Health

Summary

Mr C attends hospital regularly for treatment. On one of those occasions a member of staff handed him an envelope containing letters that Mr C had given another member of staff to read. The envelope was addressed to Mr C but it was open. Mr C was concerned because the letters contained personal information about him. He complained to the board but was dissatisfied with their response and complained to us.

When we investigated, the board said they had asked staff about this after Mr C complained but no-one could remember anything about the envelope and there was nothing documented in his file. There was no further information or evidence available, and in the absence of such evidence we could not uphold the complaint as we could not say for certain whether or not the envelope was open when it was left for Mr C.

Summary

Ms C fell while away from home and fractured her wrist. At the time she was 70 years old with a history of osteoarthritis (a common form of arthritis causing chronic breakdown of cartilage in the joints). She had a cast applied to her wrist. On returning home, she was seen at a hospital. As the bones had not lined up properly, she had an operation to correct this using a fixator (a device to fix the position of fractured bones). Ms C was unhappy when the fixator was removed, as she was told that the bones were still out of alignment and she would not regain the full function of her wrist and fingers. She questioned whether the bones had been correctly aligned before the fixator was fitted. She further complained that the anaesthesia (pain relief) given to her failed to work and that she experienced a great deal of pain. She said that the operation had not been properly explained to her and that the board had taken too long to deal with her complaint.

We investigated the complaint taking into account all the relevant information, including the complaints correspondence, relevant clinical notes and x-rays. We also obtained advice from our medical adviser, who reviewed Ms C's notes and the care and treatment she received. He said that her treatment was entirely appropriate and satisfactory. He said that sometimes anaesthesia could be imperfect, but that this did not necessarily indicate any failure by the doctors. He said that her pain was managed in accordance with accepted practice. The adviser also took the view that the board's explanations to Ms C about her operation were appropriate and reasonable.

Taking all these factors into account, we did not uphold Ms C's complaints about her care and treatment. However, there was evidence to suggest that the board took too long to deal with her complaints on these matters.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in responding to her complaint; and
• remind their staff of the importance of adhering to their stated complaints handling timescales and process.

Summary

Mr C complained that there were several errors in a letter that a doctor sent to his GP after he attended a clinic about his stomach problems. He said that this showed the doctor had not paid attention to him during the consultation. We obtained the doctor’s notes of the consultation and asked for his comments on the matter. The doctor said that he believed that the notes he took and the letter he dictated following the consultation with Mr C were accurate. Our investigation did not find any evidence to support Mr C’s complaint that there were errors in the letter.

Mr C also said that the doctor sent the letter to the wrong medical practice. Our investigation found that the letter had been sent to the correct practice and did not uphold this part of Mr C’s complaint. However, we found that when Mr C complained to the doctor about the letter, the doctor sent the complaint to Mr C’s practice, but did not respond to it.

Recommendations

We recommended that the board:

• write to Mr C to apologise for the doctor's failure to respond to his complaint.

Summary

Mr C complained that he endured more than 18 years of illness due to inadequate care and treatment by the doctors at his medical practice. Mr C said this was demonstrated by the doctors’ inability to provide appropriate care and treatment for his stomach problems or tell him about his post-prandial condition (which involved symptoms arising after he ate). Mr C said that he had lost trust with the practice doctors.

We did not uphold Mr C's complaints. Having taken advice from our medical adviser, who considered Mr C's clinical records, we decided that the practice had appropriately treated and cared for Mr C over the period in question. Our adviser said that the term 'post-prandial fatigue' is not a diagnosis as such, but is a medical term used to describe symptoms. We noted that doctors had referred Mr C to hospital at his insistence - our adviser said this sometimes happens when a doctor cannot reassure a patient about their symptoms. We also noted that tests taken at the hospital proved negative.

Summary

An advocacy worker (Ms C) complained on behalf of Mrs A, whose husband (Mr A) had been treated by the board. Mr A had become ill in October 2010, and his GP prescribed antibiotics for a presumed chest infection. Mrs A became concerned about his condition later the same day, however, and believed that her husband was having a stroke. Mr A attended the accident and emergency department of a hospital and was admitted. Records show that Mr A was found to be confused, with slurred speech and impaired mobility, but investigations found that he had not had a stroke and did not have an infection. No confirmed cause was established for his confusion, and he was discharged with a suspected Transient Ischaemic Attack (a type of stroke, sometimes called a mini stroke, that shows no evidence on CT scans but resolves in around 24 hours).

Mrs A complained that Mr A was discharged home whilst still very confused. She questioned the level of investigation into his condition. She also said that her husband had been diagnosed with lung cancer six months after his hospital admission and asked whether this should have been diagnosed at the time.

