Health

Summary

Ms C complained that her medical practice had not provided her with reasonable care and treatment. She said that they had stopped prescribing medication that she had been on long term, asked her to attend for reviews at the practice and had not supplied her with a neck collar to address the symptoms of her dystonia (a condition which causes shaking, in Ms C's case of the neck muscles). She further complained that they had not re-referred her to the dystonia clinic and declined to issue a certificate to excuse her from appearing in court.

Our investigation, which included taking independent advice from a medical adviser who is a GP, found that the actions of the practice had been reasonable, and we did not uphold Ms C's complaints. We found that Ms C had been taking a high dose of Hormone Replacement Therapy (HRT) since a hysterectomy (surgical removal of the uterus) a number of years ago. Medical opinion is that long-term use of HRT carries serious health risks and our adviser thought it was reasonable for the practice to encourage Ms C to reduce the HRT with a view to stopping eventually. When she declined to do so and also declined to attend the practice for health reviews, we considered it reasonable for them to refuse to continue to prescribe the HRT.

Ms C was also taking diazepam (a tranquiliser) to treat her dystonia. Diazepam is an addictive drug and the practice tried to encourage Ms C to attend for reviews of her long-term use of it. Again Ms C was reluctant to do so and at times the practice, therefore, prescribed a reduced amount of it until she was reviewed. This also happened when her son abused her supply. Again we considered the actions of the practice to be reasonable.

On the matter of the neck collar, our adviser said that current medical opinion is that neck collars cause the muscles to weaken and waste away which is the opposite to what is required in a patient with dystonia. Ms C had been seen twice at the dystonia clinic, where the only treatment they were able to offer her was botox injections, which she had declined. The practice invited Ms C to come in and discuss this but she declined to attend. We took the view that in the circumstances it was reasonable for the practice not to supply a collar or to re-refer Ms C to the clinic.

Ms C had not been seen in person at the practice for some six months when she asked one of the GPs by phone to write her a certificate to excuse her from attending court. The GP said that he could not do so without seeing her but Ms C said she did not want to visit the practice. We found that it was, therefore, reasonable for them not to provide the certificate.

Summary

Mrs C cancelled an appointment for a scale and polish (dental cleaning) and x-rays that her dentist had advised her to have. The dentist wrote to her explaining why he recommended the treatment. He said that she had excess tartar (dental plaque) accumulation and that x-rays of her back teeth would help determine if there were underlying problems. He also said that in most cases where patients suffer from sensitive teeth, he uses a local anaesthetic, which helps to decrease sensitivity during cleaning. He acknowledged that a patient can choose whether to continue with treatment but went on to say that if she did not have it, her teeth would require extensive scaling which might cost more. Without x-rays, he also could not guarantee that there were no undiagnosed areas of decay etc. When Mrs C attended an appointment with the dentist some eight months after the cancelled appointment, she asked for a standard clean and polish with no anaesthetic. She said that the dentist refused to treat her and when she asked to speak to the practice manager she was told to put her complaint in writing. She was removed from the dentist's practice list and not allowed to transfer to another dentist within the practice.

Mrs C was concerned about the insistence of using anaesthetic to proceed with the clean and polish and failure to provide an adequate explanation regarding why anaesthetic was required. Mrs C was also concerned about the dentist's attitude, saying he was condescending and unprofessional. She was unhappy at being removed from his list and not being allowed to transfer to another dentist within the practice. In relation to the complaints handling, Mrs C complained that she could not speak to the practice manager and that there was no attempt at informal resolution, that the dentist's response failed to answer some of her points and that the matter was investigated and responded to by the person she was complaining about. As a result, she said that she suffered anguish and upset and that she was left without NHS dental provision when she lost half a tooth which had previously been treated by the dentist.

We accepted the independent advice of one of our medical advisers that the use of anaesthetic in these circumstances is reasonable and that the dentist provided a reasonable explanation about this. We did not find evidence to support Mrs C's complaint about the dentist's attitude and we found that her removal from the list and not transferring her to another dentist in the practice to be reasonable. On complaints handling, we found that arrangements should have been made for Mrs C to talk to the practice manager but that on the whole the complaint was handled properly - Mrs C's complaint was fully considered and addressed, and she received a written response to her complaint from the dentist.

Summary

A consultant psychologist working for the board diagnosed Ms C with a histrionic personality disorder (a condition in which people act in a very emotional and dramatic way that draws attention to them). Ms C was known to frequently appear at the local accident and emergency (A&E) department and at her medical practice, and the consultant wrote to those services advising that they should manage her behaviour carefully and that they should not entertain threats of self-harm or suicide.

