Health

Summary

Mr and Mrs C complained that the medical practice inappropriately prescribed their father (Mr A) anti-inflammatory medication on a long-term basis, without also prescribing gastric protection medication. Mr A had sciatica (lower back pain caused by pressure on a nerve) and osteoarthritis (the most common form of arthritis, affecting the joints) in his knees. He had been on a non-steroidal anti-inflammatory drug (NSAID) for a number of years when he attended hospital several times complaining of abdominal (stomach) pain. He was eventually admitted to hospital, where he was found to have a massive gastro-intestinal haemorrhage (severe bleeding in the stomach/intestine) because of a bleeding ulcer. Doctors were unable to control this, and although Mr A had emergency surgery, he did not survive.

Our investigation found that guidance in 2008 said that gastric protection medication should be prescribed with NSAIDs. We upheld the complaints, as we found that from 2008 onwards Mr A should not have been prescribed a NSAID without this protection. We noted that this was in fact picked up at a medication review that year, which noted that Mr A was over 65 and a smoker and was, therefore, at increased risk of stomach bleed. The review said that if the NSAID prescription was continued, gastric protection medication should be added. The NSAID was then removed from Mr A's repeat prescriptions. However, a year later, a NSAID was added to his repeat prescriptions without gastric protection medication. The practice apologised to Mr C for this after Mr A's death and carried out a significant event analysis.

Mr C also complained that the practice failed to diagnose and treat Mr A's ulcer. Mr A had attended the hospital with abdominal pain several times, and they had told the practice about this. We found that the practice were not required to follow this up unless the hospital specifically asked them to do so, and there was no evidence that Mr A attended the practice with abdominal problems until the day before his death. That said, we found that Mr A's abdominal pain, along with the fact that he was taking the NSAID without gastric protection, should have alerted the GP to the probability that the pain was being caused by an ulcer. We found that the GP should have prescribed gastric protection at that time, although it was unlikely that this would have prevented Mr A's death.

Recommendations

We recommended that the practice:

• make the GP who examined Mr A on the day before his death aware of our finding on this matter; and
• issue a written apology to Mr C for the failure to carry out a reasonable and appropriate consultation on that day.

Summary

Miss C complained that GPs failed to carry out appropriate investigations into the symptoms her late mother (Mrs A) was presenting with from November 2010. Mrs A was diagnosed with lung cancer in May 2011 and died in August 2011. Before she was diagnosed, Mrs A had been treated and monitored for breathlessness which was not resolving with the treatment provided. The family told us that they felt that the GPs were treating Mrs A as if her symptoms were psychological and that as a result there was a delay in diagnosing the cancer.

When Mrs A (who was a smoker) first complained of breathlessness, various tests were carried out. Her chest x-ray and blood tests were reported as being normal. Mrs A continued to suffer breathlessness, however, and was reviewed regularly in the practice by the nurse. She was also seen by GPs and the

out-of-hours service. In March 2011 Mrs A was diagnosed with a chest infection and prescribed antibiotics (drugs to treat bacterial infection). When the condition persisted, she was referred for a further chest x-ray. This x-ray was reported as abnormal and Mrs A was referred urgently for a CT scan (a special scan which uses a computer to produce an image of the body), after which she was diagnosed with lung cancer.

Our investigation, which included taking independent advice from a medical adviser, found that the care and treatment provided to Mrs A was reasonable, and in line with the national and local guidance on investigating, managing and treating lung cancer. Although Mrs A had been referred for counselling from the community psychiatric nurse, we found no evidence that the GPs considered Mrs A's symptoms were psychological. The adviser said that the GPs clearly took note of Mrs A's physical symptoms and investigated them in a reasonable and timely manner, and in line with national guidance.

Summary

Mr C complained about a wide range of issues concerning aspects of his mental health care by the board over a number of years. However, on investigation, we considered that the board had done all they could reasonably have been expected to do in respect of his mental health. For example, he had been seen by a number of appropriate clinicians, there had been very thorough assessments, and he had had appropriate treatment. We acknowledged that Mr C wanted more from the board but were satisfied that the board could not reasonably have been expected to have provided more.

Summary

Mrs C had an operation, after which packing material was left in her wound. She told us that when she complained to the board about this, their response was inadequate. The board had apologised to her for the failings and explained the actions they had taken to prevent this happening again.

Our investigation found that the board had taken the complaint seriously and had carried out a thorough investigation, including obtaining statements from the relevant staff so that this was not repeated. They had reminded staff of their responsibilities. The board had also sought information from the packing manufacturers, which led to them use an alternative form of wound packing. We were satisfied that the board's investigation was appropriate, and decided that further consideration of the complaint would be unlikely to achieve any more for Mrs C.

