Health

Summary
Mr A was an elderly man with a history of hypertension, aortic aneurism, and chronic kidney disease. Mr A fell while crossing the road and was taken by ambulance to hospital, where he stayed for several days. He was discharged but remained unwell and was admitted again a few days later. He was discharged after several days. Mr A remained unwell and was admitted to another hospital about three weeks later, where he died after three days. His daughter (Mrs C) complained that the care and treatment her father received during and between his second and third admissions was inadequate, that her concerns and information she provided were not recorded or reasonably acted upon during his second and third admissions, and that the board's complaint handling was poor.

Having looked at the clinical records and taken advice from two of our medical advisers we found that Mr A's care and treatment appeared, overall, to have been reasonable. However, we upheld Mrs C's complaints. We identified a number of failings in relation to obtaining Mr A's first admission records, prescribing antihypertensive medication, communication about drug treatment and discharge planning. We also found that the board had acknowledged that information provided by Mrs C was not always recorded.

In addition, our advisers found only limited evidence of communication being recorded, which was below a standard that could reasonably be expected. We also found that, although it was reasonable for the board to have asked different clinicians for their views of Mr A's treatment, more could have been done to integrate their views into a coherent response to Mrs C's complaints. The board should have explained in advance of a meeting with Mrs C why staff responsible for the administration of records were not included, despite Mrs C having asked for them to be present. The note of the meeting should have been checked more carefully to ensure that the correct names were used, as Mr A's name was wrong in two places. In the board's response to Mrs C's final complaint, they should have provided more information about what was done to address the issues raised about Mr A's third admission, and they should have openly acknowledged their failings in handling Mrs C's complaint.

Recommendations
We recommended that the board:
• review their procedure for urgently obtaining clinical notes of patients re-admitted, to reduce the opportunities for the procedure to fail;
• review this case to improve practice on prescribing antihypertensive medication in such circumstances;
• review this case to improve practice on communicating between community and hospital care about drug treatment, and recording such communication in the clinical record;
• review their discharge policy, to ensure it complies with national guidance and that staff act in line with it;
• apologise to Mrs C for staff failing to communicate with her to a reasonable standard about Mr A and for failing to deal with her complaint appropriately; and
• review how they draft responses to complaints, to ensure these are coherent and transparent.
 

Summary
Ms C complained on behalf of her late mother (Mrs A) about the care and treatment that she received from her GP practice. Mrs A attended the surgery for a period of two years with repeated complaints of breathlessness, pain in the back and rib cage, and a cough. She made the practice aware of a family history of lung disease and lung cancer. She was treated for numerous chest infections but received little or no relief from her symptons. Mrs A's condition deteriorated and she was admitted to hospital and diagnosed with terminal cancer of the lung, liver and upper chest. Mrs A died shortly after. Ms C complained that the practice failed to properly investigate Mrs A's symptoms within a reasonable time and that they failed to suspect her condition and refer her to hospital within a reasonable time.

We found that the practice carried out reasonable investigations, but that they should have had a high index of suspicion of lung cancer given Mrs A's strong family history and that she was previously a heavy smoker. Our medical adviser said that the practice should have considered referring Mrs A to a respiratory specialist when her respiratory symptoms had persisted for more than six weeks and were unexplained. However, we also found that even if the diagnosis had been made sooner, this was unlikely to have affected the outcome because Mrs A probably had a non-curable disease at presentation. Having said that, an earlier diagnosis might have improved her quality of life because it would have allowed treatments to be explored that might have alleviated some of her symptoms.

Recommendations
We recommended that the practice:
• undertake a significant event audit and review their practice on management of respiratory symptoms to ensure that they refer for specialist advice within a reasonable time; and
• apologise for the failures identified.
 

Summary
Mrs C complained to the practice about the treatment that they provided to her late husband (Mr C). Mr C had attended various GPs at the practice between November 2010 and February 2011 with a persistent cough, breathlessness, loss of appetite and severe weight loss. Mrs C also spoke to the GPs and expressed her fears that Mr C was dying of lung cancer as she had experience of nursing both her mother and mother-in-law through the disease. The GPs told Mr C that he 'definitely did not have cancer'. Mr C was eventually referred to Ninewells Hospital where following various investigations he was diagnosed with lung cancer. He was transferred to a local community hospital where he died two weeks later.

Mrs C complained that the practice's failure to investigate fully her husband's symptoms led to a delayed diagnosis of lung cancer. Our clinical adviser, however, found that the doctors at the practice had carried out appropriate tests in an effort to reach a diagnosis and made appropriate specialist referrals where required. Our adviser found that the initial working diagnosis of lower respiratory tract infection was reasonable and that when the symptoms did not improve specialist hospital referral was instigated which initially indicated that a diagnosis of malignancy was less unlikely. The adviser explained that lymphagitis carcinomatosis is a relatively uncommon presentation of lung cancer and more so in the case of Mr C who was a non-smoker.

