Health

Summary
Ms C complained about the care and treatment provided to her late grandmother (Mrs A), by the board. Mrs A was admitted to hospital in June 2011 because of increased frailty, poor oral and dietary intake and a urine infection. She was discharged in July 2011 and died two weeks later. Ms C complained about the communication between staff and the family during Mrs A's admission to hospital. She said that, given the seriousness of her condition, staff should have been more proactive in updating the family, who only received information when they asked staff directly. Ms C also said that some staff had a negative attitude and were reluctant and ungracious when responding to requests for information. Furthermore, staff failed to make the family aware of the gravity of Mrs A's condition on discharge, which meant that the family were unprepared for her death.

We found that the amount of communication with the family appeared reasonable, but we could not establish with any certainty who prompted the discussions, or the attitude of staff during them. However, we found that the records showed that the quality of communication was variable and that there should have been more consistency in recording discussions with family members. We also found no evidence to show that Ms C and her family were told that Mrs A was likely to be approaching the end of her life.

Recommendations
We recommended that the board:
• bring our findings to the attention of relevant staff to reflect on communication with patients’ carers and families, particularly around end of life issues;
• review how communication is recorded and ensure that staff make accurate and clear records of discussions with patients’ carers and families; and
• apologise for the failures identified.

Summary
Ms C has joint power of attorney for her mother (Mrs A). Mrs A has vascular dementia and can become agitated and present challenging behaviour. As she is reluctant to take her medication, her family often disguise it in fruit juice.

Mrs A had a fall and was admitted to hospital. Her daughter complained about the care and treatment her mother received when she was there. She said that the board failed to take her advice about medication and that this led to her mother receiving it intra-muscularly. She complained that this was inappropriate. She also complained that the board failed to proactively manage her mother's care and that this led to a worsening of her condition. She further alleged that her discharge failed and that Mrs A required to be readmitted to hospital.

We obtained advice from one of our medical advisers, a specialist in acute medicine for older people, who read Mrs A's clinical records. We did not uphold the complaint about administering medication as we found no evidence in the notes to suggest that the family had told staff about how they had given this to Mrs A. Our adviser said that, in his view, the notes suggested that the board acted appropriately in the circumstances. However, because the notes omitted information that could have been expected, we decided on balance that the board did not managed Mrs A's condition proactively and upheld that complaint. We also found that the board had handled Mrs A's discharge appropriately but had failed to properly address Mrs C's written complaints as they should have done.

Recommendation
We recommended that the board:
• apologise to Ms C with regard to their failure to proactively manage her mother's care.

Summary
Miss C complained about lack of treatment for her kidney problems and the board's handling of her complaint. Following our initial investigations, and having taken advice from one of our medical advisers, we wrote to Miss C telling her that we were not upholding two of the five aspects of her complaint. This was because we found that the decisions made by the board's clinicians in relation to these matters were reasonable. We told her that we were continuing to investigate her remaining three complaints.

Miss C then contacted us to say that she was taking legal advice about these matters and asked us to stop our investigation. We were, therefore, unable to come to a decision on the other three aspects of her complaint.

Summary
Mr C complained that, on two separate occasions, a physiotherapist made inappropriate remarks to him. He also complained that the board's complaint investigation was unfair because it was mostly done by a senior colleague of the physiotherapist.

We obtained Mr C's physiotherapy records and the board's complaint file. However, we were unable to establish whether the remarks had been made. The physiotherapist herself, and one of her colleagues (who had been present on the second occasion) disputed Mr C's account. There were, therefore, no grounds on which we could uphold the complaint about her behaviour.

We explained to Mr C that it was appropriate, under the NHS complaints procedure, for the lead physiotherapist to carry out the investigation. We also explained that she had not been responsible for the complaint decision or the replies to Mr C: they had been drafted by the complaints team and considered, and signed, by the board's chief executive in recognition of his overall responsibility for complaints. The complaint file also showed that the investigation had been thorough and that Mr C had been given a full and fair hearing.

Summary
Mr C was admitted to hospital after suffering a significant stroke. He underwent physiotherapy at three different centres (Centre 1, 2 and 3) specialising in stroke rehabilitation, to progress his recovery and achieve his goals of independent mobility and returning to work. Mr C complained about the care and treatment he received at two of the centres.

Mr C complained that he sustained a serious chest and shoulder injury while on a ward at Centre 1 as a result of inappropriate handling by nursing staff and that it had been aggravated by a physiotherapist working there and at Centre 2. Mr C was unhappy with Centre 2, saying that they did not provide physiotherapy for his specific needs. He also said they blocked his request to return to Centre 3, and cancelled his appointments following his complaint.

In response to the complaint, the board said that on admission to Centre 1, Mr C's shoulder was partly dislocated. They provided a shoulder support but he was allergic to this, so pillow support was provided instead. The board told Mr C that he received appropriate physiotherapy at Centre 1 and Centre 2. They said that there was no clinical indication that Mr C needed to return to Centre 3 and that his appointments were cancelled as he no longer wanted to be treated at Centre 2.

