Health

Summary

Mr C complained about the care and treatment the board provided after he went to their accident and emergency department (A&E). He said that they failed to appropriately examine and assess his symptoms of severe abdominal pain with urinary and bowel problems. He also said that they inappropriately discharged him at 05:30 in the morning without considering whether he had the means or ability to return safely home. Mr C said that after seeking further medical assistance elsewhere, he was admitted to hospital the next day with an obstructed bowel and was kept in for assessment and treatment.

We took independent advice on this case from one of our medical advisers. The adviser said that the assessment and examination in A&E were of a reasonable standard and that the treatment Mr C received elsewhere the next day did not indicate otherwise, so we did not uphold his complaint about care and treatment. However, the adviser was critical of the board for failing to have adequate discussions with Mr C about treatment for constipation and failing to give him laxatives to take home with him. The adviser also said that they failed to discuss practical arrangements for Mr C's discharge to ensure that he could return home safely. We upheld the complaint about discharge and made recommendations accordingly.

Recommendations

We recommended that the board:

• provide Mr C with a written apology for the failings identified;
• feed back our adviser's comments on the treatment of Mr C's constipation to the staff who examined him in A&E; and
• remind relevant nursing staff of the need to discuss and make appropriate discharge arrangements for patients in A&E and record this information in the clinical notes.
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Summary

Mr C sustained head injuries in a road traffic accident. He went to hospital where his wound was dressed and he was advised to take painkillers. He attended his medical practice the following day for a change of dressing. Several days later he saw another GP who arranged for a nurse to rebandage his wound. He said that it was found to be dirty with glass fragments left in it. Mr C complained about the way his GPs managed his wound. He was also concerned about how one of the GPs managed his subsequent headaches and said he should have been referred for further investigation earlier. Finally, Mr C said that the follow-up by nursing staff, rather than his GP, was not reasonable.

We took independent advice from one of our medical advisers. They said that wound management is a nursing responsibility and that the management and follow-up was appropriate for this type of injury. In relation to the glass fragments, the adviser said these were unlikely to have caused complications and would have worked their way to the surface. It was, therefore, reasonable to allow this to happen and to treat Mr C with antibiotics rather than try to remove fragments, which might have damaged the healing process. In relation to how the practice managed Mr C's headaches, the advice was that further investigations and treatment were provided within a reasonable time, although the GP did not record information about one of the consultations. Having said that, we found that the care and treatment provided overall was of a reasonable standard.

Summary

Mrs C complained that her medical practice failed to diagnose the symptoms of kidney damage after surgery. She said that this meant she had to undergo further surgery and led to a permanent loss of kidney function. Mrs C also complained that after the surgery the practice had failed to take adequate follow-up action.

After taking independent advice from one of our medical advisers, our investigation found that the practice had acted appropriately on the symptoms Mrs C presented with after her first operation. They had monitored her situation and referred her to a specialist when it was clear that she was not recovering. We also found that the practice acted appropriately and in a timely way in trying to support Mrs C, even though they were not advised of Mrs C's discharge, nor about the specialist type of dressing that she had been fitted with. In the circumstances, we found that the practice had provided her with a reasonable level of care.

Summary

Mrs A was diagnosed a number of years ago with early onset dementia. She was admitted to a specialist psychiatric and mental health unit for assessment because of problems with her sleep pattern. During her stay she fell on the ward, breaking her left thigh, and needed a hip replacement in another hospital. Mrs A returned to the unit nine days later and a further 11 days after this fell again, after another patient pushed her. This time she broke her right hip, which also had to be replaced in the other hospital. Mrs A was discharged from there to a nursing home where she is now living. Her daughter (Miss C) complained that Mrs A was provided with inadequate care and supervision while she was being assessed. Miss C also complained that the board's responses to her complaints was inadequate.

We took independent advice from two of our medical advisers. They noted that at times, Mrs A had been on 'constant observations' (where staff were on hand with her at all times) but at other times she was not. The advisers said that Mrs A's mental health condition, falls risk, medication and physical condition were regularly and appropriately monitored and, where necessary, changes were made. Our investigation found that, although it was obviously very unfortunate that Mrs A sustained two fractures within 20 days, her care and supervision were reasonable and appropriate.

