Health

Summary

Ms C's mother (Mrs A) was admitted to a hospital accident and emergency department (A&E). In the resuscitation room three gold necklaces were removed from Mrs A, along with other jewellery which was handed to her family immediately. Mrs A was then transferred to another ward, where she passed away. On collecting Mrs A's personal belongings, her family discovered that the necklaces were missing. The A&E department was searched, with the family present, and other departments were contacted but the necklaces were not found.

Mrs A's family complained to the hospital about the loss of the necklaces. In their response, the board accepted that the necklaces had been lost there and noted that the usual procedure of sealing belongings in a bag and giving them to the patient or next of kin had not happened on this occasion, advised that the importance of documenting and caring for patients' belongings had been reiterated to staff and that new labels and a belongings register had been provided in the A&E department. The board expressed their regret at the distress that had been caused and offered their sincere apologies to the family.

Ms C was dissatisfied with this response and complained to us. We decided that the board's response had been reasonable, and did not uphold that complaint. She had made other complaints relating to the loss of the necklaces and the board's investigation, but we could not consider these as they had not yet completed the board's complaints procedures.

Summary

Mrs C complained that the board's rheumatology service (which deals with conditions affecting the musculoskeletal system, including joints, bones and muscles) unreasonably failed to offer an appointment to her mother (Mrs A). Mrs A had slipped at home the previous week, was unable to put weight on her leg, and was in pain and discomfort. Mrs A's GP had diagnosed a 'flare-up' of arthritis. Mrs C phoned the rheumatology service, where her mother had been a long-standing patient, in the hope that they would see her at the regular weekly clinic. Mrs C said that her request was unreasonably refused and that she was told that this was because the service was short staffed and clinics had been cancelled in the unexpected absence of two key members of staff.

The board said that this was not why the request was refused. They said that the specialist rheumatology nurse who spoke to Mrs C refused the request because she did not think that Mrs A's symptoms were consistent with a 'flare-up' of arthritis. The nurse advised Mrs C to take her mother to the accident and emergency department (A&E), or revisit her GP. The board said that, in spite of the lower than usual staffing levels, had Mrs A required a review because of her arthritis, then she would have been offered an appointment at a nurse-led clinic. Five days later Mrs A was admitted to A&E and was discovered to have a fracture.

Although we understood Mrs C's concerns about this, we did not uphold the complaint. This was because it was not possible during our investigation to reconcile the two very different accounts of the same phone call. There was no supportable evidence to suggest that the rheumatology service had unreasonably refused to see Mrs A on the basis of capacity alone, and there were in fact sound clinical reasons for Mrs A to be referred to A&E either directly, or via her GP.

Summary

Mrs C complained about the treatment that her late husband (Mr C) received after he was admitted to hospital with an infected ulcer on his toe. Mrs C also complained that staff did not adequately monitor how much pain her husband was experiencing and did not make adequate arrangements when he was discharged from hospital on three separate occasions, including arranging transport home.

Mr C developed ulcers and ischemia (insufficient blood flow) to his foot and underwent surgery to improve the blood flow through the artery below his knee. He was discharged shortly afterwards but a few weeks later his toe became necrotic (the tissue in the toe died because of a lack of blood and oxygen). Mr C was admitted to hospital again and the decision was taken to observe and wait for auto amputation (for the toe to fall off spontaneously). When the condition of his toe worsened, Mr C had emergency surgery, resulting in some toes being amputated. However, he died a few weeks later. Mrs C said there was an unreasonable delay in fully investigating and treating her husband's toe, which meant he had to have more radical surgery. Mrs C believed that her husband would still be alive if an operation been carried out sooner and had he not been discharged several times.

After taking independent advice from one of our medical advisers, we did not uphold Mrs C's complaints. We found that Mr C received appropriate treatment from a podiatrist (a clinician who diagnoses and treats abnormalities of the lower limb) and that there was no undue delay in referring him to a vascular specialist (a clinician who treats disorders of the circulatory system). The treatment provided by vascular surgeons was also timely and appropriate.

Whilst we identified that on one occasion there was an error with Mr C's pain relief medication, our adviser said that overall his pain was monitored adequately and appropriate pain relief prescribed. Finally, we found that the hospital acted reasonably in not providing Mr C with transport home after he was discharged, as he did not meet the relevant criteria.

