Health

Summary
Ms C made a number of complaints about her GP's handling of her healthcare. She said that the GP did not fully investigate or appropriately refer her to investigate and treat her health issues. She also complained about staff attitude in relation to a cervical cancer screening programme. In addition, Ms C was unhappy with the board's handling of her complaints, as she felt they had not addressed the issues she had raised.

We reviewed all Ms C's correspondence and obtained background correspondence and copy medical records from the board. We also took advice from one of our medical advisers. The practice concerned is administered by the health board on one of Scotland's outer islands. Therefore, the responsibility for investigating the complaints fell to the board although the GP had responded directly to Ms C on the majority of the issues. The remaining issues concerned nursing care and were investigated by the board's primary care manager.

We did not uphold Ms C's complaints. Our investigation found that all of the issues she raised had been addressed, although she did not in the end receive a detailed letter of response from the board itself. This is because due to the nature and volume of Ms C's correspondence with the board, they invoked their 'Unreasonably Demanding or Persistent Complainant Policy'. This says that once the policy has been invoked the board will not respond to further correspondence unless it raises completely new issues.

We found that the GP's treatment and management of Ms C's various medical conditions was reasonable. All relevant investigations and referrals were made in an appropriate and timely manner. Overall, our adviser described the GP's management of Ms C's case as holistic and clinically sound. Similarly, there was no evidence to suggest that the care and treatment and attitude of the nurse was anything other than reasonable and appropriate.

Summary
Mrs C received care and treatment from her GP (in a practice administered by the board) in relation to pneumonia, bunion pain and multiple sclerosis.

In 2006, Mrs C phoned her GP in the early morning, complaining of being unwell. The GP visited her at home and referred her to hospital, where she was diagnosed with pneumonia. Mrs C complained that because her GP visited after 09:00 there was a delay in admitting her to hospital. Later that month, Mrs C saw her GP about her sore bunion. In 2009, a locum GP referred Mrs C to an orthopaedic surgeon for an operation on it. Mrs C complained that the clinical picture did not alter significantly between 2006 and 2009 and that her GP should have referred her to an orthopaedic surgeon in 2006.

In November 2009, Mrs C saw a consultant neurologist (specialist in the nervous system). In February 2010, Mrs C approached her GP to follow-up on this, but said that her GP took no action. A locum GP arranged a follow-up appointment with the consultant the following month. Following investigations by the consultant, Mrs C was diagnosed with multiple sclerosis in August 2010. Mrs C complained that her GP's failure to act in February was not reasonable.

After taking advice from one of our medical advisers, we found that Mrs C's GP provided reasonable care and treatment in relation to her pneumonia and bunion. In terms of the time it took the GP to visit Mrs C after her telephone call, there were differing views about how long it was before the GP arrived. We found, however, that delay would not have affected the clinical outcome of Mrs C's condition. We did not uphold these complaints.
We did find, however, that the GP's failure to follow up on the consultation with the neurologist in February was not reasonable. Our adviser said that the GP should have been more proactive in seeking a definitive diagnosis, and that their failure to do so represented a deficiency in care. We upheld Mrs C's complaint about this.

Recommendation
We recommended that the board:
• ensure that the GP reflects on the diagnosis and management of multiple sclerosis with particular reference to the discussion of the diagnosis with patients.

Summary
Mr C complained that his GP practice decided to restrict the number of diabetic testing strips he could have, and then stopped providing them. He said that this was unfair and did not take into consideration his personal circumstances. Mr C said that self monitoring of his diabetes cannot be done efficiently without the strips, and that testing more frequently helped him manage his severe anxiety about his condition. Mr C also complained that the practice had inaccurately implied that he was selling his testing strips online.

