Health

Summary

Mrs C was due to have gynaecological surgery in hospital. When she arrived before the operation, she was seen by her consultant, who discussed changing the planned procedure to a more extensive operation. Mrs C was not given extra time to consider the implications of this, but consented to it. She complained that she did not receive adequate care after the surgery and that symptoms of complications arising from it were overlooked. Mrs C said that as a result of these complications, she lost the function in her left kidney. She also complained that there was an unreasonable delay before the board provided a response to her complaint.

After taking independent advice from two of our medical advisers, we did not uphold the complaint about Mrs C's care, as we found that the board had done all that could be reasonably expected in arranging care after surgery. The advisers said that the medical records showed that there had been no obvious symptoms of the complications, and staff had acted appropriately in discharging her. While considering that complaint, however, we noted that Mrs C was not given enough time to reflect on the changes to her surgery, which had serious implications for her ability to start a family, and we made a recommendation about this. We upheld the complaint about complaints handling, although the board had already acknowledged that their complaints handling procedure was inadequate and had taken steps to rectify this, including restructuring the complaints team and reviewing the procedure itself. Although we found that the delay in responding was unreasonable, we considered that the board had already taken enough action to prevent this happening again.

Recommendations

We recommended that the board:

• apologise in writing for the delay in providing a full response to the complaint; and
• review their procedures to ensure that for complex gynaecology patients, sufficient time is allowed for discussion of the full potential complications and implications with the patient, during the consent process, should the planned operation change.

Summary

Miss C, who is a prisoner, complained that there was an unreasonable delay in her receiving dental treatment. She also complained because the prison doctor refused to review her pain medication.

The board told us that Miss C saw the dentist for treatment but she was missed for a follow-up appointment. They told us that this probably happened because the way the waiting list system operated had changed. Miss C saw the dentist again a little over five months after her initial appointment. We agreed this delay was unreasonable and we upheld Miss C's complaint. In addition, Miss C said in her complaint to the board that her pain medication was not helping. The board told her that the doctor had said it was not appropriate to review her medication before she had been seen by physiotherapy, and had advised that if she responded poorly to physiotherapy then her medication would be reviewed. We took independent advice on this from one of our medical advisers, who said that it was not acceptable for the prison doctor to refuse to review Miss C's pain medication only after she had been to physiotherapy, as she had indicated she was in pain and her medication was not helping. In light of that, we upheld the complaint.

Recommendations

We recommended that the board:

• apologise for the delay in Miss C receiving further dental treatment; and
• take immediate steps to review Miss C's current pain medication and discuss the matter with her.

Summary

Ms C complained to the board about a possible breach of confidentiality caused by automated messages which had been left on the family's landline phone. Ms C heard no more until the board sent her a formal response to her complaint some six months later. The response explained that the automated service had been suspended until new procedures could be installed to prevent possible breaches of confidentiality.

Our investigation found that the board had treated Ms C's complaint as a return complaint rather than a new one, and that the delayed response was compounded by a period of high numbers of staff absences. We upheld the complaint but made no recommendations as the board had recently formally apologised to Ms C and provided detailed explanation of the action taken to prevent a repeat occurrence.

Summary

Mr C was admitted to a hospital accident and emergency (A&E) department after falling down stairs. On arrival his neck was immobilised in a collar, and it was noted that he had movement in his arms and legs with sensation in all his limbs. However, it was also noted that there were problems with his cooperation during this examination. A scan showed no acute fracture or bleeding and Mr C's neck collar was removed. The next morning, Mr C was found to have lost the power in his legs and he was transferred urgently to another hospital for treatment. His wife (Mrs C) complained that, given his accident, Mr C should have been kept immobile and given a full spinal scan. She also believed that proper tests were not carried out to determine the extent of his injuries and that he should have been transferred immediately to a specialist unit.

