Health

Summary
Ms C complained about the Scottish Ambulance Service’s (the service) investigation into the circumstances where her late partner's wallet went missing when an ambulance attended to him following a serious accident.

We found that initially it was reasonable for the service to wait for the result of a police investigation into the missing wallet (which concluded that it had most likely been disposed of as clinical waste). However, after receiving the police report it was 40 days before the service wrote to Ms C with this information. This was despite Ms C telephoning during that period asking for updates. We, therefore, upheld her complaint and made recommendations to address these failures. The service also told us that they did not at that time have a lost property procedure but would develop one, so we made no recommendation in respect of this.

Recommendations
We recommended that the service:
• remind staff of their responsibilities to respond to complaints in a timely manner; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary
Mrs C complained about the way an ambulance crew treated her mother (Mrs A) who had fainted and had been slipping in and out of consciousness. Mrs C said that the crew had shouted at her mother, handled her roughly and treated her as if she was drunk. Mrs C also complained about the time the Scottish Ambulance Service (the service) took to respond to her complaint.

We did not consider the specific complaint about the crew's manner as this was subject to the differing interpretations of those involved. Having taken advice from one of our medical advisers, we found that the crew carried out an appropriate assessment of Mrs A's clinical condition and that it was correct for them to decide to take her to hospital. We also found, however, that the board took too long to formally respond to the complaint.

Recommendations
We recommended that the service:
• remind staff who have a responsibility to investigate complaints about the timescales in the NHS complaints procedure; and
• apologise for the overall time taken to investigate the complaint.

Summary
Ms C complained about the treatment she received from a GP employed by the board. She visited the medical practice complaining of neck pain, muscle weakness and fatigue. Blood tests were taken and Ms C was told that she was fine. However, she was found to have low levels of vitamin D and was prescribed a calcium supplement. Ms C subsequently developed indigestion, heart palpitations, eyesight deterioration and shortness of temper. She complained to us that the GP was dismissive of her symptoms.

About six weeks after the first consultation, Ms C's condition deteriorated to the extent that she found it difficult to walk. She began taking medication that she sourced on the internet and adjusted her diet. This resulted in some improvement to her energy levels, but she deteriorated again. She went back to the GP, and it was discovered that her original blood tests had shown a vitamin B12 deficiency. Specialist investigations confirmed that this was the cause of her symptoms.

After taking advice from one of our medical advisers, we upheld most of Ms C’s complaints. We found that the board had used a number of locum (temporary) doctors throughout the period in question, which had led to a lack of continuity of care. We found that the medical practice's clinical records were unsystematic and lacked any clear management plan for Ms C. As such, an important diagnosis was missed by incoming staff. Although Ms C's B12 deficiency was overlooked we were, however, satisfied with the efforts that the GP then made to minimise the potential impact of this oversight and we did not make any recommendations about this.

Ms C had also complained about the system the medical practice had in place for requesting, tracking and reporting blood tests. While we concluded that the system in place at the time was not fit for purpose, we found that they have since introduced a procedure which is in line with good working practice. On her complaint about the board’s complaints handling, we found that many of the points Ms C raised went unanswered and we made recommendations to address this.

Recommendations
We recommended that the board:
• remind complaint handling staff of the importance of answering all points raised by the complainant; and
• take steps to ensure their complaint handling staff work in accordance with the NHS Scotland complaints procedure.

Summary
Ms C, an advice worker, complained about the care and treatment provided to Ms A. Ms A had a very complex medical and surgical history. This included a pancreatic and renal (pancreas and kidney) transplant in 2002, during which surgeons also removed Ms A's appendix. The operation note contained details of the procedures relating to the transplants, but did not refer to the removal of the appendix.

In July 2010, Ms A was admitted to hospital with abdominal pain. Following clinical examination, blood tests and a scan, clinicians provisionally diagnosed appendicitis. They operated on Ms A to remove her appendix, but surgeons could not find it. They were not aware that the appendix had been removed in 2002, and Ms A said that she had not been told about it at that time. Ms C complained that the board’s failure to tell Ms A about this or to properly record it in her medical records led to an unnecessary operation.

In August 2010, Ms A was transferred to another hospital and underwent further procedures. Shortly after one procedure, Ms A requested help from two nurses to go to the toilet. Only one nurse helped. Ms A was unable to manoeuvre and fell to the floor. She suffered a haematoma (an accumulation of blood) in her leg, which burst causing loss of blood. Ms A said this would not have happened if two nurses helped her as she requested. As a result of her fall, Ms A said that she had to undergo further surgery and suffered significant physical and mental distress.

We found that the board’s failure to record the removal of Ms A’s appendix in 2002 was unreasonable. This was compounded by the failure to tell Ms A or her GP that her appendix had been removed. Had the surgeons in 2010 known that Ms A’s appendix had been removed and thus ruled out acute appendicitis as a diagnosis, the intended appendix operation would have been prevented.

We also found that the board failed to explain the record-keeping omission when responding to Ms C's complaint.

On the issue of Ms A’s request for help from two nurses, we found that the board’s failure to listen to Ms A and provide more assistance was not reasonable and that her resulting fall had significant consequences for her. As, however, the board had already acknowledged that the nurse should have listened to Ms A, and apologised for this, we made no recommendation in respect of this complaint.

Recommendations
We recommended that the board:
• amend the transplant protocol to ensure it meets guidelines relating to communication with the patient and the patient’s GP; and
• ensure they investigate complaints fully and provide a comprehensive response to complainants.

