Health

Summary

Mrs C was assaulted, and was taken by ambulance to a hospital accident and emergency department (A&E) with two police officers in attendance. She complained that she was not fully examined and that no tests were done to assess whether or not she had a head injury, which meant that her concussion was undiagnosed. She said that this has caused her ongoing health problems.

Mrs C was discharged into the care of the police officers who took her to the police station to make her statement and then took her home. When she later applied for copies of her notes from the incident she took issue with the lack of detail in them. Mrs C complained to the board but was not satisfied with the response she received. She was unhappy that later statements made by the nurse and doctor who saw her on the night indicated that she had been uncooperative and possibly under the influence of alcohol.

Our investigation included taking independent advice from one of our medical advisers. We found that there was a disparity between the notes made at the time of the events and the later statements made by the staff who attended Mrs C. The A&E unit is a GP-led unit and on the night in question was staffed by a nurse practitioner (a specially qualified senior nurse) and an on-call GP. We found that the notes made at the time by the nurse and the GP did not record all the injuries Mrs C had suffered, as recorded by the Scottish Ambulance Service staff who took her to hospital. Nor did any of the notes taken at the time refer to Mrs C as being uncooperative or under the influence of alcohol. However, after Mrs C complained to the board, the nurse and GP were asked for statements and both then referred to her as being uncooperative, possibly due to alcohol intake. The GP said that it was because Mrs C was not cooperating that he was unable to conduct a full examination and assessment of her condition.

Our adviser found that the lack of information in the notes taken at the time did not give a full picture of Mrs C's condition on the night in question. However, he was of the view that with the information now known - that Mrs C had concussion - the management of her condition would have been the same even had the concussion been diagnosed at the time. Mrs C was discharged with a small amount of medication and with advice to return to A&E if her condition worsened. The adviser said that this would have been appropriate. He was also of the view that Mrs C's ongoing problems would probably have occurred even had the concussion been diagnosed at the time. We did, however, uphold Mrs C's complaint because no valid reason was recorded in the notes for the GP not having conducted a full assessment and examination at the time.

Recommendations

We recommended that the board:

• apologise for the failings identified during our investigation; and
• review a sample of notes to establish the quality of record-keeping of the staff involved.

Summary

Ms C complained that when she attended a physiotherapy appointment, the physiotherapist wrenched her shoulder and caused her great pain. She also complained that the home exercises that were suggested caused her more pain, and that she had not received proper instruction on how to use a pulley.

In investigating the complaint, we could not establish whether the physiotherapist actually wrenched Ms C's shoulder, but we found that it was appropriate for them to move it to assess the level of mobility. After taking independent advice from our medical adviser, we were satisfied that the physiotherapist provided appropriate treatment.

In this case, the board had also accepted that there were difficulties in communication about what a patient should report if home exercises led to an increase in pain, and they had reminded staff of their responsibilities in that regard.

Summary

Mr C's late wife (Mrs C) was diagnosed with cancer in June 2011. He complained that staff at the practice failed to take account of the seriousness of her condition and to take follow-up action. Mr C raised concerns about the way in which his wife's medication was given; a failure to document phone conversations; a failure to admit Mrs C to hospital when a provisional diagnosis of gastroenteritis (inflammation of the stomach and intestines) was made; and a failure to monitor her calcium levels. Mr C complained that, by the time Mrs C was admitted to hospital in October 2011, she was hallucinating. He believed that his wife had suffered more than she needed to as a consequence of the practice's failures or inaction.

In considering Mr C's complaint, we obtained independent advice from one of our medical advisers. Our investigation found that once Mrs C was diagnosed with cancer, her care was primarily the responsibility of the hospital and hospital staff. It was clear from hospital records that the practice was kept up to date with Mrs C's condition, and it was also clear that when requested, the practice took appropriate action. Our adviser confirmed that, in his experience, not all patients wanted to hear further from their GP, or to discuss matters with them, at what can be a busy and difficult time.

On the matter of administration of medication, we found that although Mr C was unhappy that his wife was given her medication in tablet rather than liquid form, the adviser said that there was no record on file confirming that this was required.

On the issue of Mrs C's non-admission to hospital when gastroenteritis was suspected, the adviser said that the records confirmed that this was discussed with Mr and Mrs C and it was noted that she was 'OK' to stay at home. Mr and Mrs C were given advice that if her condition worsened, they should phone NHS 24.