After taking advice from our medical adviser, we upheld two of Mrs A's complaints. We found that staff thoroughly investigated the cause of Mr A's confusion and reached appropriate conclusions. A chest x-ray taken during his admission did show an abnormality that was suspicious of, but not diagnostic of, cancer. We noted that the radiologist's report recommended investigation of this once Mr A's condition improved, but found no evidence of follow-up arrangements being made or of Mr A and his family being told of the finding.

We were unable to comment as to the extent of Mr A's confusion when he was discharged home, as when he was admitted the board failed to obtain detailed information from Mrs A about his usual state. However, we noted that a care plan and discharge plan were completed stating that arrangements had been made to provide Mr A with support at home, but found no evidence of the described actions having been taken. There was also a lack of evidence of staff discussing discharge arrangements with Mrs A. As such, we were left with doubts as to whether it was appropriate to discharge Mr A.

We did not uphold Mrs A's complaint that the board failed to provide a follow-up appointment for her husband, as we could not find evidence to show that this should have happened.

Recommendations

We recommended that the board:

• apologise to Mrs A for the issues highlighted in our decision;
• draw Mr A's case to their staff's attention to ensure that discharge arrangements are properly followed up and documented and that patients' families are routinely consulted about their perceptions of the need for support at the time of discharge; and
• consider carrying out an audit of actions that are actually undertaken in the discharge planning process against the benchmark of their discharge planning documentation.

Summary

Mr C had ulcerative colitis (a type of inflammatory bowel disease) and attended a specialist appointment at Hospital 1. He was told that he would be reviewed at a follow-up appointment in three weeks. Mr C's wife (Mrs C) complained that no follow-up appointment was arranged. Mr C's condition deteriorated and he was referred to the accident and emergency department of another hospital (Hospital 2). He was admitted and treated with intravenous drugs (drugs administered into a vein). The drugs had no effect and Mr C was identified as needing an operation. Mrs C said she was told that her husband would require two further operations after that, and that this might have been avoided had he been treated sooner.

Mrs C complained that the board did not provide Mr C with reasonable care and treatment before his surgery. She also complained that they did not take reasonable action to address a known issue with follow-up appointments and that they delayed in responding to her complaints correspondence.

We upheld all Mrs C's complaints. Our investigation found that although an initial follow-up appointment was made, later planned appointments were not confirmed with Mr C. In relation to the complaint about Mr C's treatment, our medical adviser considered that the initial prescribing of steroids was appropriate. However, as Mr C's condition worsened, he should have been admitted for a course of intravenous drugs. Delays to the follow-up appointment meant that by the time treatment was provided by Hospital 2, it was too late for it to be effective. Taking all the evidence, and the advice of our medical adviser, into account we concluded that Mr C would have required the three operations at some point. However, the delay to the follow-up appointment meant that all the surgery was required sooner than it would have otherwise been, resulting in limited time for Mr C to prepare for the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for the issues highlighted in our investigation;
• provide us with details of the service manager for medicine's review findings and any action proposed as a result of the review; and
• take steps to ensure that all patient referrals and follow-ups are acted upon in accordance with the relevant standards.

Summary

Mrs A had been treated by her GP for some time for a disease of the lungs, chronic obstructive pulmonary disease (COPD). After having problems with breathlessness for two months, she was admitted to hospital. The admitting doctor thought that Mrs A's symptoms were not typical of COPD and suspected that the cause of her distress was a pulmonary embolism (a weakness in the wall of a blood vessel in the heart or chest that can cause a sudden rupture). However, after examination, investigations and observations, another doctor noted COPD as the 'preferred diagnosis', with pulmonary embolism as a differential (or possible secondary) diagnosis.

Mrs A was discharged from hospital after two days, but collapsed and died nine days later. A post-mortem confirmed that pulmonary embolism was the cause of death. After Mrs A died, the board carried out a critical incident review (CIR) (an assessment of why the incident occurred), which found that there had been failings in her care and recommended action to remedy this.

Mrs A's daughter (Mrs C) complained to the board about her mother's death and about the action taken in response to it. She remained dissatisfied with their responses and complained to us. As the board fully accepted responsibility for Mrs A's death, our investigation focussed only on the remedial action they had taken to address the concerns raised by the CIR. We referred the CIR report to our medical adviser to assess the remedial actions taken.

Our adviser said that the CIR had been of high quality and the timelines proposed were appropriate. He felt, however, that although the board had taken positive action, some of the recommendations were still aspirational. We, therefore, asked for further evidence of the remedial action taken or on-going. From the response, we were satisfied that further progress had been made, but considered that there were still some areas requiring further action and/or monitoring. Although, therefore, we did not uphold the complaint, we asked the board to continue to work towards the aspirations in the action plan and to report back to Mrs C and to us. We also made a recommendation relating to how they use information from the DATIX system (an electronic management system for recording incidents).

