Some upheld, recommendations

Summary
Ms C's daughter (Miss A) was referred to hospital complaining of difficulty swallowing. She also had abdominal pain and tenderness. An endoscopy (an examination using a camera on a thin tube) was carried out but the endoscopist did not report any significant abnormalities. Miss A was seen by an ear nose and throat surgeon about two months later. He arranged for her to be admitted to another hospital where further examinations and tests were carried out. Miss A was found to have a large cancerous tumour in her throat. She was discharged from hospital with a plan to provide chemotherapy and radiotherapy. Before her scheduled treatment date, however, her condition deteriorated and she was admitted to hospital. Miss A received two courses of chemotherapy, but died shortly after her second treatment.

Ms C complained that her daughter's tumour was not diagnosed by the endoscopist. She felt that, had it been, Miss A could have commenced treatment sooner, and her prognosis might have been better. Ms C also raised concerns about the monitoring of Miss A's condition, communication with the family and mistakes made by the board in their minutes of a meeting with the family to discuss their complaints.

After taking the advice of two of our medical advisers, we did not uphold most of Ms C's complaints. We accepted that the endoscopy was not designed to examine the area of Miss A's mouth where the tumour was visible. Whilst we felt that some view of the mouth should have been taken, this would in fact have been to check for obstructions rather than a diagnostic examination.

We also found that Miss A had restricted movement of her neck and jaw and that this, combined with the process of swallowing the endoscope, would have restricted the available view. Although we were satisfied with the endoscopist's actions we were, however, concerned to note that she had said that she would not examine a patient's mouth prior to the procedure. We asked the board draw her attention to our comments about the importance of non-diagnostic oral examinations.

We were also satisfied that investigations into Miss A's condition were appropriately progressed after the endoscopy. One of our advisers noted that the tumour was so advanced that, even had it been found on the day of the endoscopy, Miss A's prognosis would not have been any different. We found the board's monitoring of Miss A's condition, and their communication with Miss A and her family while she was in hospital, to be appropriate. We did not find evidence of specific details being provided to the family when the hospital decided to discontinue treatment. However, we felt that it was not necessarily appropriate for staff to do so and were satisfied that the family had the opportunity to ask questions of the staff on duty.

The board's minutes of their meeting with Ms C stated that Miss A had been present, rather than her sister. We upheld Ms C's complaint about this and about the general accuracy of the minutes, recognising the impact that this administrative mistake would have had at a time of such distress.

Recommendations
We recommended that the board:
• draw our adviser's comments regarding non-diagnostic oral examinations to the endoscopist's attention; and
• apologise to Ms C in writing for their mistake in the meeting minutes.

Summary
Mrs C complained that the board refused to provide her with batteries for her privately purchased hearing aid and was unhappy with the way they dealt with her complaint. (They had previously supplied batteries for her old hearing aid, which was also privately purchased.)

Our investigation found that, when Mrs C replaced her hearing aid, the battery required was a different size. The board told her that they could no longer supply batteries because they only provide batteries that fit NHS hearing aids, which only use the same size of battery as Mrs C's previous hearing aid. We considered this to be reasonable and did not uphold this complaint.

Mrs C also complained that her complaint was not properly handled. She said that someone she had previously complained about was involved in providing information for the board's response, and the responses to her complaint were delayed and contradictory. We found that it was appropriate for the person concerned to have been involved in the complaint response, as the complaint was about policy for which the individual had responsibility. We did, however, uphold the complaint about delay as we agreed that responses were delayed and contained contradictory information, and made a recommendation to the board about this.

Recommendation
We recommended that the board:
• apologise to Mrs C for the failings identified.

Summary
Mrs A had been receiving treatment for high blood pressure for a number of years. She had three strokes within six months. Mrs A's husband, Mr C, complained that their GP practice failed to provide appropriate advice to him when he contacted them about the first and second strokes. Mr C also complained that the practice failed to respond within a reasonable timescale when Mrs A's stroke nurse reported high blood pressure results shortly before the third stroke.

In looking at the records, we could not determine exactly what was said when Mr C spoke to the practice on the day Mrs A had her first stroke, as there was no direct objective evidence. However, the records did show that the practice's advice to bring Mrs A to the evening surgery on the day of her first stroke was reasonable. While we acknowledged this, there was no record of advice given to Mr C about what to do if Mrs A's symptoms worsened. In addition, one of our medical advisers was of the view that Mrs A should have been taken to hospital that evening by emergency ambulance. In relation to the day of Mrs A's second stroke, the practice advised Mr C to bring her in for a consultation the following morning. In our view, she should have been seen and assessed on the same day, given her history and unresolved symptoms. Taking all of this into account, and noting the views of our adviser, on balance we upheld this complaint.

In relation to Mr C's second complaint, the records showed that the practice discussed Mrs A's high blood pressure results with the stroke nurse, and arranged for further review and a home visit. Our adviser's view was that the practice acted appropriately in the circumstances. Taking this into account, we concluded that the practice did respond within a reasonable timescale and, therefore, we did not uphold this complaint.

