Health

Summary

Mr C complained that the board had unreasonably failed to reimburse the costs of his Clomiphene medication (medication to increase levels of the hormone testosterone) which had previously been prescribed outwith the UK. Mr C also complained that the board had refused to reimburse his costs for attending an endocrinilogist (a medical professional who specialises in hormones) outwith the UK. Mr C maintained that the medication and service provided by the endocrinologist improved his health.

We took independent advice on Mr C's complaint from a consultant endocrinologist. We found that, although Clomiphene is effective in raising testosterone levels, it has not yet replaced the currently used testosterone supplements in the management of hormone deficiency in men. The treatment is unlicensed in the UK and, whilst a clinician could prescribe it, it would be a discretionary matter to do so, and they would have to make a specific request. We found that the board's decision not to fund the medication or the consultation costs on the basis that it was not licensed, alternative appropriate medication was available, and the condition is commonly managed in the UK, was reasonable. We did not uphold the complaints.

Summary

Mr C complained on behalf of his wife (Mrs A) who has multiple sclerosis (MS - a condition which can affect the brain and/or spinal cord). Mrs A began to experience leg and back pain and a scan showed she had a ruptured disc. She was referred to see a consultant neurosurgeon (a doctor who specialises in conditions of the nervous system, including the brain, the spine, the spinal cord and nerves). Mr C complained that, despite a number of consultations and opinions, Mrs A was not given a proper diagnosis for the cause of her leg and back pain, nor was she offered surgery or a referral out-with the board's area.

We took independent advice from a consultant neurosurgeon and that we found that Mrs A's case was complicated by her MS. We found that the care provided to Mrs A was in accordance with national guidelines and that clinicians involved made a well reasoned decision not to undertake surgery or refer her elsewhere. We were satisfied that Mrs A had been given reasonable care and treatment. We did not uphold the complaint.

Summary

Mr C complained on behalf of his late wife (Mrs A). Mrs A attended the Emergency Department (ED) at the Royal Infirmary of Edinburgh. When she attended she was unable to walk and required a wheelchair. Mr C said that Mrs A waited for nearly four hours before she was seen by a doctor, during which time her requests for pain relief were ignored. He complained that the care and treatment given to Mrs A in the ED was unreasonable. He also complained that the board gave incorrect or inaccurate information when they responded to his complaint about this.

We took independent advice from a consultant in emergency medicine. We found that in the ED Mrs A had been appropriately examined, that many aspects of her care were reasonable and that she was appropriately discharged. However, we found that she was not assessed, and reassessed, for her pain as she should have been. We found that she was given two paracetamol three hours after arriving, and then oral morphine an hour and a half later. However, we found that this delay was unreasonable and contrary to the Royal College of Emergency Medicine guidelines. We upheld this part of Mr C's complaint.

We found no evidence that the board had provided Mr C with incorrect or inaccurate information, and so we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that Mrs A's pain was not promptly assessed/reassessed and for the delay in providing pain relief.

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

• The Royal College of Emergency Medicine guidelines (management of pain in adults 2014) should be implemented.

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

Miss C was admitted to the Royal Infirmary of Edinburgh with severe sudden onset headache. A lumbar puncture procedure (a medical procedure where a needle is inserted into the lower part of the spine to test for diseases in the brain, spinal cord or central nervous system) was carried out but the results were negative and she was discharged the following day. However, she subsequently suffered ongoing headaches and low back pain. She complained that she had not been advised long term pain was a possible risk of the lumbar puncture. She also complained about how the procedure was carried out, expressing unhappiness that it was carried out by a junior doctor and questioning what had gone wrong to cause her so much pain. She also asked what her long term prognosis was.

We took independent medical advice from a consultant physician. We found that an initial headache and back pain are recognised complications of lumbar puncture procedures, but that the pain usually settles within a few days and severe ongoing pain is rare. As such, we found that it would not be expected practice for clinicians to advise patients of a risk of long term pain. We did not uphold this aspect of the complaint.

