Mid Scotland and Fife

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her late husband (Mr C) about delays in him receiving an appointment from Hairmyres Hospital (the Hospital) to have his abnormal bowel symptoms investigated.  Mrs C also complained about the lack of information given to Mr C about delay in a sigmoidoscopy (a procedure to investigative the bowel) going ahead at the Hospital’s Day Surgery Unit.

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

• (a) there was an unreasonable delay in offering appointments following a GP referral on 31 March 2011 (upheld); and
• (b) Mr C was kept waiting for an unreasonable length of time when he attended the Day Surgery Unit (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• share the failings in this case with the Patient Focus Booking Service;
• as a matter of urgency, audit a sample of patients that have been removed from the waiting list for not responding to the Patient Focus Booking Service to ensure the appointment protocol has been followed.  In addition, consider changes to the protocol to prevent the error recurring;
• provide evidence to show that the lack of communication regarding the delay and postponement in the sigmoidoscopy going ahead has been fed back to relevant staff; and
• apologise to Mrs C for the failings identified in this letter.

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

Overview
The complainant (Mr C) raised concerns about the time it took to diagnose Mr A with liver cancer.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay in diagnosing that Mr A was suffering from liver cancer (upheld).

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

• review their processes for communicating abnormal results to include referral to an appropriate lead clinician in the hospital as well as the referring doctor in light of the Medical Adviser's comments; and
• apologise for the failures identified.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late mother (Mrs A) in Stirling Royal Infirmary (the Hospital) between 21 and 23 February 2011.  This included Mrs C's concerns: that hospital staff incorrectly diagnosed Mrs A with dementia rather than delirium, and failed to obtain proper consent for surgery; about how Mrs A's urinary tract infection was treated; and, about how Forth Valley NHS Board (the Board) responded to Mrs C's complaint.

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

• (a) the Board failed to explain how their diagnosis of dementia was reached (upheld);
• (b) the diagnosis of dementia was inappropriately used to obtain consent for an operation (upheld);
• (c) the approach to managing Mrs A's urinary tract infection was inappropriate (upheld); and
• (d) there was a failure to accept clinical failings or offer an apology despite the findings of an external review (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for incorrectly diagnosing Mrs A with dementia, and incorrectly completing a Certificate of Incapacity to obtain consent for Mrs A's operation;
• apologise to Mrs C for the poor standard of care provided to Mrs A;
• review their provision of specialist ortho-geriatric care for patients like Mrs A, who commonly present with fractures but have other medical conditions that need to be managed in an orthopaedic ward;
• apologise to Mrs C for their handling of her complaint, in particular their failure to accept the findings of the external review they commissioned; and
• carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Mrs A, the handling of Mrs C's complaint, and their response to the external review they commissioned.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment her son (Master A), then six and a half years old, received from the GPs at Master A’s medical practice (the Practice) from May to August 2011.  Master A subsequently attended Ninewells Hospital in Dundee and then the Royal Hospital for Sick Children in Edinburgh, where he was diagnosed with cancer (Burkitt's Lymphoma stage IV).  He received treatment but, sadly, died.

Specific complaints and conclusions
The complaints which have been investigated are that from May 2011 GPs at the Practice:

• (a) failed to provide Master A with appropriate clinical treatment in view of his reported symptoms (upheld); and
• (b) unreasonably delayed referring Master A for a specialist hospital opinion (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  provide Mrs C and her husband with a written apology for the failings identified in this report; and
• (ii)  provide my office with evidence that this case has been discussed with all GPs involved as a learning tool and that all learning points are taken forward as part of their continuous professional development.

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

Overview

The complainant (Mrs C) said that she and four of her family members were inappropriately removed from their GPs'' list.  Mrs C said that she had not received a warning that they were to be removed from the list.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C considers that she and four of her family members were inappropriately removed from their GPs'' list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) put a process in place to ensure that the relevant regulations and guidance are adhered to before they ask for a patient to be removed from their list; and
• (ii) apologise to Mrs C for not adhering to the relevant regulations and guidance before asking for her and her family members to be removed from their list.

