Health

Summary
Mrs C complained about the food and about failure to provide a raised toilet seat, a blanket and sleeping pills during her three-day admission to a hospital. We concluded that the board had not acted unreasonably in respect of the food provided. In respect of the other issues, we concluded that there had been shortcomings but that what had happened was not unacceptable, particularly as the board had apologised and taken some action.
 

Summary
Mr C raised concerns that he was unreasonably discharged from the Glasgow Dental Hospital to his own dentist. He also felt that the hospital failed to adequately communicate with him and his dentist about the reasons for discharge and the treatment plan. We sought the opinion of our independent dental adviser who reviewed the relevant records and explained that the outstanding work required on Mr C was within the competence level of the average dentist and so the discharge decision was not unreasonable. However, the adviser explained that the information communicated to Mr C's dentist about the outstanding work did not include four teeth which were noted in the clinical record as requiring treatment but which were not included in the letter to Mr C's dentist about the outstanding treatment. We upheld this aspect of Mr C's complaint and made recommendations to the board.

Recommendations
We recommend that Greater Glasgow and Clyde NHS Board - Acute Services
Division:
• ensure that Glasgow Dental Hospital revisit their records and, if necessary, contact Mr C's dentist to discuss his remaining treatment plan and any amendments required; and
• ensure that Glasgow Dental Hospital remind staff of the importance of ensuring that the outstanding treatment plan as noted in the records is accurately conveyed to the dental practitioner and, if there is any difference between the treatment plan as noted in the patient's record and the treatment plan communicated to the dentist, the reasons for this are
noted on the records.

Summary
Mr C was a new patient at the practice and his medical records had not yet arrived. While the practice was waiting for them, Mr C asked for additional medication. When he did not receive this, he complained about how the practice had dealt with his request. We found that they had not in fact properly actioned it. We recommended that the practice apologise to Mr C and carry out a significant event analysis to identify the problem and prevent a recurrence.

Recommendations
We recommend that the medical practice:
• apologise to Mr C for the way they dealt with his request; and
• conduct an Significant Event Analysis of this incident.

Summary
Mr C raised concerns about a telephone consultation that he had with his GP. He was suffering from severe lower back pain. He told us that he believed that he should have had a home visit as he was admitted to hospital later that evening with Cauda Equina Syndrome (a disabling condition caused by compression of the nerves of the spine). Although our investigation found that the GP's management plan was reasonable, we found that her notes of the consultation were limited. Our medical adviser told us that in the circumstances a physical examination of Mr C was required. As this should have been carried out at his home, we upheld Mr C's complaint that the GP's telephone assessment of his condition was inadequate. We did, however, recognise that it was possible that the outcome would have been the same, even had the physical examination taken place.

Summary
Mr C complained that an employee of Grampian NHS Board passed on negative remarks about him (made by a third party) to his sister-in-law. This was in relation to the search for a care home for their relative, Mr A. The investigation revealed that the information had been relevant to the search and had not constituted any breach of confidentiality because Mr C's sister-in-law had power of attorney for Mr A. We also considered that the board had no responsibility to check whether the remarks were accurate or to give Mr C the chance to deny them.
 

Summary
Mr C attended the board's podiatry department in a health centre for an appointment to try on foot orthotics that had been modified for his foot. When he arrived the receptionist told him he had no appointment. Discussion about this matter escalated but, ultimately, his appointment was found and progressed as planned. He complained to the lead clinician that day but was dissatisfied with their response about the attitude and actions of the receptionist. He remained dissatisfied following completion of the the board's complaints procedure and raised these issues, as well as complaints handling issues, with us. We upheld the complaint that the receptionist had provided inaccurate information about Mr C's appointment but given that this was resolved, acknowledged and apologised for on the day, we did not consider any further action was necessary. We saw no objective evidence to support the complaint that the receptionist had been aggressive or abusive towards Mr C, and considered that the board's response to his complaints was reasonable.
 

Summary
Ms C raised concerns about the treatment she received at Dr Gray's Hospital, Elgin. She said that there was a delay in diagnosing that she had a pancreatic cyst and that she was only informed of the true diagnosis when she was transferred to Aberdeen Royal Infirmary. Our investigation concluded that it was reasonable for staff to initially believe that Ms C was suffering from an ovarian cyst and the true diagnosis was only discovered once the pathology results had been reported on. By this time, Ms C had already been transferred to Aberdeen Royal Infirmary.
 

Summary
Mrs C complained that her daughter (Mrs A) received inadequate care and treatment from Surgical Services in Stirling Royal Infirmary. Mrs C said it took the hospital six weeks to diagnose Mrs A's medical condition and that this delay could have been avoided had medical staff seen her earlier. Our investigation concluded that from Mrs A's several admissions through to her in-patient care and subsequent discharges she received appropriate care and treatment from the hospital. Although the results of a Malnutrition Universal Screening Tool (MUST) test could have been recorded in more detail, our medical adviser said that Mrs A was eventually diagnosed with a rare and complex medical condition and the investigations that were carried out were appropriate. We also did not uphold the complaint that the Board failed to respond reasonably to Mrs C's complaints about this. We noted that before she brought this complaint to us the Board had already apologised for some of the issues Mrs C had raised.

Recommendation
We recommend that Forth Valley NHS Board ensure that a written record of every MUST test is completed and filed to comply with NHS record-keeping guidelines.

Summary
Ms C took her son to see her GP. The GP diagnosed tonsillitis and prescribed penicillin. When Ms C read the patient information leaflet that came with the penicillin, it said that the dosage for a child aged five or under was less than that prescribed by the doctor. The following morning at 08:00, Ms C telephoned the surgery to explain her concerns about the dosage. She said she was told that her GP would call her back at midday. Ms C said that at 17:00, having had no response, she telephoned again. Ms C said her GP eventually called her back at 18:00, apologised for the delay and advised her to amend the dosage. It was clear from the complaint correspondence that the GP accepted that he made an error in this case, and that he had reflected on and apologised for his mistake. In order to try to provide Ms C with some reassurance on the effects of the over prescription on her son, the GP also discussed the prescribing error with a consultant paediatrician. In investigating the complaint, we took advice from one of our medical advisers about the mistake. They said that although the dose was higher than recommended it was unlikely that the prescribing error would result in any lasting harm to Ms C's son. They did, however, suggest that we made recommendations about this.

Recommendations
We recommend that the medical practice conduct a Significant Event Audit around the prescribing error.
We recommend that the GP discusses the complaint and management of paediatric problems at his next appraisal.

Summary
Mrs C raised concerns about the treatment she received at a hospital before and after the stillbirth of her daughter. These included an incorrect decision to reduce Mrs C's medication; a lack of support from midwifery staff; and that the board's response to her complaint contained factual inaccuracies. Mrs C also told us that she believed the reduction in medication had caused the stillbirth. When we investigated and took advice from our medical adviser we found that in general Mrs C's pregnancy was managed appropriately, but that there were problems after a doctor misinterpreted a blood test result. We upheld all of Mrs C's complaints, although our adviser pointed out that research did not support the view that a reduction in medication would cause stillbirth. We noted that the board had already accepted that there were failings and had taken action in an effort to prevent any repetition of Mrs C's experience. As a result of our investigation, however, we considered it appropriate to make further recommendations.

Recommendations
We recommend that Fife NHS Board:
• consider, when confirming blood results that have been passed on by telephone, providing additional confirmation such as an internal email or fax; and
• remind staff of the need to provide patients with information about support services and to record what has been provided.