led to recurrent inflammation of the pancreas (pancreatitis), inflammation of the bile ducts and jaundice (yellowing of the skin or eyes). In addition, the procedure carried a lower risk than open surgery. We considered this response reasonable as earlier investigations had showed a small stone blocking the bile duct.

However, we upheld Mrs C's complaint. Our medical adviser said that, while junior medical staff did consider at an early stage the possibility that there had been a perforation, aspects of Mrs C's after-care fell below a reasonable standard. This was because there was no senior doctor accountable for Mrs C's care after the procedure, and no clear supervision of the junior medical staff who were reviewing her. Our adviser considered that there should have been a clear and consistent action plan from the time the perforation was identified to the time Mrs C was transferred to another hospital (five days later) for surgical review. In addition, there did not appear to be any clear instructions by medical staff about feeding or fluids. Therefore, five days were lost in getting the perforation effectively healed, due to poor nutrition and the likelihood that Mrs C's immune system was weakened.

The board said that Mrs C had been sent a leaflet on the procedure which included information on the risk of perforation. Our investigation, however, identified that Mrs C was given a different leaflet that did not explain any of the specific risks. General Medical Council (GMC) guidance says that doctors must tell patients if an investigation or procedure might result in a serious adverse outcome, even if the likelihood of it happening is very small.

In addition, although the consent form Mrs C signed included information on the risks of bleeding, infection and pancreatitis, it did not include information on perforation. GMC guidance on the recording of informed consent says that the patient's medical records or consent form must record the key elements of the discussion that has taken place.

While the board explained to Mrs C the reasoning behind the medical staff's initial diagnosis of pancreatitis before the perforation was identified, there was no clear record made of any discussions the medical staff had with Mrs C either before or after the complication was identified. We noted that the board were correct in informing Mrs C that a tube had not been inserted at the time of the procedure.

Recommendations
We recommended that the board:

• apologise to Mrs C for the failings identified in our investigation;
• ensure there is clear guidance to consultants regarding the clinical oversight and management of a person's care and supervision of junior colleagues, including care arrangements to cover out of hours, weekend care and periods of leave;
• consider reviewing patient information leaflets on the procedure (ERCP) to ensure all possible risks and complications are clearly explained; and
• consider reviewing their consent policy to ensure that all common and serious risks are fully explained to patients when obtaining consent and that these are clearly recorded on the consent form. 

Summary

Mr C suffered a hand injury while he was in prison. He was treated in hospital the day he was injured, when an x-ray showed he had a metacarpal fracture (an injury to one of the small bones in the hand). The hand was strapped up, and he was seen again around a week later, when another x-ray showed the position of the fracture to be acceptable. The doctor noted that Mr C's hand should remain in strapping until the next review appointment. The next month, Mr C complained to the board that his treatment had been inappropriate. He was concerned that strapping rather than a cast was used, and said that he remained in a great deal of pain. He said that his hand was swollen and becoming deformed, with the bone sticking out. Mr C had further appointments over the next three months, and after a CT scan was taken, a hamate fracture (an injury to a small bone on the outside of the wrist) was identified in addition to the metacarpal fracture. He underwent steroid injections for pain management, and was considering surgery.

After taking independent medical advice, we did not uphold Mr C's complaint, as we found that the management of his injury had been appropriate. We found that the use of strapping to allow him to continue to move his hand, rather than a plaster cast, was appropriate for this type of injury. We also found that the hamate fracture could not be detected easily from the initial x-rays due to its position. We found that the shape of Mr C's hand was not due to the bone sticking out, but rather due to the formation of callus (thickened skin) as the injury healed. We also found that surgery at an earlier stage would not have been appropriate because time had to be allowed for healing before surgery could be carried out. We did not uphold the complaint, although we did note some minor issues in relation to the board's response to Mr C's complaint, which we drew to their attention.

