Health

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.

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.