Health

Summary
At around six weeks old, Miss C's baby (Baby A) developed laboured breathing and was not sleeping or feeding well. She was referred to hospital by her GP who noted that was symptomatic of an upper respiratory tract infection (URTI). Baby A was triaged and seen by a junior doctor at Wishaw General Hospital. She was noted as having a four-week history of worsening wheezing, cough and intermittent fever. It was also noted that Miss C described Baby A as making a 'squeaking noise' when breathing.

The junior doctor diagnosed a URTI and this diagnosis was supported upon review by a paediatric registrar. Baby A was discharged home with arrangements put in place for follow-up review at home. Baby A was reviewed three days later. She was found to have a stridor (high-pitched breathing sound, normally associated with a blockage in the throat). Further examination by a consultant, and a chest x-ray, resulted in Baby A being transferred to Yorkhill Hospital, where she was diagnosed with a hemangioma (a benign tumour partially blocking her airway). Miss C complained that Baby A's condition had not changed during the time she was at the first hospital and that, therefore, the stridor had been missed and the hemangioma diagnosis delayed. She also complained about the attitude and actions of the junior doctor and the board's complaint handling.

Our investigation did not find that the hemangioma could have been diagnosed earlier. We found that the stridor would have been an indicator for the condition, but that none of the four medical staff who originally examined Baby A recorded this symptom, which is relatively simple to identify. We were satisfied that Baby A's symptoms were indicative of a URTI and established that the symptoms associated with hemangioma can be exacerbated by URTIs, indicating that her condition likely developed and worsened. We were unable to comment in specific detail on the actions of the junior doctor, but did not find any evidence that issues complained about had any impact on Baby A's treatment. We were also generally satisfied with the board's complaint handling.
 

Summary
Mrs C's infant son (Master A) had a history of throat problems, reflux and allergies. Mrs C was concerned that he was having problems while sleeping, and she was not happy with the investigations and treatment provided by the board. The specific complaints we investigated were that there was an avoidable delay in fully investigating and diagnosing Master A's condition, and there was an error in a letter from the board regarding the date when Master A's 'failure to thrive' was diagnosed. Mrs C was also unhappy that the board had not explained to her why a flexiscope examination (a specialist examination of the throat using a camera device) was not carried out on Master A more recently.

We found from looking at the evidence, and taking advice from two of our medical advisers, that there was no reason to have repeated a flexiscope in Master A's case. In terms of referrals, investigations and treatment within the board, there was no evidence of avoidable delay. There was a delay in Master A having a polysomnography (sleep study), as he remained on a waiting list in another health board area. However, the board had limited, if any, influence over how quickly a referral to another health board would be actioned as it was not within their direct control, and there was evidence that they had pursued the referral with the other health board. As the referral had not taken place, the board acted correctly in referring Master A to a third health board area, where he was seen. Therefore, we found no evidence of avoidable delay by the board, and did not uphold this complaint.

In their letter to Mrs C, the board stated a date when 'failure to thrive' was first identified. The clinical records showed that a suggestion of 'failure to thrive' was first noted about a year previously. On that basis, we found that the board's letter to Mrs C should have accurately reflected this and, therefore, we upheld this complaint. Our decision notice drew this error to the board's attention and, therefore, we did not make any recommendations.

Summary
In late 2005, tests revealed that Mr C had elevated liver function tests and he was advised to reduce his alcohol consumption. Mr C's liver function tests became significantly elevated in 2007 and his GP believed that these were consistent with his alcohol history, a view supported by hospital specialists. In 2010, following tests, a hospital specialist diagnosed hepatitis C.

Mr C complained that his GP did not look beyond alcohol misuse as the cause of the abnormal results and that he should have been screened for hepatitis C much earlier. He said that as a result of the failure to do so, he began treatment at an advanced stage of the disease which had impacted adversely on his chances of surviving.

We found that the GP failed to fully investigate Mr C's liver functions abnormalities, particularly in 2007. Although it was impossible to say definitively whether Mr C would have tested positive for hepatitis C earlier than 2010, we found that it was possible he might have and, therefore, an opportunity to make an earlier diagnosis was missed and treatment was potentially delayed.

Recommendations
We recommended that the practice:
• review its management of liver function abnormalities including information provided in referrals; and
• apologise to Mr C for the failures identified.

Summary
Mr C complained about cosmetic dental treatment he received at a dental hospital between 2007 and 2010. Mr C initially underwent oral hygiene treatment, and then had surgical crown lengthening treatment to improve the appearance of his upper front teeth and his gum line. He had temporary crowns fitted at this time with a view to having permanent crowns fitted once the gum line had fully healed.

Mr C was dissatisfied with the outcome of the surgery, and the consultant responsible for his treatment agreed to carry out the procedure a second time. Mr C remained dissatisfied with the aesthetic outcome, and had a number of complaints about several aspects of his treatment.

