Health

Summary

Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year in being sent to see the correct consultant. Mrs C also complained that she was not referred to a bone anchored hearing aid (BAHA) clinic when she first attended for investigations, and she questioned whether this clinic existed at all. BAHAs conduct sound to the inner ear directly through the bone, rather than through the air, which is how Mrs C's current in-ear hearing aids operate. In addition, Mrs C complained that the audiology clinic had no appropriate BAHA headband trial equipment available for nearly seven months.

We were critical of the board's lack of clarity in communicating with Mrs C about the availability of BAHA headbands, and we drew this to their attention. However, it is not for us to say how the board should use their resources, and it was clear that the lack of availability of BAHA trial headbands was a resource issue that the board had tried to remedy by ordering additional units. Therefore, we did not uphold this complaint.

When we looked into Mrs C's other complaints, we found that the BAHA clinic did exist. The board accepted there were difficulties and delays in progressing Mrs C's care and they apologised to her. Our adviser noted that a key referral should have been more clearly documented, and that Mrs C should have been considered for other hearing aid technologies more quickly, given that she was unable to use air conduction devices. We concluded that Mrs C did not see appropriate staff in reasonable time and, in particular, that she should have been considered sooner for referral to the BAHA clinic, and we upheld these complaints.

Recommendations

We recommended that the board:

• review pathways from Audiology to ENT (medicine of the ear, nose and throat), so that patients who do not benefit from air conduction hearing aids can be considered for other technologies in reasonable time.

Summary

Mr C suffers from a number of painful conditions. He takes codeine (a pain relief drug) to manage the pain, but it causes severe constipation. He was prescribed Orlistat (a weight-loss drug) by his GP some years ago to help him reduce and maintain a steady weight. Mr C found that the drug also relieved his constipation. When reviewing Mr C's medication, however, his GP felt that it was no longer appropriate to continue to prescribe this. Mr C was referred several months later to a pain clinic for pain management and to explore alternatives to codeine, and to a dietician about his weight problem. However, he continues to suffer from weight gain and constipation and maintains that the benefits of taking Orlistat outweigh the risks of both that medication and the alternatives. He complained to us that the decision to stop prescribing it was unreasonable.

After taking advice from one of our medical advisers, we did not uphold Mr C's complaint. We found that the GP's decision was reasonable as Mr C had not lost weight since early 2009, and the medication is not licensed for use as a laxative. We also found that the decision followed the health board's guidelines on its use.

Summary

Mrs C complained that the health board unreasonably failed to provide a home podiatry visit for her elderly father (Mr A). Podiatry is the branch of medicine related to disorders of the foot, ankle and lower extremity.

Mrs C also complained that there was unreasonable failure to maintain Mr A's feet to an acceptable standard and to make a referral to a specialist team when required. Mrs C had concerns about the method of making home visits, about comments in some of the notes, and said there were unreasonable delays and a failure to answer her questions during the complaints process.

Mr A had a significant history of multiple illnesses, including insulin dependent diabetes and mobility problems. These were made worse in cold weather. As is standard for diabetics within the NHS, Mr A had had a podiatry assessment and was receiving regular podiatry treatment - usually attending his local clinic. However, in early December 2010 there had been heavy snowfalls and he was unable to attend a scheduled appointment. Mrs C telephoned the clinic to ask for a home visit. She said she found the attitude of the staff members she spoke to unacceptable, and that she was told that a visit would not be arranged or at least not for some weeks.

Mrs C was concerned about this arrangement as her father had had previous problems with diabetic ulcers on his feet and was complaining of a sore right foot. She spoke with the service director, and a home visit was arranged for the next day. Mr A received several treatments at home during December 2010. He was referred to the specialist team at the end of December and seen the next day. He was immediately admitted to hospital for treatment of an infected diabetic ulcer on his toe. Mr A was discharged in mid January 2011. He was readmitted five days later and died in hospital in February 2011. The primary cause of death was sepsis (infection).

