Health

Summary
Mr C complained to the board about the treatment provided to his late partner (Ms C) at a hospital in the board area. Ms C was admitted in early March 2011 and died later that month. Shortly after admission the family were told that Ms C's condition was serious. They were concerned that although in the last year of her life Mrs C had numerous tests and x-rays nobody had noticed that she had two tumours growing in her body. In particular, Mr C wanted to know why an x-ray taken in January 2011 did not ring alarm bells.

Our investigation established, however, that Ms C received appropriate investigations in hospital and that there was no evidence of any delay in her treatment. Our clinical adviser examined the x-ray image which was taken in January 2011 and found that it was appropriately reported as normal.
 

Summary
Mrs C attended her GP in January 2010 complaining of abdominal pain. She complained that from then until November 2010 when she was diagnosed as having intra-abdominal cancer, her GP practice failed to either act upon her symptoms or treat them appropriately.

Our clinical adviser found that Mrs C had significant, persistent symptoms which appeared to become worse despite a number of medications related to the gastrointestinal tract. In the adviser's view, this should have prompted a review of the diagnosis especially in the presence of a normal upper abdominal ultrasound and normal endoscopy and sigmoidoscopy (a procedure used to see inside the sigmoid colon and rectum). The adviser added that Mrs C's communications with the practice were clear and concise and that her requests for assistance were specific. Accordingly, the adviser concluded that the management of Mrs C was deficient and we upheld the complaint.

Recommendations
We recommended that the practice:
• formally apologise to Mrs C for their oversights in her management and perform a Significant Event Audit; and
• ensure that the GP discusses this case at their next appraisal.
 

Summary
Mrs C complained on behalf of her husband (Mr C) about the care and treatment he received from his medical practice in relation to abdominal pain. Mr C had been suffering from constipation for several months. A GP visited Mr C at home as he was unable to attend the practice because of the pain. Mrs C called the practice several times shortly after the home visit, telling two GPs that Mr C's condition was not improving despite intervention from the district nurse and treatment for constipation. The practice did not, however, arrange a further home visit during the telephone calls.

Mrs C telephoned NHS 24 and an out-of-hours GP examined Mr C and arranged an emergency admission to hospital. Mr C had an operation on the day of his admission given the seriousness of his condition. He had peritonitis and a large inflammatory mass related to the large bowel. His recovery was traumatic and he continues to experience significant health problems and chronic pain. Mrs C said that if the practice had properly followed up their initial home visit, Mr C would have been admitted to hospital earlier and might not have been so severely ill. She felt that his continuing significant health problems and chronic pain could also have been avoided.

We found that the information available to the GPs from the telephone calls and the district nurse should have prompted them to reassess Mr C in person and examine him. Having said that, our medical adviser said that it was not certain that the deterioration in Mr C's condition would have been picked up by clinical examination or whether it would have made any difference to the outcome. A home visit could, however, have improved the chances of a better outcome for Mr C. The practice have already recognised that there were failings and have taken some action to address these.

Recommendations
We recommended that the practice:
• review their processes around telephone consultations and report to the Ombudsman on the outcome of the review and the related training (that they have already planned); and
• review their management of diverticular disease.
 

Summary
Ms C, an advice worker, complained on behalf of Mrs A, whose husband (Mr A) was admitted to hospital in November 2009 due to depression and suicidal feelings. While he was in hospital, Mrs A and her husband found the staff's attitude to be poor. They also felt that there was a lack of support around the time of his discharge home. Some ten months later, Mr A was diagnosed with a rectal tumour. Ms C complained that staff at the hospital did not carry out investigations when Mr A advised them of rectal bleeding and changed bowel habits during his admission.

We found that there was insufficient evidence to confirm whether Mr A raised these concerns with staff during his stay. We were concerned, however, with the arrangements for his discharge and follow-up treatment and found that additional support to carry out day-to-day tasks could have been provided during his stay.

Recommendation
We recommended that the board:
• review their handling of Mr A's discharge and take steps to ensure future compliance with the guidance in the Scottish Government's Best Practice Template - 'Admission, Transfer and Discharge Protocol for hospital patients in Scotland.'
 

