Scottish Public Services Ombudsman

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  • Report number:
    201300692
  • Date:
    January 2014
  • Body:
    A Medical Practice in the Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
On 2 April 2013, the complainant (Miss C) telephoned her mother (Mrs A)'s medical practice (the Practice) and requested a house call Mrs A.  However, she said that when the GP (the Doctor) visited, she failed to examine Mrs A or ask her whether she was in pain.  Miss C said that the Doctor disregarded the symptoms she reported; refused to give Mrs A anything to help her sleep; and called her by an incorrect name.  Miss C complained that had Mrs A been examined and told treatment in hospital was necessary, the outcome for her could have been different.  Mrs A was subsequently taken to hospital where she died.

Specific complaint and conclusion
The complaint which has been investigated is that, in relation to a house call on 2 April 2013, the Doctor unreasonably failed to examine Mrs A, leading to a delay in admitting her to hospital for tests and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

  • ensures that the Doctor make a formal apology to Miss C for her failure in this matter; and
  • ensures that the Doctor completes appropriate professional training so that she is fully appreciative of the seriousness of abdominal pain in the elderly and the importance of conducting a thorough history and examination.

The Practice have accepted the recommendations and will act on them accordingly.

Download report number 201300692 as a PDF (31.84 KB)

  • Report number:
    201204479
  • Date:
    January 2014
  • Body:
    A Medical Practice in the Greater Glasgow and Clyde NHS Board area
  • Sector:

Overview
The complainant (Ms C) who was an Advocate acting on behalf of Mrs A, raised a number of concerns that the care and treatment provided by his General Practitioner (GP) to Mrs A's husband (Mr A) were inappropriate.  Ms C also complained that Mr A’s medical practice (the Practice) failed to provide an adequate response to the complaint about Mr A's treatment.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) the Practice failed to provide appropriate care and treatment for Mr A's reported symptoms of headaches; dizziness; and disorientation; in April and May of 2012 (upheld); and
  • (b) the Practice failed to provide an adequate response to the complaint about Mr A's treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

  • conducts a Significant Event Analysis of these events and that any learning outcomes are discussed at the GP's annual appraisal;
  • conducts a review of a sample of clinical records to assess whether they meet the standards recommended by the GMC.  Any learning outcomes to be addressed at the GP's annual appraisal and/or with appropriate training;
  • conducts a review of the Practice's monitoring protocol for patients taking warfarin to ensure that it is fit for purpose;
  • conducts a review and revision of its complaints procedure to ensure it complies with current NHS complaints handling guidance;
  • ensures that all staff have received appropriate training on handling complaints; and
  • issues a written apology to Mrs A for all the failings identified in this report.

Download report number 201204479 as a PDF (53.81 KB)

  • Report number:
    201203374
  • Date:
    October 2013
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview

Mr C, a prisoner, complained that the prison health centre's handling of his complaint forms was unreasonable.  He also complained that he had problems in accessing the relevant complaint forms.

Specific complaint and conclusion

The complaints which have been investigated are that:

(a) the prison health centre's handling of his complaint forms from 1 to 3 November 2012 was unreasonable (upheld); and,
(b) prisoners' access to Board complaint forms has been unreasonable (upheld).

Redress and recommendation

The Ombudsman recommends that the Board:

(i)  issue a written apology to Mr C for the failure to deal with his complaint in line with their complaints procedure;
(ii)  ensure that the local process in place for the management of prison health care complaints is in line with the good practice outlined in the Scottish Government guidance 'Can I Help You?'; and
(iii)  take steps to confirm that complaint forms are readily available for prisoners to access.

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201203374 as a PDF (37.13 KB)

  • Report number:
    201200390
  • Date:
    June 2013
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Mr C) and his wife (Mrs C) underwent a cycle of infertility treatment towards the end of 2011. This did not lead to pregnancy. Thereafter, the Greater Glasgow and Clyde NHS Board (the Board) told Mr and Mrs C that because the hormone that indicated Mrs C's ovarian reserve was low, they would not be offered a further cycle of treatment using her eggs. Instead, they were offered a further cycle with a donated egg. Mr C alleged that this decision was contrary to his and his wife's right of access to NHS treatment and against guidelines on the provision of fertility treatment in Scotland. He further complained that the delays in the process reduced their chances of success.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed unreasonably to provide a second cycle of fertility treatment of Mr C’s choosing (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) apologise to Mr C for the failures identified;
  • (ii) offer him £6,000 in the event that he seeks assisted conception treatment privately;
  • (iii) amend their policy on assisted conception to clarify that patients may not be eligible for further NHS treatment if response to treatment is poor; and
  • (iv) consider introducing a protocol to fast track patients with a potentially poor ovarian reserve.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201200390 as a PDF (30.46 KB)

