Mid Scotland and Fife

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their baby daughter (Baby C) and Forth Valley NHS Board (the Board)'s failure to diagnose meningitis and hydrocephalus when she was seen by clinicians at Stirling Royal Infirmary (Hospital 1) on
20 September 2007.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care and treatment to Baby C on 20 September 2007 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr and Mrs C for the failings identified in this report;
(ii) carry out a root cause analysis of the inadequate assessment on
20 September 2007. This should explore why the obvious concerns of the GP were not addressed by the junior paediatricians. It should also establish whether the staff grade doctor involved in the decisions was sufficiently trained and experienced to be in this position of responsibility. The Board should then give consideration to further training for the relevant staff in light of the results of their analysis of the case. They should also provide Mr and Mrs C with a full and detailed explanation of their findings and the steps that will be taken to prevent recurrence; and
(iii) note the specialist medical adviser's comments that a cranial ultrasound scan should have been performed on 20 September 2007 to exclude a build up of fluid in the brain.

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

Overview
The complainant (Miss C) raised a number of concerns regarding the treatment her late mother (Mrs A) received at Wishaw General Hospital (the Hospital). Miss C was unhappy with the level of nursing care which Mrs A received, specifically in relation to a fall she suffered in the early hours of the morning following her admission. Miss C also raised concerns regarding numerous cancellations of the proposed surgery to address damage suffered to Mrs A's femur during her fall.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the standard of nursing care provided was inadequate (upheld); and
(b) the decisions to cancel surgery were unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board (the Board):
(i) undertake an urgent investigation into the nursing staff's failure to follow the correct procedure when administering a controlled substance;
(ii) implement an action to address the failure to assess Mrs A's pain, using the Modified Early Warning System tool;
(iii) implement a formal bed move policy which restricts any avoidable movement of vulnerable patients;
(iv) clarify their policy on nursing confused patients, providing a copy of a relevant risk assessment for patients' mental capacity, along with an appropriate nursing action plan, to be adopted following a diagnosis of confusion;
(v) remind staff of the importance of frequent vital observations, particularly after incidents where patients have sustained head injuries;
(vi) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in this report;
(vii) apologise to Miss C for the failings which have been identified in this report; and
(viii) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective.

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

Overview

The complainant (Mr C) raised a number of concerns about the treatment which he had received from clinicians for a finger injury following an assault on 10 June 2007. Mr C said that a consultant orthopaedic surgeon had failed to amputate a sufficient amount of the damaged finger and that this had hampered his ability to continue with his employment as an electrician. In addition, Mr C complained that another consultant orthopaedic surgeon had agreed to further amputate the finger if alternative therapy did not work but then subsequently denied that he had promised this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the clinicians failed to obtain informed consent prior to surgery (upheld);
• (b) the decision not to provide the level of amputation requested by Mr C was unreasonable (not upheld); and
• (c) the overall treatment provided by the clinicians was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board):

• (i) apologise to Mr C for not obtaining informed consent; and
• (ii) consider whether procedures require to be amended, so that the surgeon is available at the pre-assessment clinic to discuss the level of amputation which is planned and to take consent.

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

Overview

The complainant (Ms C) raised concerns regarding the care package provided to her sister (Ms A) that was co-ordinated by North Lanarkshire Council (the Council). She believed that the number of hours care was not adequate to meet Ms A's needs, and that care providers were wrong in their view that Ms A could make decisions for herself.

Specific complaint and conclusion

The complaint which has been investigated is that Ms A was not receiving a care package that was adequate for her needs (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council and Ms C enter into constructive dialogue to resolve any outstanding issues and to deal with future changes to Ms A's care package, to help all involved understand the issues and gain reassurance about the support being provided. This would, of course, take place only with Ms A's consent in the light of the Council's stated responsibility to give primary consideration to Ms A's needs and wishes.

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

Overview

The complainant (Mrs C) was aggrieved that South Lanarkshire Council (the Council) unreasonably awarded her tenant (the tenant) empty property relief for the property she owned after she had been awarded it, and while he was continuing to use the premises for storage purposes. She complained that she was not notified that she was no longer entitled to the three month exemption period or that the tenant had been awarded the relief. She further complained that the Council were pursuing her for monies she did not owe.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Council unreasonably awarded empty property relief to the tenant after Mrs C had already been awarded it (not upheld);
• (b) the Council's decision to award empty property relief to the tenant was wrong because he was using the premises for storage purposes and they were not empty (partially upheld to the extent that the Council did not make more reasonable enquiries beforehand to inform their decision making process on how to classify a property as 'empty');
• (c) the Council incorrectly interpreted The Non-Domestic Rating (Unoccupied Property) (Scotland) Regulations 1994 (the Regulations) to mean 'non-trading' (partially upheld to the extent that the Council did not make more reasonable enquiries beforehand to inform their decision making process on how to classify a property as 'unoccupied');
• (d) the Council failed to notify Mrs C that the tenant had been awarded the relief (upheld);
• (e) the Council's application form is misleading as it refers to 'empty property' rather than 'unoccupied' and does not warn applicants that they may lose the exemption if someone with a prior interest in the property makes a successful application at a later date (upheld); and
• (f) the Council wrongly continued to pursue Mrs C for the £343.51 they alleged she owed (not upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) take the issue of non-domestic rates for discussion to the Scottish Association of the Institute of Revenues, Rating and Valuation (IRRV) before making any changes to their current procedures;
• (ii) should conduct a full review of their policies and procedures on this matter, following discussion with the IRRV, and provide clear guidance notes for staff to ensure that customers are kept informed of any changes to awards already made; and
• (iii) amend their application form to explain the definition of unoccupied property relief and include appropriate caveats/warnings. Rating notices should similarly be reworded to avoid confusion.

