Health

Summary

Ms C complained about the standard of nursing care that her late mother (Mrs A) received after she was admitted as an emergency to hospital with shortness of breath, unexplained weight loss and dehydration. Mrs A was diagnosed with cancer of the oesophagus (gullet) and died four days later after a cardiac arrest. Ms C complained about 16 incidents in the hospital and about aspects of her mother's care.

We took independent advice on this case from one of our medical advisers. She noted 13 areas where the board had acknowledged failings on their part, apologised and said that they had taken or would take appropriate remedial action. In the remaining three areas, the adviser said that when a patient was admitted with dehydration, a five hour wait for intravenous fluids was unacceptable and she would have expected these to have been started in the emergency department. She also noted Ms C's concern about her mother's white blood cell count being low and that information from hospital staff suggested there was a delay in a blood transfusion. The adviser said the records showed that the transfusion started on the day of Mrs A's admission to hospital and was not delayed. On the final point, the adviser was critical that when Ms C was called to the hospital during the night because of her mother's deteriorating condition, no-one was asked to meet her at the hospital entrance and take her to her mother's ward.

The adviser said there was evidence of significant failings that led to a traumatic experience for Mrs A in her last hours of life and to her immediate family. We noted that the board had investigated and addressed Ms C's complaint and that statements from staff members appeared to contain important reflections about their care and treatment of her mother and suggested that they were truly sorry for their failings. As the board had already taken action in a number of areas, we made recommendations to reflect this.

Recommendations

We recommended that the board:

• provide Ms C with a written apology for failing to start her mother's intravenous fluids in the emergency department;
• feed back our adviser's views on this failing to relevant staff;
• consider what local arrangements are in place to ensure that distressed relatives arriving at night are welcomed/orientated to the ward areas;
• provide us with full documentary evidence of each of the remedial actions identified in our investigation (with the exception of the apologies); and
• provide us with an update to improvements in the ward in question in the areas set out in the quality improvement plan, and demonstrate that the issues have been addressed and that learning has taken place.

Summary

Ms C, who is an advice worker, complained on behalf of Ms A about the care and treatment that her late father (Mr A) received during the last three days of his life, and about how her complaint about this was handled.

Mr A's GP referred him to a medical admissions ward. Mr A went straight to the ward, and was asked to wait in the day room. He remained there for four hours before he was seen by a doctor, given a bed, and treatment was started. Information on his referral showed he was very unwell, indicating that he had pneumonia and kidney failure. Mr A was treated with antibiotics, and was transferred to a different ward the next day.

For the next two days Mr A’s condition remained stable and his vital signs (pulse, blood pressure, temperature and oxygen levels) were taken roughly every four hours. In the evening of the second day Mr A became increasingly unwell. This was noted by staff, who increased the frequency of checks on his condition to hourly. A doctor reviewed Mr A and identified that he needed more oxygen. He arranged for a special blood test to check oxygen levels in Mr A’s blood, and asked for a repeat of this test two hours later. There are references to the results of both these tests in the clinical notes, but only the first test was noted in detail, and the second set of results were not identified by the board in their response to Ms C’s first complaint. As a result, Ms C was mis-informed about these tests. This was because the test results were held on record electronically, and were not added to the clinical file. Despite further assistance with his breathing, Mr A died the following day.

We obtained independent advice on this complaint from one of our medical advisers. We upheld the complaint about the delay in getting a bed, as his advice indicated that Mr A should not have been kept waiting in the day room of the admissions ward for such a long time, and that this created risks for patient care. We did not uphold Ms C's complaints about vital sign checks and blood tests. Our adviser reviewed all the checks made on Mr A’s vital signs and found them to be appropriate. He also reviewed blood test results from shortly before Mr A’s death, and found that they were appropriate, but criticised the way in which the board held these records and reported them to Ms C. On complaints handling, Ms C had said that she did not get a final response until more than eight months after she first complained. While we found that further issues were raised at a meeting three months after the original complaint, we found there was still a substantial delay in providing a final response, and we upheld this complaint.

Recommendations

We recommended that the board:

• raise this case at the next meeting of its clinical directorate, specifically considering the risks involved in using day rooms as waiting rooms, and considers the introduction of mechanisms to avoid these risks;
• give careful consideration to the implementation of the early identification and treatment of sepsis (blood infection), using the 'Sepsis Six' initiative;
• remind doctors of the need to record all investigation results in the case notes immediately they are available, especially for tests such as arterial blood gases, where a formal laboratory result may not be printed;
• ensure that all electronic records are reviewed during complaints handling and are passed to the SPSO on request; and
• apologise to Mr A’s family for the failures identified in our investigation.

Summary

Miss C complained that she was misdiagnosed in 2010 with ulcerative colitis (where ulcers form in the large intestine and rectum (the terminal part of the large intestine). She said that when she was offered a surgical procedure in 2012 this was inappropriate as her actual diagnosis was of Crohn's Disease (where the small intestine becomes inflamed, thickened and ulcerated).