He complained that his care and treatment was inadequate; that some information about his treatment was incorrect; and that his complaint was not properly responded to.
We did not uphold any of Mr C's complaints about his treatment. We found that Mr C's treatment plan was consistent throughout; that Mr C's oral hygiene had improved as a result of his treatment; that there was no evidence to show Mr C had received inadequate care and treatment. We found that there appeared to have been an element of miscommunication in relation to some of the issues which arose during Mr C's treatment.

We did uphold Mr C's complaint that the board had failed to advise him of the SPSO, as our contact details were not included within their final letter to Mr C. We will bring this failing to the attention of the board to prevent recurrence.

Summary
Mrs C complained that aspects of her mother (Mrs A)'s care and treatment in hospital before her death were of an unreasonable standard. On investigating the complaint, we found that much of the care and treatment that the board provided to Mrs A was reasonable and appropriate. We also found that the board had acted reasonably when they had discharged Mrs A after a previous admission to hospital. We found that there was no requirement for the board to discuss with the family or seek permission from them when they subsequently put a Do Not Attempt Resuscitation order in place, as Mrs A was able to make her own decisions at that time.

However, one of Mrs C's complaints was that the board had delayed in diagnosing a brain tumour. We received medical advice that a mini mental state examination (MMSE) should have been carried out when Mrs A was first admitted to hospital, as she was confused on admission. A brain scan should also have been considered if the MMSE results were abnormal. That said, an MMSE was carried out several months later and this was normal. Therefore, it was not possible to comment on what, if any, difference carrying out an MMSE on Mrs A when she was first admitted would have made to her prognosis. The board had written to Mrs C to apologise for the distress caused as a result of the delay in diagnosing her mother's condition.

We found that the board's communication did not meet the needs of Mrs A's family. The board had written to Mrs C stating that communication could have been improved. They said that a number of measures would be taken to improve communication between staff and to relatives. They also apologised that communication had been poor. We upheld the complaint because of these failings. However, in view of the board's response to Mrs C on these points, we had no recommendations to make.

Summary
Mr C attended the A&E department at Glasgow Royal Infirmary after a fall. He complained of severe back pain but a full skeletal x-ray was not carried out in A&E or on admission to an orthopaedic ward. Mr C was told a back x-ray was scheduled for two days' time and he could go home until then. Mr C's wife (Mrs C) reported her concerns about the proposed discharge to the consultant, who, after examining Mr C, said that an x-ray was not required and that Mr C could go home immediately.

Around two weeks later, Mr C attended the Glasgow Royal Infirmary Fracture Clinic and following an x-ray of his spine was admitted. He was examined the next day and it was decided to transfer Mr C to Spinal Injuries Intensive Care Unit at Glasgow Southern General Hospital where he was operated on for a broken back and complications with his right leg. Mrs C wished to know why the spinal injury was not picked up at Glasgow Royal Infirmary.
We found that on arrival at A&E, Mr C should have been placed flat on a spinal injury board and then examined by log-rolling to keep him immobilised but that this did not happen. We also found that staff failed to consider whether Mr C had sustained injuries elsewhere in his body and that there was a breakdown in communication between nursing and medical staff.

Although we upheld Mr C's complaint, we made no recommendations as the board had taken steps to prevent a similar situation occurring again and apologised for the failings which had been identified.
 

Summary
Mrs C complained about the treatment her mother (Mrs A) received at the Victoria Infirmary. Mrs A was admitted to hospital by emergency referral from her GP with a history of recurrent falls, drowsiness and reduced mobility. Mrs A was initially treated for a presumed infection based on abnormalities in her bloods and her presenting condition. However, no clear source of infection was identified. She was identified as being at risk of blood clots and was put on anticoagulant medication.

Nursing staff observed that Mrs A's right leg was swollen. A doctor reviewed the swelling and did not consider it to be significant. Mrs A's leg was found to be swollen again eight days later. A Doppler ultrasound (a type of ultrasound for monitoring blood flow) was carried out, which showed no signs of thrombosis. A CT scan showed that Mrs A had a mass in her pelvis. Biopsies were ordered, but because of the location of the mass and the quality of the material gathered, it took some time to obtain the eventual diagnosis of cancer of the B-cells. This diagnosis was made around a month later and three days after Mrs A's death. A post-mortem was carried out which concluded that Mrs A's death was the result of a pulmonary blood clot, caused by Deep Vein Thrombosis (DVT) in the right calf, due to a large tumour.

Mrs C complained that the board failed to take prompt or effective action to investigate the cause of her mother's swollen leg. She considered that this led to a failure to identify DVT. She also complained that delays to the biopsy results meant that there was no opportunity to treat her mother's cancer. Mrs C raised further concerns about delays to providing family members with test results and poor administration of medication.

