Health

Summary

Mrs C was referred to a hospital gynaecology clinic with a vaginal prolapse (a condition when one or more of the pelvic organs slips down from its normal position). After she was first seen, she was given an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) and given a follow-up appointment for five months after that. A couple of months before the follow-up appointment was due, however, she developed post-menopausal bleeding (PMB - vaginal bleeding occurring over twelve months after the menopause). Treatment of her prolapse was postponed while this was investigated. Mrs C had biopsies (tissue samples) taken on three separate occasions before having a hysterectomy (surgery to remove the womb) some seven months after reporting the bleeding. Mrs C complained about the length of time between her initial GP referral and her surgery. She also complained about the number of biopsies she had to have and the length of time taken between each biopsy. She felt that her treatment was delayed as a result of failed biopsies.

We took independent advice from a medical adviser, who said that the prolapse was not clinically urgent, but that PMB could be indicative of cancer and needed urgent investigation. A hysterectomy was required to deal with the prolapse, and treatment for PMB would also require a hysterectomy. However, if cancer was found in the PMB treatment, it might also be necessary to remove the ovaries and lymph nodes within the abdomen. With this in mind, we found that while the PMB was being investigated it was appropriate to postpone the prolapse hysterectomy, so that she did not have to undergo two separate operations should cancer be found.

We also found that the biopsies that were taken were inconclusive rather than incomplete. Each biopsy was necessary and completed and reported in a reasonable timescale. Ultimately, the biopsies showed no signs of cancer. We were generally satisfied with the investigation and management of Mrs C's PMB.

That said, from December 2011, the board were required to work in accordance with the national waiting time target of 18 weeks from GP referral to treatment. Although Mrs C was referred before then, we considered that the board should have been working towards the target by the time of her referral. It took 35 weeks for Mrs C to be offered treatment after her referral, and her PMB began 31 weeks after referral. As the biopsies showed that Mrs C did not have cancer, we concluded that, had the board carried out the hysterectomy to address her prolapse in line with the 18 week target, Mrs C would not have developed PMB, and as such would not have required the biopsies and other investigations that she underwent. We, therefore, upheld her complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the issues highlighted in our investigation; and
• ensure that their general gynaecology clinic have systems in place to provide treatment in line with national referral to treatment targets.

Summary

Mr C complained that his medical practice failed to provide appropriate care and treatment when he had an eye infection and unreasonably refused to allow him to see a GP.

Mr C developed an eye infection, and called his practice on a Friday to request an appointment. He was told that there were no appointments available and that he should call again on Monday. By Monday his eyes had not improved, and he contacted NHS 24 (a national phone helpline service for advice on health matters). They advised him to see his GP. His workplace occupational health team also advised him not to work, and to see his GP. When Mr C contacted the practice again, he was told that when he first called he should have been referred to the LENS service (a service set up by the regional NHS board, providing direct access to treatment for minor eye conditions). The receptionist he spoke to on this occasion apologised that he was not told this when he first called, and advised him to contact a local optician, a participant in the LENS scheme.

Mr C was treated with various eye drops but his condition was slow to resolve. He contacted the practice several times over the next two weeks asking to see a GP. Although he twice saw a nurse from the practice, he was never able to see a GP. As he was unable to see a GP, Mr C continued with the treatment provided by the LENS service and was discharged the next month with the infection resolved.

Our investigation, which included taking independent advice from a medical adviser, concluded that it was reasonable that Mr C should have been referred to and treated by the LENS service. We, therefore, did not uphold the complaint about his initial treatment. The adviser said that the care and treatment provided by the service was reasonable and appropriate, and would not have been different from the treatment provided by a GP. However, we did find that when his condition was slow to resolve, it was unreasonable that Mr C was not given the opportunity to discuss his condition with a GP and be reassured that the treatment being provided by the LENS service was appropriate. Because of this, we upheld his complaint that he was refused access to a GP during that time.

Recommendations

We recommended that the practice:

• apologise for the failings identified; and
• review their policy and procedures for the allocation of GP appointments where patients have been referred to another service, and ensure that staff are considerate of the possible need for the reassurance provided by discussion with a GP when a condition is not resolving within a reasonable time.

Summary

Miss C complained that, when she visited her GP as a new patient, he refused to prescribe her Zopiclone (a drug used to treat sleeping problems). She said she had been unable to sleep because she had been in a hypomanic stage (a period of mild over-active, excited behaviour) of her bipolar disorder (a condition that affects a person's mood) for the last two months. From previous use, she said she knew that Zopiclone would help. She told the GP that her former GP and her psychiatrist found this acceptable.

Our investigation found that the GP had been right to be cautious as Zopiclone is a drug that must be prescribed with care. For example, it is a drug that is open to abuse as a so-called street drug. Also, Miss C's medical records had not yet arrived, so the GP's knowledge of her was very limited. He did prescribe alternative medication, so there is no question that she was given nothing to help with her condition. The GP then contacted her former GP and her psychiatrist and, having been reassured by some of the information from them, prescribed the Zopiclone the next day. Our independent medical adviser considered that this was a very reasonable approach and we did not uphold Miss C's complaint.