Ulcerative colitis is one of a range of conditions known as Inflammatory Bowel Disease (IBD). Miss C had undergone an emergency ileostomy (where the damaged portion of the small intestine is removed and the remainder directed to an opening created in the stomach wall. The contents of the intestine are then emptied into a collection bag which remains in place for life unless the ileostomy is reversed.) In 2012 she was offered a reversal of the ileostomy as her condition had been stable for some time. After the reversal procedure Miss C experienced an increase in her symptoms and was admitted to hospital four times in the next few months. Her diagnosis was eventually changed to Crohn's Disease and she was advised to have her ileostomy reinstated. Miss C complained that as a result of her misdiagnosis she underwent two major but unnecessary surgical procedures as she had been told that Crohn's sufferers are 'never' offered reversal surgery.

After taking independent advice from one of our medical advisers, we did not uphold Miss C's complaints. We found that the original diagnosis of ulcerative colitis given to Miss C was not unreasonable. The adviser said that the conditions have similar symptoms but that Crohn's Disease classically involves the small intestine. In 2010 an internal examination had shown that Miss C had ulcers only in her large intestine.

The adviser also said that the offer of reversal surgery was reasonable, on the basis of the diagnosis of ulcerative colitis and in view of her condition being well managed at the time. The adviser also said that even had the original diagnosis been Crohn's Disease, it would still have been a reasonable decision, given Miss C's condition at the time. Some patients can experience an increase in their symptoms and a relapse of their condition following reversal and this is a risk that should be discussed with the patient before surgery is agreed. There was evidence in Miss C's clinical records that this was discussed with her at an out-patient appointment. Therefore, it was reasonable to offer the reversal and the resulting relapse could not be attributed directly to it. The adviser said that all IBD conditions are characterised by unpredictable symptoms and relapses, and made reference to the IBD Standards Working Group who issued national guidance in 2009.

Summary

Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical conditions and had been receiving treatment for infections. Although her condition initially improved, Miss A became lethargic and developed symptoms of liver disease. Her condition deteriorated further and she was transferred to a second hospital in a different board area for specialist treatment. Their records indicate that Miss A had pneumonia and had become increasingly confused. She died two weeks after being admitted to hospital. Miss C complained to us that staff at the first hospital did not appropriately assess and treat the cause of her sister's symptoms.

After taking independent advice from one of our medical advisers, we found that Miss A was clearly in very poor health when she was first admitted to hospital. The clinical records showed that her condition was closely monitored and that appropriate investigations were carried out. Although Miss A at first showed signs of improvement she had developed a chest infection, which resulted in her condition deteriorating. We were satisfied that the board took appropriate steps to monitor her symptoms, considered reasonable causes of those symptoms and carried out appropriate diagnostic investigations. We were also satisfied that appropriate treatments were provided and that staff involved specialists from the second hospital at an appropriate stage. We concluded that Miss A's deterioration occurred despite the investigations and treatment provided by the first hospital, rather than as the result of any failure on the part of the board.

Summary

Mr C has a long-standing lung condition. He complained that when he contacted NHS 24 as he was feeling unwell, an out-of-hours GP phoned him back and said that Mr C did not require a home visit and that he was to contact his own GP when the medical practice opened in an hour and a half's time. When Mr C attended the practice, he was prescribed medication and told to return in a week if the symptoms did not resolve. Mr C felt that the out-of-hours GP was wrong to refuse a home visit and complained about this.

As part of our investigation we obtained independent advice from a medical adviser, who is an experienced GP. She said that the out-of-hours GP took an appropriate clinical history and that their decision that Mr C should wait until the practice had opened was reasonable. Although Mr C did need to be seen by a doctor, there was no evidence that his condition was unstable or that an urgent house visit was needed before the practice opened.

Summary

Mr C was unhappy with the steps taken by the practice to assess his medical condition. He asked for an independent medical opinion but the practice refused. Mr C said that the refusal was unreasonable.

Our investigation of Mr C's complaint found that the practice diagnosed his condition and referred him to two consultants for further investigation. Mr C had refused to attend a MRI scan (a scan used to diagnose health conditions that affect organs, tissue and bone) and he also refused an offer to meet with the practice to discuss his concerns. We were of the view that the steps taken by the practice were reasonable and we did not uphold Mr C's complaint.

Summary

Ms C complained on behalf of her daughter (Ms A), an overseas student who was studying in Scotland. Ms A had developed abdominal pain, nausea and constipation. She was seen at home by a GP who examined her, carried out a urine analysis and advised her to take an over-the-counter painkiller. Five days later, Ms A’s condition had not improved so she went to the medical practice where she was seen by a different GP. Ms C was examined again and the notes record that a uterine mass (a lump in the area of the womb) was detected. The second GP diagnosed constipation, advised Ms A to take the same painkiller and a laxative (a drug to relieve constipation) and asked her to return to the practice in a week. The notes recorded that the uterine mass was to be investigated then.

Ms C was concerned about her daughter's condition, so she came to Scotland the following day and escorted Ms A home where she was seen by her local GP. An ovarian cyst (a lump or sac on the ovary) was diagnosed and Ms A had surgery to remove it. Ms C complained to us that the practice did not provide reasonable diagnosis and treatment for her daughter.

