Health

Summary

After Mr C was discharged from hospital following an operation on his bladder, he complained that his GP failed to visit him to review his wound or to provide him with treatment for a urine infection.

The clinical records showed that when Mr C contacted the practice, the GP had asked a district nurse to visit him to dress his wound. When the nurse attended, she noted that Mr C was feeling well. She visited again a couple of days later and noted that he was still improving. When the GP called him six days later, Mr C reported that he was still feeling well, but when the GP mentioned that a urine infection had been noted after an initial post-discharge district nurse's visit, Mr C became upset. Two days later Mr C contacted the practice to complain of significant pain and cloudy urine. He was then prescribed antibiotics.

We took independent advice on this case from one of our medical advisers, who is a qualified GP. He said that it was appropriate for Mr C's wound to be dealt with by district nursing staff. He also advised that it was reasonable, given the continued improvement in Mr C's condition, that the practice did not initially prescribe antibiotics for the urine infection. As the care provided by the GP was reasonable, we did not uphold the complaint. We did, however, make a recommendation to ensure that in future patients are kept fully informed about test results.

Recommendations

We recommended that the practice:

• review the way test results are communicated to patients, either by contacting them directly to provide the results or by requesting that patients contact the practice within a set timescale to obtain their results.

Summary

Mr C complained about the care and treatment he received after he was diagnosed with prostate cancer. Before the diagnosis, Mr C had been treated with finasteride and tamsulosin (drugs used to treat benign enlargement of the prostate). After the diagnosis of cancer, he was prescribed bicalutamide (hormonal therapy used to treat prostate cancer), which he took for eight months. In this time, he developed gynaecomastia (enlargement of the male breast tissue), which is a side effect of the treatment.

We took independent advice on this case from one of our medical advisers, a consultant in clinical oncology with a specialist interest in urological cancers. Mr C said that the board had recorded his PSA level (prostate-specific antigen level in the blood) incorrectly. He said that he had been on finasteride long-term at that time, which artificially reduces the PSA level. He said that the level recorded by the board should have been doubled, as research shows that finasteride cuts the true reading in half. We found, however, that the board had recorded Mr C's PSA level correctly. Although finasteride does reduce the PSA level, there is no accurate method to determine this, so routine practice is that the measured PSA level is recorded.

Mr C also complained that the board had not recorded his cancer staging (the extent of the primary tumour and the degree of cancer spread) at the time of his diagnosis. We found that the board should have recorded it, but had failed to do so. There had then been some confusion about Mr C's staging. That said, the confusion about this was of no clinical significance and would not have led to any differences in Mr C's clinical management. The board had apologised to Mr C and had also confirmed that staging is now routinely collected at the multi-disciplinary team meeting for each patient.

We found that the board had failed to advise Mr C of the risks or the options for the prevention of gynaecomastia before he began hormone treatment, although they had apologised to him for this. They sent us an information leaflet that they now give to men with prostate cancer considering hormone treatment, which includes information about gynaecomastia.

In addition, Mr C complained that the board did not monitor the risk of him developing gynaecomastia or take reasonable steps to prevent or mitigate this during the hormone treatment. We found that, in general, Mr C had been adequately managed and this management conformed with the treatment guidelines. That said, the board had delayed in reviewing the hormone treatment and so Mr C received it for longer that the planned six months. Our adviser said, however, that it was unlikely that the additional two months treatment would have had a significant impact on the extent of the gynaecomastia. We noted that the board had also apologised for this in their response to Mr C's complaint and, as they had already taken steps to address this as well as the other failings in this case, we did not find it necessary to make any recommendations.

Summary

Ms C complained about her care and treatment during the birth of her son. In particular, she was concerned about the attitude of the midwife - she said that the midwife had snapped at her, had not listened to her and had not explained what was happening. She was concerned that the actions of the midwife had almost cost her son's life.

Our investigation took into account all the available information, including the complaints correspondence and the relevant clinical records. We also obtained independent advice from a medical adviser. We found that the board had already accepted that there had been a failure in communication and had taken action to address this and had apologised to Ms C.

