Health

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.

Summary

Mr C complained that his medical practice inappropriately asked the local health board to remove him from their list of patients. He said that the practice did not give him an adequate reason for this, and simply told him to contact the board for further information. He was also unhappy about the practice's handling of his complaints.

We upheld most of Mr C's complaints. The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 outline the procedure to be followed when a practice wishes to remove a patient from their list of patients. The British Medical Association and the General Medical Council have also provided guidance on this. The practice told us that their relationship with Mr C had broken down. However, we found that they did not issue him with a warning as outlined in the regulations. The practice also failed to explain his removal from their list. It was not appropriate that they told him to contact the board about this - it was up to the practice to explain why he was removed.

Our investigation also found that the practice's complaints procedure was out of date when Mr C complained, and that they had made inappropriate comments in their response. We did not, however, uphold Mr C’s complaint that the practice took too long to deal with the matter. They issued a response as soon as they received a copy of his letter from the board.

We noted that, before Mr C complained to us, the board had arranged a meeting between him and the practice. At the meeting, the practice apologised for their failings and outlined the steps they had taken to prevent similar complaints.

Recommendations

We recommended that the practice: issue a written apology to Mr C for their failures in relation to him being removed from their list; the fact that their complaints procedure was out of date; and the inappropriate comments about other patients being placed at unnecessary risk in their response to his complaint. 

Summary

Mrs C complained that her late father (Mr A) received inadequate care and treatment while he was a hospital in-patient. Mrs C said that a nurse refused to help Mr A (who had limited mobility due to a stroke) to the toilet and then provided him with a used urinal bottle, which was also difficult for Mr A to manage. Mrs C also said that alert buzzers were inaccessible. She complained that the board had not robustly investigated her complaint to minimise the risk of this happening again, and that the remedial action they took was inadequate.

We took advice from our nursing adviser, who reviewed the records and Mrs C’s complaint. We noted that the complaint had not followed the board’s formal complaints procedure, which is normally a requirement before we can consider a complaint. However, in this case, we decided to accept the complaint and waive that requirement, as we are entitled to where we consider the circumstances make it appropriate to do so.

As part of our investigation we obtained additional information from the board about the level of service Mr A received at the hospital. We also carefully considered all the documents and advice related to Mrs C’s concerns. We found no direct evidence to support Mrs C’s concerns. We were also satisfied that the board investigated Mrs C’s complaint thoroughly and in good time and arrived at an evidence based conclusion. We noted that the local management team had implemented changes over the past year and considered these appropriate in relation to the concerns Mrs C raised.

Summary

Mrs C complained to the board about the contents of a report that a consultant orthopaedic surgeon prepared after she attended his clinic. Mrs C felt that the report understated her true clinical condition at the time, as she had to attend hospital again some five months later with a swollen leg. She was dissatisfied with the board's response to her complaint.

After taking advice from our medical adviser, we found that the consultant's recording of the appointment was reasonable. He set out his findings, as well as his future plans should Mrs C's condition deteriorate. We noted that Mrs C had to attend hospital some five months after the clinic appointment, but did not find that this indicated that the consultant's report was inaccurate.

Summary

Mr C had an overactive bladder muscle and, supported by his consultant, requested treatment with Botulinum Toxin A (Botox A) to help control his condition. The board refused Mr C’s request, and he complained to us that the refusal was unreasonable as he was aware of the treatment being made available to female patients.

Mr C also complained that the board gave him an unreasonable explanation that such drugs should only be used for patients who have extremely severe symptoms and who have accepted the associated risks. Mr C said that the board failed to take into account the severity of his symptoms and acknowledge his acceptance of the risks as he had twice previously paid to have the procedure carried out privately.

Our investigation found that the board did not deal with Mr C’s request in line with their own policies. In addition, the board acknowledged that different sets of practice had developed within urology and gynaecology, which required further review. For these reasons, we decided it was unreasonable of the board to refuse Mr C’s request and so we upheld this complaint.

We thought the board’s explanation that Botox A should only be used for patients who have extremely severe symptoms who have accepted the associated risks was not, in itself, unreasonable. It was a matter of clinical interpretation whether Mr C’s symptoms were extremely severe, and we understood the board’s explanation that it was not possible for Mr C to have accepted the risks, as the risks were unknown. However, the urology staff who had treated Mr C for several years considered him to be an ideal candidate for Botox A, and supported his attempts to get the treatment. Also, Mr C had received successful Botox A treatment twice in a private hospital. In addition, the explanation provided in the board’s response to Mr C’s consultant’s request for treatment was not consistent with their unlicensed medicines policy. Taking all of this into account, we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified in our investigation;
• consider Mr C's and his consultant's request for Botox treatment in line with the current version of the unlicensed medicines policy; and
• remind management and clinicians of the unlicensed medicines policy, and ensure that the policy is referred to and followed in relevant cases.