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

Overview
The complainant (Mr C) raised a number of concerns that his mother (Mrs A) had received inadequate care and treatment in October 2011 resulting in a failure to diagnosis kidney failure or admit Mrs A to hospital.  Mrs A subsequently died on 2 November 2011.

Specific complaint and conclusion
The complaint which has been investigated is that between September 2011 and October 2011, doctors at Mrs A’s medical practice (the Practice) failed to take into account Mrs A's symptoms, previous medical history and family concerns and that they did not arrange an emergency hospital admission (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• review the GMC Guidance on record-keeping and evaluate a sample of their case notes to see if they are fulfilling the required standards;
• review with the doctors involved in Mrs A's care the SIGN guidance on chronic kidney disease and its management and identify this as a learning need within their appraisals;
• discuss this complaint and its evaluation with the doctors involved in Mrs A's care in their yearly appraisal;
• carry out a significant event analysis of this incident and discuss the results within the practice team; and
• apologise sincerely to Mr C and his family for the failures in the care and treatment provided to Mrs A.

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

Overview
Mr C, who was a prisoner, complained to HMP Glenochil (the Prison) about the unreasonable delay in finalising his post programme report for the Core Sex Offender Treatment Programme.  In addition, Mr C complained that the Prison failed to take appropriate steps to resolve his complaint.

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

• (a) there was an unreasonable delay in completing Mr C's post programme report (upheld); and
• (b) the Prison failed to take appropriate steps to resolve Mr C's complaint (not upheld).

Redress and recommendations
The Ombudsman recommends that the Scottish Prison Service (SPS):

• (i)  review the current resourcing and management of Sex Offender Treatment Programmes to ensure appropriate steps can be taken to avoid unnecessary delays in completing post programme reports.

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

Overview
The complainant (Mr C) complained about the manner in which the University of Stirling (the University) investigated an allegation of plagiarism in relation to his son (Mr A)’s dissertation. The University's Appeal Panel found there were errors in the way the allegation had been raised with Mr A and had offered him the opportunity to attend a further meeting about it. However, Mr C thereafter complained about the manner in which the University had subsequently added an addendum to the minutes of the Exam Board relating to Mr A's dissertation which stated that it had failed on academic grounds in any event. Mr C also complained about the manner in which the University handled Mr A's subsequent complaint about the addendum.

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

1. the University unreasonably and unfairly conducted an inquiry into Mr A's alleged plagiarism as part of a viva examination (upheld);
2. having accepted that the alleged plagiarism was not investigated reasonably and fairly, the University then unreasonably added an addendum to the minute of the Exam Board meeting to imply academic failing without explanation or evidence (upheld);
3. the University unreasonably failed to inform Mr A about the addendum until he requested a meeting to discuss the alleged plagiarism (upheld);
4. the University unreasonably failed to investigate a formal complaint against the addendum to Mr A's satisfaction and refused to allow his complaint to proceed to a Complaints Panel (upheld); and
5. the University unreasonably failed to grant the outcome sought by Mr A when his appeal was upheld (not upheld).

Redress and recommendations
The Ombudsman recommends that the University:

1. make provisions for an independent re-assessment of the dissertation;
2. if required following the re-assessment of the dissertation, re-consider referral of Mr A's complaint to a Complaints Panel;
3. provide evidence to the Ombudsman of the steps taken by the University to implement improvements, as referred to in the Acting Academic Registrar's letter of 9 December 2011;
4. review their Academic Complaints Policy to consider a timescale for response, clarity in relation to sections 11.3.9 and 11.3.10, to ensure there is a procedure in place to follow up on complaints allocated for investigation, and to ensure that responses address the substantive issues raised in complaints; and
5. issue a full apology to Mr A for the failings identified within this report.

