Health

Summary

C, an advice and support worker, complained on behalf of their client (A) in relation to the care and treatment provided to A by the board.

A attended Forth Valley Royal Hospital as they had suffered a myocardial infarction (heart attack - when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle) the previous week. A presented to the hospital complaining of pain and swelling affecting their wrist. A was examined and treated for this.

A said that the board failed to provide reasonable care and treatment to them as they were not treated appropriately and questioned whether alternative treatments could have been offered. A also said that it took several visits to A&E to be treated appropriately and that they were not referred to a specialist following that first visit.

We took independent advice from an appropriately qualified adviser with expertise in emergency medicine. We did not observe any concerns with the care and treatment that A received and concluded that assessment, treatment and advice given were reasonable. Therefore, we did not uphold C's complaint.

Summary

C raised numerous concerns and complaints about repeated errors with the issuing of Movelat (pain relieving gel). C maintained the gel should be issued to them weekly but when submitting requests to receive the gel, they experienced difficulties. C received mixed responses as to why the gel was not issued. Some of the replies issued indicated the gel should be issued monthly. Other replies acknowledged that the gel should be issued weekly and explanations were offered for the error.

The evidence available confirmed that the gel was to be prescribed weekly to C. Despite this, C had to continually raise concerns in relation to ongoing errors with the prescribing frequency of the medication. It took some time before preventative steps were taken, by way of a note that was added to C's record confirming that the frequency of the prescription for the gel should not be changed.

We accepted that any delay in issuing the gel will not have had serious consequence for C, and we recognised the actions taken to minimise errors with the prescribing frequency of the gel. However, we found the administrative handling of the matter was poor. C had to unnecessarily submit repeated feedback and complaints only to receive mixed replies and for the problem with the prescribing frequency to continue longer than it needed to. As such, we upheld this aspect of the complaint.

C also complained about the decision taken by the healthcare team to discontinue a prescription for Difflam spray (an anti-inflammatory spray used to treat many painful conditions of the mouth or throat). It was explained to C that the throat spray was a short-term treatment for symptomatic relief of painful conditions of the mouth. It was noted that C had been taking the spray for several months, but there was no record to confirm the reason for that. C was reviewed by the dentist, who found no evidence of ulcers. The dentist had initially agreed to reinstate the spray but it was discontinued following a further discussion with an advanced nurse practitioner due to lack of mouth ulcers.

We took independent advice from an appropriately qualified clinical adviser, We found that the decision to stop the mouth spray had been taken in line with good practice as set out by the General Medical Council. As such, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to issue the pain relieving gel weekly, as per their prescription. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unnecessary time and trouble they had to go to in an effort to get clear explanations and replies in relation to the prescribing errors with the pain relieving gel, and to get the issue resolved.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their spouse (A) about the treatment provided to them. A had a history of cancer and attended the practice with urinary symptoms. A was later diagnosed with bowel cancer which had metastasised (spread to other parts of the body). C complained that the practice's response to A's symptoms, and the length of time it took for A's cancer to be diagnosed, were unreasonable.

We took independent advice from a GP. We considered that A's symptoms were reasonably investigated, with appropriately prioritised referrals being actioned in a timely manner. A's history of cancer was considered when assessing their symptoms. A's symptoms initially aligned with a benign (non-cancerous) condition. When A's presentation changed, appropriate steps were taken, with further investigation and referrals to secondary care. A's pain was reasonably managed. Therefore, we did not uphold the complaint.

Summary

C was admitted to hospital for an elective hernia repair. The procedure was said to have gone well and it was agreed that C could be discharged home. Before leaving hospital, C took a stroke (a serious medical condition that happens when the blood supply to part of the brain is cut off. Strokes are a medical emergency and urgent treatment is essential). In C's case, it was thought they had experienced a reaction to the medications they had been prescribed and it was deemed that they could be discharged from hospital. Once at home, C was reviewed by their GP, who arranged for them to return to hospital for further tests. Those tests confirmed that C had had a stroke prior to being discharged from hospital.