Summary

Mr C complained that GPs at the practice failed to take appropriate action after he repeatedly went there with back pain. The practice gave him pain relief, and offered physiotherapy. After he was admitted to a hospital accident and emergency department, magnetic resonance imaging (MRI scan - used to diagnose health conditions that affect organs, tissue and bone) was carried out, the result of which suggested an abnormality. On further investigation Mr C was found to be suffering from miliary tuberculosis (a form of bacterial lung infection which has spread to other organs).

We reviewed all Mr C's correspondence and obtained background correspondence and a copy of medical records from the practice. We also took independent advice from one of our medical advisers. He found that the practice's actions had been appropriate. The adviser confirmed the practice had followed guidelines in relation to the management and treatment of Mr C's back pain. He also explained that the diagnosis was rare and it was reasonable that the practice had not diagnosed it.

Summary

Mr C complained that the board provided inadequate treatment to his adult daughter (Miss A) in a hospital accident and emergency department (A&E) after a fall. Miss A had been taken there after a neighbour found her with a head injury. The doctor who saw Miss A recorded that she was intoxicated with alcohol and had abdominal and chest pain. She noted that Miss A had drunk a bottle of wine, and was difficult to assess and quite uncooperative with questioning. Miss A was initially unwilling to say how she had hurt herself, but eventually said she had fallen in her flat and had gone to the foyer to get help. However, the doctor was not convinced by this.

The doctor noted that Miss A said that the abdominal/chest pain started before she fell and was due to an existing kidney disorder. Miss A refused to have the head injury stitched, so it was cleaned and glued. The doctor arranged for a chest x-ray and routine blood tests. She gave Miss A painkillers and re-examined her after two hours, by which time, the chest and abdominal pain had improved. The doctor recorded that she thought that Miss A had likely suffered a muscular chest injury, and discharged her. Miss A was advised to see her GP in two days to get her bloods rechecked, and to return to hospital if there were any problems. Miss A declined to contact her parents for help to get home.

Miss A returned to A&E later that day, and this time told staff that she had in fact fallen off a balcony. She was admitted and was in hospital for three weeks. A CT scan (a special scan using a computer to produce an image of the body) and x-rays showed that she had suffered a number of injuries.

We obtained independent medical advice on the complaint, and found that, in general, the care provided to Miss A was reasonable. The doctor assessed Miss A in the context of the description she gave of a minor fall, and Miss A had to take responsibility for not saying what had actually happened. If the examining doctor had been aware of how the injury happened, Miss A would have been immobilised and a CT scan would have been requested, which would have shown the extent of her injuries much earlier.

However, our adviser also said that there were a few lapses in the standard of care. There was inadequate questioning about the significance of the head injury, particularly in the context of there being a four centimetre laceration to the head. If the doctor had asked about loss of consciousness, persistent headache, vomiting or amnesia memory loss, then responses might have indicated a need for a CT scan. The adviser also said that it was unlikely that a more senior doctor would have discharged Miss A, and there were a few subtle clues missed. These included a mildly raised respiratory rate, the chest and abdominal pain and a raised white cell count.

Although we upheld the complaint this was a decision taken on balance, in view of the fact that the overall care provided to Miss A was reasonable and the doctor was clearly not assisted by the fact that she was given inaccurate information about how Miss A sustained her injury.

Recommendations

We recommended that the board:

• issue an apology to Miss A for the failings identified; and
• make the doctor aware of our findings.

Summary

Following a laparoscopic hysterectomy (keyhole surgery to remove the organs and surrounding tissue of the reproductive system), Miss C began experiencing pain in her back and left leg. She was kept in hospital for five weeks and diagnosed with sciatic nerve damage (damage to the nerves of the lower back area). She told us that she continues to suffer from these problems and has been told that it could take two years for her to regain normal function. She complained that, despite corresponding with the board and attending several appointments, she has not received an explanation as to what caused these problems.

Our investigation found that the board had carried out appropriate investigations to identify the problems Miss C was experiencing and that her pain was likely to be caused by sciatic nerve damage following her surgery. This was a rare complication and not something the board could take particular precautions to avoid. We found that, although the board were not clear about what was causing Miss C's pain and carried out a number of tests to establish this, there was a lack of evidence to show that they had explained why they were carrying out these tests, the conclusion reached, and the likely outcome. For this reason, we upheld this complaint.

Recommendations

We recommended that the board:

• give Miss C a copy of her consultant's letter to her GP; and
• arrange for Miss C to meet with neurology staff to discuss her condition and likely outcome, if she wishes to do so.