Summary

Mr C was discharged from hospital after having major surgery to remove tumours from his stomach area. When the district nurse attended she noted that the wound, which was substantial, had reopened. She called the medical practice to request an ambulance. The GP was visiting patients at the time and could not be located. Mr C's wife said that if the GP could not be located within five minutes she would call the ambulance, which she did. By this time the GP was on his way to Mr C's house but, when he was advised that an ambulance had been called, he returned to the surgery. Mr C complained that the practice did not immediately call for an ambulance.

We took independent advice from one of our medical advisers, who explained that it was reasonable for the GP to wish to assess Mr C before deciding whether an ambulance was necessary. He commented that in this case it was probably necessary, but that it might not have been necessary to call an emergency ambulance. He also pointed out that the district nurse would know that she could call an ambulance directly by phoning 999 if this was required.

As our investigation found that the practice acted reasonably, and as we noted that the ambulance would not have arrived any more quickly had the GP reviewed Mr C first, we did not uphold this complaint.

Summary

Mr C, complained to us on behalf of his son (Mr A). Mr A suffered a serious leg fracture in late 2010, and underwent treatment in a hospital orthopaedic department until June 2011. At that point, he sought a second opinion and received further treatment from another health board. Mr C had a number of concerns about his son's initial treatment, including about the type of fixator (a device to fix the position of fractured bones) that was used, the pain relief provided and the timing of appointments.

Having taken independent advice from one of our medical advisers, a consultant orthopaedic surgeon, we found that the decision to use an external fixator was in itself appropriate. We noted, however, that the board had not identified that one of the pins used had been placed into one of the fractures. We also noted that Mr A was not seen by a consultant until nearly three months after surgery, although we had no concerns about the treatment provided during this period. On balance, therefore, we upheld the complaint that the initial management of his fracture was inappropriate.

We upheld the complaint that on a number of occasions during his treatment Mr A was not given adequate pain relief, but did not uphold a complaint that it was inappropriate to use a sarmiento cast (a below-knee cast that allows the knee to bend) once the external fixator was removed.

Finally, we upheld the complaint that Mr A was not given timely out-patient appointments. Mr A had review appointments in April and June 2011. He was fitted with a leg brace and advised to use his leg when walking. He was given another appointment for eight weeks later. However, we found that at that stage it was clear that the fracture was not healing and required further management, but that the board failed to recognise this. By June 2011, Mr A was suffering severe symptoms and sought treatment elsewhere. We recognised that this had been a complex injury to manage, and that the orthopaedic department might have recognised that the fracture was not healing had Mr A continued his treatment with them. However, it was clear that he had already received substandard care, given that the fact that during the April and June 2011 appointments it was not recognised that the fracture was not healing.

Recommendations

We recommended that the board:

• provide evidence to the Ombudsman that the orthopaedic department ensures timely consultant review of patients when appropriate; and
• bring our findings to the attention of the staff who treated Mr A on 1, 14 and 15 February 2011 to allow them to reflect on his pain management.

Summary

Mrs C's late mother (Mrs A) was diagnosed with cancer in 2011. Mrs C complained that when blood test results were found to be abnormal, a GP from her mother's medical practice (GP 1) failed to tell Mrs A about these when he was the on-call doctor. Mrs C was unhappy that her mother did not find out the results until nine days later when she attended the local community hospital's accident and emergency department (A&E) and GP 1 (who was the on-call GP in the hospital at the time) accessed the results.

The background to this is that another GP at the practice (GP 2) had arranged for Mrs A to attend the surgery in late December 2010 to have non-urgent blood samples taken. These were sent to the laboratory the following day where they were immediately identified as abnormal. At the time, the laboratory's procedures set out that they must communicate abnormal test results to medical staff quickly, and make a computer entry showing when the call took place and to whom. The procedure also included an out-of-hours number for laboratory staff to call if it concerned an out-of-hours GP.

