Health

Summary

Mrs C was diagnosed with breast cancer and agreed after discussion with medical staff that she would have chemotherapy followed by breast conserving surgery. Mrs C completed her chemotherapy treatment, but shortly before her planned surgery (some six months after her diagnosis) she found out the full extent of the disease and decided to have the breast surgically removed. Mrs C complained that healthcare professionals did not communicate the full extent of the disease to her or report it fully within a reasonable time. She said that as a result, her treatment plan was initially based on the incorrect belief that breast conservation was possible. Mrs C also raised a number of concerns about the board's complaints handling.

We took advice from our relevant medical advisers and found that there were failures in the board's management of Mrs C's breast cancer, and that the process to ensure that healthcare professionals communicated effectively with each other and with Mrs C was not followed. Although we considered that the board's failures made no difference to the treatment and outcome for Mrs C, they did cause her additional stress at a very difficult time. We also found some aspects of the board's complaints handling was inadequate in that there were delays and the board failed to keep Mrs C informed.

Recommendations

We recommended that the board:

• review their practice on management of patients with breast cancer to ensure it meets Scottish Intercollegiate Guidelines Network guidelines, particularly in relation to the multidisciplinary team process;
• review their complaints process to ensure it meets the requirements of the NHS complaints procedure; and
• apologise to Mrs C for the failures identified.

Summary

Mrs C had a method of contraception, an intrauterine device (IUD), fitted by a doctor in March 2010. She subsequently developed symptoms including abdominal pain, bleeding and difficulty with bowel movements. Mrs C attended the practice three days later and was prescribed antibiotics for a possible infection following the fitting. In June 2010, Mrs C found out that she was pregnant. After her baby was born, she had surgery to have the IUD removed. It was found to have caused internal damage and to have moved.

Mrs C complained that the doctor had not taken reasonable care when fitting the IUD and did not properly investigate her symptoms. Although we were unable to assess the procedure, we found that Mrs C’s medical notes were comprehensive and detailed, and that the doctor had undergone suitable update training and fitted an appropriate number of IUDs per year. We also noted that Mrs C had undergone IUD counselling before having the device fitted, where she had been told about the risks, including the risk of internal damage. Although this was a rare complication, the fact it had occurred did not mean the doctor had not carried out the procedure with reasonable care, so we did not uphold this complaint.

We also found that the practice carried out reasonable investigations of Mrs C’s symptoms. They examined her at three appointments and located the threads of the device. Guidance states if these threads can be seen and felt then it can be assumed the IUD is in the correct place. When Mrs C attended a second appointment after the fitting, she said that the symptoms had resolved so we found it was reasonable that the practice did not undertake further investigations. We also found that the practice would not have been expected to arrange an ultrasound scan to confirm the positioning of the IUD, as this is not recommended by guidelines.

Summary

Mr C complained about the board's decision to relocate the pain management clinic at a hospital. He said that the previous location for the clinic was more accessible for him and because of the relocation he now faced a journey time of over eight hours for a 15 minute appointment. In response to Mr C’s complaint, the board suggested alternative means by which he could attend the clinic but he did not feel they were appropriate. He felt the board had not taken into account his health needs when making the decision to relocate the clinic and complained to us.

We explained that health boards have the authority to take decisions about where to site services within their area. We found that in an effort to address Mr C's concerns, the board had offered Mr C reasonable solutions in order that he could access the clinic where his condition could be assessed. This included information about public transport links and the availability of patient transport services. In addition, the board also offered to pay for a taxi fare for his next appointment but said that the matter would be kept under review. The board also suggested that to avoid the need for travelling, Mr C could have a telephone consultation. We concluded that the board had taken appropriate action to assist Mr C and did not uphold the complaint.

Summary

Mr C had a history of mental health problems. In 2011 he started to become increasingly anxious with strong violent urges. He was able to control the urges but found it difficult and was concerned that he might harm friends or family members if he did not receive effective treatment. Mr C complained that his medical practice did not do enough to progress his treatment. He was unhappy with how they managed his condition, saying that they adopted a 'wait and see' approach.

The medical records showed that therapists and the practice had made a number of referrals. We were satisfied that there was a pattern of reasonable care, and that the referrals made were detailed and appropriate and responsive to Mr C's circumstances. Mr C had also asked the medical practice to prescribe medication to help with his unwanted thoughts, but this was refused. Our medical adviser considered Mr C's case and said that medication should not be used to treat personality disorders. We, therefore, found that the decision not to prescribe medication was appropriate, as Mr C had been diagnosed with a personality disorder rather than a psychiatric disorder. Mr C is receiving ongoing treatment from a psychologist and we considered this to be the appropriate treatment for his condition.

Summary

Mrs C was unhappy with the quality of the food she received while in hospital. The board said that as she had not reported it to them when she was a patient they were unable to look into her concerns. They said that they had very few complaints about food standards and reported very good results from patient satisfaction surveys.

Mrs C then complained to us about poor food quality and that there was a lack of investigation into her complaint. It is not our role to monitor food quality in hospitals. However, we looked to see whether the food quality was effectively monitored and reviewed by the board. We also looked at the food quality results from patient surveys. In both cases we found that the board achieved high patient satisfaction results. We also noted a number of actions the board was taking in response to issues that had been identified. As the board appeared to achieve good quality food standards, and responded to problems when they arose, we did not uphold this complaint.

