Health

Summary

Mr C complained on behalf of his late aunt (Mrs A) who was admitted to hospital from her nursing home with sudden pain in her legs. She had been previously diagnosed with dementia (her solicitor held welfare power of attorney) and chronic peripheral vascular disease (a long-term condition where the blood supply to the leg muscles is restricted). Mrs A was prescribed medication for pain and agitation and discharged back to the nursing home the next day. The hospital wrote to her GP and the nursing home detailing her care and said that the vascular surgical team felt that this represented an acute episode of her long term vascular disease, but had decided that surgery was not in her best interests and she should be treated with simple pain relief. They said Mrs A had complained of some pain before discharge and it was decided that this would be better controlled in her normal environment at the nursing home. The nursing home, meanwhile, had identified that Mrs A needed morphine on the day of her discharge and three days later, for the first time, there was an entry in her medical records about palliative care (care purely to prevent or relieve suffering). She was prescribed additional medication for palliative care on the following day, and the nursing home requested more morphine for her. Mrs A died six days after being discharged from hospital.

Mr C said that Mrs A's GP, nursing home and solicitor all knew that she was terminally ill when she was discharged from hospital and that this diagnosis was made while she was a patient there. Mr C said that within a few days of Mrs A being discharged, the GP told Mrs A's solicitor that she had a major inoperable blood clot in one of her main arteries and was being kept comfortable at the nursing home, but that otherwise nothing beneficial could be done and that the 'time-frame' could be days. Mr C also complained that the board failed to provide him with a proper answer about why Mrs A was not immediately referred for palliative care.

After taking independent advice from a medical adviser, who specialises in care of the elderly, we upheld Mr C's complaints. The adviser said that the care and treatment in relation to diagnosis, discharge, communication and record-keeping was below a reasonable standard and impacted adversely on the board's decision-making about palliative care. Mrs A was a vulnerable adult, and we found that the clinicians underestimated her symptoms and their severity and significance, leading to an inaccurate diagnosis and a failure to meet her palliative care needs. We also found that the board failed to provide a detailed explanation of the clinical thinking at the time of Mrs A's discharge to justify their position, which would have added to the distress of Mrs A's family.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff;
• review the admission of older adults to assess whether staff have sufficient expertise (such as consultant geriatricians) to assess such patients;
• bring the failures in record-keeping to the attention of relevant staff;
• bring the failures identified in this investigation to the attention of the board's complaints team; and
• apologise for the failures identified this investigation.

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from her medical practice before her death. Mrs C had a number of falls and twice fell down the stairs at home. This resulted in an ulcer on her leg and a large boil-like growth on her elbow. Mr C complained that although the practice treated Mrs C's elbow, they did nothing about the ulcer on her leg, which deteriorated.

We took independent advice from our GP medical adviser who said that although GPs do not treat leg ulcers, they should refer a patient to nurses or a service to administer dressings and compression bandages where appropriate. We found that the practice had appropriately referred Mrs C to the practice nurse and the district nursing service for treatment for her ulcers. We also found that it was reasonable that the practice did not initially consider the wound on Mrs C's leg to be an issue and did not consider that it required treatment until they reviewed it a few weeks later. We took the view that Mrs C's ulcers were appropriately treated.

Mr C also complained that the practice did not ensure that Mrs C was admitted to hospital when her condition deteriorated. The notes made by both the district nurses and the practice showed that Mrs C did not want to go into hospital at first. However, her condition deteriorated and the next day, she confirmed that she was now willing to go there. The practice then contacted two hospitals to try to arrange admission. We found that the delay in arranging this was not due to the practice's failure to respond, but due to problems in getting the hospitals to accept Mrs C as an in-patient, and that the actions of the practice had been reasonable and appropriate. Although we did not uphold Mr C's complaints, during our investigation we identified that the district nurses, who were employed by the local health board, had not given the practice all the relevant details about the deterioration in Mrs C's condition and so we made a recommendation about this.

Recommendations

We recommended that :

• hold a joint significant event analysis discussion with the district nurses in order to reflect and learn from this case.

Summary

Following a stroke, Mr C's late aunt (Mrs A) was transferred to a hospital for rehabilitation and discharge planning. Mrs A's solicitor had welfare power of attorney for her. Mrs A had a degree of cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember), which got worse while she was in hospital. Several months later, Mrs A was discharged to a nursing home. Mr C complained about the way the board discharged his aunt, which he said was done too quickly and without input from her family or her advocate, and about the handling of his complaint, including that the board inappropriately contacted Mrs A's solicitor about it.

