Health

Summary

Mrs C's late mother (Mrs A) was diagnosed with cancer in 2011. Mrs C complained that when blood test results were found to be abnormal, a GP from her mother's medical practice (GP 1) failed to tell Mrs A about these when he was the on-call doctor. Mrs C was unhappy that her mother did not find out the results until nine days later when she attended the local community hospital's accident and emergency department (A&E) and GP 1 (who was the on-call GP in the hospital at the time) accessed the results.

The background to this is that another GP at the practice (GP 2) had arranged for Mrs A to attend the surgery in late December 2010 to have non-urgent blood samples taken. These were sent to the laboratory the following day where they were immediately identified as abnormal. At the time, the laboratory's procedures set out that they must communicate abnormal test results to medical staff quickly, and make a computer entry showing when the call took place and to whom. The procedure also included an out-of-hours number for laboratory staff to call if it concerned an out-of-hours GP.

In their response to Mrs C's complaint, the board apologised for a failure in the timely reporting of the abnormal blood results. However, the board advised us that it was unclear to them whether the laboratory had failed to follow procedure. When we investigated, we found that it was difficult for us to be certain whether the laboratory had telephoned and told the practice the results. There was an entry on the computer system suggesting that a call had been made to GP 2. However, the surgery had closed an hour before the laboratory had apparently made the call. In addition, GP 2 saw his last patient in the surgery at 12:45 and was not the on-call doctor that particular day. There was also no entry in Mrs A's medical records to indicate that the surgery had received a call from the laboratory. There was, therefore, no conclusive evidence that confirmed that the practice were aware of the test results.

The medical records showed that GP 1 accessed the results in early January 2011 when Mrs C's mother attended A&E. We did not uphold the complaint, as we considered that GP1 had taken appropriate action to have Mrs A further assessed at that time, and there was no evidence to support that he was aware of the blood test results before he accessed them in January 2011.

Summary

Mr C complained about the care and treatment that his mother (Mrs A) received from a hospital after she was admitted with a severe headache. Mrs A was diagnosed after about 13 hours with a subarachnoid haemorrhage (a type of stroke where there is a bleed from one of the blood vessels running over the brain). Mr C was concerned about the length of time it took for the hospital to carry out a scan and felt that the brain damage his mother suffered could have been less severe had the scan been done sooner. Mr C also complained about the time it took for the board to respond to his complaint and that the response did not answer all of his concerns.

The board accepted there had been an unacceptable delay of approximately four hours between the time it was decided the scan should be done until it was actually carried out. They were unable to provide a clear reason for the delay but outlined that there were communication problems between the junior doctor and the radiology department. As a result of their findings, the board said that they would rewrite their protocol in relation to scanning and out-of-hours care.

We found further communication problems that impacted on identifying the need for an urgent scan. The medical records show that the on-call medical consultant said that Mrs A was to be scanned immediately in the event of further deterioration. However, when her condition further deteriorated early that morning, before the scan was done, neither the on-call doctor nor the radiologist was informed.

We were unable to say whether earlier diagnosis would have influenced the final outcome in Mrs A's case. However, it would have at least provided the possibility of early transfer and intervention, along with reducing the overnight anxiety the family suffered. Overall, therefore, we considered the care to be below the standard that could reasonably be expected.

We also identified significant delays in the board's responses to Mr C's letters of complaint, which were not in line with the guidance issued by the Scottish Parliament at the time. Whilst we noted inconsistencies in the board's first response to Mr C, their second response was more accurate and in keeping with the information contained within Mrs A's medical records.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failings identified in our investigation;
• review the new protocol to ensure that there is appropriate involvement of the senior medical staff responsible for the care of the patient when reviewing patient care, and that appropriate clinical features are included in the protocol to aid diagnosis;
• review clinical communication at the time of handover between all clinical staff, including radiology, to ensure urgent scan requests are effectively communicated and expedited; and
• apologise to Mr C for the delay in responding to his complaint and for providing contradictory information.

Summary

Mr C made a complaint on behalf of his partner (Ms C) who was admitted to hospital with a suspected stroke. Two days after being admitted, Ms C collapsed in the bathroom, where she was discovered by ward staff. She was moved to an acute ward and was under observation for five days until she was discharged from hospital. It was thought that Ms C, who had epilepsy, might have suffered a seizure.