After taking independent advice from one of our medical advisers our investigation found that there were clear clinical signs that should have prompted further specialist investigation. The Scottish Intercollegiate Guidance Network (SIGN) issue guidance on the investigation, management and treatment of various medical conditions. SIGN 75 (which deals with ovarian cancer) says that any woman found to have an abdominal mass should be referred to a specialist for further investigation. The adviser said that the recommended diagnostic tool in such cases is ultrasound investigation (specialist imaging using sound waves) and that the GPs who saw Ms A should have referred her urgently for this. The adviser said that it was not appropriate to have advised Ms A to take a laxative and re-attend in a week's time.

Our investigation also revealed an issue which was not known to Ms C and so was not raised in her complaint. In reviewing Ms A's medical records we found reference to the complaints letters and responses. This is contrary to the guidance issued by NHS Scotland which states that information on complaints should be kept separate from a patient's clinical records unless there is a valid clinical reason for mentioning this. There was no clinical reason to record complaints information in Ms A's records.

Recommendations

We recommended that the practice:

• issue a written apology to Ms C and Ms A for the failings identified during this investigation;
• conduct a significant event analysis (SEA) on this case and reflect on the lessons to be learned;
• ensure that the second GP is prepared to discuss the lessons from the SEA at their next GP annual appraisal, including any learning needs regarding SIGN 75; and
• familiarise themselves with the NHS guidance on complaints handling, in particular in relation to the recording of complaints in patients' records.

Summary

Mr A was diagnosed with a syrinx (cyst) in his spine. This is a rare and complex condition known as syringomyelia. Mr A was concerned that a delay of over a year between diagnosis and surgery had lessened his chances of the operation being a success. Ms C, who is an advice worker, complained on his behalf about this and also about his concerns that this caused his condition to worsen, with increased weakness in his legs, bladder weakness, shaking and nerve pain.

After taking independent advice from one of our specialist medical advisers, our investigation found that there are no national guidelines on the management of syringomyelia. Although we considered that, with hindsight, it would have been better had Mr A's initial referral been passed to a neurosurgeon rather than a neurologist, we did not find that the board delayed unreasonably in carrying out surgery. There was evidence to show that after they received a referral for a neurosurgical opinion, they arranged an appointment for Mr A two months later. When it was drawn to the attention of the board that Mr A had not received the appointment letter, arrangements were made within two months to have him assessed and surgery carried out. Our adviser was of the view that even if surgery had been carried out around the time of the initial referral, it was unlikely that it would have affected Mr A's outcome, due to the natural progression of the condition.

Summary

Mr C complained about the standard of care he had received in relation to a number of blood tests. He also complained about poor communication and the handling of his representations.

After taking independent advice from one of our medical advisers, we upheld the complaint about the blood tests. Although we found that the care and treatment Mr C received was reasonable, there was a lack of communication about the results of his blood tests. One of the tests that his GP had requested had not been taken, but Mr C was not told this and had continued to request the result. We also found that as Mr C had a low ASSIGN score (cardiovascular risk score - used to predict the likelihood of developing cardiovascular disease) some of the blood tests were unnecessary under the Scottish Intercollegiate Guidelines Network (SIGN). We did not uphold the complaint about the board's response to Mr C's representations as we found that it was reasonable.

Recommendations

We recommended that the board:

• clarify the system for improved and more timely communication of results by clinicians to patients; and
• ensure that medical officers familiarise themselves with SIGN 97 'Risk estimation and the prevention of cardiovascular disease' to ensure appropriate testing and treatment of patients based on their ASSIGN score.

Summary

When Mr C suffered severe chest pains he called an ambulance. The paramedics told him that he was not having a heart attack, but he was taken to hospital for tests. Mr C complained that, despite the paramedics having ruled out a heart attack, he was treated for one upon admission to the hospital. He raised further concerns about a lack of investigation into his chest pain once it was established that he was not having a heart attack, and a lack of follow-up appointments.

We took independent advice on this complaint from one of our medical advisers. The adviser said that paramedics would have carried out an electrocardiogram (ECG - a test to measure the heart's electrical activity and to check for a shortage of blood to the heart muscle). The ECG determines whether the patient is having an ST-elevation myocardial infarction (STEMI heart attack), which suggests a complete blockage of one of the coronary arteries. If such a heart attack is evident, paramedics will take the patient to a dedicated cardiac unit, which may not be the closest hospital. In cases of non-STEMI heart attacks (where the artery is only narrowed or partially blocked), the patient will be taken to the nearest hospital and treated with medication while further tests are undertaken. We found that in Mr C's case, the paramedics ruled out a STEMI heart attack and took him to the nearest hospital. He was still considered to potentially have a non-STEMI heart attack and was treated appropriately for this. Ultimately, tests indicated that he had a chest infection and he was treated accordingly. We were satisfied that the board acted appropriately and in accordance with national guidance for coronary artery disease.

We were also generally satisfied that appropriate follow-up appointments were made after Mr C's discharge from hospital. Although one referral to a rheumatologist was not acted upon, we did not find that this had any significant impact on the overall care provided to Mr C.