We took advice on this complaint from one of our medical advisers, who specialises in mental health. Our investigation found that the views of Mrs A and her family were not fed into the decision-making process, contrary to the board’s discharge policy, and that Mrs A was denied the opportunity to visit the nursing home before being discharged there. Her family were not kept updated and there is no evidence that the board made Mrs A, her welfare power of attorney or her family aware of her right to independent advocacy. Finally, the principles underpinning the Adults with Incapacity Act were not adhered to - as Mrs A was unable to give informed consent to treatment or to make reasoned decisions, a certificate of incapacity should have been completed and the interventions being authorised should have been set out in a care plan.

We were satisfied that the board acted properly when they told Mr C that they could not release confidential information about Mrs A without her or her solicitor's consent, because the solicitor had welfare power of attorney. However, our investigation found that early in the complaints process the board were aware of information that brought Mrs A's capacity to consent into question. We were, therefore, critical that they did not make Mr C aware of this until some five months later, after he had obtained and sent Mrs A's consent to his complaining on her behalf. Although the board provided detailed responses to Mr C's concerns, we noted delays and inaccuracies in these (particularly around Mrs A's reaction following her visit to another nursing home).

In relation to the board's handling of Mr C's complaint, we were satisfied that their actions were reasonable in light of the legal advice they received. They carried out several investigations, including having an independent healthcare professional review Mrs A's care. Mr C was disappointed that a senior official was not available to meet him when he arrived at their office (having travelled from abroad), but the board had made no arrangements to meet him at that time. Instead, they met him the following month, and although they withdrew their offer of a teleconference (following legal advice), this was not in itself evidence of maladministration. Finally, the board properly referred Mr C to the council for a response about his concerns relating to the actions of the social workers involved in his aunt's discharge.

Mr C was unhappy that the board had potentially breached confidentiality by seeking comments from Mrs A's solicitor about his complaint. It is not for us to decide whether there has been a legal breach in relation to data protection, but we can consider whether the board's actions were reasonable in the circumstances. Normally, when a family member complains on an individual's behalf, health boards do not directly contact the individual affected by a complaint, rather they would tell the family member they needed to get consent from the individual before the board would look at the complaint. In this case the board contacted the solicitor who was speaking for Mrs A, which was the equivalent of contacting Mrs A herself. Our view was that the existence of a welfare power of attorney did not mean there should be any change to the normal practice, as there are good reasons for that practice and we were aware of no reason why this situation required an unusual approach. We were critical that the board contacted the solicitor about Mr C's complaint, which would not have occurred under ordinary circumstances. We upheld both Mr C's complaints and made recommendations for improvement.

Recommendations

We recommended that the board:

• ensure patients who lack capacity are treated in line with the relevant legislation;
• inform patients with dementia and their families of the right to independent advocacy (and how to access the service) and ensure advocates are given the opportunity to express the views of their clients;
• review their complaints handling procedures in the light of this complaint to ensure that communication with families and/or individuals with welfare power of attorney are appropriate; and
• make a further apology to Mr C in light of the findings of our investigation.

Summary

Mrs C complained about the care and treatment that her son (Mr A) received when he was admitted to hospital as a voluntary psychiatric patient, after being taken there by the police. He was examined on admission and a care plan was completed. He was reviewed again the following morning by a doctor who had treated him when he had previously been admitted. The doctor gave him a pass to leave the hospital for two hours. Mr A did not return to the hospital and was found dead a number of days later.

We were able to investigate only limited elements of Mrs C's complaint, because the main aspects of it had already been investigated by the Crown Office and Procurator Fiscal Service when deciding whether to hold a Fatal Accident Inquiry. We found that the care and treatment provided to Mr A during the short time he was in the hospital was reasonable and appropriate. Communication between the doctors who saw Mr A had also been satisfactory, and it was reasonable for a doctor to previously diagnose Mr A with schizophrenia.

That said, we found that no one from the hospital had phoned Mrs C back after she contacted them the morning after Mr A was admitted, asking to speak to the doctor who had previously treated him. Our investigation found that they were not required to call her back immediately, but should have done so at some stage, as it is good practice to involve family and carers when assessing and managing patients. We, therefore, found that communication with Mr A's family during his short admission was not reasonable. However, in view of the fact that a doctor had written to Mrs C to apologise for this, we did not make any recommendations.

Summary

Mrs C complained about the standard of care and treatment her elderly mother (Mrs A) received in hospital. Mrs C felt that Mrs A was handled roughly by nursing staff and had been left on an incontinence mat with her pyjama bottoms removed and the curtain drawn around her bed in the event that she needed to go to the toilet during the night. Mrs C also raised concerns that: the number of ward moves Mrs A had during her stay in hospital caused her to be unsettled; the television facilities were inadequate; there was a delay in restarting Mrs A's statin medication (a drug used to reduce cholesterol and the likelihood of further cardiac disease); and that the standard of discharge planning was poor.