Four months later, Ms C met with a doctor at the hospital as she was concerned about what had happened. She had concerns that she had been given the wrong medication and that the collapse had not been reported as an accident nor been subject to an accident investigation. She was also unhappy about the actions of the medical team following her collapse, including the taking of a blood sample from her groin. Ms C provided a list of questions for the doctor to respond to, and he did so by letter.

Ms C remained dissatisfied and wrote again with some additional queries. This letter, however, was sent directly to the doctor and was not received by the board's complaints team. Ms C then sent her original set of questions to the complaints team, who responded. Ms C then complained to us that the board had not answered her additional questions.

During our investigation we found that the second letter had been addressed to the doctor and said that Ms C would be making a formal complaint. The doctor had, therefore, placed it in Ms C's medical file, and explained to her how to access the complaints procedure. We found this to be reasonable. However, this meant that the complaints team had not in fact seen Ms C's additional queries which is why they did not respond to them. We found that the board's responses to the complaints Ms C made to them were reasonable, and noted that the complaints team had in fact phoned her to try to establish what she was still concerned about. Although we did not uphold the complaint, we made a recommendation to allow Ms C another opportunity to raise any further matters with the board.

Recommendations

We recommended that the board:

• contact Ms C to arrange either a meeting or further correspondence to address any outstanding concerns.

Summary

Mr and Mrs C underwent in vitro fertilisation (IVF) treatment (fertility treatment) in 2010 and had a child. They understood that they were not entitled to further treatment from the health board and had been saving for private treatment. They made an appointment for a private consultation. However, Mrs C said she received a telephone call from the board in April 2011 saying she was entitled to a further cycle of treatment. On that basis, Mr and Mrs C cancelled their private treatment, and made appointments at the board's assisted conception unit. Around three months later, Mrs C contacted the board to confirm the dates of her appointment with the assisted conception unit and was told that there had been an error, and she was in fact no longer entitled to further NHS treatment.

The board conducted an investigation including tracing their call logs, but could find no record of the call to Mrs C in April 2011. There was also no record of appointments having been made for her with the assisted conception unit in 2011. The board considered Mr and Mrs C's case again, but reached the decision that they would not deviate from their normal policy on IVF to offer a second cycle of treatment. We considered the board's investigation and obtained further information. We found that there was no independent evidence to support Mrs C's position about the telephone call, although we did not disbelieve her position. We also found the board's position of following their policy to be reasonable. Although we did find that there was a delay in Mr and Mrs C obtaining IVF treatment as a result of their experiences, on balance we did not uphold the complaint.

Summary

Ms C, who is a member of the Scottish Parliament, complained on behalf of a constituent (Mrs A) who had a number of concerns about the care provided to her late husband (Mr A). Mr A had dementia and was admitted to hospital with increasing confusion, shortness of breath and infections. When investigating the complaints, we took independent advice from three advisers - a physiotherapy adviser, a nursing adviser and a consultant geriatrician (a doctor specialising in medicine for older people).

We did not uphold Ms C's complaint that Mr A's physiotherapy treatment was inadequate, as we found the treatment to be frequent. We noted that the physiotherapy team continued to try to help Mr A to mobilise although he was increasingly not able to work with them, due to his dementia. We also found that they had appropriately referred Mr A to medical staff when they noticed unusual symptoms when trying to help him to mobilise (Mr A was later diagnosed with a fractured hip).

We also did not uphold the complaint that Mr A was not given adequate assistance with eating and drinking. We found that a dietician had made appropriate assessments, it had been recognised that Mr A had increasing problems with swallowing, and the notes indicated that staff had continued to try to help Mr A to eat and drink. He had lost a lot of weight, but our medical adviser considered that this was due to the fact that he had difficulty swallowing.

We upheld Ms C's complaint that Mr A had not been given appropriate assistance with dressing on some occasions, as the board had accepted this. We also noted there was no assessment recorded in the notes about Mr A's level of independence in relation to personal care (including his ability to dress) and we criticised this.

We did not uphold the complaint that the board did not discuss with Mr A's family his transfer to a nursing home, as we found evidence of discussions of this nature in his records. We did, however, uphold a complaint that the transfer was not reasonable at that time, given that Mr A was suffering from a severe pressure sore that was not highlighted to nursing home staff by ward staff. Finally, we upheld the complaint that the pressure sore was allowed to develop and worsen. This was because, although we found evidence that a high risk area was initially recognised, there was no evidence thereafter that it was treated.

