Health

Summary

Mrs C complained about her treatment after a fall, in which she fractured her ankle. She said that she was not recalled to hospital for a follow-up appointment and that because of this staples in her wound were left in for more than two weeks longer than they should have been.

Our investigation upheld Mrs C's complaints. The board had accepted that when Mrs C was discharged from hospital no follow-up appointment was booked for her, so the staples were left in her wound for too long. Mrs C had also contracted a bacterial infection, but after taking advice from one of our medical advisers, we did not establish any clear evidential link between this and the fact that the staples were not removed earlier. As the board had already explained to Mrs C what had happened, and had apologised to her for their mistakes we did not find it necessary to make any recommendations.

Summary

Ms C visited her medical practice, complaining of pain in her lower abdomen, and was referred for an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body). When she contacted the practice for the results she was told that her GP had noted that no further action was required. A few months later, the health board contacted Ms C asking her to come back for a further scan. She initially cancelled this appointment because she had been told no further action was required. However, the hospital told her that another consultant had reviewed the first scan and thought it appropriate that she should attend for a follow up. The follow-up scan showed that cysts, which had been identified on the previous scan, had enlarged.

Ms C was unaware that cysts had appeared on the original scan and complained to the practice that she was not told about this. She remained dissatisfied with the practice response. We found that the original ultrasound scan was reviewed by two consultants and their opinion had been divided as to whether there was a need for a follow-up scan. We also found that the practice had not told Ms C about the cysts as they were an incidental finding, and not thought to be responsible for Ms C's abdominal pain.

Recommendations

We recommended that the practice:

• apologise to Ms C for the failure to explain that the cysts had been identified on the ultrasound scan;
• remind staff to ensure that all issues raised in complaints correspondence are addressed; and
• apologise to Ms C for failing to address all issues of the complaint.

Summary

Ms C complained that when her late uncle (Mr A) was a patient in hospital, staff failed to provide him with appropriate care for his pressure sore area and that pressure ulcers developed that affected his deteriorating condition.

As part of our investigation we took independent advice from our nursing adviser. The adviser said that the nursing notes showed that staff arranged for Mr A to be regularly turned, ordered a special air mattress to prevent the development of pressure ulcers, and applied cream. All of these measures were reasonable and considered good practice to prevent the development of pressure ulcers. When Mr A's general condition deteriorated, however, his skin started to break down. We did not uphold the complaint, as we found that staff assessed and monitored the situation appropriately. They took reasonable steps to prevent Mr A's skin from deteriorating and there was no evidence of any failure in the standard of nursing care provided.

Summary

Miss C broke her wrist and was taken to hospital by ambulance, although ambulance staff could not take with her the wheeled walking frame that she normally used at home. In the hospital, Miss C was helped with a wheelchair and later with a wheeled 'patient transporter'. However, she was then told that she could not use this equipment, as her broken wrist would not affect her ability to move around the ward. She was given a walking frame instead. Miss C complained that, due to arthritis and a weak grip, she could not use the walking frame. She found it to be too lightweight and unstable.

We found that the board had made arrangements for Miss C's mobility to be assessed with a view to providing her with assistance. However, Miss C was a very private and independent person, who did not wish to discuss her care or normal living practices with staff. She declined occupational therapy or physiotherapy assessment and staff were unable to fully assess her mobility needs. We were satisfied that the board considered whether Miss C was able to consent to treatment and found that, as she had decided not to undergo assessment, the decisions reached by staff were reasonable and appropriate. We did not find any evidence to suggest that Miss C was refused mobility assistance or that she did not receive a reasonable level of care.

Summary

Mrs C developed skin plaques on her legs. Biopsies (small samples) were taken for analysis, and at first it was thought these might show signs of squamous cell cancer (SCC). However, a hospital dermatologist then decided that this was hypertrophic lichen planus (HLP - which can look like SCC, but is a non-cancerous common skin disease). When, several years later, Mrs C was diagnosed with cancer in a fallopian tube, she complained that the board did not tell her that the initial biopsy reports had been overturned because of a difference of opinion between clinicians. Mrs C said that her family had a history of cancer, and felt that her health was jeopardised because the hospital dermatology department influenced the diagnosis and so she was denied the opportunity to make informed choices about her options at that time. She was also concerned that as a result of having SCC she also suffered from dermatomyositis (a muscle disease involving inflammation and a skin rash), which had not been appropriately diagnosed.

The board acknowledged that this had been a very distressing time for Mrs C and her family, and that diagnosing her skin condition had been challenging. They said, however, that Mrs C had never been diagnosed with cancer on her legs, but with various forms of eczema. Although dermatology clinicians recognised that the complexities and changes in the status of this condition could be perceived as a conflict in diagnosis, doctors who had treated her were very clear that she did not have SCC, and the samples had confirmed this. They said that the cancer diagnosis was not related to Mrs C's skin problems, but to a gene she carried that meant she was more likely to develop certain cancers. After Mrs C complained, and it was clear she was unhappy with the board's response, staff offered to meet her to discuss their response to her concerns, but she declined.

