Health

Summary

Mrs C complained about the treatment prescribed by her medical practice for fungal nail infection. In addition, Mrs C was unhappy with the practice's response to her complaint and with their view that she and her husband behaved inappropriately towards staff.

Mrs C has lupus (an autoimmune disease that causes inflammation in various parts of the body). She did not take the prescribed medication after reading on the information leaflet that it was potentially harmful to lupus sufferers, and complained that it had been inappropriately prescribed. Although Mrs C's prescription was subsequently changed, she said that the new course of treatment also had an adverse effect on her health.

As part of our investigation, we took independent advice from a medical adviser. He said that available treatments for fungal nail infection can have a number of side effects, interact with many other drugs and can cause reactions including impairment of liver function. The initial drug Mrs C was prescribed can cause a lupus type effect and the British National Formulary (BNF - national guidance for healthcare professionals regarding the prescribing of medicines) advises caution when prescribing it to patients who suffer from an autoimmune disease. Our adviser said that although the BNF does not advise against prescribing the drug, there was no record to suggest that the medical practice had considered Mrs C's medical history when prescribing it, nor did they note a follow-up plan or request blood tests.

We also found that there was no evidence to show that the medical practice considered any follow-up plan when prescribing the replacement treatment. The BNF recommends that if the treatment is prescribed for more than a month, liver function should be monitored. We noted that the blood tests taken from Mrs C after she complained of being unwell were only carried out as a result of her symptoms, rather than being planned at the time of prescribing.

We concluded that although it was reasonable for the practice to have prescribed both courses of treatment, their care of Mrs C was deficient because there was insufficient evidence to show that they had actively considered the impact on her condition or monitored the effects of the drugs.

We also identified that the practice's response to Mrs C's complaint lacked relevant information about the BNF advice, and upheld this complaint. However, we did not uphold the complaint about the allegation that she and her husband behaved inappropriately towards staff. This is because, due to a lack of independent witnesses, we were unable to know for certain whether the medical practice had acted inappropriately in saying this.

Recommendations

We recommended that the practice:

• apologise to Mrs C for failing to clearly discuss the possible risks and side effects when prescribing both drugs or to actively monitor her liver function; and
• remind relevant staff to ensure that all medicines prescribed are adequately recorded and the associated risks discussed with the patient are also noted.

Summary

Mrs C, who is an advice worker, complained on behalf of her client (Mr A) who had a hernia repair operation. Several days after the operation, a district nurse suspected that Mr A had developed an infection. Mr A saw his GP who prescribed antibiotics. Five months later, Mr A experienced a swelling at the site of the operation, which then burst. Mr A went to the accident and emergency department of a hospital, and was seen as an out-patient on several occasions over the next eight months until he had further surgery. Mrs C complained to us that the board failed to provide a reasonable standard of treatment for post-operative complications following Mr A's hernia repair surgery.

We upheld Mrs C's complaint. We found from looking at the records and obtaining independent advice from our medical adviser, that Mr A had an infected mesh (used to repair the hernia) in his wound that needed to be removed. Hospital staff treated the problem with antibiotics, in an attempt to avoid further surgery on Mr C. However, our adviser said that as surgery was inevitable, the decision to remove the infected mesh could and should have been made sooner. In addition, once the decision had been made to remove the infected mesh, there was an unreasonable delay before the surgery was carried out. We also had concerns that the record-keeping in this case was poor.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our investigation; and
• reflect on the comments of our adviser in relation to record-keeping.

Summary

Mr C complained about the care and treatment given to his late wife (Mrs C). He said that Mrs C had initially been taken into hospital with a urinary tract infection. The following month, she was transferred to another hospital for rehabilitation and physiotherapy. Later that month she was noted to have red heels, with a blister on one of them. Mrs C was discharged home shortly afterwards and Mr C said that at that time she had pressure sores. Mrs C died some six months later.

Mr C complained that his wife suffered from pressure sores while in the care of the board. He said that she was inadequately nursed and that this contributed to her death. In our investigation we took all the relevant information into account including the board's file of correspondence and Mrs C's clinical notes. We also obtained independent nursing advice about Mrs C's care and treatment.

We upheld all Mr C's complaints. Our investigation found that there was no reason not to discharge Mrs C home with dressings on her feet. However, there was also no evidence to suggest that a wound chart was completed before discharge, which would have assisted community nurses to plan their care for Mrs C. Community nurses were also not told that Mrs C's heels needed dressing and we found that communication between the hospital and the community nurses was poor. Similarly, record-keeping was below a satisfactory standard.