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

Overview
The complainant (Mrs C) raised a number of concerns that her late father (Mr A) received inadequate care and treatment while in hospital being treated for dizziness; a swollen leg; a 'blister' on his left big toe; and a general feeling of being unwell and tired.  Mrs C also complained that Mr A's falls risk was not properly assessed and monitored, resulting in a fall that caused a broken hip.  Mr A then waited some 54 hours before his broken hip was surgically repaired.  Mr A died in hospital nine days after his surgery.

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

• (a) unreasonably failed to reassess Mr A's falls risk when staff were informed that he had already fallen on the ward (upheld);
• (b) unreasonably delayed in taking Mr A to theatre when he fell and fractured his hip (not upheld);
• (c) failed to appropriately manage Mr A's intake of food and fluids (upheld); and
• (d) failed to communicate appropriately with the family following Mr A's death (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provides evidence that the falls risk assessment policy and procedures on the ward have been appropriately reviewed and any learning points form part of an action plan for improvement;
• (ii)  ensures that all nursing staff are fully aware of and trained in compiling falls risk assessments and the on-going monitoring of patients at medium or high risk;
• (iii)  reviews their procedures for assessing and monitoring patients awaiting surgery to ensure that a co-ordinated multi-disciplinary team approach is taken;
• (iv)  ensures that all staff are made aware of the importance of food and fluid intake management and take appropriate steps to ensure that patients are appropriately monitored;
• (v)  remind all staff of the importance of communicating effectively with patients, relatives and/or carers on all aspects of care, including food and fluid management;
• (vi)  ensures that all staff are made aware of the importance of good communication with families at all times, especially following a bereavement and considers providing training where necessary;
• (vii)  ensures that all staff are aware of the rules on reporting cases to the Procurator Fiscal's Office (PFO) and pass this information on to families where appropriate; and
• (viii)  considers making the leaflet 'What to do after a death in Scotland' available where appropriate.

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

Overview
The complainant (Mr C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing his lung cancer and about the way that the diagnosis was communicated to him.  Mr C had been attending the Neurology Department at Monklands Hospital (Hospital 1), when a Computerised Tomography (CT) scan at Southern General Hospital in May 2012 showed a suspected nodule in his lung.  A second CT scan was requested in June 2012, but Mr C was not told about the suspected nodule in his lung.  On 14 August 2012 Mr C was attending his GP Practice about another matter, when he was informed that the May CT scan had shown a possible diagnosis of cancer.  There were repeated delays in arranging the second CT scan and Mr C did not undergo this CT scan until 7 September 2012 at Hairmyres Hospital, despite both he and his GP pursuing the matter.  Following the second CT scan, Mr C was not seen by the Neurology department until 18 September 2012, when he was told it was almost certain that he had cancer.  He was then seen by a respiratory consultant on 3 October 2012, and a biopsy was carried out on 4 October 2012.  It was confirmed to Mr C that he had cancer of the lung on 15 October 2012.

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

• (a) the Board failed to carry out appropriate tests in order to diagnose Mr C’s condition within a reasonable timescale (upheld); and
• (b) the Board failed to keep Mr C reasonably informed about the results of his tests (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  confirm when the order-comms system will be fully operational in all the hospitals they are responsible for;
• (ii)  provide evidence that they have reviewed with the clinical staff involved why no report of the failures identified in this report was made on the Datix system;
• (iii)  provide evidence that they have carried out a Critical Incident Review;
• (iv)  review the arrangements for providing cover for absent staff to ensure that urgent test results are reviewed timeously;
• (v)  review the procedures within the Radiology Department at Hospital 1 to ensure that urgent test requests are identified and treated appropriately to avoid undue delay to patients;
• (vi)  provide evidence that clinical staff have been reminded of the importance of effective communication with patients, especially when there may have been changes to their diagnosis; and
• (vii)  apologise in writing for the failures identified in this report.

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