In response to the complaint, the practice said that Mr C was using excessive amounts of testing strips and that this view was shared by the diabetic team. Mr C had been referred to a psychologist in order to address his anxiety. The practice had restricted the number of testing strips, but had not stopped prescribing them. They had, however, refused to provide them to Mr C on demand. They also explained that they had discussed with Mr C information that they had received from the local pharmacy. This was that a member of the public had contacted the pharmacy to say that they had purchased testing strips from a website, and that the packaging it was in contained details of the pharmacy and Mr C.

We concluded that the practice had acted reasonably in reducing the amount of strips they provided to Mr C as the decision was taken after the practice had received input from the diabetic clinic and after referring Mr C to a psychologist in an attempt to address his anxiety. We also considered that the practice acted reasonably in discussing with Mr C the information they received from the pharmacy, particularly when the number of testing strips he used was highly excessive.

Summary
Ms C suffers from a rare blood disorder. In 2009, she was diagnosed with mini-strokes, and prescribed medication. Tests, however, later showed that these were not the cause and clinicians decided that migraine (severe headache) was more likely. Ms C was prescribed aspirin for the long term and was taken off the initial medication. In 2009, Ms C was taken off aspirin, although it is not clear from her medical records when exactly this happened or why. She continued to experience symptoms and was admitted to hospital in 2010 having suffered a stroke.

Ms C complained that the investigations and treatment for her symptoms were inadequate. She said that the clinicians were not sufficiently alert to the symptoms and implications of the blood disorder she had, and failed to act on her prolonged symptoms. In particular, Ms C was concerned about the decisions to discontinue medication including aspirin.

We took advice from specialist neurology (nervous system) and haemotology (blood disease) advisers. They found that the board's investigations of Ms C's symptoms were appropriate and thorough, and that it was reasonable to offer treatment on the basis of migraine as the probable cause of symptoms. It appeared, however, that one of the clinicians involved decided to discontinue aspirin, but had failed to record why. Our advisers both said that continuing aspirin would have reduced the risk of future stroke.

We concluded that the decision to discontinue aspirin was poor practice and that the failure to record this decision and the reasoning behind it was not reasonable. For this reason, although other aspects of Ms C's care and treatment were appropriate, we upheld her complaint and made recommendations to address the failures identified.

Recommendations
We recommended that the board:
• review their arrangements to discontinue prescribed medication to patients to ensure this is properly recorded and reasons provided;
• draw this investigation and its findings to the attention of the clinicians involved; and
• apologise to Ms C for the failures highlighted.

Summary
Mr C attended a hospital emergency department with his fourteen-year-old son, (Master A) who had injured his leg playing football. Master A was diagnosed with a soft tissue injury around his right leg and was discharged with painkillers. He later went to his GP, who referred him for an x-ray. This showed a significant fracture of the tibia. Mr C complained that his son was unnecessarily subjected to pain and discomfort over an 18-day period.

During our investigation, we took advice from one of our medical advisers. We found that it would have been appropriate to consider x-raying the injured area when Master A initially attended the hospital emergency department, to rule out or rule in the presence of a fracture. We considered that the doctor there failed to carry out reasonable and appropriate investigations by failing to order x-rays. If she had done so, it was likely that the fracture would have been identified and the correct diagnosis made. Had this happened, Master A would also have avoided 18 days of unnecessary pain.

The doctor concerned no longer works for the board and we found that the board should have made contact with her to tell her the outcome after Mr C's complaint had been investigated. They did not contact her until after Mr C complained to our office. However, we found that the board had spoken to other junior doctors. They had also reminded staff that complaints involving trainees should be fed back to the supervisor for their current placement, including for those who no longer worked for the board. In addition, the board had issued an apology to Mr C. In view of all of this, we did not make any recommendations to the board.

Summary
Mr C had several complaints about the care and treatment received by his late mother (Mrs A) in 2008 and 2010.