Although we did not find sufficient evidence to support that Mrs A had been handled inappropriately, we were dissatisfied with the board's explanation of why her pyjama bottoms were removed. They had said that, as Mrs A had been admitted with back pain, removal of her pyjama bottoms would prevent further painful movement during the night in the event that Mrs A needed the toilet and would also prevent them from becoming soiled. We did not consider the board's reasons were justified because the staff did not appear to have given thought to providing Mrs A with a hospital gown or arranging for her to wear a nightdress in order to maintain her dignity.

In relation to Mrs A's discharge from hospital, we upheld the complaint as we considered that care fell below a reasonable standard because Mrs A had not been reviewed by a doctor 17 days prior to her discharge and no consideration was given to either transferring her to a specialist geriatric unit in the hospital or referring her to a local geriatrician for inpatient review. We also found that Mrs A's statin medication was appropriately stopped when she was noted to have impaired kidney function, as statins can affect this. However, when Mrs A's kidney function returned to an acceptable level, no consideration appeared to have been given to re-starting it until Mrs C raised the matter at the time of discharge, so we upheld this complaint.

We did not uphold Mrs C's other complaints. Although the various moves Mrs A had between wards within the hospital were not ideal, we were of the view that these were necessary for specific reasons and to improve her clinical care. In addition, we did not consider the television facilities to be unreasonable and noted that the board had already taken steps to remind staff to ensure that patients were aware of the available facilities.

Recommendations

We recommended that the board:

• share with relevant nursing staff our comments with regard to maintaining a patient's dignity in relation to continence issues;
• ensure that Mrs A's consultant reflects on our comments regarding her discharge;
• review the hospital's discharge planning process with a view to ensuring that, where relevant, patients under the care of an orthopaedic consultant should be reviewed by geriatric services;
• remind relevant nursing staff that when patients are being transferred between wards, they should ensure the patient and their family are fully informed where appropriate;
• undertake an audit of the medicines reconciliation process for patients discharged from orthopaedic wards; and
• apologise to Mrs C for all the failures identified.

Summary

Ms C contacted us on behalf of her client (Mr A) who was unhappy with treatment he received during a hospital consultation. She said that Mr A was not provided with the correct treatment and procedures were not properly explained to him beforehand.

After taking independent advice from one of our medical advisers, we did not uphold the complaint about treatment as we found that it was reasonable given the symptoms he reported. We did, however, uphold the complaint about the explanations provided. The board told us that patients are fully informed verbally before the consultation, that they are sent a leaflet in advance by post and that Mr A had given verbal consent to the procedure. Mr A disagrees, and there was insufficient evidence for us to reach a decision on whether reasonable verbal information was in fact provided beforehand. We found that the board had no written record or evidence that the procedure was explained to Mr A, or whether he had been sent a leaflet or given verbal consent. Because of the lack of clear evidence that the board had adequately explained this to him, we upheld the complaint.

Recommendations

We recommended that the board:

• carry out a review of the patient's pathway when attending the relevant clinic, with a view to improving documentation and record-keeping to incorporate a record of all advice given, acknowledgement that the patient understands the advice and that consent had been given; and
• consider revising the appointment letter to either incorporate the information leaflet or clarify that a leaflet is enclosed.

Summary

Ms C complained on behalf of her brother (Mr A). In April 2012, Mr A was admitted to hospital as an emergency suffering from an arteriovenous malformation (AVM - an abnormal collection of blood vessels in the brain where bleeds can occur, and which can be life-threatening). There are three approaches to treat an AVM, two of which the hospital considered, but thought unsuitable. Mr A was then discharged and told that he would be referred to a hospital in England for the third type of treatment. Ms C complained that there was an avoidable delay in providing this.

As part of our investigation, we took independent advice from one of our medical advisers, who is a consultant neurosurgeon. Evidence obtained during the investigation showed that on admission, Mr A's treatment was appropriate and reasonable as were the attempts to address the AVM. We found that the three types of treatment were options (not requirements) and that Mr A's case had been appropriately referred to the English hospital for consideration, although after a long delay. Ultimately, that treatment was also found to be unsuitable, as in the clinicians' view, it could cause more harm than good. (This had not been Ms C's understanding, as she had thought the treatment was essential.)

After careful consideration, although no treatment was ultimately available to Mr A, we upheld the complaint because of the avoidable delays in referring his case on for consideration.

