Health

Summary

Mr C complained that he was given conflicting advice about what happened to his wife (Mrs A) after she had undergone a coronary procedure to address the narrowing of her arteries. Mr C was unhappy that the doctor did not reflect the seriousness of Mrs A's condition in his reports despite him being taken aside and being advised that she had a 50 percent chance of survival.

Mr C was also unhappy that the doctor maintained that there were no changes to Mrs A's electrocardiogram (ECG - a test that measures the electrical activity in the heart), despite Mrs A having very low blood pressure and a low heart rate.

In response to the complaint, the hospital said that the doctor performed a technically difficult procedure which unfortunately was associated with a complication, which was treated effectively by placing a second stent (an artificial tube) to open up the artery. The hospital advised Mr C that he was told at the time that his wife's condition was not stable and that the doctor was of the view that his reports were an accurate reflection of the events that had taken place. They also said that one of the ECGs was normal and a further one carried out the following day showed inflammation which was not felt to be serious.

After taking advice from our medical adviser, we considered that the doctor's discharge summaries sufficiently detailed the seriousness of the complication that had resulted. We also agreed with the hospital's interpretation of the ECG readings and that it was not unreasonable of the doctor to conclude that there were no changes to the first ECG. That said, we were of the view that it appeared that Mrs A had sustained a mild heart attack, but there was insufficient evidence overall to support that Mr C was given conflicting information about his wife's condition.

Summary

Mr C complained that a hospital unreasonably cancelled his late partner (Ms A)'s heart bypass surgery scheduled for May 2010. He also complained that the hospital did not take appropriate remedial action following a report commissioned by the Procurator Fiscal's Office.

Our investigation found that Ms A, who had a history of heart and other health issues, had a second heart attack in February 2010. She was assessed and was first admitted for heart bypass surgery in April 2010, in late May 2010. Although the surgery was successful, Ms A developed complications and died five days later.

Our investigation found that the hospital cancelled all elective (non-emergency) surgery in early May 2010 due to the sudden death of a senior colleague of the team who died in the unit on the day Ms A's surgery was scheduled. The hospital decided to cancel elective surgery as members of staff in the unit were affected by their colleague's death.

We took advice from our medical adviser, a cardiothoracic surgeon (a specialist in surgical treatment of organs found inside the chest). Our adviser said that due to the unusual circumstances it was not unreasonable to decide to cancel elective surgery. Our adviser reviewed Ms A's medical notes and was of the opinion that there had been no deterioration in her condition between her discharge and her readmission for surgery. He was of the view, therefore, that the delay had no bearing on the eventual outcome.

Throughout the complaints process the hospital assured Mr C and our office that a 'careful assessment' had been made of the conditions of all the patients who were discharged that day, including Ms A. Our findings did not support those assurances. Our adviser described the discharge entry in Ms A's notes as 'perfunctory and brusque'. We were concerned that the note contained no references to any examination of Ms A, to test results, or to any standard observations such as pulse, temperature, respiration rate etc. Although we did not uphold the complaint about the decision to cancel surgery in early May 2010, we made two recommendations in relation to the failings found in the discharge process and assessment.

On the matter of the report commissioned by the Procurator Fiscal's Office, the adviser said that the hospital's response to Mr C was reasonable. They noted that one issue raised in the report (the level of a blood clotting agent in Ms A's blood three days after surgery) had not been addressed in the response. However, the adviser was satisfied that staff caring for Ms A took appropriate action and that there had been no failure in care and, therefore, no need for any remedial action. The report for the Procurator Fiscal's Office did not find any evidence of service failure and made no recommendations for remedial action. We agreed that no remedial action was required.

Recommendations

We recommended that the hospital:

• review the discharge processes where surgery is cancelled or postponed for non-clinical reasons and ensure that appropriate examinations are made and recorded; and
• reflect on the quality of their responses on the specific issue of the assessment said to have been done before the patient was discharged and issue a written apology for the failings identified.

Summary

Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later.

Her daughter, Miss C, was concerned that while her mother was in hospital one of her medications, which was given by injection, was not always administered. She said that at times the injections were prepared and then left by her mother's bedside if they were not given. Miss C also complained that a pain relieving patch was not administered. The board said that the patch had been administered but was later removed. There was conflicting information from the board and Miss C about when this happened.