We found that Mrs C's calcium levels were not taken, and as she was vomiting, the adviser was of the view that when completing blood tests, this test should also have been carried out. He said that if her calcium levels were high, it might then have been possible to reduce them, and in turn this might have led to a reduction in Mrs C's sickness.

Recommendations

We recommended that the practice:

• apologise to Mr C for the failure to monitor Mrs C's calcium levels.

Summary

Mr C complained about the board on behalf of his daughter (Miss A) who had been referred to the board's Child and Adolescent Mental Health Service (CAMHS) when she was 15. Mr C and his wife attended some of the consultations with her. Miss A was prescribed with fluoxetine (a medicine used to treat a variety of mental health problems) and subsequently discharged from the service.

Four years later, Miss A was diagnosed with bipolar disorder (a condition affecting a person's moods). Mr C considered that CAMHS should have diagnosed this when Miss A saw them four years earlier. He complained to us that that the assessment and treatment package provided by CAMHS did not meet his daughter's needs and that that they did not listen to him and his wife.

Our investigation included taking independent advice from one of our medical advisers. We upheld part of Mr C's complaint, as we found that the treatment provided to Miss A by CAMHS was reasonable, but that there were a number of deficiencies in the records. In particular, there was no record of the action taken by the psychiatrist who briefly saw Miss A and no record of any formal mental state examination. Staff also failed to explicitly state the diagnosis, treatment plan and prognosis. However, the records made at the time indicated that the clinicians had listened to and reported the concerns of Miss A's parents while she was being seen by CAMHS. There was no indication that Miss A showed any symptoms or signs that were specific to the diagnosis of bipolar mood disorder at that time and there was no reason to diagnose this. The only diagnosis that appeared to be applicable during that period of assessment was of a depressive disorder. Given this, bipolar mood disorder would have been a risk for the future, but one amongst a number.

Recommendations

We recommended that the board:

• issue a written apology for the deficiencies in Miss C's records; and
• review the record-keeping in CAMHS to try to ensure that such failures are no longer occurring.

Summary

Miss C attended the dental practice complaining of pain in her lower left five tooth. She said that she specifically pointed this out to her dentist. The dentist recorded in the notes that the lower left seven tooth was mobile with a discharge of pus coming from the buccal aspect (cheek side of the tooth). The dentist then extracted the lower left seven tooth.

After around 20 minutes, Miss C returned to the practice and complained that the wrong tooth had been extracted. The dentist recorded that the lower left five tooth was mobile and then removed it. The dentist also recorded that she had apologised to Miss C and explained that the lower left seven tooth was not treatable by any means other than extraction.

In her complaint to us, Miss C understood that the dentist said she would not charge her for this extraction. Our investigation found that the notes completed at the time said that the lower left seven tooth was to be extracted, so we could not say for sure whether the wrong tooth was extracted. However, Miss C clearly thought that it was the lower left five tooth that was to be extracted. We found that the dentist did not obtain consent appropriately and did not communicate with Miss C effectively.

In responding to Miss C's complaint, the dental practice said that the dentist was aware of the crucial importance of securing valid consent prior to any treatment and would not have proceeded with the removal of the lower left seven tooth unless she believed that Miss C understood and agreed to this treatment. We concluded, however, that this was not the case and upheld Miss C's complaint that the practice had provided incorrect explanations as to why the tooth had been removed.

Recommendations

We recommended that the practice:

• issue a written apology for the failure to obtain consent appropriately for the extraction of the tooth and for failing to communicate effectively with Miss C; and
• make the dentist aware of our finding on this matter.

Summary

Mr C made a number of complaints about the care and treatment his son had received from the board. We were unable to reach agreement with Mr C on the issues to be investigated. Consequently, we were unable to take the case forward and it was closed.

Summary

Mr C complained that the board's community health partnership (CHP) did not follow consultation guidelines for the closure of his local GP practice. Mr C also complained about the standard of numerical data that the CHP used to support the closure, and that the CHP did not provide clinical or financial reasons for the closure. We did not uphold Mr C's complaints. Our investigation found that the guidelines did not go into detail about the aspects of the consultation Mr C was unhappy with, and although Mr C disagreed with the way the consultation was carried out, we found that the CHP had followed available guidelines. These did not require the CHP to provide clinical or financial reasons to patients, and we found that the reasons for the closure had been explained to patients and local consultees. The CHP did not, however, give the proper context for figures quoted in their letters, and we drew their attention to this as communication of data must be clear, given the potentially emotive nature of proposals to close surgeries. However, the data gathered by the CHP was recorded correctly in a summary of patient consultation responses, which was provided to the CHP's management when making their decision on the closure.

Summary

Ms C was in the later stages of her first pregnancy, and was expecting twins. She went to hospital because she had vaginal bleeding. She was admitted for a consultant review and discharged home the following morning. Six days later she went into advanced labour and delivered both babies, but one of her twins died shortly after birth. Ms C complained to us about her care both before and after the birth.

Ms C's complaint had several elements, including inadequate care of a pre-eclampsia risk (a condition involving a combination of raised blood pressure and protein in the urine); inadequate care during two admissions which she said resulted in the premature birth of her twins and the death of her son; inadequate care and treatment for a post-natal haemorrhage (bleeding) and subsequent removal of products; poor record-keeping and delays in holding a clinical risk review (CRR).

Our investigation included taking independent advice from one of our medical advisers. We took account of this advice along with all the evidence provided by Ms C and the board, which included an internal report and two externally commissioned consultant reviews. Our investigation found no evidence of any failure that resulted in Ms C giving birth prematurely or any failure in care that resulted in the death of one of Ms C's twins. We also did not find any evidence of clinical failure with Ms C's post-natal care, but we did acknowledge that there were documentation failures and delays in holding the CRR.

Recommendations

We recommended that the board:

• ensure that the details of a speculum examination are fully documented to include the reasons if a cervix cannot be visualised and the rationale with regard to antenatal corticosteroids; and
• ensure the full documentation of all treatments delivered to patients is appropriately and timely recorded by those in attendance as soon as is feasibly possible, with specific reference to emergency situations.

Summary

Mrs C complained about the information and care she received from a hospital after being diagnosed with proctitis (inflammation of the lower part of the bowel). Mrs C was unhappy that she was not told about the risks of developing a more severe form of the disease, and said that the hospital had not monitored her in line with the quality care standards for the healthcare of people with inflammatory bowel disease. The board told Mrs C that they considered her care to have been appropriate and said that she had been given appropriate advice when she was referred to hospital by her GP in 2006 and 2008.

During our investigation we took independent advice from one of our medical advisers, and established that the quality care standards Mrs C referred to were not in fact put in place until 2009. We considered, however, that the results of her investigations and symptoms suggested that she was provided with appropriate care and treatment. The adviser pointed out that progression of inflammatory bowel disease cannot be predicted or, indeed, prevented and that different interventions would not have prevented Mrs C's condition from worsening. We found evidence to support that Mrs C was given advice about her condition and that an information leaflet explaining the risks had been sent to her.

Summary

Mr A had a history of contact with psychiatric services since he was a teenager and had received a range of diagnoses. Mr A's mother (Mrs C) complained that a staff member in the hospital's rehabilitation unit verbally abused him and restrained him inappropriately and, when Mrs C reported this to a senior person, it was ignored.

We did not uphold Mrs C's complaint. We looked at her account of what happened and compared it with the hospital's records, and found that there was a discrepancy in the dates of when the alleged verbal abuse and restraint took place. Because of this, it was not clear whether the board investigated the incident Mrs C referred to in her complaint. We asked our mental health adviser to review all the recorded incidents throughout Mr A's admission. We were satisfied there was only one recorded episode of physical restraint being used, which took place on a different date from the alleged incident Mrs C referred to.

We found nothing in the clinical records to suggest that the amount of force used in the recorded incident was excessive. However, we accepted what our adviser said about a lack of documented detail of the restraining techniques used. We were, however, generally satisfied that Mrs C's concerns were taken seriously and investigated promptly. The investigation which was carried out appears to have been as thorough as it could have been with the evidence available. The lack of detail in the records reflects the guidance available to staff about restraint techniques and the recording of incidents of aggression from patients. We noted that, had the incident been recorded in further detail, it might have been possible for us to comment more constructively on the appropriateness of the restraint techniques used.

Recommendations

We recommended that the board:

• considers creating a specific restraint policy, detailing the techniques that can be used and the information that should be recorded in the clinical records.