Health

Summary

Miss C complained about the time that it took for an ambulance crew to attend to her late father, who had suffered a heart attack. The board explained that on receipt of an emergency 999 phone call, the nearest available ambulance was dispatched. However, when it was thought that the ambulance would be delayed due to road works, a second ambulance was dispatched and the first was stood down. The board then realised that the second ambulance had to negotiate the same road works and as a result arrived one minute after the time estimated for the first ambulance's arrival. The board explained that the first ambulance should not have been stood down and gave an assurance that lessons have been learned. We found that the board had taken the complaint seriously, and that the appropriate staff had been interviewed and reminded of their responsibilities. We took the view that further consideration of the complaint would not achieve more for Miss C.

Summary

In September 2011, the hospital introduced a new clinical model, which set up new hub and cluster units (a central point and areas for activities). Each of the four hubs supports a cluster of three 12-bedded wards, with various therapeutic, physical, creative and social activities taking place in the hub. There is a central unit where more formal therapies and educational activities are held.

Mr C, who is a patient in the hospital, complained that patients were unreasonably pressured to attend activities in the hub area and that alternatives to attending there were limited. Our investigation found that the board had already addressed staff recruitment and training issues and reviewed policies to allow a more flexible use of resources. This had allowed them to keep more wards open while still staffing the hubs, and they confirmed that in the last month Mr C's ward had not been closed. They also pointed out that sometimes they cannot keep all areas open because of staffing and safety issues.

The hospital provided details of Mr C's personal programme of activities. We noted the steps that have been taken to review and improve practices at the hospital. Independent advice received from our medical adviser on a previous similar case was that positive progress had been made. Our adviser also said that staff often have to find a balance between encouraging patients to engage with therapies and activities and making them feel pressurised.

We took the view that it was not unreasonable for patients from one area to move elsewhere when there are short term difficulties. The matter of deciding how patients should spend their time, and where, is one for the board to consider and decide upon and we found no evidence of anything having gone wrong in the process of deciding how to go about this. On the basis of the information provided and the advice previously received from our adviser, we did not uphold Mr C's complaint.

Summary

Mrs C made a number of complaints about the board's care and treatment of her husband (Mr C). Mr C had been diagnosed with rectal cancer (cancer of the lower part of the large bowel) and liver metastasis (cancer that spreads to other parts of the body).

Mrs C said that her husband had cognitive defects (his understanding was limited) and the board did not take this into account when obtaining consent for surgical procedures carried out on him. She said that Mr C was not competent to give informed consent (consent for medical procedures to take place, with a proper understanding of what these involve) and that she stressed this to every health professional she came in contact with. Mrs C was both financial and welfare power of attorney for her husband (ie she could control decisions about most aspects of his life). However, when responding to her complaint, the board said that Mr C was not at any point considered to have been incapacitated to an extent where he could not sign his own consent forms.

We upheld Mrs C's complaints about Mr C's care and treatment and about the board's complaints handling, but not her other complaints. Our investigation found that, on balance, there was evidence in the case notes to show that Mr C had cognitive impairment that compromised his capacity to provide informed consent. The clinicians involved should have documented their own assessment of his capacity, but failed to do so. We, therefore, did not know what their views on this were, or how, if at all, they had assessed Mr C's capacity to consent to medical procedures. If they believed that Mr C lacked capacity, then the provisions of the Adults with Incapacity Act should have been used, which would have ensured Mrs C's involvement as power of attorney. Mrs C's involvement in major decisions relating to Mr C's care, including consent to undergo surgery, would also have been documented. On the other hand, had the clinicians believed that Mr C did have capacity for such decision making, they should have clearly documented this. In view of this, we found that the assessment and documentation of Mr C's cognitive function and capacity to consent was below a reasonable standard.

Mr C had had a ventriculoperitoneal shunt (a device to divert fluid from the brain) inserted several years before. A central line (a tube placed by needle into a large, central vein of the body to administer drugs or take blood samples) had been placed in the same area during his treatment for cancer. Staff noted inflammation around the site of the central line and it became apparent that Mr C's confusion had worsened. Mr C's condition deteriorated and the central line was removed. A scan was then carried out, which found that there was more fluid in Mr C's brain than had previously been seen. Mr C was transferred to a neurosurgical ward (ward for surgery of the brain or other nerve tissue), but his condition continued to deteriorate and the shunt was removed. Mr C's neurosurgeon considered that his neurological deterioration was a direct result of the infected central line, although the surgical staff involved in fitting the central line disputed this. We found that the surgical staff should have avoided putting the central line in the same area as the shunt. However, there was insufficient evidence for us to decide that this caused an infection and led to Mr C's neurological deterioration. We found that the other treatment provided to Mr C was appropriate and in line with the current guidelines for the management of rectal cancer. We also found that it was reasonable to undertake keyhole surgery and that Mr C's consultant was reasonably involved in his care and treatment.