We took independent advice from an appropriately qualified clinical adviser. We found that the board failed to document the assessment of C that was undertaken prior to them being allowed to return home. Without that evidence, we were unable to determine whether the assessment of C's symptoms was of a reasonable quality. We reached the view that the board unreasonably failed to diagnose that C had suffered a stroke and upheld the complaint.

In addition, we found that the board's response to C's complaint was too brief, and lacked sufficient detail. There was little recognition that a significant diagnostic error had occurred, or the effect this may have had on C. The board's investigation and response did not note or disclose to C that there was no documentation in relation to this aspect of their care. The response also lacked appropriate detail in relation to the relevant discussions held as a result of C raising their complaint. We made recommendations to the board concerning these points.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose that they had suffered a stroke prior to being discharged home; assess them in sufficient detail; and record details of the assessment in their notes, and discharge letter. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should write to C clarifying what action was taken once the educational supervisor was informed of the matter. The response should also provide further feedback in relation to the discussion held at the general surgery meeting, and what actions may have been agreed.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their spouse (A) about the mental health care and treatment provided to A by the board. A has ongoing mental health difficulties and has been supported by both psychiatry and community psychiatric nurses, as well as more recently having psychology input.

We took independent advice from a psychiatrist (a doctor who specialises in the diagnosis, treatment and prevention of mental ill health conditions). We found that, whilst there were aspects of care and treatment that were reasonable, there had been a delay in A being given a psychiatry appointment. We upheld the complaint on this basis; however, as the board had previously acknowledged and apologised for this failing, we did not make any further recommendations.

Summary

C suffers from severe joint and musculoskeletal (relating to the muscles and skeleton) pain throughout their body. C complained that the board did not reasonably test C to establish the appropriate level of pain treatment they required. C wanted medication for pain to be administered by an intrathecal pump (a medical device used to deliver very small quantities of medications to the spinal fluid) and by trigger-point injections (a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax). The board did not consider this to be appropriate.

We considered that the board was aware of the level of pain experienced by C and that the pain management had been reasonable. We found that an intrathecal pump is usually used to target pain in a specific area for cancer patients or in palliative care, rather than where pain is benign (not directly linked to another medical condition) and widespread. We found that an implant can cause infection and that this increases over time and therefore the risk of use is lower for those in receipt of palliative care. We also found that if pain is not responsive to opioids (a type of pain relief) then delivery of opioids by this method is not likely to be effective. We also found that trigger point injections offer short-term relief and their effectiveness reduces when repeated. We therefore agreed with the board that these treatments were not appropriate for C. We did not uphold this complaint.

Summary

C complained about the care and treatment their late spouse (A) received from the practice. C had arranged a same-day appointment at the practice as A had been sick over the weekend. When the time approached; A was too ill to attend, therefore, C called the practice to request a house visit. A triage phone call took place that morning. A's symptoms were noted, advice provided and medication prescribed for sickness and diarrhoea. The following day, C requested a house visit as they felt that A's condition had worsened. Arrangements were made for a house visit to take place. C was concerned that A's condition was further deteriorating, so they contacted the practice to check when the doctor would arrive. The practice subsequently arranged for an emergency ambulance. A was taken to hospital but died shortly thereafter. The primary cause of death was found to be diabetic ketoacidosis (a complication of diabetes mellitus) and respiratory tract infection.

In responding to the complaint, the practice said that they could not always judge the severity of the symptoms over the phone; however, from the symptoms provided to the doctor, the appropriate action was taken in A's case. C remained dissatisfied with the care and treatment A had received and raised the matter with us. C was also unhappy that the practice's response to the complaint did not adequately cover all of their concerns.

We took independent advice from a GP. We found that, at the time of the triage phone call, there was an unreasonable failure to take an adequate history and further assess A (by way of an examination either by a house visit or hospital admission). We, therefore, upheld this aspect of the complaint. During our investigation, the practice provided us with some evidence of reflection and learning that had taken place.