In their response to Mrs C's complaint, the board apologised for a failure in the timely reporting of the abnormal blood results. However, the board advised us that it was unclear to them whether the laboratory had failed to follow procedure. When we investigated, we found that it was difficult for us to be certain whether the laboratory had telephoned and told the practice the results. There was an entry on the computer system suggesting that a call had been made to GP 2. However, the surgery had closed an hour before the laboratory had apparently made the call. In addition, GP 2 saw his last patient in the surgery at 12:45 and was not the on-call doctor that particular day. There was also no entry in Mrs A's medical records to indicate that the surgery had received a call from the laboratory. There was, therefore, no conclusive evidence that confirmed that the practice were aware of the test results.

The medical records showed that GP 1 accessed the results in early January 2011 when Mrs C's mother attended A&E. We did not uphold the complaint, as we considered that GP1 had taken appropriate action to have Mrs A further assessed at that time, and there was no evidence to support that he was aware of the blood test results before he accessed them in January 2011.

Summary

Mr C complained about the care and treatment that his mother (Mrs A) received from a hospital after she was admitted with a severe headache. Mrs A was diagnosed after about 13 hours with a subarachnoid haemorrhage (a type of stroke where there is a bleed from one of the blood vessels running over the brain). Mr C was concerned about the length of time it took for the hospital to carry out a scan and felt that the brain damage his mother suffered could have been less severe had the scan been done sooner. Mr C also complained about the time it took for the board to respond to his complaint and that the response did not answer all of his concerns.

The board accepted there had been an unacceptable delay of approximately four hours between the time it was decided the scan should be done until it was actually carried out. They were unable to provide a clear reason for the delay but outlined that there were communication problems between the junior doctor and the radiology department. As a result of their findings, the board said that they would rewrite their protocol in relation to scanning and out-of-hours care.

We found further communication problems that impacted on identifying the need for an urgent scan. The medical records show that the on-call medical consultant said that Mrs A was to be scanned immediately in the event of further deterioration. However, when her condition further deteriorated early that morning, before the scan was done, neither the on-call doctor nor the radiologist was informed.

We were unable to say whether earlier diagnosis would have influenced the final outcome in Mrs A's case. However, it would have at least provided the possibility of early transfer and intervention, along with reducing the overnight anxiety the family suffered. Overall, therefore, we considered the care to be below the standard that could reasonably be expected.

We also identified significant delays in the board's responses to Mr C's letters of complaint, which were not in line with the guidance issued by the Scottish Parliament at the time. Whilst we noted inconsistencies in the board's first response to Mr C, their second response was more accurate and in keeping with the information contained within Mrs A's medical records.

Recommendations

We recommended that the board:

• apologise to Mr C and Mrs A for the failings identified in our investigation;
• review the new protocol to ensure that there is appropriate involvement of the senior medical staff responsible for the care of the patient when reviewing patient care, and that appropriate clinical features are included in the protocol to aid diagnosis;
• review clinical communication at the time of handover between all clinical staff, including radiology, to ensure urgent scan requests are effectively communicated and expedited; and
• apologise to Mr C for the delay in responding to his complaint and for providing contradictory information.

Summary

Mr C made a complaint on behalf of his partner (Ms C) who was admitted to hospital with a suspected stroke. Two days after being admitted, Ms C collapsed in the bathroom, where she was discovered by ward staff. She was moved to an acute ward and was under observation for five days until she was discharged from hospital. It was thought that Ms C, who had epilepsy, might have suffered a seizure.

Four months later, Ms C met with a doctor at the hospital as she was concerned about what had happened. She had concerns that she had been given the wrong medication and that the collapse had not been reported as an accident nor been subject to an accident investigation. She was also unhappy about the actions of the medical team following her collapse, including the taking of a blood sample from her groin. Ms C provided a list of questions for the doctor to respond to, and he did so by letter.

Ms C remained dissatisfied and wrote again with some additional queries. This letter, however, was sent directly to the doctor and was not received by the board's complaints team. Ms C then sent her original set of questions to the complaints team, who responded. Ms C then complained to us that the board had not answered her additional questions.