We investigated and took independent advice from one of our medical advisers, a senior and experienced nurse. She said that the Nursing and Midwifery Council (NMC) issue guidance on the preparation and administration of drugs and that the practices demonstrated in this case did not comply with that guidance. We upheld both complaints.

Miss C said that there were inaccuracies in the fluid monitoring charts, but we could not establish the accuracy of these, given the time that has passed since. The board did say that Mrs C, who was a retired nurse, liked to maintain her independence where possible and preferred to go to the bathroom when she was able. They said that this may have introduced some inaccuracy to the charts. Our investigation found that it was reasonable to allow Mrs C to maintain her independence where possible. The nursing adviser reviewed the charts and had no concerns, and we did not uphold this complaint.

Finally, we upheld Miss C's complaint about complaints handling. We found that there were unacceptable delays in responding to Miss C's complaints. The final response took four months rather than the 20 working days required by the NHS guidance on complaints handling. In addition, our investigation found that although it largely reflected the NHS guidance, the board's complaints procedure did not fully comply with it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified by our investigation;
• provide an update on the changes to the evening medication round;
• ensure all staff are aware of and comply with the NMC standards and board policy on administration of medication;
• report on the integration of the policy on the administration of medication to the board's staff induction programme;
• provide an update on the progress of changes to the complaints and advice team; and
• ensure that their complaints procedure fully reflects the NHS guidance on complaints handling.

Summary

Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. Mr A had acute appendicitis (sudden inflammation of the appendix). His appendix was removed that afternoon. He was discharged from hospital seven days later. Mrs C complained that the service failed to attend when she called them for Mr A, and did not deal with her complaints appropriately.

We did not uphold Mrs C's complaint that an ambulance was not sent. We took advice from one of our medical advisers, who said that Mr A's condition was not detrimentally affected by not being taken to hospital by ambulance, and that the decision not to send an ambulance was correct in terms of the service's protocol. We listened to the telephone call and reviewed the service's records and procedures together with information provided by Mrs C. We decided that although the emergency medical dispatcher's communication with Mrs C was not as helpful as it could have been, the decision not to send an ambulance was reasonable in the circumstances.

We upheld Mrs C's other complaint. We found that she received a response to her complaint after eight weeks, which was longer than the 20 working days the service aimed to work to, and she was not updated with an explanation of why there was a delay. We found evidence that service staff disagreed on who was responsible for sending the update. Our adviser thought that because the service's review of Mrs C's call focused on technical aspects, rather than taking a holistic view that included Mrs C's experience, it lacked any real empathy with her situation. Their investigation report recommended that Mrs C be given a more detailed explanation of the reasons for not sending an ambulance, but we noted that this was not provided.

Recommendations

We recommended that the service:

• review this call with the emergency medical despatcher involved, and ensure that they receive appropriate support for their customer care skills to achieve the standard aspired to in the service's 999 procedure;
• review how they respond to complaints relating to incidents where callers dispute the outcome, such as this case, to ensure that investigations and responses acknowledge and take into account the service user's experience, rather than being solely driven by compliance with protocol; and
• ensure all staff dealing with complaints know who is responsible for updating complainants at particular stages of the complaints process.

Summary

Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C complained that after his operation, Mr A had been left alone without access to his buzzer, that staff failed to give Mr A prescribed laxatives, and that staff were generally rude and uncaring. However, Mrs C was mainly concerned that a nurse harshly treated Mr A.

We investigated the complaint and took advice from our nursing adviser. Our investigation found that because of Mrs C's allegation, action was taken under the health board's disciplinary policy and procedure. We also found that there was no evidence in the medical notes that Mrs C's family had been asked to contact the hospital. However, on the balance of probability, we upheld that Mr A had not had access to his buzzer and that staff failed to communicate adequately. We also upheld Mrs C's complaint that Mr A had not been given the laxatives as there was evidence of this in his medical records. We did not uphold the complaint alleging harsh treatment as there were conflicting statements about this, and there was no independent evidence to allow us to reach a decision.