Summary

Mrs C complained that her mother (Mrs A) had mobility problems, which caused her great difficulty in attending the medical practice. Mrs C wanted an assurance that the GPs would make non-emergency home visits to Mrs A if required. The practice explained that there would have to be a clinical need for a GP to make a home visit and that they thought that Mrs A could manage to attend the practice.

Our investigation found that on one occasion when a home visit was requested, a GP did attend. However, the following week a home visit was requested and a GP refused to attend as there was no clinical need and said that Mrs A would have to attend the practice. We did not uphold the complaint but we found that the GP should have involved Mrs A more in the discussions rather than correspond with Mrs C.

Summary

Mr C's wife (Mrs C) became unwell and visited her GP who arranged for tests, which showed she had kidney stones. Mrs A continued to suffer abdominal pain but a CT scan (a special scan using a computer to produce an image of the body) and various other gastrointestinal investigations (investigations of the stomach and intestine) did not show any significant abnormality. Mrs C's GP referred her to a hospital accident and emergency unit (A&E) surgical team for further assessment. An urgent out-patient CT scan was requested and she was discharged the same day.

Nine days later, Mrs C went to A&E again because she continued to suffer severe pain, and was reviewed by the medical and surgical teams. Further tests were carried out and although she could have been admitted at this time, Mrs C preferred to go home and prepare herself for being admitted in two days' time. However, as Mrs C could no longer tolerate the pain, she returned to A&E the next day and was admitted to hospital. A CT scan and biopsies (tissue samples) confirmed that Mrs C had cancer of the pancreas that had spread to her liver, and she died a few weeks later.

Mr C complained that the consultant did not examine his wife and that she was only prescribed painkillers and advised to take laxatives. We took independent advice from one of our medical advisers, who said that Mrs C was appropriately assessed and examined by the junior A&E doctor and that although laxatives had been recommended, there was evidence that the staff were also considering other causes of the pain. We also noted that relevant tests were organised, including x-rays and blood tests and Mrs A was appropriately given morphine for pain relief.

However, we upheld Mr C's complaint, as we identified that it would have been reasonable and appropriate for the consultant, as the senior A&E doctor in attendance, to have examined Mrs C to confirm the junior doctor's assessment and findings. In doing so, we noted our adviser's view that such an examination was unlikely to have resulted in an earlier diagnosis of cancer. We also considered that the consultant should have pro-actively consulted with the surgical team, rather than having done so at Mrs C's request. Finally, we were critical that the consultant did not document his consultation with Mrs C. The General Medical Council provides guidance, which says that it is good medical practice to make such a record.

Recommendations

We recommended that the board:

• inform the consultant of our findings in relation to matters related to Mrs C's examination and the documenting of his consultation.

When it was originally published on 27 March 2013, this case was wrongly categorised as ‘not upheld’. The correct category is ‘upheld’ and it was amended on 8 May 2013.

Summary

Mr C complained about the care and treatment that his late wife (Mrs C) received at the medical practice over a three month period. Mr C was unhappy that the practice did not carry out relevant investigations of Mrs C's persistent and severe abdominal pain. He told us that he felt that doctors at the practice did not listen to their concerns, and that there was a lack of support. After Mrs C was admitted to hospital, further investigations showed that she had pancreatic cancer, and Mrs C died a few weeks later.

We did not, however, uphold Mr C's complaint. Our investigation found clear evidence to show that the practice had carried out appropriate and reasonable investigations to try to diagnose the cause of Mrs C's ongoing pain. They had also referred Mrs C to a specialist for further investigation. We noted that a CT scan (a special scan using a computer to produce an image of the body) had been carried out two months before her diagnosis, but had not shown any abnormalities. Our independent medical adviser also explained that pancreatic cancer tends to present late, often with non-specific symptoms, and has some of the lowest survival rates of all cancers.

Summary

Mr C had a left knee and hip replacement several years ago. He attended the hospital's orthopaedic clinic (clinic for conditions involving the musculoskeletal system) around a year ago because he continued to have pain in his left leg and difficulty walking. He was discharged from the clinic, but was diagnosed around a year later with neuro-sarcoidosis (a chronic disease of unknown origin characterised by the enlargement of lymph nodes in many parts of the body along with nerve tissue dysfunction). Mr C complained that, despite his ongoing pain and difficulty walking, the orthopaedic consultant discharged him from the clinic without referring him to a neurologist (a specialist in the science of the nerves and the nervous system, especially of the diseases affecting them).

