Health

Summary

Mr A was an elderly man with a history of health problems and restricted mobility. He had been nursed at home for several years.

Mr A was admitted to hospital with confusion, infection and back pain. Nine days after admission, he developed pressure ulcers. Mr A remained in the hospital for around seven weeks until he was transferred to a second hospital, where he remained until his death around three weeks later.

Mr A's son (Mr C) said that his father was at known risk of developing pressure ulcers. He said that the family alerted staff to their concerns about the the need to change Mr A's position. He complained that, despite this, staff at the first hospital unreasonably failed to monitor his father appropriately and change his position frequently enough to prevent pressure ulcers developing.

Mr C also complained that there was an unreasonable delay of nine days in obtaining specialist equipment such as a special mattress. He said that when Mr A was transferred to the second hospital there was a further unreasonable delay of two days in transferring the special mattress between the two hospitals. In addition, Mr C complained that the board's response to the family's complaint about Mr A's care was inadequate.

We upheld Mr C's complaint about the two day delay in the transfer of a special mattress between the hospitals. The board acknowledged there was a delay, and our adviser's view was that such a delay was unacceptable. As a result of this failing, the board introduced a standard operating procedure to avoid future delays. We, therefore, did not find it necessary to make any recommendations about this.

We did not uphold Mr C's other complaints. We understood the family's reasons for concern about Mr A's care and treatment. However, our investigation found that Mr A's pressure areas were monitored and cared for appropriately for the first nine days in hospital. When pressure ulcers developed, they were properly cared for, in line with relevant NHS guidance. From admission to the first hospital, Mr A was on an appropriate mattress based on his pressure ulcer risk assessment score. When the score increased, a special mattress was ordered. This was in line with both the board's guidance and general NHS guidance.

We found that the board's investigation of the family's complaint and their response to it addressed the points made in the family's complaint letter, and was a reasonable reflection of Mr A's condition and the care provided to him.

Summary

Mrs C's husband (Mr C) was ill and she called NHS 24. However, she complained that the board failed to respond to her call and that the out-of-hours (OOH) doctor who came did not treat her husband appropriately. She also doubted that the doctor properly recalled the visit.

We considered all the relevant information and obtained advice from our medical adviser. We found the information about the telephone calls inconclusive. Mrs C said that the board had not called, however, the board's records said that attempts to call Mrs C were made, but were unsuccessful. We did not see any records of these specific calls, and in the absence of evidence, could not uphold this complaint.

We agreed that the OOH doctor had not properly treated Mr C in accordance with his symptoms and had kept poor records of the visit. This meant that the information that the board gave Mrs C when she complained was confusing. We made recommendations to address the failures identified.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for their oversights in this matter; and
• emphasise to the OOH doctor the importance of taking a full record and, if it has not already occurred, the OOH doctor should prepare a significant event audit on this case and discuss it at their next appraisal.

Summary

Mrs C complained about the care and treatment her dentist provided in relation to root canal treatment that resulted in the loss of her tooth. Mrs C was also unhappy that the dentist had not explained the associated risks with this treatment and that her complaint was not properly handled.

In response to the complaint, the practice manager advised Mrs C that the dentist had explained the treatment and this had been documented in her clinical records.

When we looked at the clinical records, we found that the dentist had carried out an x-ray several months before root canal treatment was attempted, and had told Mrs C that she needed this treatment or that the tooth would eventually need extraction. We also took into account that the dentist had documented that Mrs C had been told at other appointments that she still needed to have this treatment carried out.

After taking advice from our dental adviser, we considered that it was good practice for the dentist to have treated the tooth by either root canal treatment or extraction as the x-ray had indicated an area of either inflammation or infection around the tooth. We also considered the dentist's explanation to why the root canal treatment failed to be reasonable. They had said that the root of the tooth was perforated (contained holes) and the continuation of the root canal could not be found, so extraction of the tooth was the best option to ensure that the inflammation did not spread.

We also found that the practice manager had responded appropriately to the issues Mrs C had raised in her complaint. Although the letter contained medical terms that could have been better worded, we did not consider that this significantly affected the overall understanding of the response.

Summary

Mrs C complained about her diagnosis and treatment when a suspected pre-cancerous duct was found in her breast after a routine screening. She said that she was offered only radiotherapy after her operation, although she believed alternative treatments were available. Mrs C undertook her own internet research and went to a private doctor for a second opinion. Mrs C said that she was, however, being advised by her clinicians, her GP and even her family to undergo radiotherapy so she eventually signed the consent form and agreed to treatment.

Our investigation showed that several clinicians spoke to Mrs C about her condition and radiotherapy treatment. We took advice from our medical adviser, who said that the only alternative to radiotherapy was no treatment at all. This was because the type of condition that Mrs C had cannot be treated with more usual treatments for breast cancer.