Our investigation included taking independent advice from a podiatrist and a physician, and we upheld all Mrs C's complaints. The podiatrist said that although in general Mr A's feet had been maintained to a reasonable standard, by early December 2010 it should have been clear to the podiatrists that the ulcer was not healing and Mr A should have been referred to the specialist team at that stage. The podiatry adviser also found fault with the general lack of detail in the notes and said that there were some subjective rather than objective comments.

Having seen Mr A's medical records, the physician adviser said that although sepsis was the primary cause of Mr A's death it was not directly caused by the infected toe. However, Mr A had been treated for some time with antibiotics to try to address the infection in his toe. Although this was appropriate treatment, use of antibiotics in this way can kill off the natural pathogens (bacteria) within the digestive system. This can pre-dispose a patient to contracting Clostridium Difficile infection, which is what happened to Mr A. Such infection can produce a range of symptoms from diarrhoea to severe and overwhelming infection, particularly in a patient such as Mr A, with other significant medical problems. Therefore, although the infected toe did not directly lead to Mr A's death, it was a factor in it.

Recommendations

We recommended that the board:

• apologise for the deficiencies identified in our investigation;
• report on their review of the process for home visits;
• review the standard of podiatry notes; and
• provide awareness training on SIGN 116 (guidelines on the management of diabetes).

Summary

Mr C complained that his medical practice failed to provide reasonable treatment and advice to him in relation to peripheral vascular disease (PVD), a condition causing narrowing of the arteries. He attended his practice for a number of years complaining of leg pain, which the GP attributed to back problems. In 2011, after a deterioration in his condition, Mr C was admitted to hospital where he learned that he had been diagnosed with PVD in 2005. He complained that he was not told about this diagnosis and was not treated for PVD. He believed that this led to years of unnecessary pain.

We found that, as well as PVD, Mr C had serious back problems that ultimately needed surgery. Our medical adviser said that both conditions could have caused leg pain. At the time of being diagnosed with PVD, however, Mr C was in his forties. Our adviser said that diagnosis at this age was relatively unusual and, as such, Mr C's case should have been investigated, possibly with immediate referral to a specialist. Mr C's GP had prescribed aspirin and told him to stop smoking. On balance, we considered that this would have been reasonable if Mr C was supported to stop smoking and was monitored via regular blood pressure checks. However, we found no evidence in the clinical records that Mr C's GP made him aware of the diagnosis, nor that there was any support provided to help him stop smoking, nor regular monitoring of his condition. We, therefore, upheld the complaint and made recommendations.

Recommendations

We recommended that the practice:

• apologise to Mr C for the issues highlighted in our investigation; and
• review and discuss Mr C's case at a practice meeting to identify where improvements can be made to record-keeping and the treatment of future patients.

Summary

Mrs C was diagnosed with advanced bowel cancer in January 2011. She told us that from March 2010 the practice had failed to properly investigate the symptoms she was presenting with, and that she should have been referred to hospital earlier.

We did not uphold Mrs C's complaints. We found that the practice's care had been good. Our medical adviser said that, although with hindsight it could be suggested that a significant pattern was emerging, this was not evident at the time. From March until September 2010 Mrs C had presented with a variety of non-specific symptoms including exhaustion, abdominal pain, bloating and vomiting. She had been prescribed HRT (hormone replacement therapy) which had helped with some of her symptoms. However, her abdominal pain continued, and Mrs C was referred for an ultrasound scan. She also attended a hospital accident and emergency unit a couple of days before the scan appointment due to a bout of severe pain. The ultrasound scan results did not prompt further investigation, and Mrs C did not return to the practice until November 2010. At this stage she was displaying trigger symptoms for bowel cancer including weight loss and a change in bowel habit, and was urgently referred for a colonoscopy (examination of the bowel with a camera on a flexible tube) following the results of blood tests.

Although the practice could have arranged for Mrs C to undergo blood tests earlier, we did not find that their care of her had been deficient. We noted that they had carried out a significant event analysis of what had happened, and had identified some learning points for the future.