We noted that, since the time of Mr A's care in 2010, the board had implemented a range of new policies, training and audits in relation to care of patients with dementia, nutritional care and tissue viability. We, therefore, made recommendations only in respect of the implementation of these.

Recommendations

We recommended that the board:

• provide their action plan for education and staff training in relation to patients with cognitive impairment;
• provide evidence to the Ombudsman that appropriate assessment of patients' levels of independence on rehabilitative wards is taking place; and
• provide evidence that full relevant information is provided during the transfer and discharge of patients to nursing home and other community care environments, and that staff are aware of their responsibilities in this regard.

Summary

Mrs C complained about the treatment prescribed by her medical practice for fungal nail infection. In addition, Mrs C was unhappy with the practice's response to her complaint and with their view that she and her husband behaved inappropriately towards staff.

Mrs C has lupus (an autoimmune disease that causes inflammation in various parts of the body). She did not take the prescribed medication after reading on the information leaflet that it was potentially harmful to lupus sufferers, and complained that it had been inappropriately prescribed. Although Mrs C's prescription was subsequently changed, she said that the new course of treatment also had an adverse effect on her health.

As part of our investigation, we took independent advice from a medical adviser. He said that available treatments for fungal nail infection can have a number of side effects, interact with many other drugs and can cause reactions including impairment of liver function. The initial drug Mrs C was prescribed can cause a lupus type effect and the British National Formulary (BNF - national guidance for healthcare professionals regarding the prescribing of medicines) advises caution when prescribing it to patients who suffer from an autoimmune disease. Our adviser said that although the BNF does not advise against prescribing the drug, there was no record to suggest that the medical practice had considered Mrs C's medical history when prescribing it, nor did they note a follow-up plan or request blood tests.

We also found that there was no evidence to show that the medical practice considered any follow-up plan when prescribing the replacement treatment. The BNF recommends that if the treatment is prescribed for more than a month, liver function should be monitored. We noted that the blood tests taken from Mrs C after she complained of being unwell were only carried out as a result of her symptoms, rather than being planned at the time of prescribing.

We concluded that although it was reasonable for the practice to have prescribed both courses of treatment, their care of Mrs C was deficient because there was insufficient evidence to show that they had actively considered the impact on her condition or monitored the effects of the drugs.

We also identified that the practice's response to Mrs C's complaint lacked relevant information about the BNF advice, and upheld this complaint. However, we did not uphold the complaint about the allegation that she and her husband behaved inappropriately towards staff. This is because, due to a lack of independent witnesses, we were unable to know for certain whether the medical practice had acted inappropriately in saying this.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to clearly discuss the possible risks and side effects when prescribing both drugs or to actively monitor her liver function; and
• remind relevant staff to ensure that all medicines prescribed are adequately recorded and the associated risks discussed with the patient are also noted.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) who had a hernia repair operation. Several days after the operation, a district nurse suspected that Mr A had developed an infection. Mr A saw his GP who prescribed antibiotics. Five months later, Mr A experienced a swelling at the site of the operation, which then burst. Mr A went to the accident and emergency department of a hospital, and was seen as an out-patient on several occasions over the next eight months until he had further surgery. Mrs C complained to us that the board failed to provide a reasonable standard of treatment for post-operative complications following Mr A's hernia repair surgery.

We upheld Mrs C's complaint. We found from looking at the records and obtaining independent advice from our medical adviser, that Mr A had an infected mesh (used to repair the hernia) in his wound that needed to be removed. Hospital staff treated the problem with antibiotics, in an attempt to avoid further surgery on Mr C. However, our adviser said that as surgery was inevitable, the decision to remove the infected mesh could and should have been made sooner. In addition, once the decision had been made to remove the infected mesh, there was an unreasonable delay before the surgery was carried out. We also had concerns that the record-keeping in this case was poor.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our investigation; and
• reflect on the comments of our adviser in relation to record-keeping.

Summary

Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted to have red heels, with a blister on one of them. Mrs C was discharged home shortly afterwards and Mr C said that at that time she had pressure sores. Mrs C died some six months later.

Mr C complained that his wife suffered from pressure sores while in the care of the board. He said that she was inadequately nursed and that this contributed to her death. In our investigation we took all the relevant information into account including the board's file of correspondence and Mrs C's clinical notes. We also obtained independent nursing advice about Mrs C's care and treatment.

