Health

Summary
Mr C complained about the side effects that he had suffered since being prescribed gentamicin (a powerful antibiotic) while he was a hospital in-patient. He had been admitted to hospital for treatment for an infection related to his heart pacemaker (a device that regulates heartbeat).

He has since been diagnosed with gentamicin toxicity (poisoning), which has affected his balance and ability to lead a normal life. Early in his treatment, Mr C told nursing and medical staff that he felt dizzy and unbalanced, but was told it was due to the antibiotics and not to worry. Mr C understood that guidelines about the use of gentamicin said the drug should not be given for more than ten days, whereas he had taken it for 14 days. He was concerned that his medical records had not recorded all the times that he had reported dizziness. Mr C also felt that the board's complaints handling was inadequate.

We upheld Mr C's complaint that the board's actions in respect of gentamicin toxicity were unreasonable. Although the medication was appropriately monitored, we found that more notice should have been taken of the side-effects that Mr C reported. The board had upheld Mr C's complaint to them and had taken action to use the lessons learned from his case. They had provided a new prescribing guideline and reminded staff about the issues, so we did not make any recommendations. We found that their complaints handling was adequate.

Summary
Mr and Mrs C complained about the care and treatment that their eleven year old son (Master A) received for chest problems at a hospital's emergency department assessment unit. They said that it was unacceptable that the board took the time they did to diagnose Master A's tuberculosis (an infectious lung disease). Master A had four visits to the hospital in about six months, the last of which was a review appointment at a clinic, which was scheduled at his second visit to the emergency department.

We found from looking at the medical records, and taking advice from one of our medical advisers that in their own review of this case the board found that a consultant's comment on an x-ray report should have raised the possibility of a diagnosis of tuberculosis. However, due to administrative problems within the hospital this was not followed up. Although the review said that the administrative problems were being addressed, we found that the board's response to Mr and Mrs C's complaint said the same thing, eighteen months later. We saw no evidence that the matter had yet been satisfactorily resolved.

The board said they regretted that a diagnosis of tuberculosis was not reached earlier. Our medical adviser took the view that Master A's review appointment at the clinic should have been arranged sooner. Our adviser also said that tuberculosis should have been excluded or diagnosed around the time of Master A's third visit to the emergency department, and certainly by the time of the review appointment at the clinic. The delay led to a progression in Master A's condition. As the evidence indicated that it was unacceptable that the board took the time they did to diagnose Master A's illness, we upheld the complaint.

Recommendations
We recommended that the board:
• apologise to Master A and his family for the delay in diagnosing his illness;
• review the August 2009 emergency department assessment unit visit, in the light of the Ombudsman's adviser's comments, to ensure that a differential diagnosis of tuberculosis is considered in children with symptoms and examination/investigation results such as those present in Master A; and
• provide the Ombudsman with a copy of their action plan to take forward the learning points from Master A's case. The action plan should address the issues raised in 2009 and 2011 about the problems with filing timeously the emergency department assessment unit records in a child's hospital case records.

Summary
Mr C complained on behalf of his partner (Ms A) who was a hospital in-patient receiving treatment for schizoaffective disorder (a mental disorder affecting thinking processes and mood). Ms A was prescribed unilateral electroconvulsive therapy (ECT – a treatment that involves sending an electric current through the brain). This was to be provided at another hospital, as there was renovation work taking place in the ECT unit at the first hospital. After three sessions of ECT Ms A complained of gaps in her memory as well as a general feeling of her mind being blank. It was found that she had received bilateral ECT (electrical current passed through the whole brain) instead of the prescribed unilateral ECT (electrical current passed through only one side of the brain).

Mr C complained that Ms A was not reasonably administered her prescribed medication in the first hospital, as she was asleep when medication rounds took place and she was not woken. He also complained that the second hospital provided bilateral ECT without Ms A's consent and that the information provided before the treatment was not reasonably relevant to his partner's circumstances.

We did not uphold the complaints about medication and information. We were satisfied that the information provided prior to the treatment was appropriate. We found that Ms A missed medication doses on around 20 occasions, mainly of ibuprofen. However, we accepted the advice of our medical adviser that patients would not be woken for such pain medication. Ms A also missed two doses of depakote (a mood stabilising anti-epileptic drug). We found that this drug should be maintained at a certain level in the blood stream and, as such, patients should not miss their dose. However, recommended practice is for the dose to be provided as soon as possible after the patient wakes up. If they wake closer to the time when the next dose is due, then a dose can be missed rather than a double-dose being provided.