In his letters, the consultant noted that Ms C might become aggressive toward staff and suggested that the police could be called should this happen. Ms C complained that the consultant's advice to these services meant that she was prevented from receiving treatment for other conditions, in particular, for nerve pain in her legs. She also complained that the consultant did not make her aware of her diagnosis or of the fact that he had written to other healthcare services about her behaviour.

We found that it was reasonable for the consultant to send letters to the medical practice and A&E, as both services had an ongoing involvement with Ms C. Generally we were satisfied that the content of his letters was appropriate and represented advice rather than instruction. However, in one of his letters to Ms C's GP, the consultant made what we felt was a clear instruction that threats of suicide should not be tolerated. As good practice guidance says that all threats of suicide should be taken seriously and investigated, we did not find this instruction to be appropriate. Comments from the board and our mental health adviser suggested that it was likely that Ms C would have been told her diagnosis. However, there was no written record of such a discussion and nothing to suggest that she was made aware of the letters that were being sent to other healthcare services. It is an underpinning principle of mental health care that patients are involved in decisions about their care and treatment. We considered that the board had failed to involve Ms C in her care or to record her involvement, and upheld her complaints.

Recommendations

We recommended that the board:

• apologise to Ms C for the issues highlighted; and
• draw the consultant's attention to our adviser's comments about the letter.

Summary

Mr C, who is paralysed from the neck down, complained that the board unreasonably and without prior consultation proposed to change some elements of the nursing care they provide.

Our investigation, which included taking independent nursing advice, found that Mr C had been cared for by the same two nurses for much of the last 20 years. During this time their practices had changed little, which meant they were not in keeping with current good practice. Our nursing adviser, therefore, felt it was reasonable for the board to have taken the opportunity to review Mr C's care package when one of the long standing nurses retired and the team leader changed. The team leader had phoned Mr C to discuss the proposed changes, but the conversation did not go well. Mr C, therefore, felt that, rather than a discussion with him about his future care, the changes were imposed upon him. The board acknowledged that it would have been better for this conversation to have taken place face-to-face and have put this change into place for such discussions in the future.

After this, following 'moving and handling' training for the staff, it was apparent that no moving and handling assessment had taken place for a number of years. During a routine visit by two staff Mr C took exception to the way that they wanted to use a 'sliding sheet' (used to ease the moving of a patient from bed). He became upset and asked the staff to leave before the procedure he was to receive was completed. A moving and handling assessment was arranged but again this did not go well and Mr C asked the staff to leave his home. He has not received nursing care from the board since the end of September 2011.

We did not uphold Mr C's complaints, as our investigation found that the actions of the board and their staff had been reasonable. We noted that in responding to the complaints, the board offered Mr C a meeting with their associate nurse director to discuss his future care. Although at the time Mr C did not feel able to take up this offer, it remains open and we have encouraged him to take this up when he feels able to do so.

Summary

Ms C's medical practice referred her to a consultant surgeon at the hospital because she had rectal bleeding and loose stools. Tests were carried out and an inital diagnosis of proctitis (the mildest form of colitis, which is inflammation affecting the lining of the bowel causing diarrhoea and rectal bleeding).

As Ms C's symptoms did not improve with the medication that she was prescribed, she was referred to a consultant gastroenterologist (a medical professional specialising in the treatment of conditions affecting the liver, intestine and pancreas). Ms C attended several clinic appointments between March 2010 and June 2011 and had various investigative procedures carried out in response to her ongoing symptoms of fatigue and passing blood. Ms C's condition worsened in October 2011 and she was admitted to a different hospital where she underwent an emergency colectomy (an operation to remove the large bowel).

Ms C complained that the consultant gastroenterologist had failed to diagnose the severity of her condition. She felt that earlier diagnosis would have allowed alternative drug therapy to be tried which might have avoided the need for the colectomy and a stoma (a surgically made pouch on the outside of the body). Ms C was unhappy that the consultant gastroenterologist had not clearly told her that she had ulcerative colitis and that he had said at an appointment in June 2011 that there was nothing seriously wrong.

We did not uphold Ms C's complaint. After taking independent advice from one of our medical advisers, we found that Ms C was correctly referred to the consultant gastroenterologist and reviewed with a frequency appropriate to her condition and symptoms. In addition, Ms C was prescribed appropriate medication although it was identified that she had an intolerance to one of the drugs. Our adviser explained that flare-ups in ulcerative colitis can happen unpredictably and that Ms C's severe episode that led to the colectomy could not have been predicted or prevented. We found evidence that the consultant gastroenterologist clearly explained at an early stage the results of the investigative procedures and Ms C's diagnosis. However, we could not say exactly how much information they shared with Ms C about her condition, as there was a lack of documented information about this. Although we did not uphold Ms C's complaint, we drew the board's attention to the lack of information and to the relevant guidance about keeping records.

