North East Scotland

Overview
The complainant (Ms C) raised a number of concerns about her mother (Mrs A)'s care and treatment following her admission to Ninewells Hospital (the Hospital) on 3 October 2004.  Mrs A was elderly, frail and suffered from dementia.  Sadly, Mrs A died on 9 October 2004.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) drugs were administered to Mrs A inappropriately (not upheld);
(b) Mrs A was not provided with adequate nutrition (not upheld);
(c) nursing care provided to Mrs A was inappropriate (not upheld);
(d) Mrs A was not provided with appropriate medical care (not upheld); and
(e) communication with Mrs A's family was inadequate (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, by the Consultant in Clinical Oncology (the Consultant) at the Beatson Oncology Centre (the Centre).  Mrs A was subsequently admitted to Stobhill Hospital (the Hospital) then transferred to a hospice but, sadly, died the same night.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the treatment provided by the Consultant was not reasonable (not upheld);
(b) the Consultant failed to communicate reasonably with Mrs A and her family about her disease and treatment (not upheld); and
(c) the Centre failed to communicate reasonably with the Hospital following Mrs A's admission (not upheld).

Redress and recommendation
The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained on behalf of his wife (Mrs C), concerning the care and treatment she received prior to being diagnosed as having ovarian cancer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C's care and treatment were inadequate and, despite her history of breast cancer and an ovarian cyst, no follow-up appointment was made for her in November 2003 (upheld);
• (b) in Mrs C's circumstances, a hysterectomy should have been considered much earlier (not upheld); and
• (c) Mrs C's treatment was dictated by financial concerns (not upheld).

Redress and recommendations

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board) proffer a sincere apology to Mrs C for the failure to treat her properly.  Further, in view of the Consultant's comments about not doing anything differently, and given the Board's comments at paragraph 15, the Ombudsman requests that the Board provide her with a copy of the 2008 audit of Guideline 34.

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

Overview

The complainants, Mr and Mrs C, raised a number of concerns about a sequence of events which occurred when they attended the Medical Centre for an appointment with the Community Dentist (the Dentist), on 22 September 2006, for Mrs C to receive dental treatment.  Mr and Mrs C complained that the treatment Mrs C expected to receive on that day was refused.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist refused to treat Mrs C on 22 September 2006 as she could not lie completely flat on the dentist's chair (not upheld);
• (b) the Dentist told Mr C to go to a private dentist (no finding); and
• (c) Mrs C did not receive any information that there was a Senior Dental Officer for Special Care Dentistry consulting at the Medical Centre, until after she complained about the events of 22 September 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment that her uncle, Mr A, received in Vale of Leven Hospital (Hospital 1), between his admission on 23 January 2006 and his transfer to Gartnaval General Hospital (Hospital 2) on 8 February 2006.  Sadly, Mr A died on 8 March 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A was given inconsistent advice (no finding);
• (b) Mr A's pain was not managed effectively between 28 January and 8February 2006 (upheld);
• (c) Mr A's pressure sore could have been avoided (upheld);
• (d) Mr A should have been referred to the vascular surgeons more quickly (upheld);
• (e) Mr A's room was not clean and this contributed to his illness (not upheld); and
• (f) Mr A was inappropriately referred to as a problem patient (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to ensure they respond in full to formal complaints;
• (ii) ensure that the clinical team responsible for Mr A's care in Hospital 1:
• (a)  review this report; consider what lessons can be learned from Mr A's experience and review how pain is managed effectively;
• (b)  are aware of the need for accurate records to be kept; and 
• (c)  utilise best practice statements on Pressure Ulcer Prevention and the Treatment and Management of Pressure Ulcers issued by NHS Quality Improvement Scotland (March 2005 and November 2005);
• (iii) audit the use of MRSA screening on Ward 14 and report back to her proof of review and change in practice;
• (iv) ensure that the clinical team consider the lessons to be learned as a result of the failings identified in this report and report back to her changes in practice put in place as a result; and
• (v) apologise to Ms C fully and formally for the failings identified in this report;