We upheld all Mr C's complaints. Our investigation found that there was no reason not to discharge Mrs C home with dressings on her feet. However, there was also no evidence to suggest that a wound chart was completed before discharge, which would have assisted community nurses to plan their care for Mrs C. Community nurses were also not told that Mrs C's heels needed dressing and we found that communication between the hospital and the community nurses was poor. Similarly, record-keeping was below a satisfactory standard.

Recommendations

We recommended that the board:

• emphasise to the staff concerned in this case the importance and necessity of keeping properly recorded notes and of using the tools that are available to them to assist in the care and treatment of patients (eg a wound chart);
• apologise to Mr C for their failures in this matter. Also, that the apology makes specific reference to the poor treatment given to Mrs C while she was at home; and
• provide evidence to the Ombudsman about how they assure themselves that the discharge planning standards/policies relating to communication have been addressed

Summary

Ms C complained about the treatment her mother (Mrs A) received from a GP at her medical practice. Mrs A had attended an appointment with the GP in relation to rectal pain and bleeding. The GP performed an examination, diagnosed piles, prescribed a treatment, and advised Mrs A to return within seven to ten days if her symptoms did not improve. Mrs A returned some five weeks later, by which time her symptoms had worsened and she had blood in her stools. Another GP referred Mrs A to hospital for tests, and she was given a clinic appointment for just over two months later. In the meantime, Mrs A attended the practice on two further occasions, when she was seen again by the first GP. On one of these occasions, the GP physically examined Mrs A again.

Mrs A was diagnosed with colorectal (bowel) cancer after the hospital appointment. She underwent chemotherapy and radiotherapy. Due to other medical conditions, it was considered that surgery was not a suitable option and Mrs A died just under a year and a half after being diagnosed. Ms C said that if the GP had properly recognised her mother's symptoms at the start, she might have had a better life expectancy and an improved quality of life. Ms C was also concerned that, given the subsequent cancer diagnosis, the GP had said that there was 'nothing untoward' on the occasions that she examined Mrs A.

Having taken independent advice from one of our medical advisers, we found that the GP's care of Mrs A had been appropriate. We found that it was reasonable for the GP to prescribe medication for piles at the first appointment, and to advise Mrs A to attend seven to ten days later if her symptoms had not improved. We accepted that the referral was appropriate, and that there was no requirement for the GP to try to speed that up after Mrs A's later appointments. We noted that, as a hospital appointment had already been made and was due shortly, this would have had no practical impact upon Mrs A's prognosis and treatment time. We also found that the GP's statement that there had been 'nothing untoward' was made in the context of the physical examinations. It was reasonable that further tests at the hospital were needed in order to discover a cancer diagnosis.

We did draw to the practice's attention that it might have given Ms C some reassurance if they had told her that they had carried out a Significant Event Analysis (a detailed investigation into what happened) as a direct result of her complaint, and had put in place the learning outcomes that it identified.

Summary

Mr C complained about the board's actions in relation to his elderly father (Mr A). He said that his father had been admitted to hospital late in the evening. After being examined and declared fit, he was sent home in the early hours of the morning by car, with a relative. Mr C said the relative was not entirely happy with this but, nevertheless, complied. When Mr A reached home, a neighbour had to be recruited to help him get into the house. Mr C said that his father should not have been discharged, particularly because he was elderly, disabled and had memory problems.

We investigated the complaint taking all the relevant information, including all the complaints correspondence, the relevant clinical records and the board's discharge policy, into account. We also obtained independent advice from one of our advisers, who is a nurse.

In responding to the complaint, the board had confirmed that Mr A was considered fit for discharge and was keen to go home. There was, therefore, in their view, no clinical reason to keep him in hospital. They pointed out that the Scottish Ambulance Service did not provide out-of-hours transport and, as there was a relative available and willing to take Mr A home, they had asked him to do so. They said that if this had not been the case, they would have had to consider whether a taxi was appropriate.

Our nursing adviser reviewed the files and confirmed that the information in them indicated that Mr A was fit to go home. She also confirmed that Mr A was not in fact admitted to hospital, and so the board's discharge policy would not apply in his case. She said that in all the circumstances, it was not unreasonable for Mr A to return home with a relative, given that an emergency department was not an ideal place for an elderly and frail person.

Taking all the information into account, we did not uphold the complaint as we found that, while not ideal, in all the circumstances it was not unreasonable for the board to discharge Mr A home.