Summary

Mr C visited a dentist several times in the summer of 2011 where he had seven teeth removed and two fillings. Around three months later, Mr C was admitted to hospital suffering from fever and was subsequently diagnosed with sub-acute bacterial endocarditis (a chronic bacterial infection of the valves of the heart) and underwent surgery.

Mr C complained that the dentist failed to prescribe him antibiotics despite Mr C having told him that he felt feverish after the first three teeth were extracted. Mr C said that a hospital doctor had commented that patients undergoing any form of invasive dental treatment should be administered antibiotics.

We noted that the dentist treated Mr C for infected sockets in June 2011 by washing them out with an antiseptic solution and packing them with a dressing. This form of treatment is in line with guidance issued by the Faculty of General Dental Practice. National guidance issued by the National Institute of Clinical Excellence recommended that antibiotics were only to be given routinely to a small minority of patients undergoing dental treatment who have a certain heart defect. As Mr C had no previous medical history, such as a heart condition, that would require administering antibiotics before or after the tooth extractions, we considered that the dentist acted appropriately and in line with the national guidelines.

Mr C's dental records showed that he was given antibiotics in July 2011 but there was no reason given as to why these were prescribed. The dentist later explained that they were given because infection of the sockets had persisted, which we considered reasonable.

Mr C's hospital records showed that the endocarditis was caused by Strep Viridans (a bacteria found in the mouth and throat of most people). The bacteria can enter the bloodstream following a dental extraction but is usually killed by the body's immune system in a healthy person. It is normally only a problem for those with a compromised immune system or pre-existing heart defect, neither of which Mr C had at this time. We considered that it was highly likely that Mr C was infected by the bacteria following the dental extractions and that, for unknown reasons, his immune system was unable to respond to the bacteria, resulting in his endocarditis. However, this did not mean that the dental extraction was carried out incorrectly, nor that he should have been given antibiotics.

Summary

At a consultation with her GP, Mrs C said she had swollen ankles. Her GP advised her to stop taking her medication for high blood pressure, which she did. Mrs C was admitted to hospital with chest pain two months after the consultation with her GP and died several hours later. Over time, Mrs C's husband (Mr C) became concerned about a possible link between the medication being stopped and his wife's death.

Mr C complained that the GP's advice was not properly considered or reasonable. He also complained that the practice did not take reasonable steps to monitor his wife's health following their advice that she should stop taking the medication prescribed for high blood pressure.

We found, from looking at the evidence and taking advice from one of our medical advisers, that ankle swelling was a common side effect of the blood pressure medication Mrs C had been taking and, given Mrs C's symptoms, the advice to stop taking blood pressure medication was reasonable. We also found that blood tests were organised after the consultation with the GP, but that there was no clear instruction for a follow-up check of blood pressure. However, blood pressure was monitored at other appointments with staff at the practice, and was within normal limits. It was not entirely clear from the records that this was part of a systematic plan of care that followed from the decision to discontinue the medication. Therefore, we asked the practice to reflect on follow-up arrangements made for patients when medications are discontinued, and to record specific plans for follow-up within the records. However, overall, we found that there was evidence that the practice took reasonable steps to monitor Mrs C's health and we did not uphold Mr C's complaints.

Summary

Mr A's dentist gave him a filling in autumn 2011. This was a very large restoration and Mr A was treated for minor pain over the next few weeks. In early 2012 he returned to the practice with further pain associated with the tooth. The practice told him that the dentist who treated him had left, and had in fact practiced there under his own NHS contract. They offered treatment but told Mr A that they would charge for this. Mr A recalled that his previous dentist had told him that any follow-up treatment required on the tooth would be free of charge, and declined the offer of paid treatment. He returned to the practice the next month and again said that he would only consent to treatment if it was provided free of charge. He refused to sign forms consenting to paid treatment or a medical history form.

Mr A complained about this to the practice, who explained their position and advised that they had taken steps to remove him from their treatment list on the basis that Mr A had lost confidence in them.