In terms of Miss C’s long term prognosis, the adviser suggested it might be helpful for her to have her symptoms reviewed by a specialist and we suggested the board might consider offering a neurology appointment.

We found no evidence to indicate that there were any failings in the way the procedure was carried out that might reasonably explain Miss C’s ongoing pain. We also found that it is appropriate for junior doctors to carry out such procedures, under supervision, when they are at the stage of their training that the doctor who carried out Miss C's procedure was at that time. We did not uphold this aspect of the complaint.

Summary

Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms A) about the care and treatment Ms A received at the Royal Infirmary of Edinburgh. Ms A had painful and uncomfortable symptoms in her throat and neck, which affected her breathing and swallowing. After investigations were carried out, Ms A was told that no physical cause was found to explain these symptoms. Ms A was referred to psychiatry and she was diagnosed with somatoform disorder (a syndrome where someone has recurring physical symptoms thought to be caused by psychological or emotional factors). Ms A complained that following this diagnosis, she was not given treatment for her physical symptoms.

We took independent advice from a consultant psychiatrist. We found that Ms A's psychiatry assessment was comprehensive and she was diagnosed with somatoform disorder with the appropriate input of various medical specialists. We also found that a reasonable decision was made not to investigate Ms A's physical symptoms any further, as that can be harmful for someone with somatoform disorder. We did not uphold Ms C's complaint.

Summary

Mrs C complained on behalf of her adult son (Mr A) about the care he received when he presented to the emergency department at St John's Hospital. Mr A has autism (a developmental disability that affects how a person communicates with, and relates to, other people) and a learning disability and attended A&E after suffering a dissociative episode (disruption in aspects of consciousness).

We took independent advice from an emergency medicine consultant. The adviser noted that the board failed to meet contemporary best practice when taking the decision to perform a sternal rub (rubbing knuckles on the sternum as an act of stimulation); however, we did not conclude that this action was unreasonable. We found that, in one instance, staff did not communicate reasonably with Mr A. We also noted that the emergency department team did not meet with Mrs C after she made a complaint, which showed a lack of supportive partnership working. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not responding to her concerns in a way that reflected partnership working. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance . Reconsider their decision not to meet with Mrs C and Mr A. The board should inform Mrs C of whether they are prepared to offer a meeting or if an alternative arrangement to effect partnership working would be more suitable.

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

• Staff should recognise that patients with autism and learning disabilities might find the emergency department distressing and this may result in challenging behaviour.

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

Ms C attended an antenatal screening which tested for Down's syndrome before the birth of her child (Child A) and it was determined that she was at low risk to have a child with this condition. Following the birth, Child A was diagnosed with Down's syndrome. Ms C said that the board's communication with her about Down's syndrome, before and after the birth was unreasonable.

During the pregnancy, an ultrasound scan confirmed Child A had a hole in their heart. Child A died a few months after birth and Ms C complained that the board had unreasonably failed to diagnose, discuss and treat Child A's heart condition and breathing problems.

We took independent advice from a midwife and consultants in cardiology, emergency medicine and neonatology. We found that, before the birth of Child A, Ms C was given reasonable information about the Down's symdrome screening process but after their diagnosis there was little evidence of what had been said and discussed. There was no record of the conversation telling Ms C about Child A's diagnosis and the immediate plan for them. We upheld this aspect of Ms C's complaint.

In relation to Child A's heart condition and breathing problems, we confirmed that there are limitations in the antenatal screening process, with screening identifying only half the number of heart defects. We found that Child A's heart and breathing problems had been reasonably diagnosed and treated but that there were also lung problems which could have not been predicted. We did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Full records require to be maintained and available for a clinical audit trail and scrutiny.

