Mid Scotland and Fife

Overview
The complainant (Mrs C) raised a number of concerns about the care, treatment and subsequent discharge of her husband (Mr C), who has dementia, following his admittance to the Accident and Emergency Department (the Department) of Victoria Hospital (the Hospital) on 6 January 2011.

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

• (a) the care and treatment of Mr C in the Department on 6 January 2011 was not reasonable (upheld);
• (b) the arrangements for Mrs C to deal with Mr C's personal hygiene in the Department were unreasonable (upheld);
• (c) the time taken to admit Mr C to a ward from the Department was unreasonable (upheld);
• (d) the responses to Mrs C's telephone calls to the Department for information about Mr C were unreasonable (upheld);
• (e) the arrangements for Mr C's discharge on 7 January 2011 were unreasonable (upheld);
• (f) Mrs C was not provided with reasonable information upon Mr C's discharge (upheld); and
• (g) Mr C's mental health condition and Mrs C's role as his carer, next of kin and holder of power of attorney over him were not reasonably taken into account during his admission (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind nursing staff within the Department of their responsibilities with regards to patients' personal hygiene and that it is not appropriate to rely on visitors to undertake this for them;
• (ii) provide evidence to the Ombudsman that staff within the Department have undergone training in relation to the importance of good communication with patients and their families;
• (iii) review their policy in relation to ensuring appropriate discharge arrangements for patients, taking into account any vulnerabilities and risk factors;
• (iv) remind nursing staff of the importance of treating patients with dignity at all times;
• (v) review their policy in relation to providing discharge information to patients with dementia and their relatives and carers as part of the implementation of Scotland's National Dementia Strategy;
• (vi) provide evidence that, as part of the implementation of Scotland's National Dementia Strategy, staff within the Department and the Ward are given ongoing training in relation to the importance of acknowledging dementia and recognising the role of carers and next of kin; and
• (vii) provide a full formal apology to Mr and Mrs C for all of the failings identified within this report.

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

Overview
The complainant (Mrs C) raised a number of concerns about the treatment her late husband (Mr C) received whilst a patient at Hairmyres Hospital (the Hospital) in March 2010, after he was admitted on 10 March 2010 with shortness of breath. He developed pneumonia and MRSA, and Mrs C felt the Hospital were not caring for him adequately, in particular that staff did not properly recognise his needs (Mr C suffered from dementia). Mr C discharged himself against medical advice on 23 March 2010 and died at home on 2 April 2010.

Specific complaint and conclusion
The complaint which has been investigated is that during Mr C's admission to hospital in March 2010, there were unreasonable failings in his medical and nursing care and treatment in relation to pneumonia and medication (upheld).

Redress and recommendations
The Ombudsman recommends that the Lanarkshire NHS Board (the Board):

• (i) provide evidence on the implementation of Scotland's National Dementia Strategy and the Dementia Resource folder, including relevant action plans, in order to ensure: ongoing education and training for staff in the Hospital; and good communication with dementia patients and their families, involving family members in care when appropriate; and
• (ii) carry out a ward audit to ensure compliance with the Nursing and Midwifery Council's Standards for medicine management and record-keeping.

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

Overview
The complainant (Mr C) complained about changes to proposals for planning consent for a superstore to the rear of his home, specifically about the relocation of a large sprinkler tank, now sited immediately adjacent to his boundary, and also about the way Fife Council (the Council) dealt with correspondence on the matter.

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

• (a) delayed or failed to reply to correspondence (upheld);
• (b) failed in their assessment of an initial application and decision on material variations, to demonstrate that contemporary consideration was given to the materiality of the changes and whether further neighbour notification should be carried out (upheld); and
• (c) in their assessment of a second application failed to consider whether a report on environmental issues remained valid, the effect on Mr C's property of the changes, whether the application was properly described and whether the sprinkler tank complied with Council policy and design guidance (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) apologise to Mr C for the identified shortcomings in dealing with his correspondence and complaint and for the inadequacies in record-keeping; and
• (ii) assess whether there are in fact any noise problems emanating from the plant buildings, and if so, approach the superstore company.