After referrring Mr C's medical records to one of our medical advisers, we did not uphold any of Mr C's complaints. We found that while the records showed that it was difficult for him to position his arm on the pillow, which might have led to some of his pain and injury, there was insufficient evidence to support his concern that staff at Centre 1 caused damage to his shoulder through poor handling. We also established that although there was no specific record of an incident at Centre 1 that could have caused trauma to Mr C's shoulder, there were clear notes of his pain and the effect this was having on his mobility and participation in therapy. We concluded, however, that there was evidence to show that Mr C had been assessed, with treatment plans, goals and physiotherapy interventions in line with national guidelines for the management of stroke patients.

We found that the physiotherapy sessions at Centre 2 were not as regular as planned. It also appeared that Mr C was not initially provided with a home exercise programme. However, we concluded that overall his treatment was reasonable and there was evidence to show that physiotherapists there carried out an appropriate assessment, with a problem list drawn up and treatment plans put in place.

There was also evidence to show that Centre 2 fully considered Mr C's request to return to Centre 3 and gave reasons why it would not be appropriate to do so. We agreed with this decision as Mr C's level of function did not require in-patient care, and it was important at that stage for him to be in a home environment as recommended in the national guidelines.

Finally, we identified from Mr C's clinical records that referral to community physiotherapy was discussed with him as an alternative to being treated at Centre 2, as he did not want to continue his sessions there. We did not consider that Centre 2 acted inappropriately in referring Mr C for community physiotherapy treatment, as he was clearly dissatisfied with the service they were providing.

Summary
Ms C was diagnosed for a second time with cancer in the left breast and a lumpectomy (operation to remove a lump) was carried out. Ms C complained that the board failed to carry out the consultant's agreed monitoring programme of six monthly clinic reviews and annual mammograms. She said that when attending her second six monthly clinic review she was advised by one of the doctors that her next clinic review would be in one year's time due to the volume of patients. Ms C was also dissatisfied that a mammogram appointment was supposed to have been arranged but that she had to raise it with the doctor and arrange it herself. She also complained that the board's response to her complaint contained inaccurate information, in that they said she had undergone a mastectomy (opertation to remove a breast) and reconstructive surgery, which was incorrect.

The board had advised Ms C that she was being reviewed in accordance with the agreed monitoring plan of two six monthly clinic reviews, followed by yearly reviews and yearly mammograms. The board also told her that the doctor had not said that the yearly clinic reviews were due to the volume of patients, but that they were based on patient need.

We did not uphold the complaint about the monitoring programme. Although we considered that the wording of the consultant's monitoring plan was open to interpretation, our medical adviser said that the frequency of clinic reviews was appropriate and in line with the Scottish Intercollegiate Guidelines Network for the management of breast cancer in women. We could find no objective evidence to support Ms C's concern that she had been told that her next clinic review would be in one year's time due to the volume of patients.

Our medical adviser also considered that it was not unusual or inappropriate for a mammogram appointment not to have been made prior to Ms C's last six monthly clinic review. This was because it is safer to book appointments from the clinical assessment than to have requests made many months prior to the mammogram due date.

During our investigation, the board acknowledged that a mistake had been made in their response to Ms C's complaint. The board explained that Ms C's medical records had recorded the surgical options of mastectomy and reconstruction, but that these procedures had not been carried out. We upheld this complaint, noting the importance of responses to complaints being clear and accurate to ensure confidence in the professionalism of the NHS.

Recommendation
We recommended that the board:
• apologise to Ms C for incorrectly stating in their complaint response that she had undergone a mastectomy and reconstructive surgery.

Summary
Mr C's wife (Mrs C) was treated at a hospital for a number of health problems over a period of 13 years. This included a hip replacement in 2001, following which Mrs C developed a bacterial infection - Methicillin-resistant Staphylococcus aureus (MRSA). This was treated at the time, but Mrs C complained of pain in the hip from that point on.

In 1998, Mrs C was referred to haemotology for investigation of a blood abnormality. The subsequent investigations concluded that it was likely that she had a cancerous mass on her pancreas. A whipple's resection (an operation) was carried out to remove part of her stomach, duodenum, bile duct and head of pancreas. The mass was found to be benign.

Mrs C, however, experienced complications of the surgery, which left her with gastrointestinal problems (problems with the stomach and large and small intestines). In 2005, these began causing her to collapse. One such collapse caused the dislocation of Mrs C's hip replacement. The hip was put back in place, but Mrs C was discharged without a clear diagnosis of the cause of her collapse. In 2008, the hip scar became inflamed and swollen, then burst, releasing a large amount of blood and pus and immediately resolving her pain. Tests found that the hip replacement was infected with MRSA. Revision surgery was carried out, but as the bone had degraded, it was decided not to provide Mrs C with another hip replacement.