  • Report number:
    201201570
  • Date:
    May 2013
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Mrs C) complained about the care and treatment provided to her husband (Mr C) following his admission to the Royal Alexandra Vale of Leven Hospital (the Hospital). Mr C was 90 years old and was admitted because he was suffering pains in his legs; prior to his hospital admission he was living independently with no other immediate health concerns. Mr C developed pneumonia in hospital and while being treated for this developed diarrhoea, kidney failure, a pressure ulcer and severe oral thrush. Mr C subsequently died. Mrs C felt the Hospital staff's lack of timely action had contributed to Mr C's death.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) staff did not diagnose the cause of pain in Mr C's legs (not upheld);
  • (b) staff did not reasonably respond to Mr C's dehydration (upheld);
  • (c) there was an unreasonable delay in carrying out an x-ray or scan following the diagnosis of a chest infection on 25 March 2012 (not upheld);
  • (d) staff did not reasonably respond to Mr C's complaints of pain in his back on 1 April 2012 (not upheld); and
  • (e) staff did not reasonably respond to the development of thrush in Mr C's mouth (not upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) remind staff at the Hospital of the need to communicate with patients and their relatives and carers to ensure they are kept fully informed about their care and treatment, and of the importance of a proactive approach in this regard;
  • (ii) conduct an audit to ensure the timely assessment of all acute admissions by consultant medical staff;
  • (iii) review the implementation of the fluid balance chart policy, with an emphasis on the identification of the appropriate point for staff to escalate concerns to clinical staff;
  • (iv) ensure junior medical staff at the Hospital receive full training on the management of elderly and acutely ill patients with the aim of preventing kidney failure;
  • (v) conduct a significant incident review with regards to the period of care from 27 March to 3 April 2012;
  • (vi) issue a reminder to all medical staff at the Hospital to ensure that nursing staff are given timely notice of changes to patients' medication;
  • (vii) advise staff at the Hospital that, where possible, patients and their families and carers must be able to discuss care and treatment with a named point of contact within the medical team; and
  • (viii) give a formal apology to Mrs C for the shortcomings identified in this report and for the distress she has suffered.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201201570 as a PDF (42.6 KB)

  • Report number:
    201104025
  • Date:
    May 2013
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Mrs C) together with other members of her family raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) concerning the care and treatment their mother (Mrs A) received while a patient in the Victoria Infirmary, Glasgow between September and November 2010. Mrs A died in hospital on 13 November 2010.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) the care and treatment provided to Mrs A, including the management of her pressure ulcer and the use of a Certificate of Incapacity, was inadequate (upheld);
  • (b) the implementation and application of the Liverpool Care Pathway (LCP) was inadequate (not upheld); and
  • (c) communication between board staff and Mrs A's family was unreasonably poor, in particular a meeting with Mrs A's Consultant on 26 October 2010, and a telephone conversation between Mrs A's son and a medical registrar on 1 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) provide the Ombudsman with evidence that the Board's current policies and procedures regarding the prevention, management, monitoring, education and training of pressure ulcers is in line with national guidance and best practice;
  • (ii) take steps to put in place an action plan to address the shortcomings identified in this report in relation to pressure ulcer management and share this action plan with both the Ombudsman and Mrs C;
  • (iii) review how in-patient units communicate with each other about the decision making capacity of patients requiring procedures as in-patients, to ensure that a patient who is being managed under the terms of the Adults With Incapacity (Scotland) Act 2000, is known to be so by any other team undertaking a procedure that would normally require written consent;
  • (iv) consider whether the use of treatment plans (recommended for patients with complex care needs) might support the effective use and validity of Certificates of Incapacity in terms of Section 47 of the Adults With Incapacity (Scotland) Act 2000;
  • (v) review how clinicians document the fact that capacity may be lacking for one specific intervention but present for other investigations and treatments if they believe this to be the case;
  • (vi) ensure that family and carers are appropriately involved and informed of the consideration of use of the Adults With Incapacity legislation in the care of a patient and to document this clearly on the Certificate of Incapacity;
  • (vii) apologise to Mrs C and other members of the family for the failings identified in complaint (a);
  • (viii) with reference to our adviser's comments under paragraph 84 of this report, consider auditing the precise location of death of their in-patients and whether any system of prioritisation for single rooms across units might minimise this;
  • (ix) seek to ensure that any discussion that a member of staff has with a patient's family is recorded in the patient's medical records; and
  • (x) apologise to Mrs C and other members of the family for the failings identified in complaint (c).

Download report number 201104025 as a PDF (80.2 KB)

  • Report number:
    201200306
  • Date:
    January 2013
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Greater Glasgow and Clyde NHS Board – Acute Services Division (the Board).