Summary
Mrs C's husband (Mr C) was admitted to the emergency department of a hospital suffering from severe, sudden headaches and vomiting. He was seen by a doctor about four hours later. He lay in the bed for a further few hours before being taken for an x-ray and admitted to the acute medical unit. The following day, Mrs C called the acute medical unit and was told that her husband had pneumonia, which was incorrect. A scan, also undertaken that day, showed that Mr C had a sub-arachnoid haemorrhage. As soon as the results of the scan were known, he was taken to the neurosurgical unit where further tests were carried out.

Mrs C complained on behalf of Mr C about the delay in providing appropriate care and treatment to Mr C following his admission and that the acute medical unit gave her incorrect information about Mr C's condition when she contacted them.

The board had already acknowledged, in responding to Mrs C's complaint, that there was an unacceptable delay in providing Mr C with appropriate care and treatment and that incorrect information had been given to Mrs C about her husband's condition. The board's local protocol on the management of sudden onset headache also made clear that it was important that scans were undertaken as soon as possible when a sub-arachnoid haemorrhage is suspected.

The board had already taken action following Mrs C's complaint. In particular, they had apologised unreservedly for the delay Mr C experienced and that Mrs C had been given incorrect information when she called. The board also provided their action plan following Mrs C's complaint, which included a summary of learning and improvements. The learning points identified included both a specific and general reminder to staff to organise investigations promptly and the importance of giving accurate and correct information to relatives about a patient's condition. The complaint had also been discussed with the doctor concerned. We commended the board for the action they had already taken following Mrs C's complaint and had no recommendations to make.
 

Summary
Mrs C complained to the board about the treatment her late father (Mr A) received at Inverclyde Royal Hospital from the end of January 2011 until his death in early March.

The complaints included that Mr A had received a lack of continuity of care and treatment; poor communication between staff and the family; a general staff failure to recognise and address Mr A's pain; and poor record-keeping. Our clinical adviser examined Mr A's cardiac history and found that the care and treatment that had been provided was appropriate. The investigation also estabished that communication with the family was appropriate, Mr A's pain was recognised and addressed and we found no evidence that the standard of record-keeping was inadequate.
 

Summary
Mr C contacted his dental practice to bring forward an appointment for treatment. He was told by the practice manager that no earlier appointments were available. He asked to speak to a dentist but was told that none were available. The conversation became heated and the manager terminated the call.

Mr C and his wife visited the practice and were met by the practice manager who they claimed was rude and aggressive. They raised a complaint with a dentist but did not feel that he listened to their concerns. During their exchanges with the dentist and the practice manager, their relationship with the practice broke down to the extent that Mr C asked to be removed from the patient register.

Mr C complained about the practice's handling of his request for an earlier appointment and his subsequent complaint. He also complained that the practice manager was rude and aggressive during telephone calls with him. We did not find that the practice failed to deal appropriately with his appointment request or his complaint. Whilst there was corroborating evidence of the comments made by the practice manager, we were unable to conclude that she acted aggressively or rudely toward Mr C or his wife.
 

Summary
Mrs C told us that she accompanied her daughter to the medical centre to see a doctor, as her daughter had suffered an allergic reaction to silicone. An incident occurred within the premises. Mrs C's daughter was subsequently removed from the practice list for inappropriate violence and abuse towards staff.

Differing accounts of what happened have been given by Mrs C and her daughter compared with those of the practice nurse and practice manager. Mrs C wrote to one of the doctors saying that her daughter had not been abusive towards staff and asked that she be allowed to re-register. After the medical centre cancelled a meeting to discuss Mrs C's concerns, she made a formal complaint to the board as she was concerned that the medical centre were not interested in resolving the issues she had raised. The board explained to Mrs C the complaints process for family health services and acted as an intermediary between her and the medical centre.

The complaint we investigated was about the way that staff treated Mrs C's daughter on the day she attended the practice, and the way in which the medical centre handled the complaint. We found that there was insufficient evidence to support the complaint that staff had mistreated her daughter. However, we established that the medical centre did not respond to the complaint in full in good time, and we concluded that there was evidence of poor complaints handling.

Recommendations
We recommended that the practice remind staff dealing with complaints to:
• respond to all the issues raised and ensure that the letter is clearly addressed, dated and contains relevant information on who has carried out the investigation and issued the letter; and
• respond within the time frame set out in the guidance document 'Making a Complaint about the NHS'.
 

