Health

Summary

Mrs C said that her husband (Mr C), who had terminal cancer, had fallen from his bed which was in a side room in the hospital, and died later that day. Mrs C felt that staff should have kept a better watch on her husband as he had lain on the floor for some time. She felt that the level of investigation of her complaint was inadequate.

In response to Mrs C's complaint, the board had apologised that the level of observation carried out on Mr C overnight was inadequate, and said that they had reminded staff of their responsibilities. They also explained that Mr C was assessed as at low risk of falling and when he was discovered on the floor he was examined by a doctor and put back to bed. Mr C had been placed in the side room for privacy, and to allow the family flexibility in visiting. Our investigation noted that it was good practice for the board to have placed Mr C in the side room for privacy reasons. We did not uphold the complaint, as we found that the board had properly investigated Mrs C's concerns.

Summary

Ms C complained that a medical practice she was registered with failed to properly assess her or her children with regard to their symptoms. Ms C was unhappy with the practice's assessment of her thyroid (a gland in the front inside area of the neck) and matters related to a parasite (an organism that lives on or in the body (host) from which it feeds) that she believed she and her family were suffering from.

We noted that Ms C was registered with the practice for approximately three months and within that period, tests were carried out on both Ms C and her two children. We considered that the practice had carried out reasonable and appropriate investigations and that there was no evidence of parasites.

Summary

Ms C complained that a medical practice she was registered with failed to carry out adequate assessments or arrange appropriate investigations to diagnose the symptoms she presented with. Ms C was mainly concerned that the practice had not monitored her thyroid (a gland in the inside front area of the neck) or recognised the positive impact of a particular drug on her condition.

We noted that Ms C might have received more consistent care had she not seen so many different doctors there over the course of two years. However, we considered that overall the medical practice carried out reasonable investigations and made appropriate specialist referrals in response to Ms C's ongoing symptoms. The practice have since provided evidence to show that their use of locum (temporary) doctors has reduced.

Summary

Mr C complained that it took too long to deal with a treatment plan proposed by his dentist. Mr C thought that the treatment time guarantee applied and had been exceeded. However, we found that at the time of Mr C's complaint the treatment time guarantee was not in force and did not apply. We also found that his treatment plan was progressed within a reasonable timescale.

Mr C also complained that a phone call was poorly handled. We upheld this complaint because the board had acknowledged and apologised for providing incorrect information during the phone call.

Summary

Miss C had been attending her GP for a number of months with a suspected prolapsed disc (ruptured disc in the spine). Before her scheduled orthopaedic (medicine of the orthoskeletal system including the spine) appointment, her condition deteriorated suddenly. She experienced severe pain and numbness in her legs.

Due to a lack of response from her medical practice, Miss C contacted NHS 24 for advice. NHS 24 contacted the medical practice and arranged a home visit. Miss C was then advised to attend her hospital appointment, but she continued to be in severe pain. She called NHS 24 again and arrangements were made for an out-of-hours GP to contact her. The GP contacted Miss C and discussed her symptoms, which had worsened and included numbness, pain when urinating and burning sensations in her legs. The GP did not visit her or suggest a hospital attendance. Miss C was advised to self-assess her condition overnight.

The following afternoon, Miss C was admitted to hospital where she was diagnosed with cauda equina (a disorder that affects the nerves). Miss C complained that NHS 24 did not provide full details of her symptoms to the out-of-hours GP, resulting in a delay to diagnosis which has left her with nerve damage that may be permanent.

Upon reflection, after submitting her complaint to us, Miss C decided that she was satisfied that NHS 24 had in fact provided full information to the GP. She accepted NHS 24 's apology for other incorrect information provided by their staff, as well as their reassurance that steps would be taken to prevent similar issues in the future. She withdrew her complaint, and so we did not reach a finding on it.

Summary

Mr and Mrs C's son is a young adult with severe learning difficulties and various complex medical issues. Mr and Mrs C complained to the board, through an advocacy worker, about the staff member responsible for the co-ordination of nursing care at home for their son. The board responded saying that many of the issues raised had happened outwith the time limit specified in the NHS complaints procedure, and so could not be investigated. Mr and Mrs C said that they were aware of the time limit, but explained that they thought there were exceptional circumstances in their case. They asked the board to give consideration to these, and to disregard the time limit.