In investigating Mrs C's complaint, we took independent advice from one of our medical advisers, but we did not uphold her complaints. The adviser noted that Mrs C disagreed with the initial diagnosis she received from the dermatology department, but found no evidence of any failure that prevented Mrs C from making informed choices. Neither did he find any evidence that she suffered from dermatomyositis. He said that interpretation of the biopsies that were taken and differentiating between HLP and SCC is extremely difficult, but that the management of her difficult rash and skin lesions was appropriate and timely. It was not possible to verify exactly what staff said to Mrs C about the biopsies, but we found no evidence of a failure to tell her that the results had been overturned due to conflicts of clinical opinion.

Summary

Mr C complained on behalf of his wife (Mrs A) about the care and treatment she received when she attended hospital with an injury to her vertebrae (part of her spine) after falling down stairs. Mr C said the board failed to arrange appropriate pain relief for his wife before she was discharged from hospital, failed to provide her with an appropriate service for fitting her neck brace and did not carry out an independent investigation of his complaint.

After obtaining independent advice from one of our medical advisers, who is an orthopaedic surgeon, we did not uphold Mr C's complaints. The adviser said that Mrs A's medical records showed that her reported pain at the time of discharge was low. He considered it reasonable for the hospital not to supply pain killers and that it would have been reasonable for Mr C or his wife to purchase over the counter any pain killers that she might have needed. The adviser also confirmed that a brace was required for Mrs C’s injury. Although there was some dispute over how the brace came to be badly fitted or who noticed this, the adviser indicated that appropriate action was taken to fix the problem once it was identified. He also indicated that there was no evidence in Mrs A’s medical records of her having any confusion on the afternoon of her discharge, and so it was reasonable that she was given instructions on how to fit and remove her brace. The adviser said that, in his view, Mrs A’s medical treatment was entirely appropriate.

On the matter of the complaints handling, the evidence showed that the orthotist (person specialising in the use of devices to support or control part of the body) concerned was not part of the team who carried out the investigation of Mr C’s complaint. Her only involvement in the investigation was to provide a statement of her account of events and to verify that it was accurately reflected in the board’s decision letter. We considered this to be entirely reasonable.

Summary

In December 2011, Miss C attended a hospital accident and emergency department (A&E) with an injury to her little finger. She was reviewed and

x-rayed, and diagnosed with a probable dislocation at the first knuckle in the finger. The x-rays showed a small fragment of damaged bone, suggesting damage to the ligaments on the sides of the joint and some damage to the soft tissues around the finger. Miss C's finger was immobilised by strapping, and she was reviewed at the fracture clinic the next day. The doctor there confirmed that she had a type of fracture that occurs when a fragment of bone tears away as a result of physical trauma, and said that her finger should be immobilised for three weeks. Two weeks later Miss C was reviewed by another doctor. He said that two joints in her finger were becoming stiff and referred her urgently for physiotherapy. She saw a physiotherapist that day. Miss C said that when the physiotherapist manipulated her finger she felt sudden and immediate pain, and after a minute of treatment fainted with the pain. She went to A&E again several days later complaining that the physiotherapy treatment led to an injury to her finger. She complained to us that because of this she needed a further operation which resulted in her finger becoming permanently injured.

As part of our investigation, we took independent advice from a medical adviser. The adviser said that the action taken was correct for a patient three weeks after an injury in which the joints and fingers have become stiff. They noted that the clinical notes for Miss C's attendance suggest that there was stiffness and, crucially, do not mention any abnormal positional deformity in the joint that would suggest the possibility of a secondary deformity developing. Leaving the fingers stiff for longer would have increased the risk of permanent stiffness. We concluded that the doctor's referral to physiotherapy without first taking an x-ray was reasonable, and noted that it was not possible to determine when Miss C sustained the injury about which she complained.

Summary

Miss C's mother (Mrs A) was admitted to hospital for surgery. Her recovery took a long time and she developed pleural effusions (fluid that gathers around the outside of the lung). After about four months she was transferred to another hospital. At this time she was still very unwell, being tube-fed and having a urinary catheter (a thin tube used to drain and collect urine from the bladder). Tests showed abnormalities in her abdomen. At the end of that month, Mrs A was transferred to a third hospital but returned to the second hospital several days later when tests indicated a chest infection. She was diagnosed as having contracted clostridium difficile (a common healthcare-associated infection). A line to provide better access to her veins for intravenous fluids and antibiotics was inserted but became dislodged. Her condition continued to worsen and she died a few days after being transferred.

Miss C complained that during her mother's time in the second hospital the board did not reasonably attempt to address her chest condition, and failed to help with eating or to consider her dietary requirements. She also complained that the board inappropriately transferred Mrs A to the third hospital, given her chest condition, and that they failed to take reasonable steps to ensure that the access line did not become dislodged. Finally, Miss C complained about the board's complaints handling.

