Scottish Public Services Ombudsman

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  • Report number:
    201203251
  • Date:
    December 2013
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainant (Miss C) raised a number of concerns about the level of care provided to Ms A by Highland NHS Board (the Board) during her pregnancy and subsequent delivery of her baby daughter who was sadly stillborn.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide Ms A with an appropriate level of care during her pregnancy and subsequent delivery at Raigmore Hospital in December 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i)  apologise to Ms A for the failings identified in this report;
  • (ii)  review their guidance to staff on the antenatal management of women to ensure that the risks of recurrent shoulder dystocia are discussed with expectant mothers together with birthing options; and
  • (iii)  draw to the attention of the antenatal midwife who looked after Ms A, the importance of documenting previous history of shoulder dystocia in the handover note to the labour midwife.

Download report number 201203251 as a PDF (36.01 KB)

  • Report number:
    201204498
  • Date:
    August 2013
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her husband (Mr C), who was admitted to Raigmore Hospital (the Hospital) on 4 January 2012 after suffering a seizure. She complains that during his stay, Mr C was not given appropriate care and treatment, nor was he properly assessed for rehabilitation prior to his discharge.

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

  • (a) staff at the Hospital failed to provide Mr C with appropriate care and treatment following admission on 4 January 2012 (upheld); and
  • (b) staff at the Hospital failed to assess properly whether Mr C would benefit from rehabilitation on discharge from hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) make a formal apology to Mr and Mrs C for their failures;
  • (ii) ensure that the consultant physician (Doctor 2)'s next appraisal includes this case, together with reflection on the Adults with Incapacity legislation and the specific rights of patients with dementia;
  • (iii) conduct an audit on Ward 6C, relating to compliance with Adults with Incapacity legislation for patients with dementia, and satisfy themselves that all staff are fully apprised of its implications;
  • (iv) formally apologise to Mr and Mrs C for failing to assess Mr C properly prior to his discharge from hospital; and
  • (v) (with Mrs C's agreement) assess Mr C thoroughly to establish whether he would benefit from further physiotherapy input and, if he would, the Board arrange this.

 

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

Download report number 201204498 as a PDF (53.61 KB)

  • Report number:
    201200405
  • Date:
    June 2013
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment her late daughter (Miss A) received at Raigmore Hospital (Hospital 1). Miss A was seen by an out-of-hours GP at Hospital 1 and thereafter returned 24 hours later where she was admitted as her condition had seriously deteriorated. The following day, Miss A was transferred to the Royal Hospital for Sick Children in Edinburgh (Hospital 2) and sadly died two days later.

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

  • (a) the receptionist failed to obtain appropriate assistance when Miss A presented at Accident and Emergency with soiled clothing (upheld);
  • (b) Miss A was inappropriately discharged by the out-of-hours GP on 5 March 2011 (not upheld); and
  • (c) staff failed to adequately monitor or provide timely treatment to Miss A when she was admitted to Accident and Emergency on 6 March 2011 (not upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) provide the Ombudsman with evidence to support that they have reviewed their gown supplies in Accident and Emergency and informed relevant staff of the procedure to follow when alternative clothing is required;
  • (ii) remind the out-of-hours GP of the GMC's guidance in relation to record-keeping;
  • (iii) draw to the attention of relevant staff the comments by Adviser 2 and Adviser 3 regarding documenting more detailed information on intubation in this case; and
  • (iv) conduct a review of their Significant Event Analysis procedures to ensure that a detailed and robust investigation is carried out in all cases.

Download report number 201200405 as a PDF (37.81 KB)

  • Report number:
    201200733
  • Date:
    March 2013
  • Body:
    Western Isles NHS Board
  • Sector:

Overview
The complainant (Ms C), an advocate, raised a number of concerns on behalf of Mr A. Mr A’s late wife (Mrs A) was referred urgently by her GP for the investigation of symptoms suggestive of breast cancer on three occasions within a period of seven months. Mrs A was referred urgently to the Breast Clinic at the Western Isles Hospital (the Clinic) in Stornoway three times between May and November 2008 but she was not referred on to the Highland Breast Centre in Inverness (the Breast Centre) until December 2008. Cancer was diagnosed in January 2009. Mrs A was a young woman whose first child was under two years old when she first reported her symptoms to her GP. By the time the cancer was diagnosed, she was some 12 weeks pregnant with her second child. Although the child was delivered safely and Mrs A was treated for her cancer, the cancer later returned and she died aged 33 years in June 2011.

Specific complaint and conclusion
The complaint which has been investigated is that the Board unreasonably delayed diagnosing Mrs A's breast cancer (upheld).