Summary
Mrs C complained that she received poor care in hospital after undergoing a procedure to remove a gallstone from her bile duct, which resulted in her bowel being perforated. Mrs C also raised specific concerns that the risk of perforation was not explained to her; there was a lack of information given to her about what happened during the procedure, and she had not been aware of a tube having being inserted during the procedure.

The board said that the procedure was appropriate as not removing the gallstone could have led to recurrent inflammation of the pancreas (pancreatitis), inflammation of the bile ducts and jaundice (yellowing of the skin or eyes). In addition, the procedure carried a lower risk than open surgery. We considered this response reasonable as earlier investigations had showed a small stone blocking the bile duct.

However, we upheld Mrs C's complaint. Our medical adviser said that, while junior medical staff did consider at an early stage the possibility that there had been a perforation, aspects of Mrs C's after-care fell below a reasonable standard. This was because there was no senior doctor accountable for Mrs C's care after the procedure, and no clear supervision of the junior medical staff who were reviewing her. Our adviser considered that there should have been a clear and consistent action plan from the time the perforation was identified to the time Mrs C was transferred to another hospital (five days later) for surgical review. In addition, there did not appear to be any clear instructions by medical staff about feeding or fluids. Therefore, five days were lost in getting the perforation effectively healed, due to poor nutrition and the likelihood that Mrs C's immune system was weakened.

The board said that Mrs C had been sent a leaflet on the procedure which included information on the risk of perforation. Our investigation, however, identified that Mrs C was given a different leaflet that did not explain any of the specific risks. General Medical Council (GMC) guidance says that doctors must tell patients if an investigation or procedure might result in a serious adverse outcome, even if the likelihood of it happening is very small.

In addition, although the consent form Mrs C signed included information on the risks of bleeding, infection and pancreatitis, it did not include information on perforation. GMC guidance on the recording of informed consent says that the patient's medical records or consent form must record the key elements of the discussion that has taken place.

While the board explained to Mrs C the reasoning behind the medical staff's initial diagnosis of pancreatitis before the perforation was identified, there was no clear record made of any discussions the medical staff had with Mrs C either before or after the complication was identified. We noted that the board were correct in informing Mrs C that a tube had not been inserted at the time of the procedure.

Recommendations
We recommended that the board:

• apologise to Mrs C for the failings identified in our investigation;
• ensure there is clear guidance to consultants regarding the clinical oversight and management of a person's care and supervision of junior colleagues, including care arrangements to cover out of hours, weekend care and periods of leave;
• consider reviewing patient information leaflets on the procedure (ERCP) to ensure all possible risks and complications are clearly explained; and
• consider reviewing their consent policy to ensure that all common and serious risks are fully explained to patients when obtaining consent and that these are clearly recorded on the consent form. 

Summary

Mr C suffered a hand injury while he was in prison. He was treated in hospital the day he was injured, when an x-ray showed he had a metacarpal fracture (an injury to one of the small bones in the hand). The hand was strapped up, and he was seen again around a week later, when another x-ray showed the position of the fracture to be acceptable. The doctor noted that Mr C's hand should remain in strapping until the next review appointment. The next month, Mr C complained to the board that his treatment had been inappropriate. He was concerned that strapping rather than a cast was used, and said that he remained in a great deal of pain. He said that his hand was swollen and becoming deformed, with the bone sticking out. Mr C had further appointments over the next three months, and after a CT scan was taken, a hamate fracture (an injury to a small bone on the outside of the wrist) was identified in addition to the metacarpal fracture. He underwent steroid injections for pain management, and was considering surgery.

After taking independent medical advice, we did not uphold Mr C's complaint, as we found that the management of his injury had been appropriate. We found that the use of strapping to allow him to continue to move his hand, rather than a plaster cast, was appropriate for this type of injury. We also found that the hamate fracture could not be detected easily from the initial x-rays due to its position. We found that the shape of Mr C's hand was not due to the bone sticking out, but rather due to the formation of callus (thickened skin) as the injury healed. We also found that surgery at an earlier stage would not have been appropriate because time had to be allowed for healing before surgery could be carried out. We did not uphold the complaint, although we did note some minor issues in relation to the board's response to Mr C's complaint, which we drew to their attention.

