Health

Summary

Mrs C, an advocacy worker, complained on behalf of Miss A, who had hurt her leg by tearing her anterior cruciate ligament (ACL) in a skiing accident in March 2010. Miss A was referred to the hospital where she was seen by a consultant orthopaedic surgeon, who arranged for her to undergo ACL reconstruction surgery about seven months after the accident. Screws were used to reattach tendons between her knee and thighbone.

Two months after the operation, Miss A fell and hurt her knee again. She went to an accident and emergency (A&E) unit and was referred back to the consultant. X-rays taken at A&E showed that the screw in Miss A's thighbone had become dislodged. However, due to the amount of pain she was in, and the level of swelling, the consultant was unable to carry out a full examination. He noted that Miss A had a good range of movement and concluded that the screw was likely in the soft tissue, holding the ACL reconstruction in place. A few days later, Miss A's pain increased and her knee began to lock. She returned to A&E where further x-rays found that the screw was inside her knee joint. Surgery was arranged to remove it and to re-do the ACL reconstruction.

After taking independent advice from our medical adviser, we upheld this complaint. We found that there was very little detail recorded at the time about what procedure the consultant initially performed. However, from the x-ray evidence we were able to establish that the ACL reconstruction had been placed in a less than satisfactory position. We also found that the advice given to Miss A by the consultant after her second fall was inappropriate. Although the x-ray evidence was not conclusive, it was most likely that the screw had migrated into the knee joint, and in any case, it was known that the screw was not in the thighbone. As such, the ACL graft was not performing its intended task and we took the view that revision surgery should have been arranged at that time.

Recommendations

We recommended that the hospital:

• apologise for the issues highlighted in this case; and
• draw our adviser's comments to the consultant's attention.

Summary

Miss C's medical practice were concerned about her compliance with her medication. They had, therefore, previously decided, with Miss C's agreement, to dispense her medication on a daily basis. However, Miss C requested that this be returned to weekly or monthly prescriptions, and she complained when this request was refused. The practice told us that, as they continued to have safety concerns about Miss C's compliance with her medication, they had decided that daily prescribing would remain in place. Having taken independent advice from our medical adviser, we considered this to be a reasonable decision in the circumstances.

Miss C also complained that her medication was no longer being prescribed to her in tablet form. She was receiving a liquid alternative and did not feel it was working as well for her. Although the practice had advised her that the tablet form was no longer available in this country, Miss C identified a drug company who could still supply this. However, the practice noted that this was imported and unlicensed and, therefore, did not agree to prescribe it. Our medical adviser took the view that this was reasonable and said that doctors are discouraged from prescribing unlicensed medication when licensed alternatives are available. In addition, he noted that the medication was very expensive and he did not consider that it would be prudent for the practice to prescribe overly expensive drugs that were not clinically necessary.

Summary

Mrs C was on medication for serious mental health problems. She registered with a new medical practice in 2011, having been stable for a number of years on an existing medication regime. However, the new practice did not obtain her medical records nor make contact with the psychiatrist who had been treating her previously.

In March 2012, Mrs C attended the practice about a non-related medical issue and saw a doctor. During the appointment, the doctor questioned the medication regime and said that Mrs C should undergo a review, as the types of medication she was on could have serious cumulative side effects if taken long term. Mrs C was upset and anxious that the doctor proposed reviewing her medication, given that she had been stable on the regime for a number of years and had had serious difficulties in achieving this stability. She was also upset by the doctor's tone and a number of comments he made during the consultation which she felt were inappropriate when dealing with a patient with mental health problems.

We found that the aims of the consultation were valid and constituted good practice. We were, however, critical that the practice failed to obtain Mrs C's medical records or to contact her psychiatrist, as she had registered with them nearly a year before. We noted that the doctor had written details of his comments in the consultation notes, and that he himself had since accepted that these may have added to her concerns. We were critical of this, and for the fact that he did not conduct an assessment of Mrs C's health at that time, although we recognised this could have been difficult given the nature of the consultation overall. On balance, however, we did not uphold the complaint as we found the aims of the consultation about which Mrs C had complained were reasonable and should have been undertaken earlier. We did, however, make recommendations to address the shortcomings we identified that took place before the consultation.