Mrs C also complained that the practice failed to take into account her concerns about the seriousness of her husband's condition. However, our investigation found evidence that the doctors had taken on board Mr C's reported symptoms and had noted Mrs C's concerns and did not dismiss them.
 

Summary
Mrs C made a number of complaints about the care and treatment that her late husband (Mr C) received from his medical practice before his death from cancer. She complained that the practice failed to diagnose her husband's illness and order appropriate tests within a reasonable time, or to chase up the result of the tests. We took advice from our medical adviser, and found that it was in fact appropriate for the practice to refer Mr C to a specialist in order that the specialist could carry out further tests. The practice made an urgent referral, which was sent the day after Mr C attended the practice. In addition, there was no evidence that the practice were subsequently asked to chase up the results.

Mrs C also complained that the practice failed to refer her husband to hospital when he was severely dehydrated. We found that the practice had failed to carry out a reasonable clinical assessment. They had also failed to assess Mr C for hydration. We upheld the complaint as, based on the inadequate assessment, it was not possible to say whether Mr C was dehydrated or whether he should have been admitted to hospital.

In addition, we found that the practice should not have told Mrs C that she would be able to accompany her husband in the transport that they booked for him to attend hospital to get his results. The practice could not guarantee this, as space is limited when patients are being transported. We upheld the complaint, as the practice should have told Mrs C this, although we noted that they had already apologised to her for their failure to make her aware of this.

Mrs C also complained that the practice failed to provide palliative care to her husband or to offer any information about palliative care nursing. We found that the deterioration in Mr C's condition was extremely rapid, and that it would have been difficult to foresee this. We were satisfied that the practice's attempts to provide palliative care and to offer information during the short period from confirmation of his terminal diagnosis to his admission to hospital were reasonable. We also noted that the practice had taken steps to improve their delivery of palliative care.

Finally, Mrs C complained that the practice failed to show an appropriate degree of compassion throughout Mr C's illness by making inappropriate and insensitive comments. In response to her complaint about this, the practice said that part of their role in such situations is to be open, honest and realistic. Although we understood why Mr and Mrs C might have found the comments distressing, we did not find them inappropriate.

Recommendations
We recommended that the practice:
• make relevant staff aware of the need to undertake proper clinical assessment where appropriate; and
• draft a protocol for patient transport.
 

Summary
Mrs C, an advice worker, complained on behalf of Mr A about the care and treatment that his late wife (Mrs A) received in hospital. Mrs A was admitted in late October and discharged two days later with a diagnosis of oesophageal cancer. She was readmitted in November but died six days later. Mr A had concerns that his wife was discharged prematurely and that her hydration had not been maintained. He also felt staff had not been aware that she had a bowel blockage; did not take into account the possibility of sepsis; were not aware that she had been taking thyroxine; and that inappropriate arrangements had been made for her discharge.

We did not uphold the complaints as, after taking advice from our medical adviser, we found that the care and treatment that was provided to Mrs A during both admissions was appropriate. However, we noted that as a result of the complaint the board enhanced the role of the senior charge nurse endoscopy service to provide support for patients diagnosed with upper gastrointestinal cancer and introduced a checklist to improve record-keeping.
 

Summary
Mrs C complained that the clinicians at Ayr Hospital provided inadequate treatment to her late sister (Mrs A) who required cardiac surgery, and that Mrs A should have been transferred to The Golden Jubilee National Hospital for urgent surgery at an earlier date. She also raised issues about poor communication with the family and the way in which the board handled the complaint. After taking advice from one of our medical advisers, we established that Mrs A received appropriate treatment. We also found that the level of communication and complaints handling was adequate.
 

Summary
Mr C complained about the care and treatment that his 17-year-old nephew (Mr A) received from the board before his death from sudden unexpected death in epilepsy (SUDEP).

Mr A had had a suspected seizure and had seen a consultant at the board's 'first seizure clinic'. The consultant said that Mr A might have had a seizure, but needed more information. He provided Mr A with his contact details and suggested that Mr A contact him again after obtaining a phone number for a witness to the event, so that the consultant could speak to them about it. Mr C said that Mr A was not aware of the significance of not obtaining a phone number for this person. He complained that after Mr A's appointment there was no proactive follow-up by the first seizure clinic.

Our medical adviser said that it is not standard practice to provide follow-up appointments following a first seizure clinic, as in many cases it will be unnecessary. Treatment is not given if there is no immediate reason to believe that another event will happen. The patient should contact his or her GP if any subsequent suspicious event occurs. Follow-up and treatment will start if considered appropriate. In Mr A's case, the consultant tried to obtain a first-hand witness account to help him decide on this, but could not do so. We, therefore, found that the consultant's actions were reasonable.