Our investigation found that although the board was entitled to decide not to consider complaints outwith the time limit, there was no evidence that they had in fact considered the specific grounds raised by Mr and Mrs C, or explained why they did not consider the grounds to be relevant. Mr and Mrs C also said that they were misinformed about a communications book that was removed from their home, and that their complaint had been investigated by inappropriate staff members. However, we found the staff who had investigated were suitably impartial. We also found that the board made reasonable efforts to contact Mr and Mrs C's advocacy worker to discuss and clarify the outstanding issues. On balance, we did not uphold Mr and Mrs C's complaint, as we found that the board's complaints handling was generally reasonable overall, and that they proportionately responded to a number of complex and sensitive matters. However, as we did identify aspects that were not satisfactory, we made recommendations in relation to these.

Recommendations

We recommended that the board:

• provide Mr and Mrs C with confirmation that the grounds they had put forward as exceptional circumstances were considered by the board, and provide an explanation for the decision reached;
• apologise to Mr and Mrs C for the initial statement that a communications book belonged to the board, and for not informing them of or involving them in the investigation regarding the book, nor the subsequent outcome; and
• consider alternative options for Mr and Mrs C's family's contact with the Complex Care Service.

Summary

Mr C has complex needs and requires long-term care and specialist input. He has severe dementia, with limited capacity to judge distance or to understand and participate in therapies, and his wife (Mrs C) has welfare power of attorney for him. Mr C can move about, but is at particular risk of falling. In November 2007 Mr C was admitted to a continuing care ward, where he remains a patient. Mrs C made a number of complaints about aspects of the care and treatment that her husband has received. These included the actions the board took to address Mr C's condition in February 2011, medication, observation and monitoring, staffing levels, carer communication, charting and record-keeping, the standard of bathroom facilities and complaints handling.

Our investigation included taking independent advice from two of our medical advisers - one in mental health and one a GP. We took account of this advice as well as evidence from Mrs C and the board. Mrs C said that in February 2011 her husband became very unwell and staff failed to take reasonable measures to bring his temperature down and call a doctor within a reasonable time. Our investigation found that staff took appropriate action when Mr C became unwell and that their interventions overall were reasonable. In relation to the drug regime and administration, however, although we found that the principal contributing factor to Mr C's falls was most likely to have been involuntary muscle twitching, we also found that there were significant failings. These included the discontinuation of an antidepressant for three weeks; the timing of medication; and failure to ensure Mr C received prescribed medication when off the ward. We also found that the board failed to administer flu vaccinations to Mr C, either within a reasonable time or at all, placing his physical health at risk.

Mrs C also said that the board failed to ensure that Mr C was sufficiently hydrated (had enough fluids). We found that throughout the period Mr C was well hydrated and had effective liver and kidney function, but that there were inconsistencies in recording and monitoring his fluid balances. We also found that the board failed to properly assess Mr C's falls risk or properly record or implement a fall prevention care plan.

Mr C was sedated because he wandered at night due to agitation, and Mrs C felt that this could have been managed without resorting to sedation if there were more staff. We did not uphold this complaint as we found that, while it was difficult to reach a definitive conclusion on whether staffing levels were reasonable, staff used sedating medication as a last resort and then only rarely. In relation to Mrs C's complaint about bathroom facilities, the evidence available suggested that the ward is cleaned to an acceptable standard and that any problems are addressed within a reasonable time.

Mrs C said that staff communication about assessment of her husband's capacity and administration of sedative drugs was inadequate and she was also concerned that a 'do not attempt to resuscitate' certificate (DNAR - showing that a doctor is not required to resuscitate the patient if their heart stops) was signed by medical staff without her input. We upheld this complaint as we found that communication with Mrs C was not of a reasonable standard and did not comply with the Adults with Incapacity legislation. The board's record-keeping was also of concern and we found that at times it fell below a reasonable standard and did not, amongst other things, record a reasonable standard of communication with Mrs C. We also found instances of statements in the board's complaints responses that were either inaccurate or misleading, indicating that Mrs C's complaint was not investigated as thoroughly as it should have been.