There was insufficient evidence for us to determine exactly when Ms A woke up on the occasions in question or how close this was to the planned delivery of her next dose of medicine. We also found that such episodes were rare, and our medical adviser said that they did not happen close enough together to have had a significant impact on Ms A's overall wellbeing.

The board accepted and apologised unreservedly for the fact that bilateral rather than unilateral ECT was performed. This was due to different practices in the two hospitals. The board pointed out that Ms A signed a consent form allowing staff to decide what type of ECT was provided. We found that the consent form did allow bilateral ECT, but that any decision about this should be linked to clinical need and the patient's preference. We found that unilateral ECT is recommended in most cases and that by providing bilateral ECT the board increased the likelihood that Ms A would experience side effects. There was no clinical indication for bilateral ECT. The board failed to record any reasons for deviating from the prescribed treatment, and communication between the prescribing team and the team providing the treatment was poor.

In this respect, the board failed to comply with standards set out by the Scottish ECT Accreditation Network (SEAN). So although Ms A's signed consent allowed the board to carry out this treatment, we did not consider that they went about deciding to do so in the way that the consent form suggests, and we upheld this complaint.

Recommendation
We recommended that the board:
• provide us with evidence of their standardised procedure for prescribing and recording treatment within their ECT departments including specific detail as to how specific SEAN standards (10.2 and 11.8) are being complied with.

Summary
Mrs C complained about the care and treatment provided to her mother (Mrs A) in hospital. Mrs A had dementia and was admitted to hospital after a neighbour found her wandering the streets in her nightclothes. Mrs C said that her mother did not have capacity to make decisions about her own healthcare. However, we found that there was no clear statement about this in Mrs A's case records. We also found that the board's use of Adults with Incapacity documentation (which is about treating patients who are unable to give consent) was also below a standard that could be reasonably expected.

We upheld this complaint, although we acknowledged that the board had taken action in response to it. They had compiled a learning plan for the ward as there was a clear requirement to increase staff knowledge of the Adults with Incapacity framework. The board also apologised to Mrs C for these failings.

Mrs C also complained about the medication administered to her mother. Mrs A's family had felt that she was being over-sedated and took her home against medical advice. Mrs C complained that the board failed to put a discharge plan in place to ensure that Mrs A received appropriate medical treatment and support in the community. We found that it would be unreasonable to criticise the board for this, given the irregular nature of the discharge. However, we felt that the board could improve the irregular discharge form, by amending it to indicate the status of the person signing on behalf of the patient.

Our investigation found that the drugs chosen and used were standard and reasonable. However, we found that the board failed to involve the family in the decision to prescribe and administer some of the medication, as they should have done in line with the Adults with Incapacity legislation. In addition, the reason for this medication being used was documented inconsistently and in insufficient detail. We upheld the complaint. However, as the board had apologised for the problems we identified and had taken action to try to prevent them from occurring again, we had no recommendations to make.

Summary
Mr C made several complaints about the care and treatment he received in hospital, most of which we did not uphold. He said that a communication failure meant that staff were not expecting him when he arrived. However, we found that the staff nurse had been told that he was coming in and that, although there was a delay in providing him with a bed, this was not unreasonable in the circumstances. Mr C also said that he asked for a doctor when he felt that he was developing a urinary tract infection, but no doctor attended. We found that nursing staff had contacted the night team, which included medical staff, and the team had said that the staff should wait for the results of tests on a urine sample that had been taken. We found that staff acted reasonably in response to Mr C's requests and noted that a consultant saw him the next day. Mr C asked to see a doctor again the next evening. Nursing staff again contacted the night team, who said that they would see him after they had seen some other patients. However, Mr C then decided to discharge himself and was ready to leave when the team arrived.

Mr C also told us that some nursing staff displayed hostility towards him. We found no evidence of this, but noted that Mr C felt very frustrated by what he saw as staff failure to respond to his requests and wishes. We took the view that staff might have been able to prevent the situation escalating if they had more expertise in listening and responding to feedback. We noted that Mr C's complaint resulted in the board deciding that staff should have additional training in relevant techniques.