Overall we found that the level of care provided was adequate and safe and that there was nothing in the clinical records to suggest that a different course of action should have been taken. However, we were concerned that Ms C's blood pressure or pulse were not taken as required. We were also concerned that record-keeping was not to an acceptable standard, and that the failure in communication, in particular the failure to explain what was happening, had added to Ms C's concern that her baby was at risk. We upheld Ms C's complaint and made relevant recommendations.

Recommendations

We recommended that the board:

• bring the failures identified in this investigation to the attention of the relevant midwife; and
• undertake an audit of record-keeping at the maternity unit to ensure that their record-keeping is in line with Nursing and Midwifery Council guidance.

Summary

Mrs C complained about several aspects of her hospital care and treatment immediately before, during and immediately after the birth of her son. Mrs C's son was born by a forceps delivery which necessitated an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth). She also suffered a third-degree tear (a serious tear between the vagina and anus). She suffered a major haemorrhage (escape of blood) minutes later and required extensive life-supporting treatment. Mrs C was concerned that the complications she suffered might have been the result of poor care and treatment. She was also concerned that she and her husband were unsupported after such a traumatic experience and that this was causing her long-term health problems.

After taking independent advice from one of our medical advisers, our investigation found that while Mrs C had undoubtedly had a very traumatic and difficult birth experience, it was not caused by poor care or inadequate treatment. We were, however, very critical that the need to refer her to counselling services was noted in the post-natal ward but not acted on. This meant that Mrs C and her husband were not properly supported after the birth. We upheld this aspect of her complaint and made recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C and her husband for the failure to refer her for appropriate counselling while she was in the post-natal ward; and
• review the failure to refer Mrs C to counselling services and identify any improvements that can be made to the referral process in the future.

Summary

Mr C was undergoing treatment for leukaemia and had to have a 'Hickman Line' (a small tube to give long-term access to a vein to administer chemotherapy) inserted. Mr C complained that this procedure was not performed correctly as it had caused him a great deal of pain. He also complained that his complaint about it was not dealt with reasonably.

Our investigation, which included taking independent advice from one of our medical advisers, found no evidence that the procedure was not carried out properly. The adviser said that different patients experience differing levels of pain in such a procedure and there was no evidence that anything went wrong with the first insertion. However, no record of the problems Mr C experienced was made at the time. The radiologist who performed the procedure had, after speaking to Mr C after the procedure, agreed to make a record in the clinical notes and to put an alert on the electronic records saying that Mr C required sedation for any future insertion. This did not happen and, when Mr C had to be admitted for a further line to be inserted, he was distressed that the team were not aware of his experience. Because of this, although we did not uphold the complaint about the procedure, we made recommendations about record-keeping.

On the matter of the complaints handling, it was clear from our investigation that for a number of reasons, there were extended delays in the handling of Mr C's complaint. Some of these were outside the board's control but some were not, and so we upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C;
• conduct an audit of record-keeping in the department and use any learning points to formulate an action plan for improvement;
• ensure their patient information leaflet is provided to patients before consent is given and that this is documented; and
• provide evidence that the complaints handling team have learned from these events and that those learning points have been used to improve the service.

Summary

Mr C's mother (Mrs A) suffers from angina and vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). Mr C holds welfare power of attorney for her. Mrs A was admitted to hospital after she collapsed. She was discharged home after two days but was readmitted several weeks later, following episodes of dizziness and falls. She was discharged again, but six days later was admitted (by her GP) for a third time due to chest pain, shortness of breath and poor balance. It was noted in her medical records that at the point of admission she was not 'coping in her social environment'.

Mr C said that he only found out on the day of the second discharge that Mrs A was being sent home to an empty house with no other family members present. This was despite Mr C specifically requesting that Mrs A's return home should be fully coordinated with the local care team to ensure her effective transition from hospital to home. He said that there was no effective liaison with the local care team. When he raised concerns, the hospital arranged for a health care assistant to accompany Mrs A home.

Mr C also said that the referring GP had asked the board to carry out a medical and social care assessment of Mrs A in relation to her third admission. Nearly two weeks after she was admitted, he found out it had not been completed and that staff were not aware of the request. He said that staff assumed Mrs A would return home on the same care package. The review was then carried out, but Mr C believes this was only because he insisted.