Mrs C also complained that the board did not reasonably provide information about Mr C's condition. Although this was a balanced decision, we found that the information provided had been reasonable. However, we found that the board had not responded to Mrs C's complaints within a reasonable timescale.

Recommendations

We recommended that the board:

• issue a written apology to Mrs C; and
• consider how to raise awareness amongst medical and nursing staff of the need to: objectively assess cognitive function; assess and document capacity to consent; clearly document the existence of proxy decisionmakers such as a power of attorney; and, document the inclusion of the power of attorney in decision making processes more explicitly than occurred in this case.

Summary

Mrs C complained that a GP failed to physically examine her husband (Mr C) during a home visit and wrongly concentrated on his mental health problems. The practice explained that the GP believed that Mr C was depressed and that he required a psychiatric assessment, which she arranged on return to the practice.

Our investigation found that Mr C's medical records showed that the reason for the home visit was for mental health issues rather than a physical examination. Our medical adviser reviewed the records and felt they were appropriate in relation to a visit for mental health issues. We were unable to resolve the difference of opinion between Mrs C and the GP about what was actually said at the visit, but we were satisfied that the GP's actions in making a referral for psychiatric assessment were correct.

Summary

Mrs C's daughter (Miss A) attended a GP appointment with symptoms of depression. She was prescribed Prozac (an anti-depressant medication). Mrs C complained that this treatment was inappropriate. She felt that the GP had not tried to properly establish the cause of her daughter's depression and had unreasonably prescribed medication that could increase the risk of suicide in young people.

However, after taking independent advice from one of our medical advisers, we found that the GP's treatment of Miss A was reasonable. A review appointment had been made for a week later. We found that it was appropriate to prescribe such medication for Miss A's symptoms, particularly as the review appointment was in place to assess her reaction to, and mood level, whilst taking the medication.

Summary

Ms C complained about the care and treatment that her late brother (Mr A) received from a medical practice. She was very unhappy with the GP's long-term use of antibiotics in treating Mr A's skin problems. Mr A found it very difficult to leave home, and Ms C said that for almost eighteen months, the GP prescribed Mr A a large amount of antibiotics, mainly during home visits or phone consultations. Mr A had later died from cancer of the pancreas (which was unrelated to this complaint).

We took independent advice from one of our medical advisers, and reviewed Mr A's medical records, as well as the documentation provided by Ms C. While we acknowledged that the GP had considerable difficulties in managing Mr A's condition, our adviser said that it was clear that an inappropriate amount of antibiotics was prescribed over a long period, and that Mr A's condition might have been managed better by involving district nurses. We accepted this advice, upheld the complaint and made two recommendations.

Recommendations

We recommended that the practice:

• conduct a significant events review; and
• apologise to Ms C for the failures identified.

Summary

Mr C fell and injured his foot while on holiday. Upon returning home, he went to a hospital accident and emergency department (A&E) where his foot was x-rayed. He was told that this showed no problems, but he continued to experience severe pain in the following months. Some six months later, Mr C's GP referred him for further x-rays, which showed that he had a dislocated toe. He was told that, because of the amount of time that had passed, this could not be corrected without surgery. Mr C complained that staff failed to identify the dislocation when reviewing the earlier x-rays.

When investigating Mr C's complaint, the board asked a panel of six consultant radiologists (specialists in analysing images of the body) to review the x-rays. They concluded that the dislocation was not evident on the original x-rays and that Mr C's toe joint must have separated between then and the referral, when the dislocation was obvious. Mr C's consultant orthopaedic surgeon (a specialist in conditions involving the musculoskeletal system) also reviewed the x-rays. He concluded that a slight abnormality was evident on the original x-rays, but did not feel that it was reasonable to expect staff to have diagnosed a dislocation from this at the time, as it was only apparent when comparing the image to the March 2012 x-ray.

We took independent advice from two medical advisers. The first, a consultant radiologist, said that the original x-rays showed a subtle but definite abnormality, which should have led to the dislocation being diagnosed, or to further specialist opinion being sought. However, the second adviser, a consultant orthopaedic surgeon, disagreed and did not consider that staff could reasonably have been expected to diagnose the dislocation at the earlier time.