Summary

Ms C complained about what happened when she was assessed for a decision to detain her under the Mental Health Act. She said that the psychiatrist did not treat her with respect; breached confidentiality by discussing her condition in the presence of two police officers; and, after discharge and despite Ms C asking for no further contact with the psychiatrist, she was sent appointments to attend her clinic.

Our investigation, which included taking independent advice, found no evidence to show that Ms C had not been treated with respect during the assessment which took place in her flat. The notes taken by the psychiatrist and a social worker (who was present as Ms C's mental health officer (MHO)) were brief but professional. We explained to Ms C that while we did not doubt that she considered she had been treated disrespectfully, in situations where there is no independent corroborating evidence, we cannot determine which version of events is the correct one. Therefore, we were unable to uphold this aspect of her complaint.

On the matter of the discussion which took place in the presence of the police officers, our investigation found that this was reasonable. Concerns about Ms C's mental health had firstly been raised with the local mental health team by local police, who had been concerned about some aspects of Ms C's behaviour in the preceding weeks. The police officers who were present were, therefore, aware in general terms of Ms C's mental state. When the psychiatrist and the MHO needed to have a more detailed clinical discussion of Ms C's condition, they retired to Ms C's kitchen to discuss this in private. We, therefore, found no evidence of a breach of confidentiality.

In respect to the out-patient appointments sent to Ms C after her discharge, the board acknowledged and apologised for this oversight. The psychiatrist involved was the only one in the area that deals with out-patients, so the system automatically sent a follow-up appointment. This had gone out while the board were still considering Ms C's complaint as the system had not been updated. As the board had, however, already apologised for this, we made no recommendations.

Summary

Ms C complained that staff at a physiotherapy department failed to adequately manage her symptoms of severe back pain and limited mobility. Staff initially examined her and determined that she should be given conservative management (medical treatment avoiding radical therapeutic measures or operative procedures) of her pain with physiotherapy and acupuncture before she was referred for a magnetic resonance imaging scan (MRI - a scan used to diagnose health conditions that affect organs, tissue and bone). She then had a number of appointments with a physiotherapist and acupuncture was arranged. Ms C felt that her pain had continued to get worse. She then elected to have an MRI scan carried out privately. The scan showed that a surgical procedure was needed, and Ms C had this procedure privately.

Ms C complained that the physiotherapist did not refer her for an MRI scan. We took independent advice from one of our medical advisers who specialises in physiotherapy. She reviewed the board's policy for referral for an MRI scan and Ms C's clinical records. The adviser said that the treatment Ms C received was appropriate and that it was reasonable that she was not referred earlier for an MRI scan. She also confirmed that the physiotherapist followed the appropriate protocol for referring Ms C.

Summary

Mr C complained that he was unreasonably told that he had lung cancer, when in fact he had tuberculosis (a bacterial infection mainly affecting the lungs). Mr C explained that he was admitted to hospital for investigation of possible lung cancer. After a CT scan (a special scan using a computer to produce an image of the body) he was told that he had lung cancer and part of his lung would need to be removed. Mr C said the procedure was carried out, but when he received his patient discharge letter it showed his diagnosis as pulmonary tuberculosis.

Mr C's own account and the information in his medical records showed that at the time he was admitted to hospital he was aware that it was a possibility rather than a certainty that he had lung cancer. Having read Mr C's medical records, our independent medical adviser said that in later discussions Mr C was told of the likelihood rather than the certainty that the abnormality represented a lung cancer. The adviser said that, given that in his opinion the likelihood of Mr C having lung cancer at that point was at least 80 to 90 percent, it was not unreasonable to say that he might have lung cancer.

Our investigation did find a number of examples of the board failing to record information in Mr C's medical records, or entering incorrect information, so although we did not uphold the complaint, we made a recommendation about this.

Recommendations

We recommended that the board:

• feed back our findings on the board's record-keeping to the staff involved.

Summary

Miss C said that she experienced pain and difficulty eating after having her tooth filled. She was unhappy that, when she twice called the dental practice about the pain she was suffering, reception staff advised her to call the emergency dentist.

We did not uphold Miss C's complaint about her dental treatment. We could not find enough evidence to support what Miss C said about the phone calls she said she made to the dental practice after the treatment, or what was discussed with the reception staff. We noted that when Miss C visited a different dentist a few months later, the filling was removed and a small exposure of the pulp tissue was found (the pulp is the central soft core of the tooth, sometimes referred to as the nerve). Our dental adviser said that exposure of the pulp is relatively common when providing a deep filling and can often go undetected as it can be fractions of a millimetre in size. In Miss C's case, our adviser said that it was possible that a small exposure occurred following the tooth being filled but did not consider that the the treatment was inappropriate.

We did, however, uphold Miss C's complaint about complaints handling, as we found that the board had not provided a full and comprehensive response to her complaint. We noted that the board's feedback services are currently under review.

Recommendations

We recommended that the board:

• apologise to Ms C for not responding fully to her complaint; and
• update the Ombudsman when the Feedback Service review is completed.