We did uphold Mr C's complaint that the board delayed in responding when he complained to them. We found the response itself to be satisfactory, although we thought the board could have provided Mr C with more information about the training they had arranged for staff in response to his complaint.

Recommendation
We recommended that the board:
• provide us with further information about the training in de-escalation techniques that was provided to staff in response to this complaint.

Summary
Ms C was pregnant. She went to hospital, where it was found that her waters had broken and she was booked in to be admitted the next morning for an induced labour. Ms C complained to us that on the day she was admitted she did not receive antibiotics until the evening. This was contrary to the board's own policy that if an expectant mother's waters had broken she should receive antibiotics immediately on admittance to hospital to reduce the risk of infection. We upheld Ms C's complaint that there had been a delay in administering antibiotics in her case. However we did not make any recommendations as we noted the board had taken steps to address this.

Ms C underwent a long labour, and had a epidural (an anaesthetic administered by a fine tube inserted into the spine, the effects of which come on gradually and continuously) which she told us became displaced and leaked. As Ms C's labour was not progressing, staff decided that she should go into theatre for either a forceps delivery or caesarean section. To prepare her for this, she was given a spinal block (a single shot spinal injection) for more rapid and profound analgesia. The anaesthetist had difficulty placing the block, and after several attempts called a consultant anaesthetist for assistance. The consultant also had difficulty placing the block although they eventually managed to do so. Having taken advice from one of our medical advisers who is a consultant anaesthetist, we did not uphold Ms C's complaint that an unreasonable number of attempts were made to insert the block. We found that the anaesthetist had acted correctly and called the consultant within a reasonable amount of time. We also found that given that both the anaesthetist and the consultant had had difficulties in placing the block, there were no training issues identified.

The block then worked very quickly, and Ms C developed numbness in her arms and chest and had breathing difficulties. After her daughter was born, Ms C had to be placed under general anaesthetic and on a ventilator until she was able to breathe unassisted again. Although we recognised how traumatic and frightening this had been for Ms C, we did not uphold her complaint about this, as we found that it was a rare but recognised complication of a spinal block. We also found that medical staff had acted appropriately, and had met Ms C later and tried to explain to her what had happened. As general medical understanding about this complication is limited, we found that they had explained it to the best of their abilities.

Finally, Ms C complained the board had not responded to her complaints adequately, especially her concerns about the future. We did not uphold this complaint. We found that the board had made efforts to discuss Ms C's continuing concerns about future pregnancies or procedures. We considered that their position that further tests would not add anything to their knowledge of Ms C was reasonable.

Summary
Mr C complained that his 14-year-old son (Master A) had six baby teeth extracted by his dentist. At the time the family were told that this was necessary to allow room for his adult teeth to come through. Master A also had an adult molar removed, again to allow space for the rest of his adult teeth to come through. Mr C has now learned that his son has a congenital problem (a condition present at birth) that means he has no further adult teeth to come through. Mr C said that the dentist was wrong to have extracted the teeth when there was no clinical need to do so.

We upheld Mr C's complaints. We found that overall there was a lack of documentation to show what the dentist discussed with him. Although there was no evidence about whether it was clinically appropriate to have extracted Master A's baby teeth, we found that the dentist should have sought specialist orthodontic advice before carrying out the procedure. We found that the adult tooth which was extracted had been heavily filled. However, while it may have been appropriate for the dentist to have extracted it, there was no evidence that a treatment plan had been carried out or that informed consent had been obtained.

Recommendations
We recommended that the practice:
• apologise for the failure to obtain an orthodontic opinion prior to the extraction of Master A's baby teeth and for failing to explain his reasons for doing so; and
• apologise for the failure to produce a treatment plan for the extraction and for not obtaining informed consent for the extraction.

Summary
Mrs C had root canal treatment from her dentist. She complained that the dentist did not tell her that there was a risk that, if the root canal treatment failed, Mrs C could lose the tooth and ultimately need a crown. Mrs C did lose her tooth and felt that the treatment was unnecessary and that the tooth could have been saved had another form of treatment been given. She also complained that other possible treatment options were not discussed with her and the response to her complaint was unreasonably delayed and contained inaccurate information.