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

Mrs C complained to us about the care and treatment her sister-in-law (Mrs A) received at the Royal Infirmary of Edinburgh after taking two overdoses of medication within a few days. On the first occasion, Mrs A was assessed in the emergency department for risk of liver damage and then admitted to the acute medical unit. She had a psychiatric assessment the following morning and it was decided that she did not need any further in-patient psychiatric care. Mrs A discharged herself from the hospital later that day against medical advice. Mrs A was brought back to the emergency department on the following day after taking a further overdose and was then admitted to the toxicology unit. On the following day, she was transferred to a specialist liver transplant unit, although it was decided that she was not a candidate for a liver transplant. She was subsequently moved to intensive care after it was recorded that her kidneys were failing. Mrs A died there several days later. Mrs C complained about the care and treatment provided to Mrs A during each admission to the hospital.

We took independent advice from an emergency medicine consultant, a psychiatric consultant, a general medical adviser and a consultant in anaesthesia and intensive care medicine. We found that the care and treatment provided to Mrs A in the hospital throughout all admissions had been reasonable and appropriate. We did not uphold Mrs C’s complaints.

Summary

Ms C complained to us on behalf of her sister (Ms A). Ms A had sustained a head injury after a climbing accident. She attended hospital and was kept in overnight. After being discharged, Ms A became unwell, was visited at home by an out-of-hours GP and was then taken by ambulance to the emergency department at another hospital, St John's Hospital. She was diagnosed with post-concussion syndrome (when concussion symptoms last for weeks or even months after the injury which caused the concussion) and was discharged home. Ms A still felt unwell and was subsequently admitted to a third hospital and where she was diagnosed as having had a series of mini-strokes. Ms C complained that the board failed to provide Ms A with appropriate care and treatment when she attended St John's Hospital and unreasonably discharged Ms A from St John's hospital.

We took independent advice from a consultant in emergency medicine, a general medicine consultant with experience in stroke medicine and a radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans). We found that there were two documented symptoms that should have prompted the emergency staff to consider a diagnosis of stroke for Ms A. We also found failings in the board’s handling of the radiology aspects of Ms C’s complaint and her concerns about the out-of-hours GP’s notes on their assessment of Ms A. We upheld this aspect of Ms C's complaint.

In terms of Ms A’s discharge, we found that Ms A was not well enough to have been sent home and should not have been discharged from hospital. We considered that her working diagnosis should have been stroke, not post-concussion syndrome, and she should have been referred to the hospital’s stroke team. We, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and Ms A for the failings in Ms A’s care and treatment, her discharge from hospital and the investigation of Ms C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Emergency department staff should note key symptoms and reach an appropriate diagnosis, in a case such as this.
• Patients should not be discharged in circumstances such as this.

In relation to complaints handling, we recommended:

• Issues set out by patients in their complaints should be raised with relevant staff in a timeous manner.
• Complaints should be fully and appropriately investigated.

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

Mrs C complained to us that the medical practice had failed to provide appropriate care and treatment to her mother (Mrs A) at a home visit. She said that her mother had been dizzy, light-headed and off her feet and that she suffered from high blood pressure. Mrs C said that the GP recognised her mother's high blood pressure but did not take any further action and told her to wait for the district nurses, who were scheduled to visit in three days time, and that they would take further blood pressure readings, which Mrs C considered to be unreasonable. Mrs C called out the out-of-hours GP later that evening as her mother's blood pressure was still high. The offer of a hospital referral was made but Mrs A declined the offer. Mrs A was admitted to hospital two days later for a suspected heart attack and remained a patient for nearly two weeks.

We took independent advice from a GP adviser and concluded that the practice had provided a reasonable level of care. We found that the GP had carried out a reasonable examination and had concluded that there was no indication of an acute illness. The GP felt that the cause of the high blood pressure was caused by Mrs A's anxiety. It was appropriate to check the blood pressure readings and we considered that, as the district nurses were scheduled to visit a couple of days later, the matter would receive appropriate follow-up at that time. We did not uphold the complaint.