Recommendations

We recommended that the board:

• implement measures to avoid patients being given medication at the end of one medication round and the beginning of the next, thereby ensuring an appropriate period of time has elapsed between doses;
• implement checking mechanisms to ensure the prescription sheets are transcribed accurately;
• ensure patients authorised to be off-the-ward receive medication consistently as prescribed by medical staff;
• review the processes for managing, prescribing, administering and recording in relation to the flu vaccination;
• ensure that falls prevention procedures, including developing and evaluating falls prevention plans, are consistent with the board's policy;
• ensure effective systems are in place to keep staffing levels under review;
• take measures to ensure appropriate compliance with the Adults with Incapacity Act, with particular regard to DNAR decision making and communication with relative or carers;
• ensure that relatives' communication documentation is used consistently to record the nature and content of discussion with relatives or carers;
• build flexibility into the charge nurse's appointment system so that there are opportunities for communication outwith scheduled times to deal with issues as they arise;
• ensure that record-keeping reflects the care and medication given and a reasonable standard of communication;
• consider implementing unplanned visits to ensure a reasonable standard of hygiene;
• ensure complaints are investigated thoroughly and that responses are accurate; and
• apologise to Mrs C for all the failings identified in our investigation.

Summary

Mrs C's daughter (Ms A) has a history of anorexia nervosa and depression. Ms A was assessed by an on-call psychiatrist after her mother expressed a concern about a deterioration in her mental health. Ms A was allowed to go home and was to be followed up by the crisis care team. The next day, following an incident that concerned Mrs C, police brought Ms A to hospital for assessment. Mrs C attended with her. Ms A was seen by a mental health assessment nurse and a doctor in the early hours of the morning. They offered to admit her to hospital, but she refused and she and her mother returned home. However, later that day, after what Mrs C described as a violent outburst in the presence of the family doctor, police officers brought Ms A back to hospital for a further assessment. The assessing nurse decided not to detain Ms A or to offer to admit her to hospital. The next day, Ms A was detained under a short-term certificate. She was admitted to another hospital and remained there for six weeks. Mrs C was unhappy about the standard of psychiatric assessments Ms A received at the first hospital, particularly the second assessment.

Our investigation found that the first assessment was reasonable and that it was unlikely that Ms A met short-term detention criteria under the relevant legislation. We also found that the follow-up arrangements after her discharge were reasonable. However, in relation to the second assessment, we found that while the critical factors relating to her risk of suicide were assessed and the diagnosis reached was reasonable, there were instances of poor practice. In reaching their decision, the assessing nurse did not make use of all the available information which would have significantly strengthened the assessment and decision making.

Recommendations

We recommended that the board:

• put quality assurance measures in place to ensure that evidence based assessment templates are completed by relevant staff in full and as intended;
• ensure that staff involved in conducting out-of-hours and urgent assessments have (and utilise) access to previous clinical records whenever practicable, especially when considerations of risk are involved; and
• apologise to Mrs C for the failings identified in relation to the second assessment.

Summary

Mrs C, who is an advocacy worker, complained to the board on behalf of her client (Mr A), that he had been abused by a member of staff. The police had been contacted but no charges were made due to a lack of witnesses. The member of staff had also contacted the police about being assaulted by Mr A. Mr A was dissatisfied with the board's investigation into his complaint.

Our investigation found that the board had taken Mr A's allegations seriously. They had conducted a thorough investigation and interviewed appropriate staff in order to reach conclusions. We, therefore, did not uphold the complaint that the board failed to adequately investigate Mr A's complaint about being abused by a member of staff.

Summary

Mr C complained that he was unreasonably charged for a temporary lower denture that he was unable to wear because it did not fit. He was unhappy about the appearance of his new upper denture and that his dentist refused to make a new denture without charge. Mr C said that he had told his dentist that he liked the appearance of his old denture, and wanted his new upper denture to look the same.

The dental clinic told us that Mr C needed to have five teeth extracted, and they had advised him that his best clinical option was to have new temporary dentures made. Mr C instead opted to have his existing dentures adapted. We found that, as the dentist had warned that this could result in the denture being a poor fit, Mr C had not been charged unreasonably.

In relation to the appearance of Mr C's new denture we found that dentures are provided by the NHS on the basis of clinical rather than cosmetic need. Mr C told us that he had not taken his glasses to these appointments and had simply assumed that the denture would be similar in appearance to his old one. There was no evidence that Mr C had told his dentist clearly at the relevant appointments that he was totally dissatisfied with the appearance or shape of the upper denture. As there was also no evidence that he had clearly told his dentist that he wanted his new denture to look the same as the old one, we did not uphold this complaint. Nor did we find it unreasonable that Mr C's dentist refused to make a new upper denture without charge. We noted that Mr C has the option of seeing a new dentist for a second opinion.