We took independent advice from a medical adviser and a nursing adviser. The medical adviser said that before Mrs A's transfer to the third hospital there were shortcomings in diagnosing and managing the inflammation that Mrs A had and that the decision to transfer her was, therefore, questionable. The nursing adviser said that the nursing care in relation to nutrition was reasonable. However, given our concerns about the shortcomings in medical care we upheld the complaint. We were satisfied that in their complaint response the board provided a reasonable explanation for the cause of Mrs A's pleural effusions. However, we upheld the complaint about this because although they acknowledged that Mrs A's care could have been better managed, they failed to provide any further details. We also noted that they did not respond to her second letter of complaint for 14 weeks.

Recommendations

We recommended that the board:

• ensure that the failures identified are raised with the relevant clinicians during their next appraisal;
• review their complaints handling process in light of our findings; and
• apologise to Miss C for the failures identified.

Summary

Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for urinary and lower respiratory tract infections. While in hospital, Miss A became lethargic and developed symptoms of liver disease. Although she initially responded well to treatment, her condition deteriorated and she was transferred to the care of liver specialists at a second hospital in a different board area. By that time Miss A was also suffering from pneumonia and increasing confusion, and she died two weeks after falling.

Miss C complained about the quality of nursing care at the second hospital, and the level of communication with family members. Specifically, she complained that she was not told that she could visit her sister outwith the standard visiting times, and that she was not contacted during the night when her sister's condition deteriorated. Miss C visited Miss A the following morning and found that she had died. She was unattended, with unconsumed medication on and around her bed.

We found the level of nursing care to be below an acceptable standard. Miss C should have been given clearer information about visiting times and should have been contacted when her sister's condition deteriorated. We accepted advice that, although Miss A's condition was closely monitored, staff should have identified that her deterioration was indicative of a terminal decline. Their failure to do so meant that Miss C was not able to be with her sister when she died. We also found that staff failed to provide adequate supervision of Miss A's medication intake.

Recommendations

We recommended that the board:

• apologise to Miss C for failing to make her aware of their flexible visiting arrangements and for failing to contact her when her sister's condition deteriorated;
• review their visiting policy to ensure that relatives are provided with information about visiting arrangements for patients who are critically ill;
• apologise to Miss C for failing to act on the changes to Miss A's vital signs during the night before she died;
• consider whether their nursing staff would benefit from refresher training on end of life care; and
• remind nursing staff of their responsibilities in line with section 2.10 of the Nursing and Midwifery Council Standards for Medicines Management.

In March 2014, the NHS board involved in this case told us that they had identified further evidence which meant we were able to investigate further. We issued a public report of our findings on 18 February 2015, under reference 201401376. The decision below is not, therefore, the final decision on this complaint and is retained here for archive purposes.

Summary

Mrs C, who is an advocacy worker, complained on behalf of the partner of Mr A that the board failed to provide Mr A with an appropriate level of treatment. Mr A was admitted to a hospital's acute medical assessment unit with chest pain. He was transferred to the care of cardiologists (specialists dealing with disorders of the heart) who noted that he had severely high blood pressure. He was treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).

An echocardiogram (an instrument for diagnosing heart abnormalities that uses reflected ultrasonic waves to show the structures and functioning of the heart) was carried out at Mr A's bedside on the day of his admission. Two days later, he was sent for a further echocardiogram. This showed the presence of a tear in the ascending aorta (a portion of the large artery that carries blood from the left ventricle of the heart to branch arteries). A CT scan (a procedure that uses x-rays to define normal and abnormal structures in the body) was performed the same morning confirming the diagnosis of aortic dissection. Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

We took independent advice from one of our medical advisers, who said that aortic dissection is a rare condition and it is not unusual for the diagnosis of it to be missed. This is because unless a CT scan or, as in Mr A's case an echocardiogram, is performed there may be no specific pointers away from the presumed diagnosis of acute coronary syndrome. For most patients, it is relatively unlikely that a chest CT scan would be performed on a routine or even random basis. Although the fact that Mr A was at risk of aortic dissection was not picked up from the first echocardiogram, there was no recording of this and it was possible in any case that the tear developed after this had taken place.

Mr A had to wait for his operation because it was the holiday period and there was only one surgeon on call, who was in the middle of an operation. We found that it was not unreasonable that the cardiac surgeon completed the operation he was performing, before operating on Mr A. It was also likely that Mr A would have died before an operation could have been performed if he had transferred to another cardiac surgical centre. Mr A was in the acute phase and needed a very high-risk operation. In addition, we considered that Mr A had received the correct medication to lower his blood pressure and relieve his chest pain.

We found that overall, the actions of the doctors were reasonable and appropriate and we did not consider that there were any unnecessary delays.