Recommendations

We recommended that the practice:

• conduct a significant event analysis in relation to Mrs C's treatment; and
• implement a procedure to ensure that all previous medical history and treatment is obtained when registering new patients.

Summary

Mr C complained on behalf of a constituent (Mr A). He complained about the board's decision to refuse funding for Mr A's weight-loss surgery to be carried out by another health board.

Mr A had serious concerns about the care and treatment he received from the board, when he was admitted to hospital previously. As a result, during the past few years, his GP had referred him for treatment, including weight-loss surgery, to a hospital in another health board area. The hospital offered Mr A weight-loss surgery but said that it would have to be funded by his local health board. The local board decided not to approve Mr A's application for funding and instead offered him the weight-loss surgery service that they provided. Mr A, however, believed it would be in his best medical interests for the surgery to be performed outwith his local health board area.

Our investigation found that the board's decision to refuse the funding of Mr A's treatment at another health board was a discretionary decision that they were entitled to take. We cannot look at such a decision unless we find evidence that something went wrong in the way it was taken. We did not uphold Mr C's complaint, as we found that the board followed their procedures and took all relevant factors into account in reaching their decision.

Summary

Ms C complained about the care and treatment she received from a hospital. She outlined eight specific areas of concern, including communication, standard of care, waiting times, lack of after care and competence of staff. She said that she initially went to the hospital with symptoms of bowel disease, but her worsening symptoms suggested a gynaecological problem. She said that after that she experienced other health issues. She underwent an operation and was referred for treatment to another health board. Ms C’s complaint to us also included other issues of concern including misdiagnosis, inappropriate administration of medication and poor complaints handling.

Our medical adviser considered all aspects of Ms C’s complaints and said that she displayed complex symptoms and had had a thorough investigation of her gastro-intestinal tract. She had an ovarian cyst (a sac filled with fluid that forms on or inside an ovary) removed promptly and an area of endometriosis (small pieces of womb lining found outside of the womb) destroyed. We found that medication was appropriately used, communication was effective and Ms C received timely inpatient attention and after care. Having taken account of all the evidence and the advice received, we considered that the board appropriately addressed and responded to all Ms C’s complaints. Although we did not uphold her complaints, we found some delay in advising Ms C's GP of a test result.

Recommendations

We recommended that the board:

• apologise for the delay in sending the results of the echocardiogram test to the GP; and
• take steps to ensure such a delay does not recurr.

Summary

Mr C complained about the admisitration processes for outpatient appointments and complaint handling.

The SPSO investigation found that there had been a delay in Mr C being allocated his original outpatient appointment and the board acknowledged this. However, our investigation did not find that the system was 'chaotic' as Mr C claimed. To the extent identified, that is the delayed initial appointment, this complaint was upheld.

On the matter of a verbal complaint made when Mr C attended for an appointment on the wrong day due to a failure to confirm a re-arranged appointment in writing, The investigation could not establish why he was told that a person whom the board have been unable to identify would come to speak to him. No one came to speak to Mr C within 10 minutes at which point Mr C began to suffer chest pains and was taken to the accident and emergency. He was then admitted to a ward for observation for 24 hours. He asked the ward staff to pass a message to Mr A to ask him to come to speak to Mr C on the ward. This did not happen before Mr C was discharged.

Our investigation could not establish who Mr A was. The board told us that there were no male members of the complaints team in the hospital that Mr C had attended. The board tried to establish who Mr A was but no one of that name could be found on the staff lists at the time of the incident.

On the matter of the complaints handling, our investigation found that although some of Mr C's complaints had been responded to in a comprehensive and timely manner there had been some matters that were not addressed. Mr C had also asked to be reassured that the issues he had raIsed had been brought to the attention of senior managers and/or the chief executive of the board. Our investigation established that although the complaints were brought to the attention of the chief executive, Mr C was not informed of this fact. Therefore, to the extent of the failings identified, this complaint was upheld.

Recommendations

We recommended that the board:

• apolgise for the delay in providing the inital outpatient appointment; and
• apologise for the failings identified in the complaints handling.