After taking independent advice from one of our medical advisers, we found that there was evidence that the consultant carried out appropriate assessments to test Mr C's reflexes and there was no clear indication of a neurological abnormality. Referral to a neurologist would not, therefore, have been necessary at that time. In addition, we considered that it was reasonable for them to have discharged Mr C, as it was not unusual for a man of Mr C's age to experience unsteadiness following knee and hip operations.

Summary

Miss C complained that there was a lack of continuity in the midwifery care she received during her pregnancy, and that she had ongoing symptoms after being incorrectly given a general anaesthetic. Miss C was also unhappy that the board did not acknowledge her concerns about these symptoms, which included headaches, loss of vision, vomiting and dizziness.

Miss C told us that she was concerned that blood samples had been lost, that she had to repeat herself every time she saw a new midwife, and that she did not get advice when she needed it. She said that her phone messages were not returned and there was a lack of information about antenatal classes (classes for new parents before a baby's birth) and induction of labour (treatment given to bring on the onset of birth).

Our investigation found that Miss C saw three different midwives during her pregnancy, because a member of staff was off sick. However, but we did not find evidence that her overall care was inconsistent or unreasonable, and we did not uphold this complaint. The clinical records were of a good standard and there was evidence that that antenatal matters and induction of labour were discussed with Miss C. The board did acknowledge that a blood sample had been lost, but had apologised for this.

Miss C also complained that she continued to experience symptoms after an error with anaesthetic. We found that Miss C was appropriately given a spinal block (an injection of a small volume of anaesthetic into the lower spine) during a caesarean section (a surgical procedure used to deliver a baby). However, the anaesthetist then made a mistake and gave her a general anaesthetic instead of antibiotics. This resulted in Miss C losing consciousness. Although there can be an association between headaches and spinal blocks, our adviser said that Miss C's symptoms did not suggest that they were a result of anaesthetic complications. We accepted this advice and did not uphold Miss C's complaint that the board failed to recognise the long-term effects of the anaesthetic.

However, we found that the board had not provided a response to Miss C's concerns about this. Had they done so, it might have provided Miss C with some reassurance, and we upheld her complaint about the board's complaints handling.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to respond to her concerns about the potential long term effects from the anaesthetic; and
• reflect on this case and consider offering a debrief to patients shortly after significant events.

Summary

Mrs C complained about the care and treatment she received during a three-week hospital admission. Mrs C was admitted for an endoscopic retrograde cholangiopancreatogram (ERCP - a procedure where a flexible tube is passed into the small intestine) and believed that she would be discharged the same day. She said that she had to change for her surgery in a supply room, and that nursing staff were unaware of her whereabouts when the theatre porter came to take her to surgery. She also said that there was no pre-operative discussion or explanation of her impending surgery, no consultation about possible complications and risk factors, no explanation of the forthcoming surgical procedure, and no formal introduction to the surgeon or the surgical team. The procedure was difficult and a significant complication developed which meant that Mrs C remained in hospital for three weeks. The procedure proved difficult because of the narrow opening of her bile duct. She also underwent a sphincterectomy (her sphincter muscles were cut). She developed pancreatitis (inflammation of the pancreas) which caused her severe pain. Mrs C's condition deteriorated and she said that staff failed to recognise this and that her family had to alert them to her deteriorating condition. She was transferred to a high dependency unit seven days after the procedure. She also complained that staff failed to provide appropriate or effective pain control until she was prescribed a morphine pump (a medical device used to deliver pain relief into the spine) nearly two weeks after the procedure, and that the board made inaccurate statements in relation to pain relief and communicating the risks of the procedure.

After taking independent advice from one of our medical advisers, we upheld three of Mrs C's four complaints. Our investigation found that Mrs C was asked to change in a treatment room (not a supply room) and that this should not be normal practice. We noted that the board acknowledged the distress this caused Mrs C and took steps to ensure it did not happen again. We also found no evidence that Mrs C was made aware that pancreatitis is a common complication of ERCP and sphincterectomy, which is unacceptable. We did not uphold the complaint about the standard of post-operative care and treatment Mrs C received, as we found that this was reasonable, including the pain relief regime that was in place. We found that the board had correctly said that while it had been difficult to control the pain in Mrs C's case, appropriate and reasonable pain relief was provided. During our investigation, the board acknowledged that they had misinterpreted the level of discussion between the consultant and Mrs C about the risks of the procedure, and we found that they had inaccurately stated in their response to her complaint that Mrs C was informed about the risks.

Recommendations

We recommended that the board:

• ensure that staff properly inform patients of risks when they are obtaining consent for treatment and that record-keeping reflects this; and
• apologise to Mrs C for the failings identified.