On the matter of the complaint responses, our investigation found that all acknowledgements and responses to Miss C's complaint letters were sent within the local and national target timescales. Full explanations were provided and the board acknowledged that this had been a distressing experience for Mrs A and all her family. The board also apologised that in the first response Miss C had not been made aware of the SPSO process. They had not apologised for what happened to Mrs A and Miss C had been concerned about this. We took the view that as we had found that what had happened was not the fault of the board, it was not unreasonable that they did not apologise for this.

Summary

Mrs C complained that a hospital made mistakes in the reporting of an x-ray that her late mother (Mrs A) had taken on 10 April 2012 after falling in her care home and injuring her left knee. Mrs A was discharged from hospital that day but was admitted to a second hospital three days later because she was in severe pain and unable to put weight on her left leg. She was eventually found to have fractured her knee. When the second hospital asked the first hospital to carry out another x-ray seven days after the first, the first hospital found that there had been an error in the reporting of the original x-ray.

Mrs C felt that the board had delayed in taking action to investigate whether there was a problem with the x-ray or arrange a follow-up, when Mrs A's symptoms did not resolve. Mrs C was also concerned that there was a failure to establish the reasons why the x-ray was wrongly interpreted. The board had explained that the likely cause of the error was a problem with their software system for viewing x-rays, which meant that a much older image of Mrs A's knee was superimposed on the new image. They advised that the error was a rare and unusual incident but that they had made relevant staff aware of the matter to ensure it did not happen again. However, our investigation identified that there was also an error with the reporting of the x-ray that was requested seven days after Mrs A fell, as it too was initially noted as showing no fracture. The board said of this that the x-ray image on 10 April 2012 had been displayed when trying to view the image taken seven days later.

We could not say for certain whether the errors in reporting the x-rays were as a result of a failure in the software system, or the wrong x-ray being opened, or if the correct x-ray images were viewed and the fracture was simply not identified. We concluded, however, that the board had not provided sufficient evidence that they had carried out a thorough investigation into both x-ray incidents. However, we noted that the first hospital had promptly arranged for Mrs A to return the following day for a second x-ray after the fracture was identified. We upheld Mrs C's complaints about interpretation of the x-rays, but not about their follow-up action.

Recommendations

We recommended that the board:

• undertake a significant event analysis into the reporting of the x-rays taken after Mrs A's fall, to establish clearly where the fault lay in order to reduce the likelihood of this happening again; and
• apologise to Mrs C for the failings identified.

Summary

Mr C complained about the care and treatment that his wife (Mrs C) received from the perinatal (period before and after birth) psychiatric service. In particular he complained that his wife was not adequately or correctly assessed; her medication might have contributed to her illness, she was allowed unsupervised leave with their daughter when she was an assessed risk to her daughter, she was subject to undue pressure to breastfeed and that a flawed decision was made to refer his daughter to social services as a child protection case.

Our investigation, which included taking independent advice from a clinical adviser, found that the care and treatment provided to Mrs C had been reasonable overall. There was no evidence to suggest that she had not been adequately or correctly assessed or that her medication was inappropriate. The adviser was satisfied that Mrs C was appropriately supervised and there was no evidence of undue pressure to breastfeed. However, the adviser raised some concerns over a lack of consultation with and involvement of, Mr C in his wife's care and we made recommendations to address these points.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failure to complete assessment documentation as required and to involve a carer in a manner consistent with the relevant care pathway documentation; and
• audit the use of completion of the care pathway documentation relevant to this case and consider what changes are needed to ensure documentation is properly completed and utilised.

Summary

Mr C complained that there was an excessive delay in carrying out surgery on his knee. He said that this delay had breached the target waiting times. The board's position was that he had received his treatment within the target waiting times.

We noted that although there was a gap between Mr C's first consultant appointment and the second appointment (at which the decision to proceed with surgery was made) this was due to tests being carried out to ascertain if surgery was the appropriate option. There was also an issue about the complexity of the operation, which involved the removal and replacement of an existing knee replacement. Due to bone loss around the original prosthesis, a specific orthopaedic surgeon was required. The waiting time target could, therefore, only be applied once it was certain that Mr C would progress to surgery. Once this decision had been made, the operation was carried out in three weeks. We did not uphold the complaint.