To investigate the complaint, we carefully considered all the relevant information, including all the complaints correspondence and Mr C's medical records. We also obtained independent advice from a consultant in emergency medicine and took this into account. Our investigation found that although Mr C was immediately immobilised on his admission to A&E, his neck collar was removed despite recorded difficulties in completing an assessment. Relevant advanced trauma life support (ATLS) guidelines suggested that Mr C should have remained in the collar until he was determined to be neurologically normal and could have been properly assessed. We upheld the complaint that Mr C should have been kept immobile, but did not uphold the others as our investigation found that all appropriate tests were carried out to establish the extent of his injuries and that the proper protocol was followed in transferring him to another hospital, rather than to a specialist unit.

Recommendations

We recommended that the board:

• apologise to Mr C for removing the hard collar before he was confirmed to be neurologically normal; and
• take appropriate steps to satisfy themselves that, with regard to evaluation, ATLS guidelines are fully complied with.

Summary

Ms C complained that the board had failed to take action to prevent her father (Mr A) from falling while he was in hospital. The hospital had completed a nursing assessment when Mr A was admitted. It was recorded that he was able to walk independently with a stick, but that he needed bed rails. Mr A got up to go to the toilet during the night. The nightshift staff in the hospital found him standing next to the toilet, holding onto the handrail. The next day, staff found that Mr A's mobility had deteriorated. He told them that he had fallen in the toilet during the night. Staff arranged an x-ray and it was found that Mr A had fractured his pelvis.

After taking independent advice from one of our medical advisers, we found that it was appropriate to promote Mr A's independence and that it was reasonable that he was able to go to the toilet alone. Although it was decided that Mr A needed bed rails, the board's guideline for falls management stated that bed rails would not prevent a patient leaving their bed and falling elsewhere, and should not be used for this purpose. Ms C said that her father had told her that the bed rails were not up when he went to the toilet. However, the member of staff who had assisted Mr A when she found him in the toilet recorded that the bed rails were up when she took him back to the bed. Although we recognised that the fall had a significant impact on both Mr A and Ms C, we found that there was no evidence to suggest that it could have been prevented.

Ms C also complained about the board's handling of her complaint. We found that they had delayed in responding, although they had apologised to Ms C for this. They had also failed to provide a full and detailed response to the complaint. We found that they should have tried to address the points Ms C made about whether or not the bed rails were up when Mr A got out of bed. In addition, the response had incorrectly referred to her late mother instead of her father. In view of all of this, we upheld this aspect of her complaint.

Recommendations

We recommended that the board:

• issue a written apology to Ms C for incorrectly referring to her mother instead of her father in their response to her complaint and for failing to provide a full and detailed response to the complaint.

Summary

Ms C complained that a hospital appointment she attended was not carried out in a reasonable manner, including that a consultant did not have access to relevant medical records from her previous care and treatment. She also complained that the consultant did not adequately communicate with her GP.

In our investigation, we considered the information provided by Ms C, along with her medical records, as well as obtaining independent advice from one of our medical advisers. We recognised that Ms C was unhappy about aspects of the appointment, but found that there was a clear difference of opinion about what happened and the manner in which the appointment was conducted, which we could not resolve on the evidence available. We found from looking at the records, and taking account of our adviser's view, that there was no evidence that the appointment was not carried out in a reasonable manner. We also found that Ms C's medical history was noted at the time of the appointment, and that the consultant's letter to her GP was reasonable.

Summary

Mrs C complained that, after a day surgery gynaecological procedure, she developed a prolapsed bladder (when the bladder bulges or protrudes onto the front wall of the vagina). She was examined by a gynaecologist who said that the prolapse was mild. She later saw another gynaecologist privately, who said that the prolapse was more significant. Mrs C said that this was an unexpected complication and had happened because the surgeon used excessive force. As a result, she said that she is now more susceptible to infections. She also said that staff knew something had gone wrong during the procedure and that they had concerns about her general health. Mrs C explained that this has been a significant, life-changing event for her, and has had an adverse impact on her quality of life. Mrs C also complained about the board's complaints handling saying they trivialised her complaint and there were inaccuracies, and that the involvement of the gynaecologist in the complaints process was of concern.