Mrs C was also unhappy with the diagnosis of her condition. She had a mammogram (breast x-ray) and two needle biopsies (where a small amount of tissue is removed for examination). She was also seen by a consultant surgeon. Our medical adviser said that this diagnostic process complied with SIGN (Scottish Intercollegiate Guidelines Network) guidance. He did not consider that the process was overly invasive or radical. In line with the SIGN guidance, the matter was discussed at a multi-disciplinary team meeting and the options discussed with Mrs C and passed on to her GP.

Summary

Mr C and Mrs D complained about the care and treatment provided to their late mother (Mrs A) by her medical practice. Mrs A attended the practice in May 2011 complaining of pain over the previous four months. Her GP arranged a number of tests including a pelvic ultrasound scan, which was inconclusive.

In June and July, Mrs A continued to attend the practice complaining of pain. Her GP prescribed antidepressants, and medication for her spasms and pain. After further visits, the GP referred Mrs A for a routine surgical out-patient consultation in August. This referral was upgraded to an urgent priority following another GP consultation in September. Before she could attend her out-patient appointment, she was admitted to hospital by emergency services. She was diagnosed with pancreatic cancer after a scan, and died at the end of October.

Mr C and Mrs D complained that no follow-up action was taken following the inconclusive results of the pelvic scan and they believed that, given the severity of their mother's pain and the number of times she attended the practice, she should have been referred urgently to hospital for further investigation. They also said that the practice failed to prescribe pain relief within a reasonable time and they raised concerns that their mother was diagnosed with anxiety and depression. They said that anybody suffering pain of this severity would understandably be anxious and depressed and felt that this distracted the practice from properly investigating the causes of her pain.

We found that although the practice could have been more proactive in searching for the cause for Mrs A's pain, the time taken to refer her was, on balance, reasonable particularly as there was no evidence of abnormalities available to the GP in August. We also found that although there may have been an over-emphasis on the psychological aspects of Mrs A's condition, the suggestion that she was suffering from anxiety and depression was not in itself inappropriate. We did not uphold either of these complaints. However, we found that while the practice attempted to manage Mrs A's pain, pain relief was prescribed relatively late and we upheld the complaint about this.

Recommendations

We recommended that the practice:

• review the management of this case in light of our findings; and
• apologise to Mrs A's family.

Summary

Mrs C complained that a hospital gynaecology department provided her with inadequate care and treatment for ovarian cancer. She said there were inadequacies with her diagnosis and treatment and specifically a failure to properly diagnose her condition. She also said she experienced delays by the board in the way they progressed her treatment. Mrs C went to France for a second opinion from a clinically trained friend. She said she experienced problems in getting the board to provide or release relevant medical records and test results to her doctor in France. Mrs C told us that as a result, she had to undergo emergency surgery in France without this information being provided. She said that the board showed no inclination to appropriately respond to her complaint about this.

We took advice from one of our medical advisers who reviewed Mrs C's medical records. He noted that Mrs C presented with an abdominal mass and from the scan that was taken, he said it was appropriate to consider ovarian malignancy as the likely diagnosis. He said that a definitive diagnosis could only be reached by the microscopic examination of tissue obtained during surgery to remove the mass. He also said that the provisional diagnosis was not incorrect or hasty and was appropriately based on the evidence available.

Following the clinic appointment at which the abdominal mass was found, arrangements were made for Mrs C's case to be discussed by a multi-disciplinary team. This is in line with guidance, the intention of which is to ensure that patients with suspected cancer get the best possible treatment by the most appropriate team. The adviser noted that Mrs C's gynaecologist communicated the outcome of the team meeting to her, about a week after she attended the clinic, and it was arranged that Mrs C would see a gynaecological surgeon for a pre-operative assessment about three weeks after that. The adviser said that this time-frame was reasonable.

We found that it was appropriate that the consultant considered the need for patient consent before releasing medical information to a third party - in this case to Mrs C's doctor in France. There was evidence that Mrs C had received appropriate and timely communication from the board and received a follow up appointment in good time. Finally, we found that it was reasonable that the board (in the time-frame available) were not able to advise Mrs C about reimbursement of her medical costs in France and that they adequately investigated and addressed her complaint.

Summary

Mr C told us that his eye was injured in a road traffic accident some time ago. He had undergone ten or eleven operations on his eye, but complained to us specifically about his last two procedures.

Mr C told us that he had ingrown eye lashes and a hospital doctor decided to turn the eyelid out. Mr C said he was unhappy with the result, as his eye was drooping and he still had pain from the eyelashes. He said that he had laser treatment from another doctor at the hospital and this helped by getting rid of the ingrown eyelashes. However, Mr C was also eventually dissatisfied with this treatment. He also complained that he was incorrectly discharged from the hospital, that the board either did not have, or had inadequate, access to his medical records, and that they had not dealt with his complaint correctly.