Summary

Mr C's young daughter (Miss C) suffers from a number of medical conditions and has serious mobility problems. She uses either a wheelchair or a gait trainer, both of which need a lot of space for turning. After a number of years during which the family waited for a suitable house, a housing association, in conjunction with the local council, agreed to provide a new house. In relation to this, an occupational therapist from the health board assessed Miss C's housing needs and liaised with the housing association. Mr C complained that the occupational therapist did not properly assess Miss C and ensure that the house being built met her needs. He alleged that when he complained to the board about the situation, they did not properly investigate it.

Our investigation found that the procurement process for the house being built to meet Miss C's needs was not straightforward. There were a number of agencies and organisations involved and the role of the occupational therapist was to assess Miss C's needs in order to properly facilitate them in the development of the properly. The occupational therapist provided her professional opinion of what these needs were. However, during the complicated construction and development, the housing association contacted the occupational therapist about a number of design changes, which she agreed without speaking to Mr C. If followed through, one of these changes would have had serious repercussions for Miss C's mobility. We also found that Mr C had first complained to the council, who passed him on to the health board, but then the board took too long to reply to him. We, therefore, upheld his complaints about these matters, but not about the assessment of his daughter's needs, in which nothing had gone wrong.

Recommendations

We recommended that the board:

• apologise to Mr C for the errors identified, and for the delay in responding to his complaint.

Summary

Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when he attended the practice while experiencing heart symptoms, he was seen by a nurse and then sent home after discussing his condition with a doctor, having been told he might have shingles. He said that when he returned home, he was so ill that he required an emergency ambulance to take him to hospital.

To investigate the complaint, we obtained independent advice from one of our medical advisers, and took this into account with all the available information, including the complaint correspondence and relevant clinical records. We upheld the complaint, as our adviser identified a number of problems in handling Mr C's blood samples. They also said that when Mr C went to the practice he appeared to be suffering from a number of symptoms indicating the likelihood of a heart attack, which should have been addressed differently. In accordance with relevant guidance he should have received a detailed assessment by a doctor and been treated with glyceryl trinitrate spray to relieve pain.

Recommendations

We recommended that the practice:

• review their transport procedures after blood samples are taken from patients;
• carry out a review of their system and submit the results to their Community Health and Care Partnership lead for an external review;
• review their management and procedures of 'walk in patients' and clarify and review their Practice Nurse/Advanced Practice Nurse competencies/ autonomy;
• discuss Mr C's case as part of the GP appraisal process;
• carry out a significant event analysis; and
• note the 'identification and management of acute myocardial infarction' within their appraisal learning needs and review SIGN Guidance 93 (guidance for dealing with such matters).

Summary

Mr C, an advocate, complained on behalf of Mrs A that there was avoidable delay in her medical practice diagnosing that she had unknowingly contracted a sexually transmitted disease (STD). She had been attending her medical practice for more than two years with the symptoms but it was not until she was referred to an STD clinic that this was diagnosed. When Mr C complained to us, Mrs A was still undergoing treatment for the condition.

After taking independent advice from one of our medical advisers, we upheld this complaint. Our investigation found that an opportunity to diagnose the STD in August 2009 was missed. The adviser was critical of a lack of detail in the clinical notes, which made it difficult to assess whether or not the condition could have been diagnosed even earlier than that. They said that delay in diagnosing STDs can have serious consequences, as the presence of one can indicate the presence of others, some of which can have serious health effects. Undiagnosed STDs can also be passed on to new or different partners. The adviser also said that the delayed diagnosis probably contributed to the length of Mrs A's treatment.

Recommendations

We recommended that the practice:

• apologise for the failings identified during our investigation;
• conduct a significant event audit of this matter and share the outcome with Mrs A and Mr C; and
• conduct an audit of a selection of medical notes across the practice to ensure that the standards set by the General Medical Council are being met, and if any failings are identified ensure that appropriate training and discussion at annual appraisal(s) takes place.