Redress and recommendation
The Ombudsman recommends that the Board:

  • (i) issues a written apology for the failings identified.

 

The Board have accepted the recommendation and will act on it accordingly.

  • Report number:
    201102952
  • Date:
    February 2013
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainant (Mr C) raised a number of concerns against Highland NHS Board (the Board) regarding the care and treatment his late father (Mr A) received from Dr MacKinnon Memorial Hospital, Broadford. Mr C stated that the Board failed to provide adequate care and treatment for Mr A from 31 May 2010 up to his death on 4 June 2010.

Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:

  • (a) treat Mr A's constipation and subsequent complications appropriately (upheld); and
  • (b) communicate effectively with Mr A, Mr C and Mrs C (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) ensure that treatment is initiated by clinical staff in good time when a patient's condition deteriorates and appropriate details of this are recorded in their medical notes;
  • (ii) ensure that all relevant clinical details are recorded legibly by all doctors in the medical notes as and when they have reviewed a patient;
  • (iii) ensure that staff consider the reasons for abrupt changes in patients, to ensure that reasonable action is taken to limit the chances of further problems developing;
  • (iv) ensure that admission forms include prompts which assess a patient's cognitive function or capacity to participate in decision making;
  • (v) ensure that nursing admission notes are completed appropriately for every patient;
  • (vi) ensure that when a patient displays uncharacteristic behaviour, appropriate and timely cognisance is taken of this and any subsequent action required is recorded;
  • (vii) ensure that measures are taken to feed back the learning from this event to all staff, to ensure that similar situations will not recur;
  • (viii) conduct a review of end-of-life care, with specific reference to completion of Do Not Resuscitate forms;
  • (ix) ensure that DNAR discussions with family members are documented; and
  • (x) issue Mr C with a full and sincere apology for the failings identified in this complaint.

 

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

Download report number 201102952 as a PDF (62.58 KB)

  • Report number:
    201104965
  • Date:
    January 2013
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment given to her daughter (Ms A) prior to her death in October 2011.

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

  • (a) staff discharged Ms A from hospital on 12 August 2011 despite her suffering from a wound infection and temperature (not upheld);
  • (b) during the period 14 August to 21 September 2011, staff failed to provide an adequate level of care and treatment to Ms A (upheld); and
  • (c) during the period 14 August to 21 September 2011, staff failed to ensure that Ms A received an adequate level of fluid and nutrition (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) apologise to Mrs C for their failures with regard to Ms A's care and treatment;
  • (ii) bring the findings of this complaint to the attention of the consultant physician concerned for discussion at his next appraisal;
  • (iii) apologise for their failure to properly address Ms A's nutritional status and to follow NHS Standards; and,
  • (iv) emphasise to appropriate staff the necessity of following existing standards with regard to food and nutrition and to satisfy themselves that these standards are met.

 

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

Download report number 201104965 as a PDF (32.06 KB)

  • Report number:
    201100845
  • Date:
    November 2012
  • Body:
    The Highland Council
  • Sector:

Overview
The complainant (Mr C)'s son (Mr A) was a pupil at a school in the Highland Council (the Council)'s area. Mr A was unable to sit his Higher Physics examination due to a family bereavement. Assurances were given by his school (the School) that he would be awarded a grade based on his preliminary examination results. However, the evidence provided by the School in support of Mr A's performance did not comply with the requirements of the Scottish Qualifications Authority (SQA) and Mr A was awarded a lower grade. Mr C complained that the School did not use a prelim paper of the required standard and that they did not provide adequate evidence to the SQA in support of the subsequent appeal of Mr A's Higher Physics Result. Mr C also complained about the Council's handling of enquiries and complaints from him and his wife (Mrs C).

 
Specific complaints and conclusions
The complaints which have been investigated are that:
  • (a)  the School did not use a paper of the required standard in conducting a prelim examination for Higher Physics in early 2010 (upheld);
  • (b)  the School's submission of evidence of Mr A's performance in Higher Physics to the SQA in 2010 was not reasonable (upheld); and
  • (c)  the Council did not respond reasonably to Mr and Mrs C's enquiries and complaints (upheld).
 
Redress and recommendations
The Ombudsman recommends that the Council:
(i)         
ensure that the School develops a procedure for checking all prelim examination papers for compliance with SQA standards;
(ii)        
work with the SQA to increase their understanding of the SQA's standards and how SQA staff assess the suitability of prelim papers;
(iii)       
conduct a review of the types of evidence that will be accepted by the SQA in support of appeals and absentee assessments;
(iv)       
ensure that the SQA's comments on the marking of Mr A's prelim examination have been fed back to the Principal Teacher concerned; and
(v)        
issue a formal written apology to Mr A for the failings highlighted in this report.
 
The Council have accepted the recommendations and will act on them accordingly.

Download report number 201100845 as a PDF (36.93 KB)

  • Report number:
    201102612
  • Date:
    November 2012
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainants (Mr and Mrs C) lost their son (Baby A) following his premature birth on 5 January 2011. Their complaint concerns the care and treatment provided at Caithness General Hospital, Wick (Hospital 1) and Raigmore Hospital, Inverness (Hospital 2) during and after Mrs C's pregnancy. Mr and Mrs C believe that they received a poor standard of care from both Hospital 1 and Hospital 2 and said that the loss of Baby A has had a devastating effect on their lives.

Specific complaints and conclusions
The complaints which have been investigated are that Highland NHS Board (the Board):

  • (a) unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld);
  • (b) inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld);
  • (c) unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld);
  • (d) unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld);
  • (e) inappropriately placed Baby A in what looked like a cardboard box (not upheld); and
  • (f) unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) ensure that each operator at Hospital 2 is compliant with the RCOG Green Top Guideline No 8 on amniocentesis;
  • (ii) review the amniocentesis consent form and patient information sheet used at Hospital 2, so as to take account of the five good practice points referred to in paragraph 17; 20
  • (iii) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (a);
  • (iv) review the local guidance at Hospital 1 and Hospital 2 concerning suspected fetal abnormalities discovered on any obstetric ultrasound scan. Where an abnormality is suspected there should be a clear pathway for specialised fetal medicine assessment and no delay in referral of the patient to a specialised hospital department;
  • (v) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (c);
  • (vi) provide evidence of the review of the guidelines for staff referred to in the letter from Doctor 3 to Mr and Mrs C dated 21 April 2011;
  • (vii) reflect on the Adviser's comments about examination options after a stillbirth/late miscarriage where the baby has a structural abnormality; and
  • (viii) review Hospital 2's post mortem patient information sheet and consent form, so as to include the four examination options listed in paragraph 74.

 

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

Download report number 201102612 as a PDF (61.62 KB)

  • Report number:
    201103227
  • Date:
    August 2012
  • Body:
    Highland NHS Board
  • Sector:

Overview
The complainants, Mr C and Ms C, raised a number of concerns about Ms C's unplanned homebirth of their daughter (Baby A), and her death. The complainants believe that the loss of Baby A was totally avoidable and blame Highland NHS Board (the Board) for what happened.

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

  • (a) the Board failed to provide adequate advice, care and treatment before, and during, the birth of Baby A (upheld);
  • (b) the Board failed to provide adequate care and treatment to Mr and Ms C following the birth (upheld);
  • (c) the Board failed to keep adequate and timely records of the birth and aftercare provided to Ms C (upheld);
  • (d) the Serious Untoward Incident report failed to investigate and report adequately on all the issues regarding the birth and aftercare and the Chief Executive's response failed to investigate the matter adequately or to make any recommendations to avoid a recurrence (not upheld); and
  • (e) the Board incorrectly stated that Baby A was stillborn (not upheld).

 

Redress and recommendations
The Ombudsman recommends that the Board: Completion date

  • (i) make a full and sincere apology for the failures identified in Complaint (a); and
  • (ii) emphasise to all midwifery staff the necessity of compliance with the relevant rules in relation to the completion of notes.

 

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

Download report number 201103227 as a PDF (77.35 KB)

  • Report number:
    201103076
  • Date:
    August 2012
  • Body:
    Western Isles NHS Board
  • Sector:

Overview
The complainant (Ms C) complained on the behalf of the aggrieved (Mr and Mrs A) about the care and treatment received by Mrs A from Western Isles NHS Board (the Board) in December 2010. Mrs A was taken to Uist and Barra Hospital (the Hospital) with abdominal pains. Two days later Mr A was advised Mrs A was suffering from acute renal failure, was dying and no further treatment could be provided for her. However, Mrs A was subsequently able to be airlifted to the mainland for treatment. She went on to make a full recovery.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not provide reasonable care and treatment to Mrs A between 5 and 9 December 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

  • (i) provide an updated version of the action plan to evidence that all of the identified actions have been implemented;
  • (ii) provide further details about planned training for medical staff at the Hospital, which should include refresher training on the causes of opiate toxicity and enhanced training in relation to venous access;
  • (iii) conduct a random case note review at the Hospital; and
  • (iv) provide a full apology to Mr and Mrs A for the failings identified in this report.

Download report number 201103076 as a PDF (68.19 KB)

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