Summary
Mrs C complained about the care and treatment that her late husband (Mr C) received from the board's out-of-hours service and in hospital. Mrs C said the response from the out-of-hours service was inappropriate, as the attendant arrived without batteries and sterile gloves and asked her to provide these. Mrs C also said she was refused an ambulance, and so took Mr C to hospital in her car. As there were no independent witnesses to the out-of-hours service's visit to Mrs C's home, we could not prove what took place. Therefore, in the absence of any direct objective evidence, we did not uphold this complaint.

Mrs C said the board failed to diagnose and treat her husband. We found from looking at the clinical records and after taking advice from one of our medical advisers that, although there were issues with a delayed gastroscopy and poor recording and communication about Mr C's' mobility, we could not conclude that the board failed to diagnose and treat him. We did not, therefore, uphold this complaint, although we made a recommendation related to it.

Mrs C said the board failed to record and/or pass on Mr C's wishes about resuscitation, and that Mr C was later resuscitated after a collapse. The board appeared to accept Mrs C's account that she was not given an indication that Mr C was ill enough for her to advise hospital staff of his wishes about resuscitation. However, when she felt his condition had deteriorated, she told a nurse, although the nurse did not record this or pass the information to medical staff. The board said there would be a review and confirmed to our office that nursing staff had been spoken to. As Mrs C's evidence was not disputed, we concluded that the board failed to record and/or pass on her husband's wishes about resuscitation and upheld this complaint.

Mrs C said the board provided poor general care. We found from looking at the clinical records and taking advice from one of our medical advisers that, while it was clear that the events of Mr C's final days were deeply upsetting for Mrs C and her family, we could not conclude that the board provided poor general care to Mr C. We did not uphold this complaint.

Mrs C said there was poor communication from staff to her and her husband. We found there had been failings in communication and we upheld this complaint.

Finally, Mrs C said the board failed to order a post mortem to confirm the cause of death. We found from looking at the evidence, and taking advice from one of our advisers, that medical staff were confident of Mr C's final diagnosis and, therefore, there was no need for a post mortem. Our adviser agreed with this, in terms of Crown Office and Procurator Fiscal Service guidance and the clinical records. However, our adviser's view was that it was inappropriate for medical staff to presume what Mr C's wishes regarding a post mortem might have been, and that it would have been reasonable for them to have offered Mrs C the option of a hospital post mortem. However, as there was no requirement for the board to order a post mortem to confirm the cause of death in this case, we did not uphold the complaint.

Recommendations
We recommended that the board:
• ensure that clinical records document a patient's mobility, and that such information is communicated to relatives/carers on discharge;
• review their threshold for initiating discussions with patients/carers about resuscitation, given the record of a 'guarded' prognosis in this case; and
• review their practice on when a hospital post mortem should be offered to relatives/carers.
 

Summary
Mrs C was admitted to hospital for removal of her ovaries. Complications arose which resulted in an extended stay in hospital. Mrs C complained that the board failed to provide appropriate care and treatment during the first five months of her stay in hospital, which included an injury to her bowel leading to a colostomy, as well as septicaemia, pneumonia, kidney failure and becoming infected with clostridium difficile. Mrs C also complained that for over a year the board failed to disclose to her that an ovary had adhered to her bowel.

Although there is no question that Mrs C suffered serious consequences as a result of the injury to her bowel, resulting in an extended stay in hospital and the need for ongoing care and treatment, we did not uphold the complaint about care and treatment. We found from looking at the medical records, and taking advice from two of our medical advisers, that it was not possible to say definitively how the bowel injury was caused, but it was a recognised complication of abdominal surgery.

Both advisers said it was unlikely that the injury, as the cause of Mrs C's symptoms, could have been identified sooner, and they were satisfied that the board provided reasonable care and treatment. We did, however, conclude that medical records could have been clearer. There was no documentation in the medical records to confirm that Mrs C was given an explanation of the procedure used during, and the findings and outcomes of, the surgery to remove her ovaries. There was no evidence that this information had been deliberately withheld, but the lack of records was not in keeping with the General Medical Council's Good Medical Practice guidance. Given this, we could not conclude that Mrs C was provided a clear and consistent explanation of events and, therefore, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for their failure to provide a clear and consistent explanation of events;
• remind medical staff in the hospital of the need to maintain clear and thorough medical notes, in line with Royal College of Physicians' guidelines on standards for medical record-keeping; and
• remind medical staff of the importance of recording details of explanations given to patients, in line with the General Medical Council's Good Medical Practice guidance.