We upheld Mr C's complaint about the care she received in 2008. Mr C's mother had been admitted for acute pulmonary oedema (fluid in the lungs), and as part of her treatment, an arterial line (a thin tube) had been inserted into her arm so her blood pressure could be monitored. Swelling developed around the line which was then removed, and a pseudo-aneurysm (a collection of blood under the skin from a leak in an artery) developed. We found no errors in relation to the way the line had been inserted, and our medical adviser said that a pseudo-aneurysm is a recognised complication of the use of an arterial line. However, because clear records were not kept of the management of this complication and as Mrs A had moved between units during this time, the cause of the swelling was not properly identified at first. There was also a failure to conduct a prompt medical review of the event.

Mr C was also concerned that when Mrs A had a scan of her abdomen, she had to drink a large quantity of liquid. He felt that, as Mrs A had fluid retention problems, this caused her to collapse in the scanner. We found no evidence to suggest that intake of the fluid caused his mother to collapse. We also found that the scan and giving the fluid in preparation for it were appropriate clinical treatments in the circumstances. However, we were critical that fluid balance charts were not completed for Mrs A at this time, considering her complex fluid management situation. We made recommendations to address these failings.

We did not uphold Mr C's complaint that a doctor had inappropriately noted Mrs A as a 'do not resuscitate' patient without the family knowing about this. We found that a doctor can make this decision without consultation with a patient or their family, in circumstances when resuscitation is considered ineffective. We noted that it is good practice to discuss such a decision when appropriate, and found evidence that such discussions had taken place with Mr C.

We did not uphold Mr C's complaint about Mrs A's care in 2010. We found that the use of intravenous (administered into the vein) antibiotics had been appropriate, even when giving regard to Mrs A's fluid retention problems. This was because she had a severe infection, and other clinical issues indicated that intravenous antibiotics were an appropriate method of treatment. Although Mr C was also concerned that Mrs A had difficulty passing urine, which he felt was not adequately recognised or treated, we found that this was due to kidney failure, rather than because of any clinical mismanagement.

Recommendations
We recommended that the board:
• provide evidence to the Ombudsman that staff within the hospital have received training for the care of arterial lines and the complications that can occur, including the need for prompt medical review of any complication;
• undertake an audit of record-keeping within the hospital to ensure medical records are completed timeously and comprehensively, including for patients who are moved between units within the hospital; and
• provide evidence to the Ombudsman to demonstrate that staff in the hospital are aware of the importance of completing fluid balance charts for patients with complex fluid management requirements.

Summary
Ms C attended the accident and emergency department of a hospital with abdominal pain three times in two months. Clinicians diagnosed a possible urinary infection and discharged her with pain relief. Ms C complained about the care and treatment she received during these visits to hospital. She said that clinicians failed to investigate her symptoms properly and arrange appropriate referrals.

Ms C had an ultrasound scan a couple of months later, which identified fibroids (non-cancerous tumours that grow in or around the womb) and a mass near her pelvis. This was confirmed by an MRI scan which was taken shortly after. Ms C complained that the board's response to the ultrasound scan lacked urgency and that a more senior doctor should have looked at it to avoid the need for an MRI scan.

About two months later, a consultant gynaecologist reviewed Ms C and provisionally diagnosed a degenerating fibroid. Ms C underwent a full hysterectomy (removal of the womb) shortly after. During the operation, numerous fibroids were noted in addition to a large mass, and it was later confirmed that the mass was a tumour. Ms C complained that she underwent a hysterectomy that might not have been necessary and which could have been avoided if she had been referred to an oncologist and/or had a biopsy carried out beforehand. She also complained about the board's response to her complaint saying that it contained a number of inaccuracies.

We upheld two of Ms C's complaints. After taking advice from our medical adviser, we found that she should have been reviewed by a more senior doctor when she went back to the hospital with the same problem. The adviser also said that the doctor concerned should have widened the range of possible diagnoses they were considering, after the results of a dipstick test ruled out a urinary tract infection. However, we found that their response to the ultrasound scan was reasonable and that ordering an MRI scan as a result was appropriate. We also found that the decision not to involve oncology or conduct a biopsy was reasonable in light of Ms C's presenting condition at the time, as was the decision to proceed with a hysterectomy.