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) staff failed to provide Mr C with timely and adequate pain relief when he reported problems with his catheter (upheld);
  • (b) staff inappropriately discharged Mr C from hospital when he was suffering from a high temperature and wound infection (not upheld);
  • (c) staff failed to ensure that an adequate home care package was in place on discharge from hospital, including palliative care, or provide advice about agencies which could assist if required (upheld);
  • (d) the level of communication between staff and Mr C's family was inadequate (upheld); and
  • (e) on 15 and 16 July 2011, Out-of-Hours Service GPs failed to adequately assess Mr C (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) make Mrs C a formal apology for their shortcoming in this matter and for the distress she and her family have suffered;
  • (i) emphasise to all the staff involved, the importance of keeping full and timely notes;
  • (ii) review the circumstances of complaint (a) and demonstrate to the Ombudsman that they have a programme in place to prevent such a situation occurring again;
  • (iii) make specific apology to Mrs C for failing to make proper arrangements for Mr C's care and support on his discharge from hospital;
  • (iv) in the wards concerned, review the procedures for patients' discharge to satisfy themselves that appropriate action is taken;
  • (v) make a specific apology for their failure to communicate adequately; and
  • (vi) taking into account the failures in communication, the Board should demonstrate to the Ombudsman the action to prevent such a situation occurring again.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201200306 as a PDF (45.39 KB)

  • Report number:
    201103604
  • Date:
    December 2012
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Ms C) complained that Greater Glasgow and Clyde NHS Board (the Board) failed to take appropriate action when her family reported that her daughter (Miss A) was suffering from mental health problems. Miss A subsequently jumped from a window in her fourth-floor flat. She suffered serious injuries to her lower body.

Specific complaint and conclusion
The complaint which has been investigated is that Community Psychiatric Nurses (CPNs) failed to take appropriate action to safeguard Miss A when it was reported that she was suffering from mental health problems (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) issue a written apology to Ms C for the failure to carry out a reasonable telephone assessment when they spoke to Miss A and for the failure to raise concerns with a Mental Health Officer;
  • (ii) review how risk is assessed and recorded in relation to telephone assessments in such circumstances to try to ensure as far as possible that patients assessed over the telephone receive the same quality of assessment as those spoken to face-to-face; and
  • (iii) clarify to relevant staff the criteria or threshold regarding when concerns should be raised with a Mental Health Officer.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201103604 as a PDF (26.74 KB)

  • Report number:
    201102521
  • Date:
    December 2012
  • Body:
    Greater Glasgow and Clyde NHS Board
  • Sector:

Overview
The complainant (Mrs C) raised a number of concerns against Greater Glasgow and Clyde NHS Board (the Board) that her late father (Mr A) had been inappropriately cared for by nursing staff in Dunrod F Ravenscraig Hospital (the Hospital) from 2 February 2011 up to his death on 24 April 2011.

Specific complaints and conclusions
The complaints which have been investigated are that:

  • (a) nursing staff unreasonably failed to monitor and maintain Mr A's fluid levels (not upheld);
  • (b) nursing staff unreasonably failed to deal with incontinence issues (not upheld);
  • (c) nursing staff unreasonably failed to maintain a reasonable level of hygiene for Mr A (upheld);
  • (d) there were inadequate transfer systems and documentation in place (upheld);
  • (e) there was poor communication from staff (not upheld);
  • (f) nursing staff unreasonably failed to pass on information to the relevant Social Work team when Mr A was transferred and this delayed the process of establishing a suitable nursing home for him to go to (not upheld);
  • (g) inadequate attention was paid to Mr A's dignity by ensuring that his clothing was appropriately attended to (upheld); and
  • (h) the investigation of Mrs C's complaint to the Board was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) ensure that measures are taken to feed back the learning from this to nursing staff to avoid similar situations recurring;
  • (ii) provide him with an update on the actions they have taken to ensure such an incident does not recur;
  • (iii) ensure that communication between family members and staff are appropriately recorded;
  • (iv) ensure that measures are taken to feed back the learning from this to complaints investigation staff to avoid similar situations recurring; and
  • (v) apologise to Mrs C for the failures identified in this report.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201102521 as a PDF (43.39 KB)

  • Report number:
    201102830
  • Date:
    November 2012
  • Body:
    Greater Glasgow and Clyde NHS Board - Acute Services Division
  • Sector:

Overview
The complainant (Ms C) complained about the lack of communication with her family after her mother (Mrs A) was admitted to the Emergency Department in the Victoria Infirmary in Glasgow (the Hospital). Mrs A was 84 years old and had a history of dementia. The family were not told that Mrs A's condition in the Hospital had deteriorated. Mrs A subsequently died and Ms C considers that the family lost the opportunity of being with Mrs A at the end of her life.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's lack of communication with the family just before Mrs A's death was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) issue a written apology to Ms C for the failure to inform her of the deterioration in her mother's condition; and
  • (ii) provide him with an action plan and / or steps in place to ensure communication with relatives and carers is addressed within the Emergency Department.

 

The Board have accepted the recommendations and will act on them accordingly.

Download report number 201102830 as a PDF (25.04 KB)

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