Health

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.

Summary

Mr C complained when his local medical practice decided to remove him from their patient list. His new medical practice is located some miles from his home and getting to it causes him inconvenience and expense. Mr C said that he did not understand why he had been removed from the practice list.

Our investigation found evidence that the practice had properly explained their decision, and the reasons for it, to Mr C and had then removed him from the list. However, we upheld the complaint because they had not issued Mr C with a warning about his behaviour in the twelve month period leading up to the decision, which they were contractually obliged to do.

Recommendations

We recommended that the Practice:
• revise their policy relating to the removal of patients from practice list; and
• apologise to Mr C for failing to issue a warning prior to removal from patient list.

Summary

Ms A requested that her first appointment with a new medical practice be longer than usual. Ms A was late for the appointment, and when the GP refused to see her she became upset. She wrote a letter about the situation while she was in the practice but this was not responded to. Within a few days she was informed that she had been removed from the practice list.

Ms A's representative (Ms C) complained to the practice on her behalf. They replied, saying that their views about the length of the scheduled appointment, how late Ms A had been and the behaviours she had displayed were different from those of Ms A. Ms A was dissatisfied with their response and raised her complaints with us.

We decided that the practice had reasonably fulfilled a request for a prescription and passed Ms A's records to her new practice. However, as they had not met the requirements of the relevant regulations for the immediate removal of a patient from a treatment list, we upheld Ms A's complaint that her removal had been inappropriate. We also upheld Ms A's complaint that the practice did not respond reasonably to complaints submitted about this matter.

Recommendations

We recommended that the practice:

• apologise to Ms A that her removal from their practice treatment list was not appropriate;
• review their procedure for the removal of patients from their treatment list to ensure that it complies with the relevant regulations, guidelines and guidance;
• apologise to Ms A that they did not respond reasonably to her letter; and
• review their complaints procedure to ensure that it is in line with the NHS Scotland complaints procedure.

Summary

Mr C complained that when his late father (Mr A) went to his medical practice in December 2011 they did not fully assess his condition and showed a lack of urgency in following up with his father. Mr A had a history of myeloma (cancer of the bone marrow) and had received treatment, including a stem cell transplant, between 2009 and 2011. In late 2010 and in November 2011 Mr A was told there was no trace of the disease left.

In late November and early December 2011 Mr A started to complain of breathlessness, weight loss, decreasing energy levels and back pain. His son and wife were concerned and persuaded him to speak to his GP on 6 December, as he was due to attend the practice that day for blood tests. Mrs A accompanied Mr A to the surgery and when she realised that Mr A was only due to see the practice nurse for the blood tests, asked that Mr A be seen by a GP.

One of the GPs (not Mr A's regular GP) saw Mr A as an emergency appointment. Although they examined him and made notes, our investigation found that there was no record of the presence or absence of anaemia (iron deficiency) or of the standard observations of pulse, temperature, respiration rate etc that would be expected for a patient reporting the symptoms that Mr A was suffering. The GP diagnosed a chest infection and prescribed an antibiotic. He told Mr A to make a follow-up appointment for seven days time, at which blood tests would be taken if there was no improvement in his symptoms.

Mr A forgot to make the follow-up appointment but six days later his son was so concerned that he tried to speak to Mr A's regular GP but was unable to do so. He did manage to speak to her the following day and she arranged urgent blood tests. The laboratory that conducted the tests were so concerned by the results that they contacted the local out-of-hours GP service that evening. A GP reviewed the results and notified the practice, but considered that a full GP review could wait until the next day. Mr A saw his regular GP, who immediately advised him to go to the local hospital and called ahead to make arrangements for him to be seen there. Mr A was admitted, but died in hospital the next day.

We upheld Mr C's complaint. Our medical adviser said that the GP should have had further blood tests done on 6 December, with a GP review on receipt of the results. The blood test that the practice nurse had taken was to check Mr A's cholesterol level and would not have told the GP anything about his condition or the cause of the symptoms Mr A complained of. The adviser also said that while it might have been reasonable for the GP to prescribe the antibiotic, the fact that he suspected an infective condition should have rung alarm bells in a patient with Mr A's history of myeloma. He thought that the symptoms Mr A was reporting should have triggered a more robust follow-up.

Recommendations

We recommended that the practice:

• issue a written apology to the family of the late Mr A;
• ensure that the GP conducts a significant event audit, to be discussed at his next appraisal; and
• conduct a review of a sample of clinical records to ensure that consultations are appropriate and accurately and fully recorded.

Summary

Mr C was dissatisfied after treatment from two dentists during 2010. He complained by telephone in January 2011. He also sent a complaint by email in June 2011 when the practice approached him for payment of an outstanding bill. Mr C's email was acknowledged by the practice by email three working days later, but as Mr C received no formal response to his complaint he telephoned several times between June and October 2011. He sent a further email in October 2011 which was acknowledged six working days later. Again he received no formal response to the complaints and approached us in January 2012. He complained that the practice had failed to respond appropriately to his complaints.

We upheld Mr C's complaint. Our investigation found that the practice's complaints policy and procedure did not comply with relevant NHS legislation and guidance at the time. The guidance said that complaints to family health service providers should be acknowledged within three working days and a full response provided within ten working days. The practice complaints policy said that they would acknowledge complaints within seven working days and respond within 20 working days.

Our investigation also showed that the practice did not comply with their own timescales. Although the two emails Mr C sent were acknowledged, there is no evidence that any of his calls were recorded, acknowledged or responded to. In addition, when we made enquiries to the practice these were either not responded to or the responses were very delayed.

Recommendations

We recommended that the practice:

• issue a written apology to Mr C; and
• review and amend the practice complaints procedure to comply with the requirements of the NHS legislation and guidance.