Recommendations

We recommended that the board:

• remind staff to regularly ask patients about the accessibility of their buzzer on the ward and give consideration to completing a ward audit to establish that buzzers are accessible;
• make Mrs C and Mr A a formal apology for their failure in this matter; and
• provide evidence that remedial action has been taken to ensure a similar situation does not reoccur.

Summary

Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year in being sent to see the correct consultant. Mrs C also complained that she was not referred to a bone anchored hearing aid (BAHA) clinic when she first attended for investigations, and she questioned whether this clinic existed at all. BAHAs conduct sound to the inner ear directly through the bone, rather than through the air, which is how Mrs C's current in-ear hearing aids operate. In addition, Mrs C complained that the audiology clinic had no appropriate BAHA headband trial equipment available for nearly seven months.

We were critical of the board's lack of clarity in communicating with Mrs C about the availability of BAHA headbands, and we drew this to their attention. However, it is not for us to say how the board should use their resources, and it was clear that the lack of availability of BAHA trial headbands was a resource issue that the board had tried to remedy by ordering additional units. Therefore, we did not uphold this complaint.

When we looked into Mrs C's other complaints, we found that the BAHA clinic did exist. The board accepted there were difficulties and delays in progressing Mrs C's care and they apologised to her. Our adviser noted that a key referral should have been more clearly documented, and that Mrs C should have been considered for other hearing aid technologies more quickly, given that she was unable to use air conduction devices. We concluded that Mrs C did not see appropriate staff in reasonable time and, in particular, that she should have been considered sooner for referral to the BAHA clinic, and we upheld these complaints.

Recommendations

We recommended that the board:

• review pathways from Audiology to ENT (medicine of the ear, nose and throat), so that patients who do not benefit from air conduction hearing aids can be considered for other technologies in reasonable time.

Summary

Mr C suffers from a number of painful conditions. He takes codeine (a pain relief drug) to manage the pain, but it causes severe constipation. He was prescribed Orlistat (a weight-loss drug) by his GP some years ago to help him reduce and maintain a steady weight. Mr C found that the drug also relieved his constipation. When reviewing Mr C's medication, however, his GP felt that it was no longer appropriate to continue to prescribe this. Mr C was referred several months later to a pain clinic for pain management and to explore alternatives to codeine, and to a dietician about his weight problem. However, he continues to suffer from weight gain and constipation and maintains that the benefits of taking Orlistat outweigh the risks of both that medication and the alternatives. He complained to us that the decision to stop prescribing it was unreasonable.

After taking advice from one of our medical advisers, we did not uphold Mr C's complaint. We found that the GP's decision was reasonable as Mr C had not lost weight since early 2009, and the medication is not licensed for use as a laxative. We also found that the decision followed the health board's guidelines on its use.

Summary

Mrs C complained that the health board unreasonably failed to provide a home podiatry visit for her elderly father (Mr A). Podiatry is the branch of medicine related to disorders of the foot, ankle and lower extremity.

Mrs C also complained that there was unreasonable failure to maintain Mr A's feet to an acceptable standard and to make a referral to a specialist team when required. Mrs C had concerns about the method of making home visits, about comments in some of the notes, and said there were unreasonable delays and a failure to answer her questions during the complaints process.

Mr A had a significant history of multiple illnesses, including insulin dependent diabetes and mobility problems. These were made worse in cold weather. As is standard for diabetics within the NHS, Mr A had had a podiatry assessment and was receiving regular podiatry treatment - usually attending his local clinic. However, in early December 2010 there had been heavy snowfalls and he was unable to attend a scheduled appointment. Mrs C telephoned the clinic to ask for a home visit. She said she found the attitude of the staff members she spoke to unacceptable, and that she was told that a visit would not be arranged or at least not for some weeks.

Mrs C was concerned about this arrangement as her father had had previous problems with diabetic ulcers on his feet and was complaining of a sore right foot. She spoke with the service director, and a home visit was arranged for the next day. Mr A received several treatments at home during December 2010. He was referred to the specialist team at the end of December and seen the next day. He was immediately admitted to hospital for treatment of an infected diabetic ulcer on his toe. Mr A was discharged in mid January 2011. He was readmitted five days later and died in hospital in February 2011. The primary cause of death was sepsis (infection).

