North East Scotland

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Greater Glasgow and Clyde NHS Board – Acute Services Division (the Board).

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

• (a) staff failed to provide Mr C with timely and adequate pain relief when he reported problems with his catheter (upheld);
• (b) staff inappropriately discharged Mr C from hospital when he was suffering from a high temperature and wound infection (not upheld);
• (c) staff failed to ensure that an adequate home care package was in place on discharge from hospital, including palliative care, or provide advice about agencies which could assist if required (upheld);
• (d) the level of communication between staff and Mr C's family was inadequate (upheld); and
• (e) on 15 and 16 July 2011, Out-of-Hours Service GPs failed to adequately assess Mr C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make Mrs C a formal apology for their shortcoming in this matter and for the distress she and her family have suffered;
• (i) emphasise to all the staff involved, the importance of keeping full and timely notes;
• (ii) review the circumstances of complaint (a) and demonstrate to the Ombudsman that they have a programme in place to prevent such a situation occurring again;
• (iii) make specific apology to Mrs C for failing to make proper arrangements for Mr C's care and support on his discharge from hospital;
• (iv) in the wards concerned, review the procedures for patients' discharge to satisfy themselves that appropriate action is taken;
• (v) make a specific apology for their failure to communicate adequately; and
• (vi) taking into account the failures in communication, the Board should demonstrate to the Ombudsman the action to prevent such a situation occurring again.

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

Overview
The complainant (Ms C) complained that Greater Glasgow and Clyde NHS Board (the Board) failed to take appropriate action when her family reported that her daughter (Miss A) was suffering from mental health problems. Miss A subsequently jumped from a window in her fourth-floor flat. She suffered serious injuries to her lower body.

Specific complaint and conclusion
The complaint which has been investigated is that Community Psychiatric Nurses (CPNs) failed to take appropriate action to safeguard Miss A when it was reported that she was suffering from mental health problems (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a written apology to Ms C for the failure to carry out a reasonable telephone assessment when they spoke to Miss A and for the failure to raise concerns with a Mental Health Officer;
• (ii) review how risk is assessed and recorded in relation to telephone assessments in such circumstances to try to ensure as far as possible that patients assessed over the telephone receive the same quality of assessment as those spoken to face-to-face; and
• (iii) clarify to relevant staff the criteria or threshold regarding when concerns should be raised with a Mental Health Officer.

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

Overview
The complainant (Mrs C) raised a number of concerns against Greater Glasgow and Clyde NHS Board (the Board) that her late father (Mr A) had been inappropriately cared for by nursing staff in Dunrod F Ravenscraig Hospital (the Hospital) from 2 February 2011 up to his death on 24 April 2011.

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

• (a) nursing staff unreasonably failed to monitor and maintain Mr A's fluid levels (not upheld);
• (b) nursing staff unreasonably failed to deal with incontinence issues (not upheld);
• (c) nursing staff unreasonably failed to maintain a reasonable level of hygiene for Mr A (upheld);
• (d) there were inadequate transfer systems and documentation in place (upheld);
• (e) there was poor communication from staff (not upheld);
• (f) nursing staff unreasonably failed to pass on information to the relevant Social Work team when Mr A was transferred and this delayed the process of establishing a suitable nursing home for him to go to (not upheld);
• (g) inadequate attention was paid to Mr A's dignity by ensuring that his clothing was appropriately attended to (upheld); and
• (h) the investigation of Mrs C's complaint to the Board was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feed back the learning from this to nursing staff to avoid similar situations recurring;
• (ii) provide him with an update on the actions they have taken to ensure such an incident does not recur;
• (iii) ensure that communication between family members and staff are appropriately recorded;
• (iv) ensure that measures are taken to feed back the learning from this to complaints investigation staff to avoid similar situations recurring; and
• (v) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Ms C) complained about the lack of communication with her family after her mother (Mrs A) was admitted to the Emergency Department in the Victoria Infirmary in Glasgow (the Hospital). Mrs A was 84 years old and had a history of dementia. The family were not told that Mrs A's condition in the Hospital had deteriorated. Mrs A subsequently died and Ms C considers that the family lost the opportunity of being with Mrs A at the end of her life.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's lack of communication with the family just before Mrs A's death was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a written apology to Ms C for the failure to inform her of the deterioration in her mother's condition; and
• (ii) provide him with an action plan and / or steps in place to ensure communication with relatives and carers is addressed within the Emergency Department.