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

Overview
The complainant, Mrs C raised a number of concerns about the way in which her husband (Mr C) was cared for and treated while he was a patient in Queen Margaret Hospital, Dunfermline.

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

• (a) there was a lack of urgency and avoidable delays in investigating Mr C's condition and providing him with a definitive diagnosis (upheld);
• (b) there were avoidable delays in chasing up test results from Royal Infirmary Edinburgh following Mr C's mediastinoscopy on 15 March 2010 (upheld);
• (c) there was unnecessary delay in referring Mr C to the Western General Hospital (not upheld);
• (d) it was unnecessary and inappropriate to move Mr C so often (upheld); and
• (e) staff attitude was unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that Fife NHS Board (the Board):

• (i) apologise to Mrs C for their delays in this matter;
• (ii) arrange for the Urology MDT cancer network to review this case and act upon any recommendations made;
• (iii) look at their monitoring and follow-up procedures with a view to making them more robust;
• (iv) formally apologise to Mrs C for moving Mr C 13/14 June 2010; and
• (v) consider their own bed transfer policy and practice with regard to the findings of this part of the complaint and to ensure that they are appropriate.

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

Overview
The complainant (Mrs C) raised a number of concerns about the investigation and diagnosis of her sister (Mrs A)'s breast cancer by Mrs A's GP practice (the Practice) from May 2010 until November 2010.

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

• (a) the Practice failed to investigate Mrs A's symptoms properly within a reasonable time (upheld);
• (b) the failure by the Practice to diagnose Mrs A's condition was not reasonable (not upheld); and
• (c) the Practice failed to refer Mrs A to hospital within a reasonable time (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) undertake a further Critical Event Analysis of Mrs A's care to consider their care of patients with cancer, particularly around presentations which may signal metastatic disease; and
• (ii) apologise to Mrs A and her family for the failures identified.

The Practice have confirmed they will act on the recommendations accordingly.

Overview
The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her late mother (Mrs A) during an admission to Queen Margaret Hospital in Dunfermline (the Hospital) between 12 April 2010 and her death on 5 May 2010.

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

• (a) failed to continue with antibiotic treatment after the course of Amoxicillin (an antibiotic) was completed at 22:00 on 1 May 2010, despite Mrs A's rapidly deteriorating condition (upheld);
• (b) failed to act on the concerns Mrs C raised on 2 May 2010 (upheld);
• (c) were unaware that Mrs A was expectorating thick green sputum (matter coughed up from the lungs) on 1 May 2010, when this is documented in the medical records (upheld);
• (d) failed to inform Mrs C about Mrs A's deteriorating condition (upheld);
• (e) failed to ensure that oral medication administered to Mrs A when she was in a semi-conscious state did not remain in her mouth from 08:00 on 5 May 2010 until Mrs C pointed this out at 14:00 on 5 May 2010 (not upheld);
• (f) failed to provide an Incident Report regarding when Mrs A was inappropriately handled and spoken to (upheld);
• (g) failed to ensure complaint (f) was investigated (upheld);
• (h) disagreed about the cause of death after the Death Certificate was issued and registered (not upheld); and
• (i) made inconsistent statements in their original complaint response to those made at a face-to-face meeting - specifically about the presence of infection (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide me with an update regarding their implementation of the measures described in their letter to my office dated 24 March 2011;
• (ii) review the means by which the clinical judgements of HAN members who see patients independently are monitored;
• (iii) conduct a review of information handover from team to team, with a view to identifying how this can be strengthened;
• (iv) consider Adviser 2's comments on the failings in Mrs A's nursing care and draw up and implement an action plan to address these failings;
• (v) apologise to Mrs C for the failure to investigate complaint (f) properly;
• (vi) ensure that serious complaints are appropriately recorded and investigated;
• (vii) inform me of the outcome of their discussions with regard to completing death certificates and tell me what measures they have taken to ensure that, in future, the cause of death listed on a death certificate is accurate; and
• (viii) ensure that clinical records are thoroughly reviewed as part of their investigation process and prior to providing responses to complaints.