Summary
Mr C underwent a hernia repair and had a testicle removed in January 2011. He later developed a painful swollen lump where his testicle had been. He attended a post-operative review with the consultant surgeon about six weeks after surgery and was advised this was a haematoma (an accumulation of blood) that would decrease over time. However, the lump became bigger and Mr C went to the hospital's accident and emergency unit a few weeks later, where the lump was drained.

In May 2011 Mr C’s GP made an urgent referral for him to be seen again at the hospital. The referral was considered, and re-graded as routine, and Mr C was given a general surgery appointment for August 2011. His GP, however, wrote to the hospital again, and a consultant identified that Mr C should be seen by the surgeon who had operated. He was given an appointment at that clinic for July 2011. Mr C said he would like further surgery to remove the haematoma, and was monitored in relation to this until he was given a date for surgery.

He complained that there was a delay in treating his ongoing difficulties. We found that, although Mr C was initially treated appropriately in his post-operative review, a failure to record full clinical findings after the haematoma was drained meant that a possible opportunity to refer him for a further clinic review had been missed. Although we accepted the board’s general position about the re-grading of referrals, we could not find evidence of why Mr C's initial referral was re-graded as routine. We also found that the board did not appear to operate a mechanism for identifying patients like Mr C who needed to be referred back to their operating surgeon. The board also acknowledged that there had been a delay from the point of referral until the offer of an appointment. In the circumstances we found this to be unreasonable, and upheld Mr C’s complaint.

Recommendations
We recommended that the board:
• review the referral system to ensure when referrals are re-graded the reasons for doing so are clearly documented and communicated; and re-referred patients are routed back to the appropriate consultant; and
• provide a full apology to Mr C for the failings identified.

Summary
Ms C complained that her medical practice had kept information from her about her hospital test results. She also said that when she wrote a formal letter of complaint to the practice they had failed to address the issues she raised.

Our investigation found, however, that the practice had correctly reported the outcome of the hospital tests to Ms C and that their response letter to the complaint was appropriate.
 

Summary
Mrs C complained about aspects of nursing care that her late father (Mr A) received in hospital in the two months before his death. The complaints included that Mr A was not provided with basic nursing care in relation to personal and oral hygiene or to ensure that he had adequate food and drink. Mrs C also complained about the time her father spent waiting in accident and emergency to be admitted to a ward and that the staff failed to listen when the family pointed out Mr A's inabilities to care for himself.

We took advice from one of our medical advisers, who is a senior nurse. We upheld two of Mrs C's three complaints. We found that the records showed that the level of nursing care provided was appropriate, but it was unacceptable that Mr A had to wait for more than seven hours to be admitted to hospital. Also, although Mr A was in hospital for about six weeks, there was little evidence of communication from the nursing staff to his family, even in the final days of Mr A's life. We, therefore, found that communication from the staff to the family was inadequate and that the record-keeping about this should have been better.

Recommendations
We recommended that the board:
• remind nursing staff of their responsibilities to ensure that record-keeping is maintained in accordance with the Nursing and Midwifery Council Code and Record Keeping guidelines; and
• apologise for the failure to admit Mr A to a ward within an acceptable timeframe.

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital. Mrs A had been admitted for a suspected stroke. A diagnosis of a TIA (transient ischaemic attack or 'mini-stroke') was made and Mrs A was discharged on a Friday to a facility staffed by mental health staff. Mr C and the mental health staff were concerned about Mrs A's condition and tried to arrange for Mrs A to be transferred back to the hospital but were told this could only happen after she had been assessed by a clinician. Mrs A was assessed on the Monday and was transferred back to the hospital, where tests revealed she had suffered a stroke. Mr C complained that Mrs A had not been fit for discharge on the Friday. The board conducted a significant event review which concluded that there was a breakdown in communications and staff at the facility did not follow recognised procedures and made several recommendations. Mr C also complained that the board failed to respond to his requests to meet with senior staff.

After taking advice from two of our advisers, a consultant physician and a senior nurse, we upheld Mr C's complaints. We found that poor record-keeping at the time of transfer contributed to a breakdown in communication between medical and nursing staff about Mrs A's condition, and that the board should have kept Mr C updated about plans for a meeting with staff.

Recommendations
We recommended that the board:
• share our findings with the staff involved and remind them of the importance of completing comprehensive discharge documentation to assist the receiving clinicians;
• apologise to Mr C for the way in which it dealt with his request to meet senior managers; and
• apologise to Mr C for the failings identified during this investigation.

Summary
Mr C was unhappy about the poor service he said he received from his medical practice, in particular the long wait for an appointment. He also said the practice had failed to advise him of the appointment procedure when he and his wife joined the practice and that their complaints procedure was not fit for purpose.

We found that the practice did operate an appropriate appointments procedure which complied with the guidance set out by Health Rights Information Scotland. We also found no evidence to suggest that the practice had failed to advise Mr C about the appointments procedure when he joined. Our investigation of Mr C's complaint showed that the practice's complaints procedure was accessible and fit for purpose.

Summary
Mrs C complained that medical staff delayed in diagnosing her son’s appendicitis. She said that this left him in severe pain and distress. We investigated the complaint and took specialist medical advice. Although it did take some time for appendicitis to be diagnosed, the advice we received was that that there were good reasons for this. Mrs C’s son’s clinical history and his signs and symptoms were not those of classical appendicitis. We found that it was appropriate for staff to consider other potential diagnoses. We also found that staff carried out appropriate investigations during that time, and that there was no delay in taking Mrs C's son to theatre after the results of a scan were reviewed.