Mr C complained that the whipple's procedure had been unnecessary. He was also critical of the board's investigation of the cause of Mrs C's blackouts and the failure to resolve her MRSA infection. He believed that this had been present since 2001 and had caused the bone degradation which prevented a further hip replacement from being provided.

We did not uphold Mr C's complaint. We took advice from one of our medical advisers, who said that the risks associated with the whipple's resection were significantly lower than that of carrying out a biopsy (which might lead to a false-negative result and a lack of treatment for an incurable cancer). If identified early enough, pancreatic cancer can be cured by surgical resection and we, therefore, found it appropriate for the whipple's resection to go ahead without tissue analysis.

We found that there was an opportunity to diagnose Mrs C's gastrointestinal problems after she collapsed in May 2005. However, appropriate investigations were carried out to rule out obvious causes for her collapse and we found the conclusions reached to be reasonable. A clear diagnosis was made within the following four weeks and treatment was provided quickly.

With regard to the MRSA infection to Mrs C's hip, the evidence that we reviewed suggested that it was very unlikely that this had been present since 2001. Our adviser explained that infection can be contracted through any part of the body via a number of means and can accumulate at a single site. X-ray evidence showed no sign of bone degradation in 2006, but it was obvious in 2008. We, therefore, considered that surgery in 2005 was a likely source of the infection and the bone degradation would have occurred after that.

Whilst the combination of significant, overlapping, health issues clearly had a significant impact on Mrs C's overall wellbeing, we were generally satisfied that the board provided reasonable and appropriate treatment through each of the three departments that treated her.

Summary
Mr C was concerned about his prescription for gluten-free products, and wrote to his GP practice several times about it. The GP responded explaining that they also wished to resolve the issues about Mr C's prescription and invited him to make an appointment to discuss this. Mr C was unhappy with this response and complained to us that since he registered with the practice they had refused to prescribe gluten-free products to him.

The practice told us that they believed that each request had been fulfilled as Mr C had wished, although they recognised that he remained dissatisfied. Our investigation found no evidence that the practice had refused to prescribe him with gluten-free products. We also found that their actions in seeking resolution of the matter were reasonable.

Summary
Mrs C, an advice worker, complained on behalf of Mrs A. Mrs A said that a nurse at her medical practice cut her internally during a smear test, leaving her with injuries. Mrs C complained that the nurse did not acknowledge her failings and that the practice failed to deal appropriately with Mrs A's concerns about her treatment.

During our investigation, we obtained copies of the patient complaint log, the minute of an investigatory meeting held by the practice to discuss the complaint and the practice's complaints procedure. We also asked the practice for information about the complaint.

The practice said they accepted that initially the nurse did not acknowledge her failings in carrying out the attempted smear. They expressed concern that she failed to react appropriately at the time or to acknowledge this later. The documentary evidence showed that the practice noted these concerns at the time of their investigation of the incident. We upheld the complaint about the nurse.

Mrs C complained about the practice's handling of Mrs A's concerns, in particular, the practice manager's conduct and the practice's failure to respond to a letter from Mrs C about the treatment. Having looked into this, we found that there was insufficient evidence to suggest that the practice failed to deal with Mrs A's concerns appropriately, and we did not uphold this complaint. However, there were two matters that we considered the practice could have handled better and we made recommendations to address these.

In addition to investigating these complaints, we agreed to ask the practice for evidence of the remedial action they said they had taken as a result of Mrs C's complaints. It was clear from the information we obtained that they did take some action. However, we were concerned that the practice failed to verify if the nurse asked a female GP to observe her smear taking technique, and that not all of the remedial action taken was documented. For these reasons we made a further recommendation.

Recommendations
We recommended that the practice:
• apologise to Mrs A that the nurse failed to acknowledge her failings in carrying out the attempted smear;
• write to Mrs C and Mrs A to apologise for failing to inform them that the nurse had left the practice and for failing to respond to Mrs C's letter; and
• amend their procedures for handling complaints to include the following steps: 1. to follow up on any remedial actions suggested as a result of an investigation of a complaint; and 2. to ensure that all remedial actions are documented.

Summary
Mr C complained that the board did not provide pelvic support girdles, which he considered his partner needed because of pelvic pain in pregnancy. We explained to him that our role in such complaints is limited because it is not for us to tell the NHS how to use their financial resources. Our role was solely to consider if the board's decision making had been flawed.

The board had taken a decision six years earlier not to provide these support belts because there was not enough likelihood of benefit. Our investigation found that the board had consulted various studies and European guidelines since then to ensure that the decision remained up-to-date. We concluded that this was appropriate decision making. Mr C had also been concerned that the decision seemed to be based on cost, rather than clinical need. However, health boards have to manage their resources carefully and are expected to reach decisions by considering factors such as a balance of cost and likely benefit. We considered it entirely reasonable for the board to take account of cost.