Ms C, who is an advice worker, wrote to the local health board on Mr A's behalf and this was passed to the practice for a response. The practice repeated the information they had given Mr A about his treatment and his removal from their practice list. They also offered him the cost of the treatment he had experienced problems with, but noted this was not the full amount he had paid at that time, as that had included treatment for another matter.

Mr A remained dissatisfied and Ms C complained to us on his behalf. We did not, however, uphold the complaint as we decided that there was no evidence of service failure. This was because the practice were correct in saying that the responsibility for treatment lay with the dentist who provided it and not themselves, now that he had left the practice.

Summary

Ms C's mother (Mrs A) was admitted to a hospital accident and emergency department (A&E). In the resuscitation room three gold necklaces were removed from Mrs A, along with other jewellery which was handed to her family immediately. Mrs A was then transferred to another ward, where she passed away. On collecting Mrs A's personal belongings, her family discovered that the necklaces were missing. The A&E department was searched, with the family present, and other departments were contacted but the necklaces were not found.

Mrs A's family complained to the hospital about the loss of the necklaces. In their response, the board accepted that the necklaces had been lost there and noted that the usual procedure of sealing belongings in a bag and giving them to the patient or next of kin had not happened on this occasion, advised that the importance of documenting and caring for patients' belongings had been reiterated to staff and that new labels and a belongings register had been provided in the A&E department. The board expressed their regret at the distress that had been caused and offered their sincere apologies to the family.

Ms C was dissatisfied with this response and complained to us. We decided that the board's response had been reasonable, and did not uphold that complaint. She had made other complaints relating to the loss of the necklaces and the board's investigation, but we could not consider these as they had not yet completed the board's complaints procedures.

Summary

Mrs C complained that the board's rheumatology service (which deals with conditions affecting the musculoskeletal system, including joints, bones and muscles) unreasonably failed to offer an appointment to her mother (Mrs A). Mrs A had slipped at home the previous week, was unable to put weight on her leg, and was in pain and discomfort. Mrs A's GP had diagnosed a 'flare-up' of arthritis. Mrs C phoned the rheumatology service, where her mother had been a long-standing patient, in the hope that they would see her at the regular weekly clinic. Mrs C said that her request was unreasonably refused and that she was told that this was because the service was short staffed and clinics had been cancelled in the unexpected absence of two key members of staff.

The board said that this was not why the request was refused. They said that the specialist rheumatology nurse who spoke to Mrs C refused the request because she did not think that Mrs A's symptoms were consistent with a 'flare-up' of arthritis. The nurse advised Mrs C to take her mother to the accident and emergency department (A&E), or revisit her GP. The board said that, in spite of the lower than usual staffing levels, had Mrs A required a review because of her arthritis, then she would have been offered an appointment at a nurse-led clinic. Five days later Mrs A was admitted to A&E and was discovered to have a fracture.

Although we understood Mrs C's concerns about this, we did not uphold the complaint. This was because it was not possible during our investigation to reconcile the two very different accounts of the same phone call. There was no supportable evidence to suggest that the rheumatology service had unreasonably refused to see Mrs A on the basis of capacity alone, and there were in fact sound clinical reasons for Mrs A to be referred to A&E either directly, or via her GP.

Summary

Mrs C complained about the treatment that her late husband (Mr C) received after he was admitted to hospital with an infected ulcer on his toe. Mrs C also complained that staff did not adequately monitor how much pain her husband was experiencing and did not make adequate arrangements when he was discharged from hospital on three separate occasions, including arranging transport home.

Mr C developed ulcers and ischemia (insufficient blood flow) to his foot and underwent surgery to improve the blood flow through the artery below his knee. He was discharged shortly afterwards but a few weeks later his toe became necrotic (the tissue in the toe died because of a lack of blood and oxygen). Mr C was admitted to hospital again and the decision was taken to observe and wait for auto amputation (for the toe to fall off spontaneously). When the condition of his toe worsened, Mr C had emergency surgery, resulting in some toes being amputated. However, he died a few weeks later. Mrs C said there was an unreasonable delay in fully investigating and treating her husband's toe, which meant he had to have more radical surgery. Mrs C believed that her husband would still be alive if an operation been carried out sooner and had he not been discharged several times.