Recommendations

We recommended that the board:

• emphasise to the staff concerned in this case the importance and necessity of keeping properly recorded notes and of using the tools that are available to them to assist in the care and treatment of patients (eg a wound chart);
• apologise to Mr C for their failures in this matter. Also, that the apology makes specific reference to the poor treatment given to Mrs C while she was at home; and
• provide evidence to the Ombudsman about how they assure themselves that the discharge planning standards/policies relating to communication have been addressed

Summary

Ms C complained about the treatment her mother (Mrs A) received from a GP at her medical practice. Mrs A had attended an appointment with the GP in relation to rectal pain and bleeding. The GP performed an examination, diagnosed piles, prescribed a treatment, and advised Mrs A to return within seven to ten days if her symptoms did not improve. Mrs A returned some five weeks later, by which time her symptoms had worsened and she had blood in her stools. Another GP referred Mrs A to hospital for tests, and she was given a clinic appointment for just over two months later. In the meantime, Mrs A attended the practice on two further occasions, when she was seen again by the first GP. On one of these occasions, the GP physically examined Mrs A again.

Mrs A was diagnosed with colorectal (bowel) cancer after the hospital appointment. She underwent chemotherapy and radiotherapy. Due to other medical conditions, it was considered that surgery was not a suitable option and Mrs A died just under a year and a half after being diagnosed. Ms C said that if the GP had properly recognised her mother's symptoms at the start, she might have had a better life expectancy and an improved quality of life. Ms C was also concerned that, given the subsequent cancer diagnosis, the GP had said that there was 'nothing untoward' on the occasions that she examined Mrs A.

Having taken independent advice from one of our medical advisers, we found that the GP's care of Mrs A had been appropriate. We found that it was reasonable for the GP to prescribe medication for piles at the first appointment, and to advise Mrs A to attend seven to ten days later if her symptoms had not improved. We accepted that the referral was appropriate, and that there was no requirement for the GP to try to speed that up after Mrs A's later appointments. We noted that, as a hospital appointment had already been made and was due shortly, this would have had no practical impact upon Mrs A's prognosis and treatment time. We also found that the GP's statement that there had been 'nothing untoward' was made in the context of the physical examinations. It was reasonable that further tests at the hospital were needed in order to discover a cancer diagnosis.

We did draw to the practice's attention that it might have given Ms C some reassurance if they had told her that they had carried out a Significant Event Analysis (a detailed investigation into what happened) as a direct result of her complaint, and had put in place the learning outcomes that it identified.

Summary

Mr C complained about the board's actions in relation to his elderly father (Mr A). He said that his father had been admitted to hospital late in the evening. After being examined and declared fit, he was sent home in the early hours of the morning by car, with a relative. Mr C said the relative was not entirely happy with this but, nevertheless, complied. When Mr A reached home, a neighbour had to be recruited to help him get into the house. Mr C said that his father should not have been discharged, particularly because he was elderly, disabled and had memory problems.

We investigated the complaint taking all the relevant information, including all the complaints correspondence, the relevant clinical records and the board's discharge policy, into account. We also obtained independent advice from one of our advisers, who is a nurse.

In responding to the complaint, the board had confirmed that Mr A was considered fit for discharge and was keen to go home. There was, therefore, in their view, no clinical reason to keep him in hospital. They pointed out that the Scottish Ambulance Service did not provide out-of-hours transport and, as there was a relative available and willing to take Mr A home, they had asked him to do so. They said that if this had not been the case, they would have had to consider whether a taxi was appropriate.

Our nursing adviser reviewed the files and confirmed that the information in them indicated that Mr A was fit to go home. She also confirmed that Mr A was not in fact admitted to hospital, and so the board's discharge policy would not apply in his case. She said that in all the circumstances, it was not unreasonable for Mr A to return home with a relative, given that an emergency department was not an ideal place for an elderly and frail person.

Taking all the information into account, we did not uphold the complaint as we found that, while not ideal, in all the circumstances it was not unreasonable for the board to discharge Mr A home.

Summary

Mr C had a hernia operation, but was admitted to hospital a week later with severe pain in his testicles. It was discovered that the blood supply to one of his testicles had been cut off and it had to be removed. The surgeon said that the obstruction in the blood supply had been caused by a combination of the hernia operation and a vasectomy that Mr C had previously had. Mr C complained to us about the standard of the hernia repair surgery.

We found that the hernia operation Mr C had was the standard procedure. Our medical adviser said that the operation note was a well-completed document that complied with good surgical practice. We also found that it was appropriate that the operation was carried out by a suitably experienced junior doctor under the direct supervision of a surgeon. Damage to the blood supply to a testicle is a recognised, but rare, complication of hernia surgery. If a testicle does not have any blood supply, it has to be removed. However, our adviser said that there was no evidence that Mr C's earlier vasectomy had been a factor in the complication he suffered and we told the board this.

Mr C also complained that the board failed to adequately communicate with him before and after his surgery. We found that the consent forms for the operations had been completed appropriately. The surgeons also recorded that they met Mr C before and after the operations to discuss the procedures. Mr C disputed this and his version of events clearly conflicted with the surgeons. However, there was no clear and objective evidence to support his complaint about this matter.

Summary

Mr C complained about the care and treatment provided by his dentist in 2010. He said that a denture and replacement filling were not completed properly, and that an existing cavity (area of decay) was not discovered and/or treated.