As part of our investigation of Mrs C's complaint, we took independent advice from one of our medical advisers. Their advice, which we accepted, was that there was no evidence to link Mrs C's bladder prolapse with the procedure. We also accepted the medical adviser's comments that there was no evidence showing that the surgeon failed to carry out the procedure to a reasonable standard. Although we appreciated that Mrs C had been deeply affected by her experience, we found that post-operative interventions were reasonable and in line with standard practice, and we were satisfied that there was no evidence showing that staff expected Mrs C to experience more than the usual amount of pain from the procedure. Furthermore, we noted the adviser's comments that there was no evidence in Mrs C's records of any concern about her general health condition. In terms of the way the board dealt with the complaint, we were satisfied that they treated it seriously and that any discrepancies about the severity of the prolapse in their responses were not evidence of complaints mishandling. Nor was there any evidence the investigation was compromised by the gynaecologist's role.

Summary

Mr C complained that a GP provided him with inadequate care and treatment. Mr C visited the GP because he had pain on the left side of his head. He said the GP diagnosed shingles and prescribed inappropriate medication, an antidepressant.

We looked at Mr C's medical records and took independent advice from one of our medical advisers. In the absence of any independent evidence from the consultation, however, we could not reach a definitive finding on exactly what was said there. We found that the medical records showed that the GP had noted that there was no shingles rash present, and had treated Mr C for nerve pain. We also found that the medication prescribed was appropriate for this, as although it is an antidepressant, it is also frequently used to treat nerve pain. We concluded that the GP provided a reasonable level of care and treatment in the circumstances.

Summary

Mr C complained on behalf of his daughter (Ms A) about the care and treatment she received when twice admitted to hospital. Mr C questioned whether Ms A was properly assessed on both admissions and why, although he said she had suicidal thoughts, she was discharged on the second occasion with a large amount of drugs, before taking an overdose. He believed that this would not have happened if things had been handled differently, and that they should have dealt with her medical problems holistically.

The complaint was investigated and all the relevant information, including the complaints correspondence and the relevant medical records, was given careful consideration. We also obtained independent psychiatric advice from one of our medical advisers. As part of the investigation, the adviser reviewed Ms C's records with specific reference to the assessments made on her admissions and the circumstances of her discharge. He was satisfied with these and had no criticism to make about them. While Mr C believed his daughter had psychiatric problems which meant she should have stayed in hospital, our investigation found that on both admissions, she was a voluntary patient. She had been admitted primarily in relation to her excessive drinking and her admissions were based on an agreement that if she was found to possess or use alcohol she would be discharged. As Ms C had broken that agreement, she was discharged, and the records showed that reasonable outside support arrangements had been put in place for her. We did not uphold the complaint but as our adviser said that, though they would not have changed the outcome, there were some things that could have been done better, including the use of ICD10 (a classification of mental and behavioural disorders - clinical descriptions and diagnostic guidelines) we made some related recommendations.

Recommendations

We recommended that the board:

• consider using ICD 10 diagnoses;
• give attention to the dates on which letters are compiled and dispatched to satisfy themselves that they are issued in a timely manner;
• identify the responsibilities of agencies involved, and further, identify the lead; and
• review the procedure for passing information to carers and satisfy themselves that it is fit for purpose.

Summary

Miss C complained that out-of-hours hospital staff did not take account of her recent bowel surgery in providing diagnosis and treatment when she attended there because she had not opened her bowels for several days. Miss C said that as a result of this, she developed peritonitis (inflammation of the tissue lining the abdomen) and had to undergo further surgery, including having a colostomy bag.

After taking independent advice from one of our medical advisers, we found that the assessment carried out by the out-of-hours service was appropriate and there were no signs of peritonitis at this time. The records showed that the nurse who dealt with Miss C carried out appropriate examinations, and sought advice from medical staff when giving medication. We could not say for certain what the nurse said to Miss C, but there was evidence to suggest that Miss C was given the opportunity to be admitted to hospital (although we noted that she did not consider that she was in any position to make this decision at the time). We concluded after seeing the medical records that Miss C developed clear signs of peritonitis after she was admitted the following day to a different hospital, but that these symptoms had not been apparent when she attended the out-of-hours service.