Health

Summary
Mrs C complained about the hospital treatment provided to her late father (Mr A) who had chronic obstructive pulmonary disease. Mr A became ill at home and was admitted to Glasgow Royal Infirmary suffering from pneumonia. He died in hospital ten days later.

Mrs C complained that attention was not paid to Mr A's nutritional needs and that she 'constantly' asked staff to tube-feed her father but that this was not done. She also complained that staff decided that Mr A was not to be resuscitated if his breathing or heart failed, but that this decision was not discussed or agreed with the family. She said that the family were not made aware of the seriousness of Mr A’s condition and that although Mr A died at 09:40, the time of death was not certified until 10:30 and in that time the doctor did not approach or attend to Mr A in any way.

We took advice from one of our medical advisers. This established that Mr A’s clinical treatment was appropriate and that as his nutrition and hydration were appropriately maintained, a naso-gastric tube was not necessary. We found, however, that there had been failures in communication. One of the board’s doctors said he had told a family member that Mr A’s death was imminent, but could not remember to whom he had spoken. The family, on the other hand, said they were not aware how serious Mr A’s condition was. They were shocked when he died, and concerned that staff did not attend when that happened. From a staff perspective, Mr A did not have long to live and, believing that his family knew this, staff had left them to spend the last moments alone with him. Our adviser, however, commented that he would be concerned if a doctor did not – even briefly – establish that death had actually occurred and confirm this to the family. All of this shows that the family and staff had different understandings of the seriousness of Mr A’s condition. The problem was caused by a breakdown in communication and a lack of documentation of what was actually said and to whom. The board had already apologised for the communication failure and drawn up an action plan to address this for the future. As a result of what we found in our investigation, however, we recommended that they add to it.

Recommendation
We recommended that the board:
• review their action plan to include information about how nurses and medical staff deal with the difficult issue of who informs relatives of the presence of a Do Not Resuscitate form (if appropriate) and about communication when a patient is gravely ill and at the point of death.
 

Summary
Mr C complained about the care and treatment that his late mother (Mrs A) received from her medical practice prior to her death. He alleged that the practice either failed to diagnose her or diagnosed her incorrectly and that, as a consequence, she did not receive appropriate and timely treatment. Mr C also complained that despite the fact that Mrs A had recently undergone chemotherapy for the treatment of cancer, and was in remission, she was given the 'flu vaccine’. He considered that this was inappropriate and led to her unexpected death.

Our investigation found that on the basis of the information available to them, the practice treated and cared for Mrs A appropriately. Our medical adviser also confirmed that the 'flu vaccine’ was not contra-indicated, and was in fact recommended for patients like Mrs A who had lowered immunity as a consequence of her illness and treatment.
 

Summary
Ms C was referred to a dentist for root canal treatment under sedation. Following treatment, Ms C developed an infection, which she felt was due to inappropriate dental treatment. She also complained that, when she attended to have her stitches removed, the dentist initially refused to do so until Ms C's outstanding account was paid.

We established that the dentist had provided appropriate treatment and that it is recognised that infections can develop following root canal treatment. Our dental adviser noted, however, that the dentist should have carried out a post treatment x-ray, which would have made him aware that part of the sealant material had become dislodged. For this reason we upheld the complaint that the treatment was not performed properly, and drew the attention of the dentist to our adviser's view.

We did not uphold Ms C’s other complaints that the infections arose as a result of poor treatment and about the dentist's attitude when Ms C returned to have the stiches removed. Our adviser noted that it would be normal practice to ask a patient to settle their account on completion of treatment and in any event the dentist did remove Ms C's stitches even though the account had not been paid.

Summary
Miss C complained about the care and treatment her mother (Mrs A) received in hospital after she suffered severe burns to her body. Miss C said that her mother had made a good recovery from a skin graft. However she believed that an error inserting a needle into Mrs A's left arm caused her mother to suffer a life threatening flesh eating bug (necrotising fasciitis) requiring intensive care treatment and a longer stay in hospital. She said that Mrs A was left with a damaged arm and suffered unnecessary trauma.