We did not uphold Mr C's complaint. We found it likely that Mr C's toe had a dislocation when he went to A&E. However, it was clear from the conclusions reached by a number of professional medical personnel that this was not easy to diagnose from the initial x-rays. Although, with the benefit of hindsight and the later x-ray, it was possible to determine that there were abnormalities in the initial x-rays, we considered that the original conclusions reached were reasonable, based on the evidence available at the time.

Summary

Mr C was unhappy about a delay in reporting the result of a test carried out on a blood sample from his late mother. He said that by the time the board contacted the GP with the result of the test, his mother had deteriorated and required hospital admission. He complained to us that the board's investigation of his complaint was inadequate.

We took independent advice from one of our medical advisers. In considering the complaint we noted that the board had apologised for the delay in reporting the result. They explained that this was caused by human error, and that they had reminded the staff member of their responsibilities. When the error was discovered, urgent action was taken to contact Mr C's mother's GP. Our medical adviser said that the time taken to report on the blood sample was in fact reasonable, but that the member of staff had missed an opportunity to report it sooner. We did not uphold the complaint as we found that the board had carried out a thorough investigation, and had taken appropriate action to prevent this happening again.

Summary

Mr A's late wife (Mrs A) was in hospital, and had developed symptoms that suggested she might be infected with legionella (the bacterium that causes legionnaire's disease). Blood tests were taken, but Mrs A died the next day, before the results were known. The hospital issued a death certificate and Mr A organised his wife's funeral. However, when the undertaker tried to collect Mrs A's body the day before the funeral, the hospital would not release it. This was because the legionella tests had come back positive and the procurator fiscal had been informed. Mr A was left not knowing when he would be able to hold his wife's funeral, and said that he did not receive a clear explanation of the reasons for the delay or what would happen if the tests were positive. Because of the delay, the family had to cancel the funeral which both caused extreme distress and inconvenienced them, as family members were travelling from other parts of the UK.

The further tests, however, showed that the first result had been a 'false positive' and Mrs A did not have a legionella infection. An advocacy worker (Ms C) complained to us on Mr A's behalf about the board's administration and communication. She said that the board had issued the death certificate prematurely and delayed in deciding not to release Mrs A's body. She also said that their communication was unreasonable in that they delayed in telling the appropriate people that Mrs A's body was not to be released, provided an inadequate reason for not releasing Mrs A's body, and failed to provide reasonable information about what would happen if the test results were positive or about when Mrs A's body would be released.

We did not uphold the complaint that the board's administration of matters was unreasonable, as we found no evidence of delay in deciding to release Mrs A's body. Our investigation found that the decisions about this were taken as quickly as they could have been. We also found that it was reasonable for them to issue a death certificate, as the main causes of death were appropriately recorded.

However, we did uphold the complaint that the board's communication was unreasonable. Although a doctor had contacted Mr A at the right time to explain why Mrs A's body could not be released, we found no evidence that the doctor explained to him the implications of a positive test result. Although we acknowledged that normally the chance of a positive test was small, we found that Mr A and his family should have been told of the possible implications in order that they could make informed choices about important matters such as funeral arrangements.

Recommendations

We recommended that the board:

• take steps to ensure that, where similar circumstances arise, medical staff make relatives aware of the potential impact of a positive test result.

Summary

Mrs C complained about the care given to her mother (Mrs A) by the practice GPs. Mrs A had rheumatoid arthritis (an inflammatory condition that mainly affects flexible joints) and osteoporosis (a condition that affects the bones, causing them to become fragile and more likely to break). She injured her ankle, which caused her severe pain, and she could not put weight on her foot. Mrs A's medical practice did not arrange for this to be x-rayed, and it was some time later that an out-of-hours doctor sent her for an x-ray, which identified a fractured tibia (shin bone) and fibula (bone on the outside of the lower leg). Mrs C complained that the practice unreasonably failed to arrange for Mrs A to be x-rayed.

Our investigation found that, over a two week period after the injury, the GPs twice visited Mrs A at home as well as having a phone consultation, yet did not arrange an x-ray. They instead diagnosed a flare up of arthritis and prescribed pain relief, with increased dosages when the pain did not subside (and indeed worsened). We found that the GPs should have arranged for an x-ray to be taken, particularly as Mrs A had osteoporosis and taking into account her age, frailty and the fact that she could not put weight on her foot. We also upheld the complaint that a phone consultation was inappropriate after the two home visits. We found that further action should have been taken at this time and that the decision to simply increase pain medication during a phone consultation was unreasonable.

Recommendations

We recommended that the practice:

• provide a formal written apology for the failure in service Mrs A experienced; and
• provide evidence to the Ombudsman that a significant event analysis has been carried out and of any service improvements that are identified following it.