Our investigation included taking independent advice from a podiatrist and a physician, and we upheld all Mrs C's complaints. The podiatrist said that although in general Mr A's feet had been maintained to a reasonable standard, by early December 2010 it should have been clear to the podiatrists that the ulcer was not healing and Mr A should have been referred to the specialist team at that stage. The podiatry adviser also found fault with the general lack of detail in the notes and said that there were some subjective rather than objective comments.

Having seen Mr A's medical records, the physician adviser said that although sepsis was the primary cause of Mr A's death it was not directly caused by the infected toe. However, Mr A had been treated for some time with antibiotics to try to address the infection in his toe. Although this was appropriate treatment, use of antibiotics in this way can kill off the natural pathogens (bacteria) within the digestive system. This can pre-dispose a patient to contracting Clostridium Difficile infection, which is what happened to Mr A. Such infection can produce a range of symptoms from diarrhoea to severe and overwhelming infection, particularly in a patient such as Mr A, with other significant medical problems. Therefore, although the infected toe did not directly lead to Mr A's death, it was a factor in it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified in our investigation;
• report on their review of the process for home visits;
• review the standard of podiatry notes; and
• provide awareness training on SIGN 116 (guidelines on the management of diabetes).

Summary

Mr C complained that his medical practice failed to provide reasonable treatment and advice to him in relation to peripheral vascular disease (PVD), a condition causing narrowing of the arteries. He attended his practice for a number of years complaining of leg pain, which the GP attributed to back problems. In 2011, after a deterioration in his condition, Mr C was admitted to hospital where he learned that he had been diagnosed with PVD in 2005. He complained that he was not told about this diagnosis and was not treated for PVD. He believed that this led to years of unnecessary pain.

We found that, as well as PVD, Mr C had serious back problems that ultimately needed surgery. Our medical adviser said that both conditions could have caused leg pain. At the time of being diagnosed with PVD, however, Mr C was in his forties. Our adviser said that diagnosis at this age was relatively unusual and, as such, Mr C's case should have been investigated, possibly with immediate referral to a specialist. Mr C's GP had prescribed aspirin and told him to stop smoking. On balance, we considered that this would have been reasonable if Mr C was supported to stop smoking and was monitored via regular blood pressure checks. However, we found no evidence in the clinical records that Mr C's GP made him aware of the diagnosis, nor that there was any support provided to help him stop smoking, nor regular monitoring of his condition. We, therefore, upheld the complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mr C for the issues highlighted in our investigation; and
• review and discuss Mr C's case at a practice meeting to identify where improvements can be made to record-keeping and the treatment of future patients.

Summary

Mrs C was diagnosed with advanced bowel cancer in January 2011. She told us that from March 2010 the practice had failed to properly investigate the symptoms she was presenting with, and that she should have been referred to hospital earlier.

We did not uphold Mrs C's complaints. We found that the practice's care had been good. Our medical adviser said that, although with hindsight it could be suggested that a significant pattern was emerging, this was not evident at the time. From March until September 2010 Mrs C had presented with a variety of non-specific symptoms including exhaustion, abdominal pain, bloating and vomiting. She had been prescribed HRT (hormone replacement therapy) which had helped with some of her symptoms. However, her abdominal pain continued, and Mrs C was referred for an ultrasound scan. She also attended a hospital accident and emergency unit a couple of days before the scan appointment due to a bout of severe pain. The ultrasound scan results did not prompt further investigation, and Mrs C did not return to the practice until November 2010. At this stage she was displaying trigger symptoms for bowel cancer including weight loss and a change in bowel habit, and was urgently referred for a colonoscopy (examination of the bowel with a camera on a flexible tube) following the results of blood tests.

Although the practice could have arranged for Mrs C to undergo blood tests earlier, we did not find that their care of her had been deficient. We noted that they had carried out a significant event analysis of what had happened, and had identified some learning points for the future.

Mrs C also complained she should have been sent for an earlier colonoscopy, rather than the ultrasound scan. We found, however, that sending her for the ultrasound scan was appropriate, given the symptoms Mrs C was displaying at the time. We also found that the practice acted reasonably after receiving the scan results, although we noted that they missed an opportunity to review Mrs C in person at that stage, and drew this to their attention.