Whilst we found that the board did not regularly assess Mrs A's risk of blood clots during her admission, we were satisfied that this would not have had a detrimental impact on her treatment. We considered that there were opportunities for further Doppler ultrasounds to be carried out, but were ultimately satisfied that it was reasonable for the board not to undertake these tests in the circumstances.

There was no evidence of DVT following the Doppler ultrasound and we found that Mrs A's mass (which was likely to cause leg swelling) and the fact that she was already receiving anticoagulant medication indicated that there were alternative causes for her swelling other than DVT. We did not find that the board unduly delayed providing family members with test results.

Similarly, the evidence presented to us showed that it was difficult to obtain biopsy samples from Mrs A's mass and, once obtained, the diagnosis of cancer of the B-cells was complex, requiring specialist opinion. We were satisfied that the biopsies were ordered, and their results reported, as quickly as possible. With regard to the provision of medication, we found that cough medicine prescribed for Mrs A was taken to a different patient in error. We also established that Mrs A was prescribed the wrong dose of anticoagulant medication and that doses may have been missed on more than one occasion. Whilst we were unable to confirm that doses were definitely missed, we considered that the lower dose provided would have increased Mrs A's risk of developing blood clots.

Recommendations
We recommended that the board:
• apologise to Mrs A's family for the failure to properly prescribe and record certain anticoagulant drugs;
• remind staff of the importance of recording and signing for all administered medication; and
• draw clinical staff's attention to the guidance in the Therapeutics Handbook for Thromboprophylaxis for Medical Patients (guidance on the administration of anticoagulant drugs to patients with an increased risk of blood clots).

Summary
Mr C complained about the care and treatment he received from his medical practice. Specifically, he said that he had been prescribed the wrong drugs for his illness. He maintained that he had resisted the prescriptions but that his GP had refused to change or stop his medication. He believed that his continuing mental health problems were as a consequence of receiving the wrong drugs.

The investigation found no evidence to suggest that the treatment given to Mr C was incorrect. We also did not find any evidence to suggest that Mr C had asked for his prescriptions to be changed or stopped or that his requests had been refused. We found that all the drugs prescribed to Mr C were appropriate for his presenting condition, and we did not uphold his complaint.

Summary
Mrs C complained on behalf of her family about their removal from a GP list. The family, a mother suffering from terminal cancer and two adult daughters, temporarily moved house and left the area after having been registered at the practice for a number of years. When the family returned to the town, but not to their former home, they applied to re-register at the practice.

Their application was refused because of a deteriorating relationship between Mrs C's daughters and the practice, which had been on-going for three to four years. Mrs C claimed that the family had been removed from the list without explanation and that when reasons were given they were inaccurate and inappropriate. She also complained that correspondence about the matter was not responded to.

Our investigation found that the family had been removed from the list when they removed themselves - albeit temporarily - from the geographical area covered by the practice. At this time, a collective decision was taken by the practice that should the family return to the area they would not be re-registered due to the breakdown of the relationship between the practice and Mrs C's daughters.

The family did move back into the area but not to their former home and there were other practices closer to their current address. Therefore, it was thought beneficial for the family to register with a GP closer to their home address due to Mrs C's cancer treatment. When Mrs C's daughters appealed to the practice for their mother alone to be re-registered this was refused, as it was not thought practicable.

Our investigation found that reasonable explanations had been provided to the family as to why they could not be re-registered and that the original removal for geographical reasons had been appropriate. It also found that correspondence on the matter had been responded to by the practice in a timely and reasonable manner. We, therefore, did not uphold the complaints.

Summary
Mrs C's late husband (Mr C) was a cancer sufferer. She complained that his practice failed to prescribe him antibiotics when blood test results suggested he had an infection and also that they failed to contact him when repeat blood tests were returned early and before he was scheduled to return to the practice. She also complained that the GP(s) failed to spot the seriousness of his condition.

Mrs C had to call an ambulance for her husband five days after his blood tests suggested an infection. He was taken to Ninewells Hospital where he died shortly afterwards of cardiac arrest and sepsis. Mrs C was told that her late husband's body had been overwhelmed by the infection and she felt that this caused or contributed to her husband's cardiac arrest.

We took advice from a medical adviser, who said that the actions of the GPs had been reasonable. He concluded that the GPs had taken full recognition of Mr C's condition and medical history. He also said that as the first blood test results were not conclusive, it had been appropriate to repeat them. The results from the second tests were also not conclusive and in some areas had actually improved. Our adviser took the view that it was, therefore, reasonable for the GPs to wait for the scheduled appointment to review Mr C. He also concluded that the infection which overwhelmed Mr C, although showing early but non-specific signs in the blood tests taken by the GPs, could not have been predicted from the results available to them at the time.

We did not uphold this complaint.