Our medical adviser reviewed Mr C's medical history and treatment from 2001 when Mr C had first presented with trichiasis (eyelashes misdirecting towards the surface of his eye). The adviser said that there was no evidence to support Mr C's view that he had not received appropriate treatment. We found no evidence to suggest that Mr C was incorrectly discharged from the hospital or that the board did not have appropriate access to his medical records.

Mr C was dissatisfied with the board's complaint responses. However, we considered that the board appropriately investigated and answered the issues he raised.

Summary

Ms C (an advice worker) complained about the care and treatment provided to her client (Mrs A) by her medical practice.

Mrs A has a history of early osteoporosis (abnormal loss of bone tissue causing fragile bones), and a family history of osteoporosis. In 2010, her GP prescribed her with a long-term course of steroids for another condition. The GP planned a scan to measure her bone density in May 2010, but the hospital did not receive a request form. For the next five months, Mrs A attended the practice complaining of severe back pain. She said that she raised the possibility of osteoporosis with her doctors. She also went to her local accident and emergency department three times because the pain was so bad. The practice treated her symptoms as mechanical back pain. They referred her to a physiotherapist, ordered x-rays and blood tests, and prescribed painkillers. In November 2010, another doctor referred Mrs A for a scan. This showed that she had severe osteoporosis and fractures to four vertebrae.

Ms C complained that her client was not told about the potential side effects of the steroids and was not given medication to counteract the side effects. She said that the scan should have been carried out earlier and that the practice did not reasonably monitor Mrs A. She also raised concerns about the level of steroids prescribed. Mrs A now has severe osteoporosis and daily pain, curvature of the spine and has lost three inches in height. She said that the failures by the practice had a significant adverse impact on her quality of life.

Our investigation found that Mrs A was at high risk of developing osteoporosis and we identified failures in treatment, monitoring, communication and record-keeping. Mrs A should have been given treatment to counteract the effects of the steroids and the practice should have ensured a scan was performed earlier. However, we found that the dose, duration and adjustment of the steroids was reasonable in relation to the symptoms she was displaying. It was not certain whether earlier treatment would have made a difference to the outcome, but it was clear that specialist intervention was delayed which caused Mrs A distress.

Recommendations

We recommended that the practice:

• review its record-keeping, particularly relating to advice on medication with significant side effects; and
• confirm they have implemented the recommendations in their significant event analysis and report back to us on progress.

Summary

Mrs C complained that the board had not explained bruising on her son's chest and neck after he came out of the operating theatre following a procedure. She said that her son (who has a blood disorder) had undergone the procedure regularly over the past eight years but had never sustained bruising. She was also concerned that the board's response to her complaint was contradictory.

The board told Mrs C that the likely cause of the bruising was a combination of force used to remove heart monitor stickers and her son's blood disorder. The board explained that the blood disorder was likely to have been a contributory factor to the bruising on the neck area as no stickers had been placed in this area and it appeared Mrs C's son had been lying on the heart monitor lead during the procedure.

We took advice from our medical adviser, a specialist in working with children with blood disorders. He advised that the most likely cause of the bruising on the chest area was the normal amount of force needed to remove the heart monitor stickers, which was made worse by Mrs C's son's blood disorder. He also considered that the bruising on the neck was likely to have occurred as a result of her son's lying position on the wires during the procedure.

We accepted this advice and did not uphold the complaint, but we made a recommendation to ensure that in future parents are aware of the possibility of such bruising.

Recommendations

We recommended that the board:

• ensure that parents and carers of children with low platelet counts are warned, either at general counselling stage or when seeking consent for an operative procedure, about the possibility that mild to reasonable force could cause unnaturally severe bruising.

Summary

Mrs C complained about the treatment that her late son (Mr A) received at a cancer centre where he had been admitted for a course of chemotherapy. She complained that when it was noticed that he was suffering from side effects of anti-sickness drugs, the consultant who prescribed the medication delayed in stopping it. She also said that the consultant failed to consult with other clinicians about the appropriateness of the prescribed drugs and failed to take Mr A's complex medical conditions into account.

Mrs C also complained that the consultant failed to explain the possible side effects of the medication, and that when she formally complained to the board she was not treated sympathetically and they took a long time to respond to her complaint.

We did not uphold Mrs C's complaints. Our investigation found that the clinicians involved were fully aware of Mr A's medical history, took his concerns seriously and treated him appropriately. We also found that they investigated his symptoms properly to determine the underlying cause. The medical notes showed that communication between clinicians had been excellent, and that staff took time to discuss Mr A's condition and medication with him and his family.

Finally, we found that the board's complaints handling was good. We found that they had provided responses that were thorough, detailed and empathetic. However, we found that the board failed to provide updates for a period of time before sending their final response. We drew this to their attention, but made no recommendation.