Mrs C also complained she should have been sent for an earlier colonoscopy, rather than the ultrasound scan. We found, however, that sending her for the ultrasound scan was appropriate, given the symptoms Mrs C was displaying at the time. We also found that the practice acted reasonably after receiving the scan results, although we noted that they missed an opportunity to review Mrs C in person at that stage, and drew this to their attention.

Summary

Mrs C went to her dental practice to have a tooth removed and a neighbouring tooth filled. She returned to the practice several weeks later complaining of toothache and saw another dentist. Mrs C decided to have the problematic tooth extracted. Mrs C said that before the extraction she clearly told the dentist that her toothache was originating from the tooth that had recently been filled. Shortly after the extraction, she returned to the dentist complaining that he had removed the wrong tooth. The dentist said he had tapped on both neighbouring teeth several times to find out which tooth was causing Mrs C pain, and that she several times identified the one he extracted as the problematic tooth. Mrs C did not recall the dentist tapping her teeth but even if he did, she said that she did not know if she could have said which tooth was causing pain when tapped, given the recent extraction and that she had painful toothache in the same area. Mrs C later had the problematic tooth extracted and remains very distressed at the effect of the three adjacent missing teeth.

We did not uphold the complaint. We found that the dentist carried out an appropriate examination, which led him to a reasonable diagnosis, and that the extraction of the tooth was reasonable. We also found it reasonable that that the dentist failed to apologise for the extraction.

When this report was first published on 24 October 2012, it was incorrectly categorised as being about Greater Glasgow and Clyde NHS Board.  This was due to an administrative error which we discovered on 31 October 2012, and for which we apologise.

Summary

Ms C, an advocate, complained on behalf of Miss A who had a blood condition that caused her to have two deep vein thromboses (DVTs - a blood clot in a deep vein). She was required to regularly attend an anticoagulation clinic so that her International Normalised Ratio (INR – a test used to determine the likelihood of the blood clotting) levels could be monitored and managed. Ms C complained that the board failed to maintain effective control of Miss A's INR levels and failed to offer her alternative medications that might improve her quality of life.

We found that Miss A's target INR levels were increased in 2006 following her second DVT. We accepted independent advice from our medical adviser that this would normally only happen if a patient had a thrombosis (blood clot) whilst their target INR level was at a lower range. This was not the case for Miss A. However, the consultant who decided to increase the target INR level had retired and there was insufficient evidence available for us to rule out a legitimate clinical reason for increasing the target level. Alternative medications are available for patients who are at risk of thromboses or haematomas (bleeding into the tissue around the veins). However, we found that this medication carried a greater risk to the patient than the warfarin that Miss A had been prescribed.

Summary

Ms C complained about her late mother's (Mrs A) care and treatment in hospital. Mrs A fell while in hospital as an in-patient.

Ms C said that, due to her mother's risk of falling, it had previously been agreed that she should always be accompanied to the bathroom. However, in September 2011, Mrs A fell when she went there on her own. Mrs A was found and returned to bed by staff but, Ms C said, she was not properly examined and a doctor was not asked to examine her. Ms C considered this inappropriate because her mother had a history of falls, had recently broken her hip and had osteoporosis. Ms C said that her mother was eventually sent to another hospital for x-rays after she saw a doctor the next day. However, she alleged that the nurse accompanying Mrs A there did not have proper instructions and Mrs A's neck was not x-rayed.

Ms C said her mother complained of neck pain on her return, and was referred back to the other hospital the next day for a neck x-ray. It was established that she had a neck fracture. Mrs A later died and Mrs C believed that this was as an indirect result of what she considered to be the lack of care in September 2011.

We obtained independent advice from our nursing adviser and a medical adviser, who considered Mrs A's medical records. Our nursing adviser said that while Mrs A was known to be at risk of falling and that it had been agreed that she was to be accompanied to the bathroom, she was not considered to need 24 hour observation. The nursing adviser said there was also a balance to be achieved between promoting independence and mobility, and the need to assist. In her opinion, the adviser said that the hospital took all reasonable steps to prevent falls and promote mobility but that Mrs A had gone alone to the bathroom without being seen.