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

Overview
The complainant (Mrs C) raised a number of concerns about delays and failures in the care and treatment provided to her mother (Mrs A) by a medical practice (the Practice) between November 2009 and August 2010. Mrs C was also dissatisfied with aspects of the Practice response to her complaints.

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

• (a) the care and treatment which the Practice provided to Mrs A between late 2009 and August 2010 was inadequate (upheld);
• (b) the Practice did not take reasonable action in response to information provided about planned investigations of Mrs A's health (not upheld); and
• (c) the Practice response to Mrs C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A for their failure to reasonably assess and oversee her care and treatment in 2009 and 2010;
• (ii) ensure that their GP records accurately reflect and define patients' symptoms and consultants' findings as part of the on-going diagnostic process; and
• (iii) apologise to Mrs A and Mrs C for the failure to adequately address the complaint.

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

Overview
The complainant (Ms C) raised concerns about the care and treatment provided by her GP Practice (the Practice) over a two-year period in that the Practice failed to act on the 'red flag' symptoms she had of a brain tumour within a reasonable time and diagnose her condition.

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

• (a) the Practice failed to properly investigate Ms C's symptoms within a reasonable time; (upheld) and
• (b) the failure by the Practice to diagnose Ms C's condition was not reasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) review their practice to ensure they refer for specialist advice within a reasonable time;
• (ii) ensure their record-keeping complies with General Medical Council guidance;
• (iii) update their knowledge of diagnosis and management of persistent upper limb symptoms; and
• (iv) apologise to Ms C for the failures identified.

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

Overview
In February 2010, the complainant (Mrs C)'s late mother (Mrs A) was admitted to Drumcarrow Lodge of Stratheden Psychiatric Hospital (the Hospital). She was hearing voices and suffering from hallucinations and paranoia. Mrs A was discharged from the Hospital on 31 May 2010 after her mental health problems had been resolved. However, Mrs C alleged that the Hospital paid scant regard to Mrs A's physical condition and did not assess this properly before her release. Mrs A died from heart failure on 5 June 2010 after an emergency admission to Ninewells Hospital, Dundee, on 2 June 2010. Mrs C submitted a formal complaint about the way the Hospital dealt with Mrs A's physical care and treatment but she alleged that the responses she received were unreasonable.

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

• (a) physical care and treatment of Mrs A, while she was a patient at the Hospital, were unacceptable (upheld); and
• (b) responses to Mrs C's complaints about Mrs A's physical care and treatment were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) offer Mrs C a full and sincere apology for their failures with regard to Mrs A's treatment;
• (ii) share this report with the team involved and with the Consultant Psychiatrist and remind him of his overall responsibilities in such cases;
• (iii) look into the process of issuing referral letters, to ensure that any failures to respond are chased up and into the fact that a letter appeared to have been signed by a trainee psychiatrist when she was on holiday;
• (iv) apologise to Mrs C for their failures with regard to the investigation of her complaint; and
• (v) review the rigour of their complaint handling process, with particular relevance to timescale and investigative thoroughness.

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

Overview
The complainant (Mr C) complained that, as a result of his GP Practice (the Practice) failing to act on his enquiries about a follow up chest scan, there was an 18 month delay in him receiving the scan. When the scan was eventually performed he was diagnosed with lung cancer, and underwent surgery shortly thereafter.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay between November 2008 and May 2010, caused by the Practice, in Mr C receiving an MRI scan (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) conduct a Significant Event Analysis on this case;
• (ii) ensure that the GP discuss this case with his appraiser at his next GP appraisal; and
• (iii) provides Mr C with a full apology for the failures identified within this report.

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