The Council have accepted the recommendations and will act on them accordingly. I am pleased to note that, before the report was published, the Council accepted my recommendation that they write off the £343.51 Mrs C owed. This was in recognition of the fact that they intend to review their practices and procedures on non-domestic rates in light of this complaint, and in recognition of the poor customer service Mrs C received.

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment of his 86-year-old father (Mr A) at one of the hospitals of Forth Valley NHS Board (the Board), Stirling Royal Infirmary (the Hospital), between his admission, following a fall, and his death there, several months later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) aspects of the care and treatment fell below a reasonable standard (not upheld); and
• (b) the Board's handling of the complaint fell below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the psychiatric care and treatment of her late husband (Mr C) who suffered from bi-polar affective disorder.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's GP Practice failed to properly monitor his lithium levels (not upheld);
• (b) Forth Valley NHS Board (the Board) inappropriately discharged Mr C from psychiatric care (upheld);
• (c) the Board failed to provide Mr C with appropriate psychiatric care from October 2005 to October 2006 (not upheld); and
• (d) the Board failed to take Mrs C's input on Mr C's psychiatric condition and requirements (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) develop more effective and practical policies for dealing with a breakdown in doctor-patient relationships and for referring patients between services; and
• (ii) apologise to Mrs C for discharging Mr C without ensuring that necessary support mechanisms were in place.

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

The Ombudsman has no recommendations in respect of Mr C's GP Practice.

Overview

The complainant, Mrs C, raised several concerns about the care and treatment provided to her mother (Mrs A) at Stirling Royal Infirmary, following her admission on 29 May 2006. Mrs A did not respond to treatment and the decision was taken to pursue palliative treatment only. Sadly, Mrs A died on 7 June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was proposed, inappropriately, to send Mrs A to a ward where her family could not be guaranteed to have access to her at all times (upheld);
• (b) the bed managers initiated inappropriate conversation in Mrs A's room (upheld);
• (c) when Mrs A moved from a High Dependency bed, intravenous medication was stopped and no adequate alternative medication was arranged (upheld);
• (d) medical staff failed to review Mrs A's medication (upheld);
• (e) the response to Mrs C's complaint was inadequate and did not address her concerns (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Mrs C for the shortcomings identified in this report and specifically for the actions of the bed managers;
• (ii) review the operation of the Palliative Care Manual in relation to the bed management of terminally ill patients;
• (iii) ensure that this incident is discussed at the bed managers' annual appraisals;
• (iv) remind staff of the importance of documenting concerns raised by patients and their families in the patient's clinical records;
• (v) review their pain management documentation and recording;
• (vi) demonstrate how they will ensure that the two documents Living and Dying Well and Palliative and End of Life Care in Scotland can be implemented and that such change in practice can be reviewed by all hospital staff on a regular basis;
• (vii) conduct an audit in prescription chart recording over a six month period;
• (viii) ensure that night staff recognise when there is a need to contact on call staff to review medication for patients in pain; and
• (ix) ensure that information is obtained from the staff involved to allow complaints to be investigated appropriately and all issues raised in complaints are addressed.

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

Overview

The complainant (Mrs C) raised a number of concerns about the quality and quantity of information provided to her late daughter (Miss C) following her diagnosis of epilepsy in April 2006. Mrs C considered that Miss C was denied an opportunity to fully understand the consequences of not taking her prescribed medication on a regular basis and that this may in turn have contributed to Miss C's premature death.

Specific complaint and conclusion

The complaint which has been investigated is that Fife NHS Board (the Board) failed to provide Miss C with adequate information thereby denying her appropriate care and management between April 2006 and her death in October 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide written information to patients following diagnosis on a proactive basis and in line with that recommended in SIGN 70;
• (ii) advise her when the epilepsy nurse-specialist is in post; and
• (iii) apologise to Mrs C that written information about Miss C's condition and changes in her drug regime were not made available to Miss C and that there is no evidence of an individualised decision being made not to tell Miss C about Sudden Unexpected Death in Epilepsy.

The Board have accepted and acted on recommendations (i) and (ii). Recommendation (iii) has not been accepted (see paragraph 48).

The Ombudsman will ask the Scottish Intercollegiate Guidance Network (SIGN) to consider the findings of this report as part of their on-going consideration of the review of the guidelines on Epilepsy in Adults (SIGN 70). Further, in light of the difference in views recognised in paragraph 48, the Ombudsman will ask that the Directorate of Health and Wellbeing consider the need for more research into patient views on information giving and into the possible risk factors for SUDEP and the use of this research to inform ethical guidance.

Overview

The complainant Mrs C raised a number of concerns about the care and treatment provided to her daughter (Ms A) who had mental health problems. Ms A's treatment was provided by Clinical Psychologists and was then transferred to a Community Psychiatric Nurse.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms A's treatment from the Clinical Psychologists was withdrawn inappropriately (not upheld); and
• (b) explanations provided to Mrs C and Ms A were inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Mrs C and Ms A for the failures identified in this report;
• (ii) remind staff that clinical decisions should be documented and of the importance of doing this; and
• (iii) remind staff that adequate explanations of clinical decisions need to be provided to patients.

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