On being discovered after her fall, we found that Mrs A was given first aid and observations were commenced. The nursing staff consulted on-call medical staff who said they should continue with observations every two hours, with a medical review taking place the next day. If anything changed, nursing staff were to contact the on-call medical staff again. The medical adviser said that Mrs A was sent to the other hospital with a referral letter (which they said was of good quality) but essentially she was being sent for review and it was the responsibility of the receiving doctor to decide what treatment to give. The receiving doctor did that and discussed the matter with his superior. A neck x-ray was not carried out. The nursing adviser also confirmed that the member of staff accompanying her was acting as a chaperone.

Taking all of the above into account, we did not uphold Ms C's complaints about her late mother's care and treatment. We did, however, uphold her complaint about their complaints handling. Ms C had said that she found the board's replies confusing and contradictory. We reviewed the correspondence during our investigation and found that the information passed to Ms C was indeed contradictory. As, however, the board had already acknowledged this and apologised, we did not make any recommendation.

Summary

Mrs C told us that her late mother (Mrs A) was admitted to hospital for oesophageal (gullet) enlargement to help reduce a thin membrane that had formed in her gullet. This was to be a day procedure. However, following the procedure, Mrs A suffered complications and remained in the hospital where further surgery took place. Her condition worsened and she was transferred to another hospital in the board's area where she died. Mrs C and her family complained to the board that Mrs A received inadequate care and treatment, communication and nursing care while a patient in the hospital. Mrs C said that there was a failure to take Mrs A's visual impairment into account, and was dissatisfied with the response she received to her complaint.

Two of our medical advisers reviewed Mrs C's complaint and Mrs A's medical records. After carefully considering their advice, we found that there was no evidence that Mrs A had not received appropriate care and treatment from the hospital and from nursing staff. We also found that, overall, the communication with Mrs C, Mrs A and her family was acceptable. We did not uphold any aspects of these complaints.

However, one of our advisers, a nursing adviser, was critical of the lack of documented information and care planning about Mrs A's visual impairment. We considered that the board failed to take Mrs A's visual impairment into account and upheld this complaint.

Recommendations

We recommended that the Board:

• ensure that, where a patient is visually impaired, this is recorded and taken into account of in their nursing assessment and care plan; and
• advise us of the outcome of any discussions with the Royal National Institute of Blind People concerning measures to improve the future care of patients with visual impairment.

Summary

Mr C had a gastric band fitted to help him lose weight. However, he felt that he would be able to lose more weight if he had a gastric bypass (a procedure that involves the creation of a small pouch at the top of the stomach with staples). As he had gallstones and was due to have his gallbladder removed, the board decided that they would carry out a sleeve gastrectomy (surgery to decrease the size of his stomach) at the same time as the gallbladder operation. However, in a letter to Mr C about this, the surgeon incorrectly said that he was to have a gastric bypass. Mr C said that he only found out 20 minutes before the operation that he was to have a sleeve gastrectomy and not a gastric bypass. He complained to us about the board's decision not to let him have gastric bypass surgery at the time of the operation.

Having taken independent advice from our medical adviser, it was clear from the medical records that the board had decided to carry out a sleeve gastrectomy. However, we found that their communication with Mr C before the operation was inadequate. They incorrectly told him that he was to have a gastric bypass. They also failed to review him, which meant that the surgeons were unaware that he had in fact lost sufficient weight to no longer require either a sleeve gastrectomy or a gastric bypass. By the time the operation was carried out, Mr C no longer met the criteria in the national guidelines for these operations.

We did not, however, uphold Mr C's complaint. We found that the board were not obliged to carry out a gastric bypass simply because of the error in the surgeon's letter. In fact, the correct course of action would have been not to provide either procedure. We found that the board had apologised to Mr C for their poor communication. We were also satisfied that they had taken steps to try to prevent similar problems occurring.

Mr C also complained about the board's ongoing position that they would not give him a gastric bypass. We found that he still did not meet the criteria for this at the time he made his complaint to us. There was also no evidence that the board told him that the sleeve gastrectomy was the first step in a two-step operation to give him a gastric bypass.