After taking independent advice on this case from one of our medical advisers, we upheld Mr C's complaints. Our adviser said that when people with dementia are being transferred home from hospital, there should be a proactive risk assessment. This should consider the person's physical and cognitive abilities, the home circumstances and whether anyone will be at home to receive them on arrival. The board failed in this respect. We also accepted the adviser's comments that there was no evidence that Mrs A was involved in her care in any meaningful way or that involvement of her relatives occurred in a planned or proactive manner. These failings were exacerbated by failures in record-keeping. Related to this, the board failed to formally assess Mrs A's capacity to consent to treatment, despite the evidence that her capacity was impaired, and they failed to acknowledge and effectively respond to Mr C's welfare power of attorney status.

In relation to the discharge, our adviser said that while there was no evidence the GP requested an assessment, in light of the evidence available to staff from Mrs A's second admission to hospital, a review of her care package should have been planned. Having said that, the adviser also said that the referral to the hospital discharge team took place within a reasonable time. However, it was not clear to us that without Mr C's intervention, this would have taken place, particularly in light of the failures in record-keeping.

Recommendations

We recommended that the board:

• ensure that communication with relatives and/or carers of people with dementia is a planned process - in particular with regard to discharge;
• ensure that the standard documentation is effectively utilised and completed;
• ensure that all staff are aware of the legislation with particular reference to consent, capacity and record-keeping, including completing section 47 certificates and recording that relatives and/or carers have welfare power of attorney;
• bring the failures identified to the attention of relevant clinical staff; and
• apologise to Mr C for the failures identified.

Summary

Mr C complained that his dentist did not provide a reasonable standard of treatment. At Mr C's initial appointment, the dentist carried out a detailed examination. She noted that there was extensive decay in one of his lower wisdom teeth and that it might require extraction. When Mr C returned to start the treatment, the tooth was drilled to remove the decay, but this led to exposure of the nerve. The dentist covered the exposed nerve by dressing it with a paste to treat inflammation/infection, and a filling material. She told Mr C that the tooth would need to be extracted at a later appointment.

Mr C attended the dentist again two days later as he had pain and swelling around the tooth. The dentist gave him an antibiotic and reduced the filling by cutting it back (this eases symptoms slightly by preventing the patient putting pressure on the tooth when biting). The next day, Mr C contacted NHS 24, as he was concerned about increasing swelling and pain around the tooth. He was referred to an emergency dentist who prescribed a different antibiotic. Mr C saw his dentist again several days later. She was unable to extract the tooth because of the swelling, although she thought that it had gone down slightly. Mr C was later admitted to hospital because the swelling had increased. It was found that he had an abscess and he had an operation to drain the abscess and to extract the tooth.

Mr C complained about the dentist's failure to extract the tooth. As part of our investigation we took independent advice from our dental adviser. We found that the decision to delay the extraction of the tooth until such time as it could be fully assessed was reasonable because of the risks associated with extraction of a lower wisdom tooth. However, the dentist had used a substance called glass ionomer to fill the tooth when the nerve was exposed. Our adviser said that this was not an appropriate choice for an exposed nerve and the dentist should have chosen a more appropriate sedative dressing material. This would have reduced the risk of complications and pain while Mr C was waiting for the tooth to be extracted. In addition, we found that the dentist had failed to ensure that the infection could drain away when the abscess began to develop. This allowed pus to continue to accumulate within the tooth, which then spread into the surrounding tissues and made the swelling worse. In view of this, we found that the dentist had not provided Mr C with a reasonable standard of dental treatment.

Recommendations

We recommended that the dentist:

• ensures that she has learned lessons from this case;
• issues a written apology to Mr C for the failure to use an appropriate sedative dressing material and for the failure to establish drainage in the tooth; and,
• ensures that responses to complaints provide information about how to refer the complaint to the SPSO.

Summary

Ms C, who is an advocacy worker, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A's late husband (Mr A) before he committed suicide. Mr A had a history of depressive illness. He was referred to a community psychiatric nurse (CPN). He saw both the CPN and the board's mental health assessment service before he was admitted to hospital after presenting with suicidal thoughts. He took his own life two days after being discharged from hospital.