The clinical advice that we received from our medical adviser is that necrotising fasciitis is a very uncommon condition and can be difficult to diagnose because it usually presents with oedema (swelling). Mrs A had oedema in her legs, groin and arms. Our adviser said that necrotising fascitis is even rarer as a consequence of inserting a needle, and that in Mrs A’s case it would have been difficult to make the diagnosis earlier. The department of burns and plastic surgery acknowledged that there was a delay in diagnosing the condition, but had learnt from this. The board had also issued an apology. Accordingly, while we appreciated that Mrs A suffered trauma and distress, we considered the delay in diagnosis was not unreasonable given the symptoms that Mrs A had. We, therefore, did not uphold the complaint.

Miss C also complained there was unreasonable delay before a central line was inserted into her mother’s left arm. Our adviser said that it is not appropriate for any junior doctor to have five attempts to insert a cannula, as happened with Mrs A before a central line was inserted. The board conceded that the number of attempts at cannulation was excessive but had learned from what happened to Mrs A. In particular, they had produced a policy to deal with this. While we welcomed the introduction of the policy, and acknowledged that lessons had been learned by clinical staff, we considered there was an unreasonable delay in inserting a central line and we upheld this complaint.

Finally, Miss C complained that there was unreasonable delay before a naso-gastric tube was inserted and that her mother should have been fed in this way much earlier. We did not uphold this complaint. The clinical advice we received from our adviser was that overall the nutritional care and treatment Mrs A received was appropriate and there was no unreasonable delay in inserting a tube.

Recommendations
We recommended that the department of burns and plastic surgery:
• should consider obtaining early advice from general physicians, nephrologists and of intensive care staff where there are problems with fluid balance in patients with complications.
We recommended that the board should:
• establish a policy, including indications, for central venous lines in complicated burns patients;
• provide an update on the review of the West of Scotland Regional Burns Unit Venous Access Policy;
• provide evidence that audits are undertaken regularly to monitor compliance with the board’s guidelines for the prevention and management of adult in-patient falls and that results indicate a reasonable standard of care; and
• ensure that, where appropriate, a daily medical entry is included in the records of all in-patients.
 

Summary
Mrs C’s husband (Mr C) was admitted to hospital with breathing problems and fever. He was diagnosed with pneumonia with a background of chronic lung disease, and given antibiotics. He continued to be treated over the next few days during which his condition slowly improved (although he continued to experience breathlessness) and he was being considered for discharge. However, Mr C suffered a cardiac arrest and collapsed in his room. Although staff tried to resuscitate him, unfortunately Mr C did not recover. One of the nursing staff contacted Mrs C, who lives in a remote location around 200 miles from the hospital, and advised her to come to the hospital quickly as her husband had ‘taken a turn for the worse'. Mrs C and her family immediately drove to the hospital, only to discover that Mr C had already died. When Mrs C was told the time of her husband’s death, she discovered that he had died before the telephone call was made.

Mrs C and her family had a number of complaints about Mr C’s care and treatment, and communication difficulties they had experienced with the staff. They were also concerned that the hospital had not taken sufficient action as a result of their experiences.

We did not uphold the complaint about Mr C’s care and treatment. We found that the management plan was comprehensive, that Mr C was regularly observed, and that the choice of antibiotics demonstrated good practice. Unfortunately, Mr C died due to a sudden and unpredictable cardiac arrest caused by underlying ischaemic heart disease. We did, however, uphold the complaint about communications. We found that the way staff dealt with Mrs C and her family was extremely unsatisfactory, from being advised to come to the hospital as quickly as possible to the way they were greeted there and told by the staff that Mr C had died. The family were made to wait some time, and the doctor who broke the bad news had not been present at the resuscitation efforts. We found this to be poor care of a family being advised of a bereavement. Given, however, that the hospital had made an unreserved apology, particularly on behalf of the individual staff involved, we had no recommendations to make. We did not uphold the complaint about the action taken because the hospital provided good evidence of the action plan that they implemented as a result of Mrs C’s complaint. This involved more staff training about communication and dealing with families in outlying areas, and ensuring that the learning outcomes from the complaint were implemented throughout the hospital.
 

Summary
Miss C complained that she was not given adequate information and advice by the board before she had a contraceptive implant fitted. She said that this resulted in an unplanned pregnancy. Miss C was also unhappy with the support given by the board when she discovered that she was pregnant.