Mr A was subsequently admitted to hospital after collapsing. Guidance from the Scottish Intercollegiate Guidelines Network (SIGN) on epilepsy (SIGN 70) says that the diagnosis of epilepsy should be made by a neurologist or other epilepsy specialist. Mr A was given a provisional diagnosis of epilepsy by a general physician at the hospital, referred to a neurologist, then discharged. Mr C complained that the board failed to involve Mr A's parents in discussions about his diagnosis, treatment and advice before he was discharged.

Our medical adviser said that once over the age of 12, the law assumes that a person can make their own decisions about their health care unless there is evidence to suggest they cannot. Health workers are not usually allowed to tell such a patient's parents anything unless the patient has agreed to this. Mr A was aged 17 at the time. Unless the board had evidence to suggest that he could not make his own decisions about his health care, they were not required to involve his parents in discussions about his diagnosis, treatment and advice. Mr C also complained that Mr A was discharged from hospital with no verbal or printed information about epilepsy. He said that no individual or personal assessment was undertaken of Mr A's circumstances and no information was provided about SUDEP.

In general, patients should be fully informed about the risk of any condition and its treatment. Although death from SUDEP is rare, most patients should be given information about it at some point soon after a diagnosis of epilepsy has been made. This will help patients to understand the issue and put it in perspective. However, detailed information about epilepsy and the risk of SUDEP should be provided as part of comprehensive counselling about risks and prevention. This should be provided by or arranged by neurologists after a definitive diagnosis of epilepsy has been made. Mr A had not seen a neurologist.

Mr C complained that the board had delayed in arranging an appointment for Mr A with a neurologist. The appointment arranged for Mr A was some 17 weeks after he was discharged from hospital. Mr A died before the appointment. Although we did not uphold Mr C's other complaints, we upheld this one as we found the delay unacceptable. Our medical adviser pointed out, however, that the risk of SUDEP cannot be eliminated and it is not possible to say that an earlier appointment at the neurology clinic would have prevented Mr A's death.

Recommendations
We recommended that the board:
• issue an apology to Mr A's parents for the delay in arranging an appointment for him with a neurological consultant; and
• take steps to ensure that patients who have been given a provisional diagnosis of epilepsy are seen by specialists as soon as possible so that a definitive diagnosis can be made and, where appropriate, detailed and specific information can be given.
 

Summary
Mrs C said that for eleven years she had been prescribed MST (morphine sulphate based medication) but had received a letter from her medical practice saying that the drug would no longer be prescribed. Mrs C complained that she had asked for the decision to be reconsidered but was told it was final. Mrs C said that because of the decision to stop her prescription she suffered very badly from withdrawal symptoms.

As part of our investigation, we discovered that the medical practice had received anonymous information alleging that Mrs C was selling her MST tablets. Because of this the practice requested a toxicology report on a urine sample. This did not show the presence of opiates and so the medical practice considered that it was reasonable to stop prescribing them. As it appeared that Mrs C was not taking the MST prescribed to her, the practice also considered it unlikely that she would have suffered withdrawal symptoms. We did not uphold the complaint but we made a recommendation to the practice.

Recommendation
We recommended that GPs at the practice:
• in future similar cases should seek patient consent before a toxicology screen is requested.

Summary
Mrs C’s two-year-old daughter was diagnosed with hip dysplasia. Mrs C felt that her GP should have diagnosed this sooner. She complained that the GP had not properly carried out developmental examinations of her daughter during the first year of her life. The board told Mrs C that the GP had reviewed her computer records and felt that they contained a reasonable level of detail for such an examination. No abnormality had been observed. They said that the GP’s usual practice would be to properly examine a baby at such an examination and that hip dysplasia can be difficult to detect in the early stages. The GP apologised for not having written in the parent-held medical records.

Mrs C, however, was dissatisfied that the board had not presented evidence that usual and proper procedures had been followed. She was concerned that the clinician had not noticed the extra skin crease and leg length discrepancy that she believed had always been present. She was also concerned that the board do not carry out further tests on older babies if hip dysplasia is difficult to detect in early stages. She recalled that her older daughter had had an examination at 8-9 months. The board said that records showed that Mrs C’s daughter’s hips were examined at birth and at six weeks, and that these examinations were properly recorded. They advised that the 8-9 month examination was discontinued in 2005, after the introduction of new guidelines. Mrs C was dissatisfied with this response and brought her concerns about the board’s complaint handling to us. We found that the board had not reasonably considered Mrs C's complaints, as they based them only on the GP's recollections. Given this, we upheld Mrs C's complaint.

Recommendation
We recommended that the board:
• apologise to Mrs C that their handling of her complaint was not reasonable.
 

Summary
Mrs C complained to us about aspects of her care and treatment by a hospital gynaecology department. We did not investigate the complaint as we decided it was out of our jurisdiction under Section 7 of the Scottish Public Services Ombudsman Act 2002.