In considering this complaint, we took independent advice from our psychiatric adviser, after which we upheld only one of Ms C's four complaints. Ms C had complained that the CPN delayed in referring Mr A to hospital. Our investigation found, however, that the CPN had not delayed in referring him to a consultant psychiatrist at the hospital. We were also satisfied that there were reasonable attempts to manage Mr A with other treatments, and noted that there was contact with other parts of psychiatric services at an early stage.

Ms C also complained that the board failed to make a reasonable diagnosis or offer reasonable treatment and medication to Mr A when he was admitted to hospital. Our investigation found that Mr A's case was complex and he had diagnoses of personality disorder and depression. The risks he presented were considered and assessed, but it was concluded that he did not meet the criteria for detention. We found that attempts had been made to manage his case with appropriate drug and psychological treatments and our adviser said that his treatment and medication were reasonable.

Ms C also complained that the board failed to carry out an appropriate risk assessment. She said that they failed to properly assess the risk of suicide and child protection issues. She also said that they had failed to involve Mrs A when deciding to discharge Mr A. We found that the hospital had carried out frequent risk assessments on Mr A in a satisfactory manner. He did not show impaired decision-making and so could not be detained in hospital. We also found that Mrs A was involved as far as possible in her husband's care, and that child protection issues were taken into account. However, we upheld the complaint about the assessment of risk, as we found that Mr A had been discharged to his brother's home. We considered that the hospital should have asked Mr A for consent to contact his brother in order to involve him in the discharge plan, and to check if there were children at his address. We noted that the standard documentation around discharge had not been completed and had this been done, it could have acted as a prompt to contact Mr A's brother.

Recommendations

We recommended that the board:

• make the staff involved in Mr A's care and treatment aware of our findings.

Summary

Ms C complained about a delay by her GPs in diagnosing that she was pregnant. She initially went to the practice to report a missed period, and was advised to take a further pregnancy test, which was negative. She attended the practice five months later saying that she had bloating and constipation. The GP thought she was constipated and prescribed a laxative. Ms C then went on holiday where she participated in various activities. She returned to the practice and it was then diagnosed that she was pregnant. The practice apologised for the missed diagnosis of pregnancy, but said that the GPs had dealt with the symptoms that she reported and had focused on the history of bloating and constipation. They also said that Ms C's complaint would be included in the appraisal folder and discussed at appraisals later in the year, where lessons learned are shared with colleagues.

We obtained independent advice on the complaint from one of our medical advisers, who considered Ms C's medical records in detail. Their advice was that the actions of the GPs were appropriate, although the diagnosis of pregnancy was missed. In such cases, as long as the clinicians involved took reasonable action based on the symptoms that were presented, we have no grounds to criticise their actions. Our adviser had no concerns about the GP's actions and prescription, and noted that the GP had told Ms C to return for re-evaluation if the symptoms did not settle.

Summary

Mrs C's mother (Mrs A) suffered a stroke after undergoing surgery for a fractured hip. Mrs C complained that the operation had taken too long and that her mother was not provided with a reasonable level of care during and after the surgery. She also believed that her mother did not receive adequate treatment after the stroke was diagnosed, as she did not receive a scan to confirm the diagnosis and was not moved onto a stroke ward.

After taking independent advice from one of our medical advisers, we upheld the first complaint as we found that the operation to repair Mrs A's broken hip did not follow best practice. She was not operated on within the 24-hour time limit set out in Scottish Intercollegiate Guidance Notes (SIGN), and the fit of the artificial hip was not properly checked, which meant the operation took 45 minutes longer than planned and unnecessarily increased the risks to Mrs A during surgery. We found that the board had not acknowledged or investigated these failings sufficiently in their investigation of Mrs C's complaint.

We did not uphold Mrs C's other complaints as we found no evidence to show that Mrs A was inappropriately discharged from the recovery room to a ward when she failed to recover from the anaesthetic, nor that her treatment was not reasonably managed when it was realised that she had suffered a stroke.

Recommendations

We recommended that the board:

• provide evidence that staff have been reminded about the importance of using trial stems prior to the insertion of cement during arthoplasties (a surgical procedure that restores the function of a joint);
• remind all staff of the importance of the 24-hour safe period set out in SIGN guideline 111;
• remind all staff of the importance of making clear, accurate notes for all clinical decisions; and
• apologise in writing for the failings identified in our investigation.