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

Overview
The complainant (Ms C) raised a concern that undue pressure was put on her to take prophylactic antibiotics during her labour by staff at the Southern General Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that Ms C was unreasonably bullied into taking prophylactic antibiotics (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) bring this report to the attention of relevant staff including the second registrar to ensure lessons are learned and highlight the relevant guidelines and guidance on group B streptococcus and consent;
• (ii) review the guidance on group B streptococcus to clarify the limited circumstances where a child protection order should be considered;
• (iii) consider a multi-disciplinary approach involving obstetricians and paediatricians when a patient refuses treatment in similar situations; and
• (iv) apologise to Ms C.

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

Overview
The complainant (Mr C) complained about a significant pressure ulcer he developed after being admitted to Perth Royal Infirmary (the Hospital). Mr C said that the pressure ulcer affected his quality of life because he had to endure an extended period of bed rest.

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

• (a) Mr C was provided with inadequate care and treatment which allowed him to develop a pressure ulcer (upheld); and
• (b) there was a failure to deal with his complaint appropriately (upheld).

Redress and recommendation
The Ombudsman recommends that Tayside NHS Board:

• (i) ensure their tissue viability training programme provides education and training for the assessment, grading and treatment of pressure ulcers in line with national guidance;
• (ii) undertake an audit of wards within the Hospital to ensure pressure ulcer care and management is in line with national guidance and best practice; and
• (iii) provide details of the outcome of their review of their complaints procedure to ensure investigations are evidence based and undertaken without undue delay.

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

Overview
The complainant (Ms C) raised a number of concerns about the diagnosis of her brother (Mr A)'s cancer. She complained that the health centre Mr A attended (the Practice) situated in the Greater Glasgow and Clyde NHS Board area, failed to take Mr A's complaints of back pain and reduced mobility seriously and that their lack of proactive investigation of his symptoms meant that Mr A's diagnosis was delayed. Ms C also complained about the Practice's handling of her formal complaint.

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

• (a) provided Mr A with inadequate care and treatment during the months prior to his death on 26 January 2011 (upheld); and
• (b) dealt inadequately with Ms C's subsequent complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) consider Mr A's case with a view to improving their procedures for proactively ensuring the completion of diagnostic investigations which have been identified as necessary for their patients;
• (ii) draw all GPs' attention to the Adviser's comments regarding record-keeping;
• (iii) review the outcome of this complaint alongside their complaint procedure to avoid similar situations recurring;
• (iv) apologise to Ms C and her family for the failings identified in this report.

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

Overview
The complainant (Mr C) complained about Glasgow City Council (the Council)'s handling of financial assessments carried out for his parents, both of whom required residential care. Mr C's complaint was considered by a Social Work Complaints Review Committee. However, they declined to comment on the substantive part of his complaint. Mr C complained that there was no mechanism for appealing the original decision which he felt was made improperly. He also raised concerns about the Council's communication.

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

• (a) the Council unreasonably failed to properly apply the Charging for Residential Accommodation Guidelines rules in respect of both Mr C's mother's and father's circumstances (not upheld);
• (b) the Council unreasonably excluded the substantive decisions on financial assessments and interpretation of Charging for Residential Accommodation Guidelines from the remit of the Complaints Review Committee (upheld);
• (c) the Council unreasonably failed to inform Mr C that the substantive element of his complaint would not be considered by the Complaints Review Committee, despite his making it clear that that was what he wanted to be addressed (upheld);
• (d) given that the Complaints Review Committee excluded the matters, the Council has unreasonably failed to put in place a proper review or complaints process for Social Work Services' substantive decisions on financial assessments and interpretation of Charging for Residential Accommodation Guidelines (upheld); and
• (e) following the Complaints Review Committee which upheld Mr C's complaint about failures of communication, the Council continued to demonstrate significant failures in communication (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) take steps to inform any complainants progressing to review by a CRC of the extent of the CRC's remit and powers;
• (ii) ensure that CRC members have appropriate training and access to expert advice to deal with all matters presented to them;
• (iii) arrange for Mrs A's financial assessment to be independently reviewed; and
• (iv) apologise to Mr C for the failings identified in this report.