We upheld Mr C's complaint, as our investigation found that the treatment was not of a reasonable standard. We took independent advice from our dental adviser, who commented that there was no record in Mr C's dental notes of the purpose of his first appointment with the dentist. Although the next three appointments followed what would be considered best practice, the adviser said that there appeared to be problems with the denture from the start. She also noted that subsequent adjustments appeared only to make matters worse. There was a lack of detail in the notes about a treatment plan or discussion of treatment options relating to the filling. The adviser was concerned that the filling was done after the construction and fitting of the new denture and said that normal practice would have been to do the filling first.

On the matter of the undetected cavity, the adviser said that this was likely to have been present during the treatment but might not have been visible in the mouth. It should, however, have been detectable on an x-ray. She noted that the later removal of this tooth by Mr C's new dentist caused further problems with the denture. X-rays were taken in May 2010 but the records do not make it clear what type they were; on which teeth they were taken or the reason for taking them. The adviser said that Mr C had had considerable work done on his teeth since these x-rays and further x-rays should have been taken before making the denture, as these might have revealed the cavity.

Overall, the dental adviser was concerned that the standard of the records did not conform to that expected by the General Dental Council or the Faculty of General Dental Practice (UK).

As the practice waived the cost of treatment after Mr C complained to them, we made no recommendation about this, although we did make recommendations to address the other failures our investigation found.

Recommendations

We recommended that the dentist:

• reviews her practice in relation to this complaint - this to be discussed at her next annual appraisal;
• reviews the standard of her record-keeping with particular regards to the level of detail of the treatments undertaken and discussions on treatment options and consent - this to be discussed at her next annual appraisal; and
• issues a written apology for the failings identified.

Summary

Mr C complained about the care and treatment received from his dentist, including that: a root canal treatment was not completed properly; despite requesting a white filling the filling provided was grey; the dentist allowed bleach from a syringe to spill on to Mr C's suit and allowed the syringe to fall on to Mr C's thigh.

We upheld Mr C's complaint. Our investigation, which included taking independent dental advice, found that the root canal treatment (a deep filling of the root of a tooth) was not completed properly. Our adviser said that the dentist should have used a rubber dam, which would have protected Mr C's gums from the hypochlorite (bleach) used during the treatment. The adviser was also of the opinion that, although the end result could be deemed acceptable, the root filling was slightly short of the tip of the root canal. She was also concerned at the lack of detail in the dental notes, including a failure to document the working lengths of the canals or what substance was used to wash them out.

On the matter of the type of filling used, the adviser stated that it would be normal practice within the NHS to use an amalgam (grey or silver) filling. She said that white fillings can be provided but that this would be on a private basis. The adviser also commented that it is considered best practice to restore a root filled tooth with a crown (a metal and/or porcelain restoration made in a laboratory which covers the tooth) and that all the various options should have been discussed with Mr C. However, we found no evidence that this was done. Overall, the dental adviser was concerned that the standard of the records did not conform to that expected by the General Dental Council or the Faculty of General Dental Practice (UK).

On the matter of the incident with the syringe, the dentist acknowledged that this had happened but he could not at the time of the investigation, some two years after the incident, recall exactly what had happened. He acknowledged that the bleach had damaged Mr C's trousers, and that Mr C had complained about it. The dentist said that he apologised to Mr C at the time and offered a compensatory payment, which Mr C accepted. In the circumstances, we took no further action on this element of the complaint.

Recommendations

We recommended that the dentist:

• reviews his practice in carrying out root canal treatments with particular regard to the use of rubber dams - this to be discussed at his next annual appraisal;
• reviews the standard of his record-keeping with particular regard to the level of detail of the treatments undertaken and discussions on treatment options and consent - this to be discussed at his next annual appraisal; and
• issues a written apology for the failings identified.

Summary

Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her throat and did not take her temperature or carry out any other tests. Miss C also said that her GP suggested she should go to the ear nose and throat (ENT) ward if she had any further problems, although her understanding was that she could not do this. The GP diagnosed post-operative pain and muscle spasm and prescribed strong analgesia (pain relief) and anti-inflammatory gargles (solutions used to treat throat conditions).

We upheld Miss C's complaint and made two recommendations. Our investigation found that, while the GP's diagnosis and the medication prescribed were reasonable, his advice to attend ENT was not helpful.

Recommendations

We recommended that the practice:

• review their actions in light of the findings; and
• apologise to Miss C for the failings identified.

Summary

Mrs C, who is an advocacy worker, complained on behalf of her client (Mr A) that the board did not make information about NHS continuing healthcare publicly available. Mr A had disputed the grounds on which his late father was considered liable for care home fees, as he felt that his father's placement related to health needs rather than social care needs. At the time of the placement, Mr A was not told that the NHS could fund care costs in care homes. Our investigation found that Mr A's father had been placed temporarily in the home for respite care, and he did not require an emergency hospital admission. The decision was then taken to make the care home placement permanent and health board staff were not asked to contribute to any assessments. The board accepted that at the time of the placement they had not made information about NHS continuing healthcare publicly available. They had since done this, and had apologised to Mr A.