Recommendations

We recommended that the board:

• formally apologise to Ms C and her brother for the delay and confusion over his referral;
• review referrals within the department of neurosurgery and satisfy themselves that these are made in a timely manner and that communication is clear; and
• review the situation in the department of neurosurgery with regard to discharge letters and satisfy themselves that they are typed and issued within appropriate time limits.

Summary

Miss C complained about the care and treatment provided by her former dentist, together with the way in which her complaint was handled. During the course of our enquiries, the dentist acknowledged that there were failings in Miss C's follow-up treatment and the handling of her complaint. In order to address these issues, the dentist agreed to apologise to Miss C and reimburse her for the cost of her treatment. Miss C was satisfied with the proposed action and so we considered her complaints resolved.

Summary

After she was diagnosed with osteoarthritis (the most common form of arthritis), Mrs C had hip replacement surgery. She went back to see the surgeon because she had pain in her hip. He thought that her symptoms suggested trochanteric bursitis (a condition that causes pain over the outside of the upper thigh, usually due to inflammation or injury to some of the tissues that lie over the top of the thighbone). He injected the tender area with a local anaesthetic and steroid on a number of occasions and arranged for her to attend physiotherapy.

When the problems persisted, Mrs C was referred to another surgeon. He said that the pre-operative x-ray showed minimal osteoarthritic change, and thought that the diagnosis of trochanteric bursitis was improbable. He said that the pain might be related to infection or mechanical loosening and organised a bone scan and then an MRI scan, although these did not show any abnormality. The surgeon decided that there were some problems with the hip replacement and that there was enough evidence to support replacing it with a different type. He then carried out this operation.

Mrs C complained to us that the board had failed to carry out appropriate hip replacement surgery in the first operation. After taking independent advice from one of our medical advisers, however, our investigation found that it was reasonable and appropriate to carry out a total hip replacement and that the surgery was carried out to a reasonable standard. Although the first operation failed to achieve the aim of the surgery, which was pain relief, the operation note was clear and did not indicate any problems. A small number of patients have significant pain following hip replacement and we were unable to say what had caused Mrs C's pain. There were no identifiable technical errors and we found that the initial surgery was carried out to an acceptable standard.

Summary

Mr C had been diagnosed with a retroperitoneal liposarcoma (a malignant soft-tissue tumour) which was removed. Two years later, a CT scan (a special scan using a computer to produce an image of the body) showed that the tumour had grown back, and it was decided that scans should be carried out to monitor its growth. The scans showed that the affected area had grown and so it was decided to surgically remove the tumour. When the operation was carried out, it was not possible to remove the tumour completely. The right ureter (the tube that carries urine from the kidney to the bladder) was also involved in the tumour and it was divided and closed off.

Mr C complained that the surgeon failed to obtain an up to date CT scan of the affected area before he carried out the operation. After taking independent advice from one of our medical advisers, we found that such a scan was not needed as it would not have changed the need for or prevented the surgery on Mr C's ureter. We also found that all the required investigations were performed and documented before Mr C had the operation.

We did, however, uphold his other complaints. Mr C complained that the surgeon had failed to obtain informed consent from him for the operation. He said that he thought that only the tumour would be removed and had never been told that surgery on other tissue or organs might be required. The board's consent policy clearly says that it is essential for health professionals to clearly document both a patient's agreement to treatment and the discussions that led to that agreement. The policy says that this will be done either using a consent form that the patient signs, or by documenting in the patient's case record that they have given verbal consent. We found that the clinical decisions and surgical treatment were correct and in line with the accepted standard of practice for this operation. However, there was no documented evidence that Mr C was given sufficient information before the surgery about possible loss of kidney function. Consequently, we found that that there was no evidence that the board had communicated with Mr C effectively during the consent process.

Several weeks after Mr C was discharged from hospital, he was admitted to another hospital with hydronephrosis in his right kidney (a condition where one or both kidneys become stretched and swollen because of a build-up of urine). Mr C said that he and the staff in the other hospital were initially unaware that his right ureter had been intentionally closed off. Because of this he was initially diagnosed with a possible kidney stone, before it was identified that the problem was related to the surgery on his ureter.

We found that it was not possible to say whether Mr C was given sufficient information after the operation, as there was no written documentation of the discussions on ward rounds. The board said that he was told what had been done. However, it was clear that after the operation Mr C was not fully aware of the extent of the surgery he had. We could not say whether this was because he was told, but did not retain the information, or because this information was not given to him. However, important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes and there was no evidence in Mr C's notes that staff had effectively communicated details of the operation to him.

Recommendations

We recommended that the board:

• consider if their consent form should be reviewed in order that there is a section to record possible risks and complications; and
• remind the relevant staff involved in Mr C's care and treatment that important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes.