Health

Summary

Mr C complained that an optometrist used incorrect optical notes when undertaking his consultation and did not realise his mistake until Mr C pointed it out to him. The optometrist explained that he picks up the optical records for the next patient in the queue before entering the waiting room and calling their name. He said he followed the standard process on this occasion. He explained that it became clear during the consultation that Mr C's optical history and examination results did not correspond with the optical records he held. He then checked the name and established from Mr C that he was not the patient called. He explained that he called for a different patient in the waiting room but Mr C came forward.

Our investigation found that Mr C suffered no ill effects from this consultation. In addition, there were no witnesses to the consultation itself and we did not consider it proportionate to try and trace other patients who were in the waiting room and who may have witnessed the optometrist calling for the appointment. As we could not reasonably obtain sufficient evidence to allow us to reach a clear conclusion on what happened that day, we did not uphold Mr C's complaint.

Summary

A nurse working for the board's child and adolescent mental health services wrote to the local social work department about Ms C's teenage son, who lived in a children's home. Ms C considered the letter to be one-sided and unfair, and said that the nurse should not have written an assessment of her son without having met him.

Our investigation found that the nurse had been asked to assess Ms C's son. She had written the letter at the request of the social work department, and it was intended solely to represent the views that the nurse had obtained in discussion with the manager of the children's home. The discussion with the manager had been the starting point of the assessment that the nurse was asked to make, and he had also arranged to have two meetings with Ms C's son as part of his detailed assessment. We were satisfied that the letter was accurately based on the nurse's clinical record of his discussion with the manager, that it accurately explained the purpose of the letter and the context of the information in it and that it was appropriate for such a letter to be written.

Summary

Mr C’s wife (Mrs C) was diagnosed with breast cancer in June 2009. In early 2010, she developed problems going to the toilet. Mr C said this became an ongoing problem that caused his wife extreme pain and discomfort. Mrs C’s GP referred her to hospital for x-rays of her spine and pelvis which were carried out in July 2010 and showed no significant abnormality. In view of Mrs C’s history of breast cancer, the radiologist recommended a bone scan which was performed in August 2010. Although the bone scan findings noted ‘increased uptake’ (an abnormality) in both sacro-iliac joints (joints in the lower back next to the pelvic region), the opinion was that this could be due to mechanical reasons in the joints, as Mrs C had undergone hip operations 15 years previously.

Mrs C's GP then referred her to a different hospital for further investigation as she was having difficulty walking. An MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) was carried out in September 2010 which identified extensive cancer and Mrs C passed away in April 2011. Mr C complained to the board that he felt that something might have been missed on his wife’s x-ray and that she should have been diagnosed earlier, sparing her a lot of pain, and possibly prolonging her life.

After taking advice from two of our medical advisers, including a cancer specialist, we found that reasonable investigations were carried out after Mrs C's GP referred her for further investigation. There was no clear evidence of cancer from the earlier blood tests, x-rays and bone scans. We also found that the description given and findings reached on the x-rays and bone scan were accurate and that only two weeks had passed between the bone scan and the MRI scan being undertaken. We could not, therefore, conclude that there had been a delay in Mrs C being diagnosed.

Summary

Ms C complained that the treatment provided by an orthopaedic (dealing with conditions of the musculoskeletal system) department was not of an acceptable standard. Ms C was unhappy with the treatment she received in relation to her deformities in her feet as a result of bunions and thought that mistakes had been made.

After taking independent advice from one of our medical advisers, a consultant orthopaedic surgeon, we did not uphold her complaint. We recognised that this had been and continued to be, a difficult time for Ms C and that she had undergone three operations. However, we found no evidence that the treatment provided was not of a reasonable standard. The surgery initially carried out did have complications, and as a result of those complications there was a need for two more operations, however, this was not due to any fault in the treatment provided.

Summary

Mr C complained to us about the eye treatment that he received in hospital. Mr C is registered partially sighted and felt that his glaucoma (abnormally high fluid pressure in the eye) became considerably worse while under the care of the hospital. He was concerned that they treated him without obtaining a copy of his previous medical records from a hospital in England. As he remained unhappy with the treatment, his GP referred him to another hospital. Mr C also complained that information in his medical records had been crossed out and that the board’s response to his complaint contained errors and omissions.

After taking independent advice from one of our medical advisers, we considered that Mr C had been reviewed at reasonable intervals and noted that his eyesight had not deteriorated during the time he was seen at the hospital. However, we upheld his complaint about treatment as we found that the hospital did not act quickly enough in obtaining a copy of his medical records from the hospital in England. Had this information been sought at his first clinic appointment, the clinicians would have known a reasonable target pressure for which to aim in Mr C's case. In addition, the hospital did not take an image of his optic nerves or measure the central corneal (transparent part of the external coat of the eye covering the iris and the pupil) thickness in order to ensure his eye pressure levels were accurate as possible in line with National Institute of Clinical Excellence (NICE) guidelines. We also considered that it would have been reasonable for Mr C to have been offered treatment at his third appointment. We did not identify any concerns with the information that had been crossed out in Mr C's medical records but upheld the complaint about complaints handling as we noted that the board had apologised for providing incorrect information about an appointment in their complaint response.

Recommendations

We recommended that the board:

• remind relevant staff involved in Mr C's care that a summary of a patient’s previous eye treatment for glaucoma should be requested from the previous healthcare providers at the time of their initial clinic appointment; and
• ensure that as part of the initial assessment, optic nerve head imaging and central corneal thickness measurements are carried out in line with NICE guidelines.

Summary

Mr C complained that the board did not reasonably investigate his complaint in which he raised concerns about the quality of service his mother received during a visit to an eye clinic. As after six months the board had not sent a final response to Mr C about his complaint, he contacted us.

Our investigation established that the response was delayed because of a combination of human error and failures in the complaints handling process. The board have now updated their process in an effort to prevent a repeat occurrence, along with taking steps to increase staff awareness.

Recommendations

We recommended that the board:

• provide Mr C and his mother with an apology for the failings which have been identified in dealing with his complaint;
• apologise to Mr C for providing him with incorrect information as to the reasons why his mother was not seen on a certain date in March; and
• remind their service providers to provide timely responses to the feedback service in order that timescales can be met.

Summary

Mrs C complained that the medical practice had unreasonably removed her name from the list of patients who were entitled to receive the flu vaccination. She said she had been told to wait in the chance there was a surplus of flu vaccinations. Mrs C, who has a medical history of non-hodgkin’s lymphoma (a cancer which affects certain cells in the lymphatic system) was in remission but had received the flu vaccination for many years previously. Mrs C then purchased the vaccination privately. She also contacted her haematologist (a specialist concerned with the study of blood and blood-related disorders) who wrote to the practice. As a result, Mrs C was reinstated to the list of patients entitled to receive the vaccination.

The practice explained that Mrs C's condition was stable in 2011. She was not receiving immunosuppressant therapy (treatment to suppress immune response) and did not satisfy the criteria for groups who require the vaccination. Mrs C's records did not contain a marker that would have highlighted her eligibility for the vaccination and the GP who was reviewing patients on the list had used her clinical judgement and decided not to allow Mrs C the vaccination.

We upheld Mrs C's complaint. Our investigation found that the GP was entitled to decide whether individual patients satisfied the criteria for the vaccination and had used her clinical judgement. Our medical adviser explained, however, that although Mrs C was not on immunosuppressant therapy at the time, her past history of lymphoma made it likely that she would be prone to infections. The adviser felt that most GPs would cover such patients using immunisations such as the flu vaccination. We found that the practice could have taken a more proactive role when they told Mrs C that she was not going to have the vaccine. They could also have made contact with the haematologist themselves when Mrs C reported her concerns or have offered her a face-to-face meeting to discuss the matter in more detail.

Recommendations

We recommended that the practice:

• apologise to Mrs C for the failure to take her circumstances fully into account; and
• consider holding a significant event analysis in order to establish if there were any missed learning opportunities.

Summary

Mrs C complained that delays in the investigation and treatment of her late husband's cancer hastened his death. She also complained about a lack of nursing and personal care provided to him, including pain relief; inappropriate discussions about resuscitation; a shortage of beds in the specialist respiratory ward and the hospice; delays in giving her access to her late husband's medical records; and that the board delayed in dealing with her complaints.

Our investigation found that Mr C had been investigated for pain, stiffness and swelling in his legs and ankles, which was attributed to a rheumatic condition. However, as this condition can also affect the lungs, a chest x-ray was taken in January 2011. The x-ray was reported to be normal and Mr C's treatment and monitoring of the rheumatic condition continued. In February 2011 Mr C's condition had deteriorated, and he had lost weight. He returned to the rheumatology clinic for further investigations. Various investigations including computer tomography (CT – a special investigative scan) and positron emission tomography (PET – a special investigative scan) were undertaken and Mr C was diagnosed with lung cancer in March 2011. The cancer was an aggressive one and by the time of diagnosis it had already spread and was considered to be inoperable. Despite treatment, including chemotherapy, Mr C died in June 2011.

We took independent advice from three of our medical advisers - a respiratory physician (lung specialist), an oncologist (cancer specialist) and a senior nurse. The respiratory physician was critical that the January x-ray was reported as normal as there was what he felt to be 'unequivocal', if fairly subtle, indications of abnormality on the x-ray. However, he and the oncologist agreed that even had this x-ray been correctly reported and a referral to the chest clinic made in January 2011 the outcome and duration of Mr C's life would have been the same. They also agreed that Mr C’s management was otherwise appropriate and timely. The nursing adviser was, however, critical of the lack of assessment, monitoring and review of Mr C’s pain; the standard of the notes; and the lack of personal care, including washing, provided to him.

Our investigation identified several areas of concern and we upheld five of the six complaints. The only complaint we did not uphold was that about the lack of beds in the respiratory ward and hospice. We found that the only reason Mr C was not transferred was because there was a particularly high demand for beds at that time. Mr C was transferred to the respiratory ward as soon as a bed was available, but died before a bed was available in the hospice.

Recommendations

We recommended that the board:

• issue a written apology;
• review a sample of x-ray reports to ensure that no others have been mis-reported;
• review the process of reporting on x-rays to ensure timely reporting;
• ensures that all relevant information is recorded on the multi-disciplinary team meeting forms;
• reviews the policy on ordering PET scans in line with SIGN (Scottish Intercollegiate Guidelines Network);
• review training on the discussion, decision making, review and recording of 'do not resuscitate' decisions;
• ensure that all nursing staff are aware of and implement national and local guidance on assessment, management and review of patients' pain;
• ensure that all nurses are aware of the need to provide regular and appropriate personal care where patients require assistance;
• ensure that all nurses are aware of and implement national guidance on record-keeping issued by the Royal College of Nursing; and
• report on the remedial action taken to prevent a recurrence of delays on access to copy medical notes.

Summary

Mrs C complained that the medical practice did not provide reasonable care and treatment to her husband (Mr C). Mr C had gone to the practice complaining of back and neck pains; pins and needles in his fingers, and difficulty walking and working. After several appointments, he saw Doctor 1, who recorded that he told Mr C that the problem was probably related to his spine and nerve entrapment. Doctor 1 also recorded that he had referred Mr C to physiotherapy and neurology (which deals with problems of the nervous system). He later completed a referral to physiotherapy, but there is no evidence that he completed a referral to neurology at that time.

Mr C saw another GP, Doctor 2, several days later. Doctor 2 recorded that Mr C had worsening pain in his arms, spine and back and some muscle spasms in the lumbar region. He also recorded that Mr C had weakness and numbness in his hands and was awaiting a neurology appointment. Mr C then saw Doctor 1 again. This was nearly three weeks after Doctor 1 had agreed to refer him to physiotherapy and neurology. Doctor 1 recorded that the pain was increasing despite analgesia (pain relief). He also completed a letter for urgent referral to neurology, as there was no sign of a referral being completed after the earlier visit. Mr C went to the accident and emergency department of a hospital (A&E) two days later. He was transferred to another hospital and an MRI scan (a diagnostic procedure used to provide three-dimensional images of internal body structures) led to a diagnosis of a serious back condition. Mr and Mrs C considered that this condition could have been prevented had the practice acted sooner.

After taking independent advice from one of our medical advisers, we found that the practice's general care and treatment of Mr C was reasonable, apart from the delay in sending the neurology referral letter. That said, Doctor 1 referred him to neurology urgently when it became clear that the initial (non-urgent) referral had not been done. In addition, he was transferred to another hospital for urgent treatment after attending A&E. In view of this, it is unlikely that the failure to complete the initial neurology referral had any significant impact on Mr C’s subsequent care and treatment.

Mrs C also complained that the practice’s response to Mr C’s complaint unreasonably contained inaccuracies. However, we found that the comments in the practice’s response were confirmed by Mr C’s medical records.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C for the failure to send the referral letter.

Summary

Mr C, who is a prisoner, complained that the health board inappropriately failed to conduct an adequate occupational therapy assessment to inform his needs and requirements as a disabled prisoner. However, he was freed from prison whilst we were investigating his complaint and did not provide us with a contact address. We were unable to obtain a contact address for Mr C and we had no option but to close our file on his case.