Recommendation
We recommended that the practice:
• review their protocol for the management of hypertension, in terms of the threshold for referring patients to a hospital consultant. This would include urgent referral and emergency ambulance transfer to hospital of patients suspected of stroke if symptoms persist on assessment.

Summary
Ms C was admitted to hospital on two occasions. She said that before each admission she had lodged an advance decision with the board to cover the care and treatment she was prepared to accept. She was unhappy with the care and treatment she received. She said it did not agree with her advance decision; that the advance decision was not recorded in her notes until after the first admission; she waited around six hours before receiving treatment; she was incorrectly told to take her own medication; staff took offence at her; her advance decision was not respected and it was inappropriate for staff to ask about her mental health problems.

Our investigation took account of all the available information, including Ms C's medical records. We obtained medical advice from two medical advisers.

A medical adviser said that advance decisions are drawn up to indicate how an individual would wish to be treated, should they be unable to make that decision at the time. There was no indication in the medical records that Ms C was in that position at the times concerned. However, we found that the advance decision was not inserted in her records at the right time and that on admission, she waited too long before receiving treatment and we upheld her complaints about these matters. We also found that staff told her, incorrectly, to continue taking her own medication once she was admitted to a ward and that in view of this a member of the medical team (correctly) refused to continue to give her strong apin relief. There was, however, no evidence to show that a member of staff took any offence at Ms C or her requests. We also found that it was appropriate for staff to discuss Ms C's mental health with her even though it had no apparent bearing on her physical presentation at the time.

Recommendations
We recommended that the board:
• apologise for the delay in 2010 in attaching the advance decision to the relevant notes;
• audit their current process to lodge records information and act on any recommendations subsequently made; and
• review the means, in Crosshouse Hospital, by which they ensure that acute admissions are promptly assessed by medical and surgical staff in their acute wards and that actions taken to ensure attainment of the four hour target do not compromise patient care. An audit of time from presentation at Accident and Emergency to review by medical staff would support such an aim.

Summary
Mr C's wife (Mrs C) was admitted as an emergency case to hospital, but passed away the next day. Mr C was unhappy that the board did not contact him to tell him that his wife had died, and that he only found this out when he called to ask how she was. Mrs C had also wished for her body be donated for the benefit of medical science, and Mr C complained that the board unreasonably failed to contact a local university to arrange for her body to be taken there for this.

Our investigation found that when admitted to hospital, Mrs C had said she had no next of kin and had asked that her GP be told about any changes in her condition. We, therefore, did not uphold this complaint. We also found, however, that Mr C had been in touch with the hospital enquiring about her condition, but no note had been made about this, nor had the board given him a full explanation of their findings. We, therefore, made recommendations to address this.

We upheld the complaint about what happened to Mrs C's body as we found that the board were aware of Mrs C's wishes but that after she died they failed to contact the university to explore the possibility of donation. We also found during our investigation that the board's initial decision not to refer Mrs C's death to the procurator fiscal was incorrect and that they did not properly investigate Mr C's complaint or make him fully aware of what they had found out.

Recommendations
We recommended that the board:
• apologise for not having provided a full explanation of their findings when responding initially;
• apologise to Mr C for their failure to act upon his wife's wish to have her body donated to medical science; for initially failing to make the correct decision on referral to the procurator fiscal; for failing to thoroughly investigate his complaint and for failing to report the findings of their investigation to him;
• feed back the Ombudsman's views on this complaint to the staff involved to try to ensure that such failings do not happen again; and
• write to the Ombudsman to explain what action they have taken to implement the remedies suggested as a result of their investigation and provide evidence regarding their implementation.

Summary
Mr C rears cattle. He complained about the actions of an officer working on behalf of the Animal Health and Veterinary Laboratories Agency (AHVLA) (an executive agency of the Department for Environment, Food and Rural Affairs, working partly on behalf of the Scottish Government). He also complained about the AHVLA's handling of his complaints.

Mr C complained that the officer had been aware of the location of some of his cattle, yet had written asking for clarification of their whereabouts. Mr C said that one of the officer's colleagues had told the officer where the cattle were. We did not , however, uphold this complaint as there was no evidence available to suggest that the officer was in fact aware of the location of the cattle. Although there appeared to have been some misunderstanding during the correspondence between the officer and Mr C, it was clear that the movements of the cattle were complex and we considered it reasonable for the officer to seek clarification of their whereabouts.

Mr C also complained that the officer had unreasonably requested that Mr C present his cattle for testing, when the officer had not done anything about the situation for over two years. Our investigation established there were a number of sound reasons why he had not made contact with Mr C during that time. These included that Mr C had made a complaint about the officer to the Royal College of Veterinary Surgeons; there were ongoing criminal proceedings against Mr C in relation to the Tuberculosis Order 2007; and the Rural Payments and Inspections Directorate were trying to complete inspections of the cattle. The officer had, therefore, been advised to await the conclusion of all of these before contacting Mr C again about tuberculosis testing, which is why the delay occurred. On that basis we did not uphold this complaint.

We upheld Mr C's complaint about the AHVLA's complaints handling, as we found that they did not respond fully to all aspects of Mr C's complaint letter.

Recommendation
We recommended that Scottish Government:
• review their complaints handling procedure to ensure complainants receive full responses to complaints.

Summary
Mrs C complained about aspects of the care and treatment provided to her late mother (Mrs A) in hospital after she fell at home in a sheltered housing complex.

Mrs C said that there was difficulty in receiving accurate information from staff about her mother's condition and whether she was going to be taken to theatre. In addition, Mrs A had gone eight days without food; and the family could not understand how Mrs A could die of pneumonia in hospital two weeks after a simple fall with no injuries.

We took advice from two medical advisers who established that Mrs A was an elderly lady in poor health. On looking at the board's care and treatment of Mrs A, we found that she had a number of pre-existing medical conditions, which meant that she did not have the physical reserves to cope with the complications that followed her fall.

Our advisers confirmed that Mrs A received appropriate care and treatment while in hospital and that it was necessary for her to be fasted in order to manage her condition, and, therefore, we did not uphold this complaint.

We did, however, find that there were failings in the way in which medical staff communicated with the family, and delays in the handling of Mrs C's complaint.

Recommendations
We recommended that the board:
• remind staff of the importance of communication with relatives about a patient's care and treatment;
• remind staff to respond to complaints in accordance with the guidance contained in the NHS complaints procedure; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary
Miss C raised a number of concerns about the treatment her late father (Mr A) received in hospital.

Mr A had become unwell after surgery, complaining of abdominal pain. He was found to have several bleeding ulcers. Mr A received treatment for these, but his condition deteriorated and he died a few days after the surgery took place. Miss C felt that there had been a delay in transferring Mr A to theatre and then for surgery, and that his pain relief was inadequate. She felt that a proton pump inhibitor (PPI) (a drug that reduces acid in the stomach) should have been prescribed earlier.

Having looked at the case, our medical adviser found that Mr A had received reasonable treatment and that there were no unreasonable delays. We found that Mr A was taken to theatre for surgery when it was clinically appropriate to do so.

We did, however, find that Mr A's pain management was inadequate for a period during the admission. While recognising that Mr A's pain was difficult to manage, our adviser was concerned that someone with a history of chronic duodenal (lower intestine) ulcers did not have PPI protection throughout his recovery. We took the view that Mr A's abdominal pain should have been identified and addressed earlier and made a recommendation to the board about this.

Recommendation
We recommended that the board:
• apologise to Miss C for the failure to fully address Mr A's pain issues.

Summary
Mr C attended his GP, complaining of blurred vision. Two days later, he attended again with the same symptoms. The GP telephoned the hospital to ask for an appointment to be provided more quickly and was told Mr C would be seen as soon as possible.

Just over a month later, Mr C saw a consultant ophthalmologist who could not find anything wrong. Mr C questioned this and was told that the consultant could send him for a scan. Mr C attended for a scan three weeks later. The following week, the consultant telephoned and said that the results of the scan showed Mr C had suffered a stroke and urgently needed to attend the stroke clinic. Mr C was dissatisfied with the consultant's attitude and was unhappy that it took over nine weeks to diagnose that he had suffered a stroke.

After taking advice from one of our medical advisers, we found that Mr C's symptoms were not typical of a stroke and that the consultant had carried out an appropriate assessment. We did, however, uphold his complaint that there was a delay in the board providing him with an ophthalmology appointment after the GP asked for Mr C to be seen more urgently.
 

Recommendation
We recommended that the board:
• apologise to Mr C for the failure to act on the second GP referral.
 

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital.

Mrs A was admitted with shortness of breath, and was in hospital for five days. She was discharged back to her care home but when she arrived there, staff were concerned about her condition. They contacted a GP who authorised that Mrs A be redirected to the community hospital. She was admitted to the community hospital, where she died of pneumonia some five hours after admission.

We upheld most of Mr C's complaints. We noted that before we began our investigation, the board had already accepted there were failings and communication problems, and had set out an action plan to prevent a repeat occurrence. We also established that there were communication failings between staff about the facility to which Mrs A should have been discharged. Initially the consultant had deemed that Mrs A should be discharged directly to the community hospital for palliative care but they refused as Mrs A did not require rehabilitation. This information was not passed back to the consultant, and a junior doctor decided that Mrs A could then be discharged back to the care home.

We took advice from one of our medical advisers who said that the board failed in the overall management of the care of and discharge planning for Mrs A. It appeared that arrangements for her discharge were managed by junior medical and nursing staff without any involvement of more senior staff. The inadequate arrangements that resulted from this meant that Mrs A and her family were badly let down during the final hours of her life.

Recommendations
We recommended that the board:
• take into account the adviser's comments on the action plan and provide a more detailed consideration of the failings which have been identified and demonstrate how effective the suggested measures have been; and
• apologise to Mr C for the overall manner in which Mrs A's discharge from hospital was handled.