Overview
The complainant (Ms C) raised a number of complaints with Grampian NHS Board (the Board) about the care and treatment she received whilst being treated as an in-patient at Brodie Ward (the Ward) at the Royal Cornhill Hospital (the Hospital) in Aberdeen in 2010. She was dissatisfied by the Board's response to her complaints.

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

• (a) the care and treatment provided to Ms C on her admission to the Ward of the Hospital on 5 February 2010 was inadequate; (upheld)
• (b) the observations levels to which Ms C was subjected and the locking of the Ward door at night were inappropriate; (upheld)
• (c) there were communication issues during Ms C's stay on the Ward: including that she had difficulty in speaking to her named nurse; and that she was given inappropriate 'advice' on self-harming by a Staff Nurse (Staff Nurse 1); (upheld)
• (d) inadequate care and treatment was provided to Ms C after she took an overdose on 24 February 2010; (upheld)
• (e) it was unreasonable that on the occasions that Ms C expressed a desire to leave hospital she was 'threatened' with formal detention; (upheld)
• (f) the action taken following the incidents on 1 and 4 March 2010 was inappropriate and inadequate; (upheld)
• (g) staff on the Ward had an unreasonable approach to weight/body mass index (BMI) policy; (upheld) and
• (h) the Board unreasonably delayed in responding to the complaint made by Ms C on 25 May 2010. The Chief Executive did not respond until almost four months later on 6 September 2010. (upheld)

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman that interim care plans are developed for patients on admission to the Ward, and that all appropriate documentation within patient records is being completed;
• (ii) develop a search policy to provide guidance to staff on the issues of patient dignity and safety;
• (iii) review their observation policy to take cognisance of the shortcomings identified, and ensure that the observation policy leaflet for patients is finalised and distributed to all patients on the Ward;
• (iv) review their policy in relation to door locking on the Ward at night to take into consideration the additional issues highlighted;
• (v) provide evidence to the Ombudsman of staff training in relation to communication with mental health patients, which should include guidance on ensuring professional and appropriate record-keeping by staff in relation to patients;
• (vi) develop a policy to reflect the Mental Welfare Commission's guidance in relation to short term detention, for staff use and guidance and ensure this is distributed to staff;
• (vii) undertake an audit to ensure incidents are being recorded appropriately on Datix;
• (viii) ensure staff are aware of their responsibilities in relation to patient confidentiality;
• (ix) develop policy for staff to advise of appropriate steps to take in relation to patient measurements, in conjunction with the Quality Improvement Scotland guidelines;
• (x) ensure that complainants are kept up to date in relation to the progress of their complaints, and are given full information about the options available to them;
• (xi) provide evidence to the Ombudsman that the Board operates a rights and values based approach in relation to the care of patients within the Adult Mental Health Directorate;
• (xii) draw this report to the attention of all the staff involved in Ms C's care; and
• (xiii) provide a full apology to Ms 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 concerns on behalf of her mother (Mrs A) regarding the treatment that she received from Greater Glasgow and Clyde NHS Board (the Board). Mrs A attended Victoria Hospital (the Hospital) after breaking her ankle. She was treated for this but subsequently experienced severe pain and blistering around the ankle. Mrs A was later found to have a second fracture, which had previously been undetected. Mrs C complained about the Board's failure to diagnose the second fracture and about the initial treatment that Mrs A received, which she believed caused her blistering.

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

• (a) the Board failed to diagnose Mrs A's os calcis fracture in good time (upheld);
• (b) the Board's treatment of Mrs A's broken ankle was inappropriate (upheld); and
• (c) the Board's complaint handling was poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) present Mrs A's case and this report's findings to Orthopaedic, A&E and complaint handling staff at a suitable staff forum, such as a mortality and morbidity meeting;
• (ii) review their procedures for assessing patients' suitability for discharge to ensure that social and medical considerations are given the appropriate consideration; and
• (iii) consider providing further training to staff on patient discharge eligibility assessment.

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