Finally, although we found that much of the board's response was accurate, it did contain two inaccuracies. More seriously, the board did not respond appropriately to Ms C's complaint about her hysterectomy.

Recommendations
We recommended that the board:
• forward a copy of the decision letter and Ms C's letters of complaint to the relevant clinician to reflect on;
• draw up a written policy clearly stating the need for senior review when a patient presents to accident and emergency complaining of the same problem; and
• apologise to Ms C for the inaccuracies contained in their response and their failure to provide a substantive response to her concerns about her hysterectomy.

Summary
Mrs C was unhappy with the care and treatment provided to her late father (Mr A). She complained that the board failed to reasonably monitor Mr A after he had a heart pacemaker (a device that regulates heartbeat) fitted, and that they unreasonably delayed in identifying that, after Mr A had knee replacement surgery, his anticoagulant (blood clot preventing) medication was causing nausea (sickness).

We did not uphold Mrs C's complaints. We looked at the medical records and took advice from one of our medical advisers and found that the board monitored Mr A reasonably after his pacemaker was fitted. Our adviser was of the view that the care provided was in line with appropriate standards for the insertion and follow-up of pacemakers. The records suggested that Mr A had a combination of nausea, fatigue, diarrhoea and generalised weakness after knee replacement surgery. His blood count had fallen and his kidney function had worsened to some extent.

Our adviser said that just after an operation none of these symptoms or problems was unusual in patients in Mr A's age group, and all could have a wide variety of causes. Our adviser said that a worsening in kidney function could cause nausea, as could many medications used around the time of surgery.

Taking all this into account, there was no unreasonable delay in suggesting that the anticoagulant medication used might have been responsible for Mr A's nausea, and no unreasonable delay in changing it to another drug. Overall, our adviser said that no aspect of the care Mr A received fell below a standard that could reasonably be expected.

Summary
Mrs C fractured her right leg and was admitted to hospital for treatment. She was reviewed several times over a number of months. Mrs C complained that the care and treatment provided by the board was not reasonable. In particular, she said she was told by a consultant at one particular clinic that her leg was okay, and she should exercise it as much as possible. Mrs C was unhappy that she was given this advice without an x-ray being taken.

We did not uphold Mrs C's complaint. We found from looking at the medical records and taking advice from our medical advisers that x-rays from before and after the clinic appointment showed that the broken leg was in the process of healing. Our adviser said it was appropriate that Mrs C was told to move her leg, as that was a process known as dynamisation, which could be helpful in establishing a firm union of the broken bones. Overall, the adviser said that the care and treatment provided to Mrs C was reasonable. It took account of her underlying medical conditions and physical situation, and her treatment followed an appropriate course.

Although, therefore, we did not make any specific recommendations to the board, we did point out that they might wish to consider how staff should communicate medical terms to patients in plain language, such as the difference between the 'clinical healing' of a fracture, and 'healing'.

Summary
Mr C complained about cataract surgery carried out by a trainee surgeon. During the operation the iris of his eye was damaged. Mr C's concerns were that he had not been advised that a trainee surgeon was to carry out the surgery and that it was not appropriate for a trainee to have done so.

We took advice from one of our medical advisers who is a consultant ophthalmologist. We did not uphold the complaint that it was inappropriate for the trainee, an experienced cataract surgeon who had nearly completed their training, to have carried out the operation. This is normal practice and there was adequate supervision. However, before the surgery took place, Mr C should have been told of the possibility that the surgeon might be a trainee. As he was only told that the doctor who operated might be a different doctor from the consultant he had been seeing, we upheld this complaint.

Recommendation
We recommended that the board:
• take steps to make patients aware that procedures could be carried out by trainee staff under supervision. This advice could be incorporated in a patient information leaflet, consent form, or documented in the patient's records.