Dentists have a duty to explain any commonly encountered or serious risks and any risks of particular concern to the patient. We found that there was no evidence to show that the dentist had done so in Mrs C's case. Nor was it clear whether the dentist discussed other treatment options (in this case, extraction of the tooth) with Mrs C. We upheld this complaint.

We did not uphold the complaint that root canal treatment was inappropriate. Although the results of such treatment can be uncertain, our dental adviser said that it was the only long term treatment with any possibility of success for the symptoms Mrs C was experiencing.

Finally, we upheld the complaint about the dentist's complaints handling. We found that ten weeks was an unreasonable length of time for Mrs C to wait for a response to her complaint, that she had not been proactively updated on its progress by the dentist and that the letter contained inaccuracies.

Recommendations
We recommended that the practice:
• apologise for unreasonably failing to explain the risks associated with root canal treatment or to discuss other options available with her;
• apologise for the unreasonable time it took to respond to her complaint; and
• ensure complainants are updated on the progress of their complaint in a timely manner and advised of the date by which they can expect a response.

Summary
Mrs C complained about treatment she received from a dental practice. She had had a replacement bridge fitted which caused her difficulties. The practice and Mrs C had different views about what had happened. Mrs C said her dentist had advised her to have the bridge replaced, but the practice said that Mrs C had expressed dissatisfaction with her original bridge and had made several requests for it to be replaced. When we looked at the written records, these did not show that Mrs C had been fully informed of the risks of having her bridgework replaced. On this basis we upheld the complaint as we found that Mrs C had not been able to give fully informed consent to the procedure.

Mrs C also complained that the bridge was inadequate. It fractured, fell out on several occasions and Mrs C developed abscesses. We found that the practice had replaced the old single-unit bridge with a bridge in two parts, which was not in the original approved treatment plan. After taking advice from our dental adviser, we found some aspects of the work unsatisfactory, in particular that Mrs C's bite was not properly assessed at the fitting stage, the bridge had to be re-fixed a number of times and the porcelain had fractured. We also upheld this complaint.

Finally, although we recognised that the practice had refunded Mrs C the cost of the bridge and referred her for specialist treatment, we found that they had failed to correct the work, as Mrs C has continued to experience numerous difficulties.

Recommendations
We recommended that the practice:
• provide evidence to the Ombudsman that they take steps to ensure patients give fully informed consent by advising them of potential risks with
• undertake and meet the cost of any further treatment as laid out within the suggested treatment plan in the specialist's letter.

Summary
Mr C told us he had a history of chest tightness, chest pain and severe heartburn. He said he twice raised concerns about these symptoms with his GP. Shortly afterwards, while working overseas, Mr C suffered a heart attack and had a coronary artery bypass graft (a surgical procedure to improve blood supply). When he came back to the UK, he asked his GP to refer him to a cardiologist (heart specialist) for review. His GP felt that this was unnecessary as Mr C had already received the best treatment for his condition and appeared to be recovering well. As Mr C needed a fitness to work certificate, he was ultimately referred to a cardiologist, but this was done privately.

Mr C complained that the practice failed to appropriately assess the symptoms that he had reported before he had the heart attack. He also complained that it was unreasonable of them not to refer him to a cardiologist after he returned to the UK.

We found no evidence in Mr C's clinical records that he had told the practice about his chest tightness and heartburn. Whilst recognising that he may have provided this information without it being recorded, we were unable to say conclusively that the records were deficient or that the practice failed to act on information that Mr C provided about these symptoms. We did not uphold this complaint.

We did, however, uphold his complaint about referral. Mr C was ultimately referred to a cardiologist and we did not find it unreasonable that this was done privately, given his desire to return to work. However, we found that it would have been good practice for a referral to have been made when he returned to the UK, as a cardiologist was able to perform specific tests that would highlight the extent of residual damage to the heart. The cardiologist ultimately found that Mr C had a blood clot which necessitated a change in treatment plan. We felt that this highlighted the benefit of referral to cardiology but also considered that there was a strong argument for referral in the circumstances of Mr C's case, particularly as his surgery was performed overseas where practices may be different.

Recommendations
We recommended that the practice:
• apologise for their failure to refer him to cardiology; and
• share our adviser's comments with their GPs with a view to identifying any points of learning that can be taken from this case.