Summary

Mr C visited a dentist several times in the summer of 2011 where he had seven teeth removed and two fillings. Around three months later, Mr C was admitted to hospital suffering from fever and was subsequently diagnosed with sub-acute bacterial endocarditis (a chronic bacterial infection of the valves of the heart) and underwent surgery.

Mr C complained that the dentist failed to prescribe him antibiotics despite Mr C having told him that he felt feverish after the first three teeth were extracted. Mr C said that a hospital doctor had commented that patients undergoing any form of invasive dental treatment should be administered antibiotics.

We noted that the dentist treated Mr C for infected sockets in June 2011 by washing them out with an antiseptic solution and packing them with a dressing. This form of treatment is in line with guidance issued by the Faculty of General Dental Practice. National guidance issued by the National Institute of Clinical Excellence recommended that antibiotics were only to be given routinely to a small minority of patients undergoing dental treatment who have a certain heart defect. As Mr C had no previous medical history, such as a heart condition, that would require administering antibiotics before or after the tooth extractions, we considered that the dentist acted appropriately and in line with the national guidelines.

Mr C's dental records showed that he was given antibiotics in July 2011 but there was no reason given as to why these were prescribed. The dentist later explained that they were given because infection of the sockets had persisted, which we considered reasonable.

Mr C's hospital records showed that the endocarditis was caused by Strep Viridans (a bacteria found in the mouth and throat of most people). The bacteria can enter the bloodstream following a dental extraction but is usually killed by the body's immune system in a healthy person. It is normally only a problem for those with a compromised immune system or pre-existing heart defect, neither of which Mr C had at this time. We considered that it was highly likely that Mr C was infected by the bacteria following the dental extractions and that, for unknown reasons, his immune system was unable to respond to the bacteria, resulting in his endocarditis. However, this did not mean that the dental extraction was carried out incorrectly, nor that he should have been given antibiotics.

Summary

At a consultation with her GP, Mrs C said she had swollen ankles. Her GP advised her to stop taking her medication for high blood pressure, which she did. Mrs C was admitted to hospital with chest pain two months after the consultation with her GP and died several hours later. Over time, Mrs C's husband (Mr C) became concerned about a possible link between the medication being stopped and his wife's death.

Mr C complained that the GP's advice was not properly considered or reasonable. He also complained that the practice did not take reasonable steps to monitor his wife's health following their advice that she should stop taking the medication prescribed for high blood pressure.

We found, from looking at the evidence and taking advice from one of our medical advisers, that ankle swelling was a common side effect of the blood pressure medication Mrs C had been taking and, given Mrs C's symptoms, the advice to stop taking blood pressure medication was reasonable. We also found that blood tests were organised after the consultation with the GP, but that there was no clear instruction for a follow-up check of blood pressure. However, blood pressure was monitored at other appointments with staff at the practice, and was within normal limits. It was not entirely clear from the records that this was part of a systematic plan of care that followed from the decision to discontinue the medication. Therefore, we asked the practice to reflect on follow-up arrangements made for patients when medications are discontinued, and to record specific plans for follow-up within the records. However, overall, we found that there was evidence that the practice took reasonable steps to monitor Mrs C's health and we did not uphold Mr C's complaints.

Summary

Mr A's dentist gave him a filling in autumn 2011. This was a very large restoration and Mr A was treated for minor pain over the next few weeks. In early 2012 he returned to the practice with further pain associated with the tooth. The practice told him that the dentist who treated him had left, and had in fact practiced there under his own NHS contract. They offered treatment but told Mr A that they would charge for this. Mr A recalled that his previous dentist had told him that any follow-up treatment required on the tooth would be free of charge, and declined the offer of paid treatment. He returned to the practice the next month and again said that he would only consent to treatment if it was provided free of charge. He refused to sign forms consenting to paid treatment or a medical history form.

Mr A complained about this to the practice, who explained their position and advised that they had taken steps to remove him from their treatment list on the basis that Mr A had lost confidence in them.

Ms C, who is an advice worker, wrote to the local health board on Mr A's behalf and this was passed to the practice for a response. The practice repeated the information they had given Mr A about his treatment and his removal from their practice list. They also offered him the cost of the treatment he had experienced problems with, but noted this was not the full amount he had paid at that time, as that had included treatment for another matter.

Mr A remained dissatisfied and Ms C complained to us on his behalf. We did not, however, uphold the complaint as we decided that there was no evidence of service failure. This was because the practice were correct in saying that the responsibility for treatment lay with the dentist who provided it and not themselves, now that he had left the practice.