Summary

Mrs C had a history of tiredness and told us that she had a number of medical conditions. She complained that a medical practice, and one GP in particular, provided her with inadequate care and treatment over a seven year period. Specifically, Mrs C said that the GP; refused to investigate her symptoms; claimed to make referrals which turned out not to be the case which, in her view, prevented other doctors from investigating and treating her symptoms; inappropriately offered her cognitive behavioural therapy (CBT); and inappropriately prescribed and failed to monitor the use of a beta blocker for her symptoms, which Mrs C said almost led to her death.

Mrs C's letters and the medical records showed that the experiences she described were clearly very difficult and distressing for her. However, the GPs and hospital doctors she was referred to had not been able to medically explain her symptoms or find any abnormalities from their investigations. We did not uphold Mrs C's complaint. Our investigation found that the practice explained to Mrs C how they had treated her. Also, our medical adviser did not find any evidence that Mrs C's GP acted unreasonably when investigating her symptoms, making referrals, offering CBT or prescribing the beta blocker.

Summary

Mr C, who is a prisoner, complained that the board unreasonably delayed in providing dental treatment. Although Mr C was waiting to see a dentist before the board took over responsibility for prison healthcare in November 2011, he did not bring the matter to their attention until May 2012. He was seen the following month and the board explained the steps they had taken to reduce waiting times for dental treatment. We considered this reasonable and did not uphold the complaint.

Summary

Mrs A was an elderly woman with cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). She was admitted to hospital in April 2011 after falling at home and had an operation to repair a fractured hip. Mrs A developed an abnormally large volume of fluid in her feet and ankles and a leg infection. In July 2011, she was transferred to another hospital for treatment but was considered too frail for an operation and returned to the first hospital several days later. Mrs A was transferred to a third hospital at the end of August and died several months later. Mrs A's daughter (Ms C) complained about numerous aspects of her mother's care and treatment, including wound management and treatment, falls prevention, loss of hearing aids and teeth, the suitability of the ward and failure to carry out a Doppler test to assess her blood flow.

Our investigation found that the care and treatment in relation to wound management and treatment, the suitability of the ward, and failure to carry out the Doppler test was reasonable. There was no evidence to suggest that a Doppler test should have been carried out earlier, and the tissue viability nurse visited Mrs A at frequent intervals, documented their assessments and plans and took into account the overall requirements of Mrs A’s health and wellbeing. On the loss of hearing aids and teeth, we recognised the impact of this on Mrs A, but we were unable to establish how these were lost. It can be very difficult to prevent the loss of such items and we found staff took reasonable action to find and replace them. However, in relation to falls prevention, we found that the hospital failed to adequately risk assess, keep the assessment under review or have a cohesive falls prevention plan as part of the overall care plan.

Recommendations

We recommended that the board:

• take steps to ensure that ward staff comply with guidance on falls prevention; and
• apologise to Ms C for the failures identified.

Summary

Mrs C complained that her late husband Mr A (who had terminal cancer), had suffered during his illness up to his death. Mrs C stated that in her view, she could not believe so many things had gone wrong with the care and treatment Mr A had received from the practice over 17 months. These issues were a failure to follow up Mr A’s admission to a hospital in the board’s area after the hospital had discharged him; that a practice GP had provided incorrect information about Mr A during a home visit and that the practice failed to follow the appropriate processes and procedures when completing the Do Not Resuscitate Form (the DNR).

Our adviser considered all aspects of Mrs C’s complaint and said that Mr A had lung cancer and that it was the responsibility of the hospital clinician that arranged Mr A’s investigation to follow up and act on the results, not the practice.

Our adviser stated that a practice doctor had provided incorrect information during a home visit; however, the practice doctor had speedily corrected this and apologised.

The adviser stated that the DNR Form (as part of end-of-life care), assists with the management of terminally ill people and compliments the expertise of those using it. We took account of the adviser’s advice and considered that the practice had followed the correct DNR procedures. Mrs C’s complaint was partially upheld.

Recommendations

We recommended that the practice:

• re-examine along with the District Nursing Team as a whole, their role in this case within the Liverpool Care Pathway continuous Quality Improvement Programme (to include the completion of the DNR form), to see (and reinforce) if there are lessons to be learned and how they can be applied to prevent such a scenario arising in the future (reference to both complaints 3 and 4).