Health

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.

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.