After taking independent advice from one of our medical advisers, we did not uphold Mrs C's complaints. We found that Mr C received appropriate treatment from a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb) and that there was no undue delay in referring him to a vascular specialist (a clinician who treats disorders of the circulatory system). The treatment provided by vascular surgeons was also timely and appropriate.

Whilst we identified that on one occasion there was an error with Mr C's pain relief medication, our adviser said that overall his pain was monitored adequately and appropriate pain relief prescribed. Finally, we found that the hospital acted reasonably in not providing Mr C with transport home after he was discharged, as he did not meet the relevant criteria.

Summary

Mr C was discharged from hospital after having major surgery to remove tumours from his stomach area. When the district nurse attended she noted that the wound, which was substantial, had reopened. She called the medical practice to request an ambulance. The GP was visiting patients at the time and could not be located. Mr C's wife said that if the GP could not be located within five minutes she would call the ambulance, which she did. By this time the GP was on his way to Mr C's house but, when he was advised that an ambulance had been called, he returned to the surgery. Mr C complained that the practice did not immediately call for an ambulance.

We took independent advice from one of our medical advisers, who explained that it was reasonable for the GP to wish to assess Mr C before deciding whether an ambulance was necessary. He commented that in this case it was probably necessary, but that it might not have been necessary to call an emergency ambulance. He also pointed out that the district nurse would know that she could call an ambulance directly by phoning 999 if this was required.

As our investigation found that the practice acted reasonably, and as we noted that the ambulance would not have arrived any more quickly had the GP reviewed Mr C first, we did not uphold this complaint.

Summary

Mr C, complained to us on behalf of his son (Mr A). Mr A suffered a serious leg fracture in late 2010, and underwent treatment in a hospital orthopaedic department until June 2011. At that point, he sought a second opinion and received further treatment from another health board. Mr C had a number of concerns about his son's initial treatment, including about the type of fixator (a device to fix the position of fractured bones) that was used, the pain relief provided and the timing of appointments.

Having taken independent advice from one of our medical advisers, a consultant orthopaedic surgeon, we found that the decision to use an external fixator was in itself appropriate. We noted, however, that the board had not identified that one of the pins used had been placed into one of the fractures. We also noted that Mr A was not seen by a consultant until nearly three months after surgery, although we had no concerns about the treatment provided during this period. On balance, therefore, we upheld the complaint that the initial management of his fracture was inappropriate.

We upheld the complaint that on a number of occasions during his treatment Mr A was not given adequate pain relief, but did not uphold a complaint that it was inappropriate to use a sarmiento cast (a below-knee cast that allows the knee to bend) once the external fixator was removed.

Finally, we upheld the complaint that Mr A was not given timely out-patient appointments. Mr A had review appointments in April and June 2011. He was fitted with a leg brace and advised to use his leg when walking. He was given another appointment for eight weeks later. However, we found that at that stage it was clear that the fracture was not healing and required further management, but that the board failed to recognise this. By June 2011, Mr A was suffering severe symptoms and sought treatment elsewhere. We recognised that this had been a complex injury to manage, and that the orthopaedic department might have recognised that the fracture was not healing had Mr A continued his treatment with them. However, it was clear that he had already received substandard care, given that the fact that during the April and June 2011 appointments it was not recognised that the fracture was not healing.

Recommendations

We recommended that the board:

• provide evidence to the Ombudsman that the orthopaedic department ensures timely consultant review of patients when appropriate; and
• bring our findings to the attention of the staff who treated Mr A on 1, 14 and 15 February 2011 to allow them to reflect on his pain management.