We found that the board had given Miss C adequate information and advice before the implant was fitted. A full and comprehensive assessment was carried out and appropriate information was noted. Miss C was told that they could not rule out the possibility that she was already pregnant, as she had recently had a contraceptive failure. They also gave her condoms and told her that she should use these for the next seven days. However, we found that the board failed to tell Miss C’s GP that the contraceptive implant had been fitted, despite having her consent to do so. That said, they had already reminded staff about this and had apologised to Miss C, so we made no recommendation. When Miss C said she was pregnant, however, they failed to tell her about a counselling service that was available so we made a recommendation related to this. There was no evidence that staff acted unreasonably when Miss C told them that she was pregnant, or that they gave her misleading or untruthful information when the implant was removed. In addition, we found that the board dealt with her complaint in line with the complaints process in place at that time and responded to all of the issues Miss C raised.

Recommendation
We recommended that the board:
• consider drafting a protocol for use when a failure of contraception is discovered. This could include discussing any need for counselling.
 

Summary
Ms C complained on behalf of her mother (Mrs A) about the care and treatment Mrs A received from a hospital both as an in-patient and an out-patient. Ms C complained that the hospital delayed in providing Mrs A with surgery, and that there had been different views among hospital clinicians about how the surgery would be carried out.

After taking advice from two of our professional medical advisers, we did not uphold either of Ms C’s complaints. Although surgery was delayed, we found that there were medical reasons for this; that the hospital had correctly followed procedures and that Mrs A was on an appropriate clinical pathway, given the health issues she presented during the period in question.
 

Summary
Mrs C complained that her GP practice removed her and her husband from their list of patients without an appropriate explanation. Mrs C also complained that the practice failed to make sufficient adjustments for her disability in dealing with her complaints. In particular, she said that the practice declined to deal with the matter verbally.

The practice had asked Mr and Mrs C to register with another practice, and later removed them from the practice list. They told Mr and Mrs C that this was because of a breakdown in the doctor/patient relationship, but did not give a more specific reason. We found that in asking them to register elsewhere, the practice had, in effect, already taken the decision to remove Mr and Mrs C from the list, and did not leave any room for negotiation. They should have first warned Mr and Mrs C that they were at risk of removal, and explained the reasons for this. The practice did not keep a written record of the reason why they did not give a warning. Neither did they keep a written record of the grounds for a more specific reason not being appropriate. We concluded that the practice removed Mr and Mrs C from their list without providing them with an appropriate explanation, so we upheld this complaint.

Mrs C also asked the practice to deal with her complaints verbally, due to her disability. We found from looking at the practice's records that they did speak to her by telephone. However, Mrs C was not willing to discuss her complaints in any detail on the telephone. The practice were willing to meet with Mrs C, but before they or Mrs C could take this further, they decided to remove her from their list. After this, understandably, Mrs C did not pursue her complaints with the practice. We took advice from our professional medical adviser, whose view was that the practice acted reasonably in relation to Mrs C's disability while they were dealing with her complaints. We concluded that, from an administrative point of view, the practice did try to make sufficient adjustments for Mrs C's disability, and did not decline to deal with the matter verbally. Therefore, we did not uphold this complaint.

Recommendations
We recommended that the practice:
• apologise to Mr and Mrs C for failing to deal with their removal from the practice list in line with the NHS Regulations; and
• review their procedure for removing patients from the list, to ensure that future actions are consistent with their obligations as set out in the NHS Regulations.
 

Summary
Mr C complained that the board failed to reimburse his travel expenses in respect of two appointments at a hospital in England in June and October 2010. Our investigation found that the board had in fact arranged and paid for Mr C's travel in June, but that he had chosen to make alternative and unnecessary arrangements for another date. We considered that it was reasonable for the board not to reimburse Mr C's expenses in those circumstances. With regard to the October appointment we found that the board had told Mr C before he travelled that they did not support this treatment and would not refund his expenses. As travelling expenses require the approval of the board we did not uphold this complaint.
 

Summary
Mr C had requested a home visit early in 2010 which was refused. In December 2010 he contacted the practice by email to ask why the visit had been refused and to ask for a copy of the practice policy on home visits.

The practice manager responded five days later by email explaining the policy on home visits. The final paragraph of the emailed letter stated that Mr C's previous email had 'sullied' the patient / doctor relationship and Mr C was to be removed from the list. Mr C complained that the decision to remove him from the GP list without prior warning was unreasonable. We found that it was not appropriate for the practice to have taken the action they did without first giving Mr C a warning and we, therefore, upheld his complaint.

Recommendations
We recommended that the practice:
• apologise to Mr C for the failings identified in this report.