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

Overview

The complainant, Ms C, an advocacy worker complaining on behalf of a woman (Mrs A), raised concerns regarding the care and treatment provided to Mrs A in respect of her bowel operation at the Royal Alexandra Hospital (the Hospital) on 24 February 2003.  Mrs A was unhappy with the lack of information provided to her, her family and her general practitioner (the GP), the timing of her discharge, the failure to timeously diagnose an abscess in her bowel and the failure to arrange a follow-up appointment.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was insufficient communication by the surgical team with regard to operative risks, the complications that arose and the information provided to the GP following discharge (upheld);
• (b) following the operation, Mrs A was discharged prematurely from the Hospital (upheld);
• (c) the clinicians involved failed to diagnose an abscess in Mrs A's bowel within a reasonable time-frame (upheld); and
• (d) a follow-up appointment was not arranged after Mrs A was discharged (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider the way that they currently record episodes of communication. As a minimum, they should remind staff of the importance of recording significant communication episodes between clinical staff and their patients and their carers. These records should include the time and date of such episodes, the parties present, matters discussed and the patient/carer's understanding of the same;
• (ii) consider introducing measures to ensure that any known complications of surgery which occur, and any resultant consequences, are recorded on the discharge sheet and sent to patients' GPs in a timely manner;
• (iii) inform the Ombudsman of any changes that they have made in response to the Scottish Executive Health Department's guidance 'A Good Practice Guide on Consent for Health Professionals in NHSScotland' (June 2006); and
• (iv) consider introducing measures to ensure that biopsy results following local trans-anal surgery are reviewed urgently and any full thickness perforation is specifically recorded in the case notes. When such perforations are recorded and the patient is still in hospital, the Board should take steps to ensure that the patient is not discharged until reviewed by a senior surgeon. When any such results are received after a patient has been discharged, these should be reported immediately to the patient's GP and an urgent review by the surgical team should be arranged.

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

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.

Overview

The complainant (Mr C) claimed that Aberdeen City Council (the Council) failed to take appropriate action in response to complaints made by him regarding the anti-social behaviour of neighbours, and that the Council's response to his complaint about this was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was inaction or inappropriate action taken by the Council in response to Mr C's complaints about anti-social behaviour (not upheld); and
• (b) the Council's response to Mr C's complaint about their alleged inaction or inappropriate action was inadequate and inappropriate (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had been wrongly diagnosed as having Bells Palsy by an NHS24 Nurse Adviser (the NHS24 Adviser) after he contacted NHS24 complaining of numbness in his face and index finger, slurred speech and a headache.  Mrs C also complained that Mr C had been informed of the diagnosis inappropriately by the NHS24 Adviser and that he should have arranged for an ambulance for Mr C and treated him as a medical emergency.  Instead, Mr C was advised by the NHS24 Adviser to attend the Primary Care Emergency Centre (PCEC) and an appointment made for him there.

Mr C drove to the PCEC himself and was seen by a GP (GP 1), who made a diagnosis of Transient Ischaemic Attack (TIA).  After this consultation, he was allowed home and advised to see his own GP if he did not begin to feel better.  Mr C then waited in the PCEC car park until Mrs C arrived.  He re-attended the PCEC where, after a 30 minute wait, he was seen by a second GP (GP 2).  Mr C was then admitted to hospital and found to have suffered a stroke.  Mrs C complained about the consultation with GP 1 and the care offered to Mr C by the PCEC and Lanarkshire NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was wrongly diagnosed and informed inappropriately of the diagnosis over the telephone by the NHS24 Adviser (upheld);
• (b) the NHS24 Adviser failed to treat Mr C as a medical emergency and should have arranged an ambulance, instead of sending Mr C to an out-of-hours GP practice (upheld);
• (c) GP 1 diagnosed Mr C wrongly and, therefore, treated him inappropriately (upheld);
• (d) GP 1 did not offer to admit Mr C to hospital (no finding);
• (e) GP 1 failed to record sufficient data about his consultation with Mr C (upheld);
• (f) GP 1 rushed his consultation with Mr C (not upheld) and;
• (g) Mr C waited an unreasonably long time on re-attending the PCEC (not upheld).

Redress and recommendations

The Ombudsman had no recommendations to make in relation to NHS24.

The Ombudsman recommends that the Board:

• (i) ensure that GP 1 shares this report with his appraiser at annual review and that he reflects on the comments made in this report regarding the diagnosis of a TIA;
• (ii) review GP 1’s record-keeping to ensure it meets the required standards of the regulatory bodies; and
• (iii) write to Mr C with an apology for the failures which have been identified in this report.

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