Recommendations

We recommended that the board:

• incorporate specific elements into rural practitioners training programmes to address any issues identified from DATIX incidents;
• continue to work towards establishing an integrated networking system within the organisation; and
• set up a formal, structured clinical audit programme agreed with the clinical director.

Summary

Mrs C became pregnant at the age of 40. Her pregnancy appeared to progress well, but at just over 37 weeks it was discovered that her baby had died. Mrs C’s baby was stillborn the following day. Mrs C made a number of complaints about the care that she, her baby and her husband received both during and following her pregnancy.

Mrs C was concerned that she had been placed on a midwifery led care pathway. Having taken advice on this from our medical advisers, we found that this was appropriate, as she had no apparent risk factors. Her age was taken into account appropriately, with an extra appointment for a fetal growth scan (a scan to detemine the growth and health of the baby) with an obstetrician at 12 weeks. We also found that Mrs C’s care complied with the governmental guidelines 'Pathways for Maternity Care' and did not uphold this complaint.

Mrs C also complained that the systems of routine scans and antenatal checks did not provide enough care to mothers and babies. She was concerned, in particular, that no further midwifery appointments were offered after 35 weeks, and that additional checks were not carried out on her. We found, however, that the care in place was appropriate, that Mrs C had had a suitable number of midwifery appointments at the appropriate stages throughout her pregnancy, and that a balance had to be struck between positive elements of providing reassurance and detecting disease for which there is an intervention, and negative elements of creating anxiety and possibly unnecessary early delivery. We did not uphold this complaint.

Mrs C said that the postnatal care offered to her and Mr C was inadequate and did not offer enough support for their bereavement. We found that, although the postnatal care by the midwives was adequate, Mrs C was not contacted by a health visitor. The board said that a health visitor would not visit in the event of a stillbirth, but the advice we received indicated that contact would have been appropriate. We upheld this complaint and recommended the board reconsider their policy in this regard.

Mrs C also complained that the information offered by the board about loss in pregnancy was inadequate. We did not uphold this complaint as we found the information offered by the board through parentcraft classes was proportionate and appropriate.

Finally, Mrs C complained that the board did not fully address some of the issues she raised with them. We upheld this complaint as we found a number of errors in the information the board gave Mrs C throughout their correspondence with her. There was also an unnecessary delay in providing the results of a second opinion post-mortem report that Mr and Mrs C had requested.

Recommendations

We recommended that the board:

• provide us with evidence that they have reviewed their policy and clarified the role of health visitors in the event of stillbirth and neo-natal death, to ensure sufficient information is communicated effectively during the midwifery discharge process;
• provide Mrs C with a copy of the second opinion post-mortem report and offer her an appointment to discuss the findings; and
• provide Mr and Mrs C with a full apology for the failings identified.

Summary

When Miss C was admitted to a ward for a mental health assessment, she was unhappy with the attitude and conduct of a nurse. She complained that the nurse had shouted at her and that she had to ask other staff to intervene. The board responded to the complaint, saying that staff recollections differed from Miss C's recollections, but that all staff members involved agreed that she had been distressed and a situation had developed. Miss C was dissatisfied with the board's investigation into her complaint.

We explained to Miss C that we would not consider her complaint about the nurse's conduct as this was open to differing interpretations of those involved and there was an absence of independent witnesses. We did consider whether the board's investigation was adequate, and found that there was evidence that the relevant staff had been interviewed and provided statements.

Summary

Mr C had chronic pain in his back and leg which had previously been relieved by epidural injections (injections into the spine to relieve pain or inflammation). In May 2011, he was referred for a further injection. He said that during the procedure the consultant anaesthetist hit bone and a nerve in his back, and had attempted to place the injection several times before placing it 'anywhere he could'. Mr C said that the pain in his back had been intense, and that he now had a permanent numb leg with loss of muscle tone, caused by the inadequate administration of the injection. He felt the procedure had caused him irreparable nerve damage, and he had gone on to have a second opinion and investigatory tests in relation to this from another board area.

After taking advice from our medical adviser, we decided that we could not definitively conclude that Mr C's symptoms were a result of the procedure being performed inadequately. We found that in this type of procedure it was not unusual for several attempts to be made to site a needle, and that bones in the spine could in fact be used as a landmark to help place the injection accurately. We also found that nerve damage was a rare but recognised complication. We did not uphold the complaint but noted that the consent documentation did not record that nerve damage was discussed with Mr C as a potential complication. Although Mr C had not raised this as a specific complaint, we drew it to the board's attention.