Health

Summary
Mrs C suffered urinary problems and underwent a cystoscopy (a medical procedure used to examine the inside of the bladder) in hospital. She subsequently developed symptoms similar to cystitis and was diagnosed to have contracted pseudomonas (a serious infection caused by bacteria). She complained that the board failed to follow appropriate decontamination procedures before carrying out the cystoscopy. While responding to our investigation enquiries for further information, the board found that there had in fact been a case of cross contamination. This had not been identified when Mrs C initially made her complaint to the board.

As a result of this new information, Mrs C decided to take legal action against the board, and subsequently withdrew her complaint with us. As a result, we made no finding on her complaint.

Summary
Mrs C was admitted to hospital for a gastroscopy (a procedure in which a thin, flexible tube is used to look inside the stomach) under general anaesthetic. She waited in the day room until she was allocated a bed. During this time a member of staff discussed confidential information with her while she was with other patients. Mrs C complained that the discussion should have taken place privately.

When Mrs C returned to the ward after the procedure, she went to the toilet to find bedpans piling up and their contents spilling on the floor of the only cubicle available. Nursing staff responded immediately when Mrs C raised the matter, but she was still unhappy and complained to us.

Mrs C later underwent a further test. She complained that staff told her that the consultant would give her the results of the test within a few days (or her GP would, within two weeks) and that the board failed to do either. The consultant wrote to Mrs C within five and a half weeks with the results.

We found that the board should not have discussed personal medical information with Mrs C in front of other patients or left bedpans piling up in the ward toilet, and upheld both complaints. However, we did not make any recommendations as the board had already taken action to address these failings. We did not find that the time the board took to provide the results of the test was unreasonable.

Summary
Mrs C, an advocacy worker, complained on behalf of her client (Mrs A) that hospital staff failed to adequately record and deal with a fall that Mrs A sustained in hospital. Mrs A said that staff had manhandled her, and had thrown her onto a bed, and that she was then denied medical treatment.

After consulting our medical adviser, we found that staff had not acted in accordance with moving and handling guidance and that they failed to appropriately record the circumstances of Mrs A's fall. We found, however, that staff were acting in Mrs A's best interests at the time by putting her back to bed rather than lowering her to the floor and obtaining a hoist which may have taken some time. We saw no evidence that Mrs A's safety was compromised by these actions. As the board had already taken action to prevent a repeat occurrence, we did not make any recommendations.

Summary
Mr C, an advocacy worker, complained on behalf of Mr A that his condition was not properly diagnosed and that he was prescribed a named drug inappropriately. He alleged that the consultant concerned had been dismissive and did not review Mr A again as promised.

We obtained advice from one of our medical advisers, who considered Mr A's clinical records. We established that the assessment of Mr A and his treatment were appropriate, as was the drug prescription given to him. However, we also found that follow-up arrangements were far too lengthy given Mr A's presenting symptoms, which were progressive. Our adviser said that arrangements should have been made sooner given that Mr A’s symptoms were unresolved and that the results of a procedure at the hospital required evaluation.

Recommendations
We recommended that the board:
• offer Mr A an apology for their failure to review him at an earlier date; and
• the consultant review his follow-up practice in similar circumstances.

Summary
Mrs C complained about the care and treatment she received at a dermatology clinic for a lesion on her breast. Mrs C developed a rash that spread to both breasts and was of the view that Dermol 500 (a moisturiser with antiseptic agent) was the underlying cause of scarring to her breasts. Mrs C was seen frequently over a five month period and was prescribed various topical creams. Mrs C also said that one of the doctors had not examined her and felt that, had he done so, the problems she experienced could have been avoided.

In response to the complaint, the board advised that they did not believe that this cream was the cause of the rash. However, they said that Mrs C had been advised to avoid using it.

We did not uphold Mrs C's complaint. Our medical adviser was unable to identify the cause of the rash, but considered that it was unlikely to be Dermol 500 as it is a moisturiser widely used for adults and children, and allergic reactions are very uncommon. The clinic had conducted a patch skin test but did not include the agents within Dermol 500. Whilst, therefore, there is a small possibility that an allergy could occur, we considered that the clinic took reasonable action in advising Mrs C to stop using it. Also, although it is unclear how thoroughly the doctor examined Mrs C, the clinical records reflected that a visual examination was carried out. We considered that a physical examination would not have been expected in this case.

We also considered that the strength of the topical steroid prescribed as a short-term measure was appropriate and would not have caused significant thinning of the skin. A biopsy result showed Mrs C's skin to be eroded in a relatively superficial way. We concluded that Mrs C's overall treatment was appropriate and that residual staining of the skin was likely due to the severe rash.

Summary
Mrs C went into labour in the early hours of the morning. She telephoned the maternity assessment unit and was advised to attend. After an assessment and test, the midwife told Mrs C that she was in early labour. She was discharged and advised to return to the unit at 12:00 that day. Shortly after arriving home, Mrs C called the unit again as her contractions were increasing and she was becoming more distressed. The midwife advised her to attend the unit. While getting dressed to go there, Mrs C felt her baby's head appear. Her husband helped deliver the baby and they were transferred to hospital by ambulance shortly afterwards.

Mrs C complained that the board put her and her baby's health at risk because of the quality of midwifery service provided. She was unhappy that staff could not find her health records when she first arrived at the unit. She was also unhappy at being advised to return home despite not feeling well due to having bad and regular contractions which were every five minutes. Mrs C said that the midwife had told her that, although she was in early labour, she should not give birth within the next 12 hours.

Mrs C also complained that, when she called the hospital again shortly after returning home she said that she was bleeding and involuntarily pushing. She said she was told that she was probably in early labour but could come to the hospital if she wished. Mrs C also raised concerns that the placenta was not removed before she arrived at the unit.

We took advice from one of our medical advisers, a midwifery specialist. Having looked at all the medical records and the advice given, we considered that it was reasonable for Mrs C to have been discharged. Whilst we had concerns about the midwife's comments regarding whether delivery was likely within a 12 hour period, we noted that the board have since taken steps to address this by discussing it with the member of staff involved.

Telephone records noted that Mrs C's contractions were increasing and that she was becoming more distressed but it was also noted that there was no reported bleeding or abdominal pain. We also established that, although the midwife did not believe delivery was imminent, Mrs C was offered an ambulance but declined because her husband was going to take her to the unit as soon as she got dressed. We considered that the retained placenta was managed appropriately in terms of the Scottish Emergency Maternity Care Course for non-maternity professionals. This was because Mrs C was stable and there was no evidence of third stage complications, such as haemorrhage.

Overall, although we recognised that Mrs C found events distressing, we concluded that her overall care was reasonable and appropriate.

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.