Health

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.

Summary

C fell and injured their head, requiring emergency surgery and the removal and replacement of part of their skull. Tayside NHS board carried out the surgeries and provided rehabilitative care. C complained that the board failed to properly insert the ceramic bone replacing the portion of skull taken out, causing disfigurement. C was also not satisfied with the explanations given by the board in relation to the care provided.

We took independent advice from a consultant neurosurgeon (a surgeon specialising in surgery of the brain and nervous system). We found that the board provided reasonable treatment to C. C’s injuries required two emergency operations, both of which were reasonably carried out. The board provided a custom-made plate to replace the portion of the skull lost due to the head injury. The surgeries and follow-up care provided to C were of an extremely high standard. While there was a complication with one of the surgeries, this was a known complication for cranial surgery which the board accepted and apologised for. After the operations were completed, the board provided rehabilitation to C through multiple rehabilitation schemes. This was reasonable. As such, we did not uphold this aspect of C's complaint.

We also considered C’s complaints that the board had failed to provide a reasonable explanation about the treatment they received. We found the board provided reasonable explanations to C about the treatment they provided. Clinicians spoke with C on multiple occasions to discuss the outcomes of the surgeries. The board took account of C’s cognitive difficulties when communicating with them and exceeded the level of standard care required in terms of communication. The board’s response to C’s complaint explained the outcome of C’s surgeries including the impact on C’s facial appearance. This was reasonable. As such we did not uphold this aspect of the complaint.

Summary

C complained about the treatment their late spouse (A) received from Tayside NHS board. Following a fall, A required emergency hip replacement surgery. A developed a severe infection in their wound following the surgery and later died as a result of this infections. C complained that the board inappropriately ignored issues with A’s stomach when prescribing antibiotics. C also considered that A was required to attend hospital appointments unnecessarily when their condition became untreatable. C stated that at a meeting to discuss their complaint after A’s death the board told them that A had not been expected to live. C said they were shocked and had not been told this before.

The board stated A’s treatment had been reasonable. Staff had responded appropriately to A’s serious infection. Although every step had been taken to avoid infection, these did occur. A’s condition had been regularly reviewed and advice taken from microbiology specialists to try and optimise A’s treatment.

We took independent medical advice from a orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found A’s treatment was reasonable. They were regularly reviewed and their antibiotics were changed in order to try and improve their outcome. In addition, we noted that A’s condition was such that it was not unreasonable for them to have their wound dressed as an out-patient. Therefore, we did not uphold C’s complaints.

Summary

C, an advice and support service worker, complained on behalf of their client (A) regarding care and treatment A received from the board. A presented to University Hospital Monklands with abdominal pain, which had been treated as a urinary infection. It was thought that the symptoms were related to their kidneys. A had a scan days later and as a result was diagnosed as having a twisted right ovarian cyst which required surgery. C complained that there had been a misdiagnosis and delay in carrying out a scan. They questioned whether the ovary would not have needed to be removed had the correct diagnosis been made earlier. C also complained that A’s mobility and pain were not properly assessed, and compression stockings were not provided.

In responding to the complaint, the board apologised that there had been a breakdown in communication regarding the scan and advised that this would be discussed with the doctor in further detail. In terms of the nursing care provided, the board did not identify any failings.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) and from a registered nurse. In terms of the medical care, we found that A’s ongoing pain three days after being treated for urine infection was uncommon and that a diagnosis of kidney stones or another cause of pain should have been considered. We considered that a scan should have been carried out on the day it was originally planned and it was unreasonable care that this did not happen. However, we did not consider that A’s outcome of undergoing surgery and having an ovary removed would have been affected by the delay in the scan. Nevertheless, we found that the delay resulted in A being in pain for longer and acknowledged that this was distressing for them. We upheld this complaint.

In terms of the nursing care, we found it was reasonable not to have provided A with compression stockings. However, we considered there were failings in a mobility assessment not being carried out, and there was no clear care plan for their persistent and unresolved pain. Had there been so, this may have led to escalation to medical staff; a review of their pain; and expedited some of tests, if it was recognised pain was becoming difficult to manage in the context of an undiagnosed cause. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the following aspects of their care: that there was no differential diagnosis or a plan on management clearly recorded; that there was no medical review of A’ pain and observations documented; that there was no explanation about why the original plan for a CT scan was changed to an ultrasound scan and then changed back; that there was a delay in performing a CT scan; and that A’s mobility was not reasonably assessed or at least documented. 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:

• Clearer record for pain relief and management is required to accurately assess pain with escalation to medical staff as appropriate.
• Documentation on rounds should provide adequate reflection of clinical examination, review of observations, possible diagnosis, and plan of management.
• Nursing staff should ensure, where relevant, a patient’s mobility is assessed and documented.

Summary

C complained on behalf of their partner (A) after A's leg was amputated above the knee without C’s consent. We did not uphold this complaint as there was evidence of discussion with A prior to the operation and a consent form had been signed by A.

C also complained that the board unreasonably amputated A’s leg above the knee when a toe amputation would have been sufficient. A’s leg was vascularised down to their knee and there were significant problems with A’s foot. A toe amputation would not have been sufficient. It was reasonable to amputate A’s leg rather than conduct by-pass surgery. We did not uphold this aspect of the complaint.

C also complained that a Do Not Attempt Cardia Pulmonary Resuscitation (DNACPR) was put in place while A was unable to consent to it and that A was later discharged with this. We noted that there were issues relating to retaining a copy of the DNACPR on file, it but as consent was obtained once A was able to consent, we did not uphold this aspect of the complaint.

C also complained that the board changed their response to the complaint regarding consent to A’s amputation. The board had originally stated that A had been unable to consent to the amputation at the time and that it was performed out of medical necessity; however, later they located documentation to show that A had actually consented. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to conduct an accurate investigation of their complaint. 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:

• Ensure clinical staff who have been asked to provide information relating to a complaint to the complaints team, check their understanding against contemporaneous clinical records, when giving statements for internal investigations. Ensure the complaints team ask staff feeding back comments if they have checked their understanding against contemporaneous notes.

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 sibling (A) following A's contact with a health board’s mental health service when they were in crisis. C was concerned about the standard of care and treatment provided to A. C’s concerns were wide-ranging and covered numerous aspects of the provision of care and treatment. C said this included repeated, unreasonable, failures by staff to recognise and diagnose A with psychosis and paranoia, to prescribe appropriate medication, to communicate adequately with A or their family or both, adequately supervise A, to agree a care plan and put in place appropriate discharge care, and to admit A as an in-patient at each emergency department attendance.

We took independent advice from a consultant psychiatrist and from a mental health nurse. We found that the diagnosis was appropriately assessed and reasonable conclusions reached on management and treatment of A. However, we also noted some concerns about aspects of communication with A and their family and found significant shortcomings in relation to record-keeping about a discharge from one hospital admission in particular. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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:

• Ensure relevant clinical staff at Wishaw General Hospital are aware of their responsibility to document patient management decisions in relation to General Medical Council Good Medical Practice Guidelines.

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.