We did, however, uphold the complaint about the lack of investigation into Mrs C's concerns, but we did not make recommendations. We felt that the board could have examined whether there were any specific reasons why food quality might have been affected during the period of Mrs C's stay, and that they had missed the opportunity to tell her about the active steps they were taking to improve food quality.

Summary

Mr C asked us to take forward a complaint after the death of his mother (Mrs A). Mrs A initially complained to us about a shortfall in care she said she had received from her medical practice from 2003 onwards. She told us that the matter only came to light in 2011.

Mrs A said that, despite repeatedly attending the practice from 2003 to December 2010, she was not checked or referred by the practice to see if she had a more serious underlying condition. Mrs A was diagnosed with lung cancer in or around June 2011 and died in November 2011. Both she and her son considered that there had been a failure to diagnose or pick up on her symptoms from 2003 onwards.

Our investigation, which involved taking advice from our medical adviser, found that while it was clear that Mrs A attended the practice for a variety of medical concerns from 2003 to 2010, she received appropriate care and treatment for the symptoms she presented with during this period. We found no evidence that the practice failed to pick up or diagnose cancer symptoms. Our adviser also said that from reading the progression of Mrs A's symptoms in her medical records, it was unlikely that the outcome would have been altered by an earlier diagnosis.

Summary

Mr C pursued a complaint on behalf of his late mother (Mrs A), who passed away from terminal cancer soon after bringing her complaint to us. Mrs A’s complaint letter to the board said that they had not provided her with regular checks when she had heart problems diagnosed. She said that in her view, this contributed to her cancer remaining undiagnosed until it became terminal.

We took advice on the complaint from one of our medical advisers, a consultant in acute medicine, with specialist experience in heart disease in older people. Our investigation found no evidence of any failure to carry out appropriate or regular checks for Mrs A’s heart problems relative to the recorded symptoms she displayed at any given time.

Summary

After Mrs A had a knee replacement operation she was discharged home into the care of the district nursing service (district nurses visit and treat patients at home). Her daughter (Mrs C) complained about the care Mrs A then received - in particular, that two clips were not removed. Mrs C said that this caused her mother to suffer an infection, and that this was not properly treated in that on one occasion, dressings were not available. She also said that Mrs A was not provided with antibiotics quickly enough. Mrs C considered that her mother suffered unnecessarily because of this, and lost mobility and independence.

We investigated the complaint and took advice from our nursing adviser. We found that, contrary to what Mrs C thought, wound clips are not normally counted as they are put in and taken out, and are generally obvious. Although two clips were left in Mrs A's knee for a short time, the adviser could not conclude that this led to the infection. However, the adviser also said that the notes taken at visits were not of good quality and that not all actions taken were noted. Nevertheless, the records suggested that there was no delay in giving Mrs A appropriate antibiotics. Although it was regrettable that Mrs A contacted an infection, we could not determine with certainty that this was as a result of a lack of care. We did, however, uphold Mrs C's complaint that on one occasion the wound was not dressed.

Recommendations

We recommended that the board:

• emphasise to all district nursing staff the importance of adhering to the Nursing and Midwifery Council 2009 Guidelines 'Record keeping

Summary

Mr C complained on behalf of his brother (Mr A), an adult with a mental health condition. Mr A had permission to leave the mental health unit where he lived to visit his own home for a few days. However, at the end of that time, no one came to collect and return him to the unit. As he did not return, the unit told his family and the police. The police found Mr A at his home and damaged his door to gain entry. They removed him from his home and took him back to the unit. Mr C complained about the trauma that the whole incident would have caused his brother.

When Mr C complained to the board, they acknowledged immediately that there had been a communication breakdown regarding the arrangements for collecting Mr A at the end of his home visit. They described the steps they were taking to help prevent the same thing from happening again.

Mr C remained dissatisfied and complained to us. As the board had acknowledged a shortcoming, we upheld the complaint. We considered that the action the board had taken in response to the event was good but did not go quite far enough as it would not necessarily prevent a recurrence.

Recommendations

We recommended that the board:

• put in place a written policy or guideline for staff, in relation to patients who are using a pass, for example for a home visit.

Summary
Mr C went to a hospital accident and emergency unit after falling from height. He complained that the care and treatment he received there was inadequate. He said that there was a failure to x-ray and diagnose a fracture that caused him severe pain in the weeks after. Mr C said he was eventually x-rayed about two weeks after the fall and told about the fracture five days after that. He wanted to know why he was not x-rayed when he first went to hospital, considering the accident he had and the pain he was in. He also said that when he complained to the hospital about his care and treatment, they delayed in responding to his concerns.

We did not uphold Mr C's complaints. We took advice from our medical adviser, who said that the need for an x-ray was a matter of clinical judgement. He said that the assessing clinician should (and did) take into account Mr C's age and gender, how the injury happened, look for various external evidence of injury, as well as evidence of nerve or spinal damage, and assess Mr C's mobility. He commented that a spinal fracture from low impact injury is unusual in men of Mr C's age, and that an x-ray was not mandatory in his situation. He said that the judgement of the assessing clinician that an x-ray was not necessary was not unreasonable, even with the benefit of hindsight.

We also found that there were valid reasons for the delays in the board responding to Mr C's complaint. This included that a consultant whom Mr C wished to meet to discuss his concerns was abroad for several months. When the board told Mr C about this, he said he wished to wait for the consultant to return. We also noted that the board kept Mr C regularly updated about his complaint during this period and gave him the opportunity to contact us if he so wished.