During our investigation we found that the second letter had been addressed to the doctor and said that Ms C would be making a formal complaint. The doctor had, therefore, placed it in Ms C's medical file, and explained to her how to access the complaints procedure. We found this to be reasonable. However, this meant that the complaints team had not in fact seen Ms C's additional queries which is why they did not respond to them. We found that the board's responses to the complaints Ms C made to them were reasonable, and noted that the complaints team had in fact phoned her to try to establish what she was still concerned about. Although we did not uphold the complaint, we made a recommendation to allow Ms C another opportunity to raise any further matters with the board.

Recommendations

We recommended that the board:

• contact Ms C to arrange either a meeting or further correspondence to address any outstanding concerns.

Summary

Mr and Mrs C underwent in vitro fertilisation (IVF) treatment (fertility treatment) in 2010 and had a child. They understood that they were not entitled to further treatment from the health board and had been saving for private treatment. They made an appointment for a private consultation. However, Mrs C said she received a telephone call from the board in April 2011 saying she was entitled to a further cycle of treatment. On that basis, Mr and Mrs C cancelled their private treatment, and made appointments at the board's assisted conception unit. Around three months later, Mrs C contacted the board to confirm the dates of her appointment with the assisted conception unit and was told that there had been an error, and she was in fact no longer entitled to further NHS treatment.

The board conducted an investigation including tracing their call logs, but could find no record of the call to Mrs C in April 2011. There was also no record of appointments having been made for her with the assisted conception unit in 2011. The board considered Mr and Mrs C's case again, but reached the decision that they would not deviate from their normal policy on IVF to offer a second cycle of treatment. We considered the board's investigation and obtained further information. We found that there was no independent evidence to support Mrs C's position about the telephone call, although we did not disbelieve her position. We also found the board's position of following their policy to be reasonable. Although we did find that there was a delay in Mr and Mrs C obtaining IVF treatment as a result of their experiences, on balance we did not uphold the complaint.

Summary

Ms C, who is a member of the Scottish Parliament, complained on behalf of a constituent (Mrs A) who had a number of concerns about the care provided to her late husband (Mr A). Mr A had dementia and was admitted to hospital with increasing confusion, shortness of breath and infections. When investigating the complaints, we took independent advice from three advisers - a physiotherapy adviser, a nursing adviser and a consultant geriatrician (a doctor specialising in medicine for older people).

We did not uphold Ms C's complaint that Mr A's physiotherapy treatment was inadequate, as we found the treatment to be frequent. We noted that the physiotherapy team continued to try to help Mr A to mobilise although he was increasingly not able to work with them, due to his dementia. We also found that they had appropriately referred Mr A to medical staff when they noticed unusual symptoms when trying to help him to mobilise (Mr A was later diagnosed with a fractured hip).

We also did not uphold the complaint that Mr A was not given adequate assistance with eating and drinking. We found that a dietician had made appropriate assessments, it had been recognised that Mr A had increasing problems with swallowing, and the notes indicated that staff had continued to try to help Mr A to eat and drink. He had lost a lot of weight, but our medical adviser considered that this was due to the fact that he had difficulty swallowing.

We upheld Ms C's complaint that Mr A had not been given appropriate assistance with dressing on some occasions, as the board had accepted this. We also noted there was no assessment recorded in the notes about Mr A's level of independence in relation to personal care (including his ability to dress) and we criticised this.

We did not uphold the complaint that the board did not discuss with Mr A's family his transfer to a nursing home, as we found evidence of discussions of this nature in his records. We did, however, uphold a complaint that the transfer was not reasonable at that time, given that Mr A was suffering from a severe pressure sore that was not highlighted to nursing home staff by ward staff. Finally, we upheld the complaint that the pressure sore was allowed to develop and worsen. This was because, although we found evidence that a high risk area was initially recognised, there was no evidence thereafter that it was treated.

We noted that, since the time of Mr A's care in 2010, the board had implemented a range of new policies, training and audits in relation to care of patients with dementia, nutritional care and tissue viability. We, therefore, made recommendations only in respect of the implementation of these.

Recommendations

We recommended that the board:

• provide their action plan for education and staff training in relation to patients with cognitive impairment;
• provide evidence to the Ombudsman that appropriate assessment of patients' levels of independence on rehabilitative wards is taking place; and
• provide evidence that full relevant information is provided during the transfer and discharge of patients to nursing home and other community care environments, and that staff are aware of their responsibilities in this regard.