In terms of C's concerns about the practice's response to their complaint, we found that they had appropriately contacted C in a timely manner in an attempt to obtain clearer information about C's specific concerns. Whilst it was not clear whether the practice attempted to get a better understanding of the complaint over the phone when C declined the offer of a meeting to discuss their complaint, we did not consider that they had failed unreasonably to respond to the complaint. We, therefore, did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable failure to gather sufficient information, including history, examination and testing, in order to make an informed diagnosis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the treatment their child (A) received within A&E at Western Isles Hospital. A was initially seen by a doctor who diagnosed a migraine. A They returned to A&E when their condition deteriorated, and was seen by another doctor, who diagnosed a migraine and possible virus. Following a third visit to A&E, A was diagnosed with a rare condition which is a complication of sinusitis. C complained that one doctor was dismissive and did not take A’s symptoms seriously.

We took independent advice from an A&E consultant. We noted that A was diagnosed with a rare condition that A&E staff would not be expected to diagnose. However, we considered that signs were missed that A had a potentially serious underlying condition. While they were satisfied that both initial doctors who saw A initially carried out appropriate examinations, we noted that the blood tests results were not consistent with the diagnosis of migraine or viral infection. We considered that A should not have been discharged before all the blood results were available. We also considered that A should have been reviewed by a senior doctor before discharge on the second attendance, given that it was an unplanned return. We concluded that there was a failure to take appropriate action, which resulted in a delay in investigating and accurately diagnosing A’s serious underlying condition. Accordingly, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for discharging A from A&E on two occasions without blood tests results having been identified and acted upon; for not arranging senior review on the second occasion; for the diagnosis being inconsistent with the blood results; and for the consequent delay in further investigation and accurate diagnosis of a serious underlying condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients returning to A&E with the same complaint should be reviewed by a consultant. The board should consider developing a policy for senior review of unplanned emergency department return patients, if one is not already in place.
• The board should feed this decision back to Doctor 1 and Doctor 2 in a supportive manner and ask that they reflect on A’s case, especially with regard to the abnormally elevated neutrophil white blood cell count.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late adult child (A) during an out-of-hours (OOH) GP visit. A had been experiencing symptoms including exhaustion, vomiting, and lack of appetite. A was examined and given anti-sickness medication, and advised that they should contact their own GP the next day for urgent follow-up review. A died the following day of acute myeloid leukaemia (an aggressive and fast progressing cancer of the white blood cells).

We took independent advice from a GP. We found that, because A was clinically stable (i.e. blood pressure, pulse and oxygen levels were normal), it was reasonable for the OOH service to advise for A to see their normal GP the following day for further investigations, particularly given that the OOH GP service cannot undertake investigations such as blood tests. We did not uphold this aspect of C’s complaint.

However, we noted that the board had undertaken significant review of the events, and although the conclusion was that the OOH GP service did not act unreasonably in their appointment with A, we considered that the board had taken significant steps to ensure that all learning possible has been taken from this case.

C also complained that the board’s handling of their complaint was unreasonable, as they considered that the family should have been more involved before any investigation took place. We considered the board’s actions in relation to complaints handling to have been reasonable and we did not uphold this aspect of C’s complaint.

Summary

C complained on behalf of their family member (A) about a delay in diagnosis of A’s type 2 Diabetes Mellitus (an adult onset diabetes, occurs when the body cannot produce sufficient insulin to absorb blood sugar - T2DM).

A was initially diagnosed with type 1 Diabetes Mellitus (T1DM) by their GP and began taking insulin. Over the following years, A was reviewed in the board’s diabetes clinic at varying intervals. After a number of years, and after further tests were performed, A’s diagnosis was changed to T2DM, and their treatment was altered.

In response to our enquiries, the board said they considered that A’s care was appropriate and that there was no delay in diagnosis. We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that there was an unreasonable delay in diagnosing A with T2DM. We found that it would have been reasonable to consider a potential diagnosis of T2DM at the time of the initial T1DM diagnosis, or soon after. We also found that the treatment used for T2DM could have been provided to A much earlier and we noted that there were a number of opportunities over the following years to reconsider the basis for the diabetes and thus additional treatment options. We upheld C’s complaint and made recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the unreasonable delay in reaching a correct diagnosis for their diabetes. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinicians should remain mindful of diabetes patients with atypical presentations when considering a diagnosis. Patients should receive the appropriate treatment for their condition.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.