North East Scotland

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment of his sister, Miss A, during an admission to Ninewells Hospital (the Hospital) in the 13 days leading up to her death.  Mr C believed that had failures in Miss A's care and treatment not occurred, the outcome might have been different for her.

Specific complaints and conclusions

The complaints which have been investigated are that Tayside NHS Board (the Board):

• (a) failed to make an urgent and correct diagnosis of Miss A's condition when she was admitted to hospital (not upheld);
• (b) failed to provide urgent and appropriate treatment to Miss A (upheld);
• (c) failed in their duty of care towards Miss A (upheld);
• (d) failed to treat Miss A without delay due to holidays and staff not being available and, in particular, delayed in arranging a second Computerised Tomography scan (CT scan) (upheld);
• (e) might have saved Miss A's life had they not failed to provide her with urgent and appropriate treatment (not upheld);
• (f) stigmatised Miss A in relation to her alleged alcohol abuse and this affected the nature and urgency of the treatment she received (not upheld);
• (g) failed to explain to Mr C how the figure of 70 units of alcohol a week was noted as Miss A's alcohol intake on admission (not upheld);
• (h) failed to explain to Mr C why Miss A was unconscious during the first few days of her admission (upheld); and
• (i) failed to have a single doctor in charge of Miss A's care, which made communication with Mr C very difficult (upheld).

Redress and recommendations

The Ombudsman recommends that the Board inform ward staff and relatives of the named consultant in charge of a patient's care either in the form suggested by the Adviser at paragraph 56 or similar.

The Board have accepted my recommendation and will act on it accordingly.

I am also pleased that the Board, in response to my investigation, have repeated their apology to Mr C and his family for the failings in Miss A's care.  I am also satisfied that the recommendations the Board put in place when initially responding to the complaint (see paragraphs 13 to 14 above) adequately address the central failings highlighted in complaints (b), (c) and (d), as they will ensure appropriate medical management and review and better care planning.  It is unfortunate that, while the Board put appropriate recommendations in place in response to Mr C's complaint, they did not sufficiently acknowledge the nature and seriousness of the problems that occurred in this case when they wrote to Mr C.  This has led to an unusual situation whereby the Board did not fully explain and acknowledge problems that occurred when responding to the complainant's complaint, but nevertheless put in place recommendations that, as it happens, adequately address the issues and failings that have been highlighted in this report.  Consequently, while there have been serious failings in relation to Miss A's care and treatment, I have no recommendations regarding complaints (b), (c), and (d) because measures have already been taken by the Board that appropriately remedy the complaints.

Overview

The complainant (Mrs C) raised a number of concerns about the care her late brother (Mr A) received in the days before he died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was not kept properly informed about Mr A's condition (upheld);
• (b) Mr A's condition was not adequately monitored on the night he died (not upheld);
• (c) the way Mr A's death was communicated to the family was inappropriate (not upheld);
• (d) a member of the nursing staff was rude to the family (upheld); and
• (e) some of Mr A's personal belongings were lost during his stay in hospital (not upheld).

Redress and recommendations

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

• (i) apologise to Mrs C for shortcomings in communications about Mr A's condition;
• (ii) take further action to ensure that a proactive approach is taken to establishing good communication with relatives;
• (iii) use this complaint as a case study to illustrate the importance of good communication with relatives, especially when the hospital are aware that the patient is unlikely to survive; and
• (iv) apologise to Mrs C formally for the conduct of a member of nursing staff and also give consideration to providing to staff dealing with patients and their families a more focussed reinforcement of the importance of good customer care through, for example, appropriate training.

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

Overview

The complainant (Mr C) raised a complaint about a delay in a referral for a urodynamics study at the Department of Urology (the Department) in the Southern General Hospital (the Hospital).  Mr C had not received an appointment after he had cancelled three previous opportunities to attend the Department.  Mr C complained that he had been told his name had been taken off the waiting list at his request.  Additionally, Mr C was unhappy that the complaint response from the Chief Executive of the then South Glasgow University Hospitals Division, wrongly referred to his original out-patient referral as having come from his General Practitioner (GP), rather than the Gastrointestinal Clinic at the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had an excessive wait for an appointment at the Department (upheld);
• (b) Greater Glasgow and Clyde NHS Board (the Board) had wrongly stated that Mr C's GP had referred him to the Department (upheld); and
• (c) Mr C was removed from the waiting list although he had not asked for this (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board apologise to Mr C for their error in saying the referral was from Mr C's GP;
• (ii) staff members are reminded of the importance of keeping accurate and contemporaneous records to verify their understanding of all patient information; and
• (iii) the Department staff are reminded of the value of alerting patients' GPs to the changes in the clinical care of patients on their practice list.

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

Overview

The complainant (Mr C) raised a number of concerns about Aberdeen City Council (the Council)'s handling of his objection to his neighbours planning application for an extension to the neighbouring property.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) failure to consider Mr C's request for a site visit by the Committee (upheld);
• (b) dissatisfaction with the formal reply to Mr C's complaint about the failure to consider the site visit request (not upheld); and
• (c) failure to consider the planning application properly (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council ensure that appropriate procedures are in place so that the Committee is made aware of any requests for site visits that are made, and responds to them appropriately.

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

Overview

In October 2004 a planning application was submitted to Dundee City Council (the Council) by the agent of the applicant.  The applicant sought planning permission to build a detached house in the side garden of an existing house on a residential street.  Two neighbours (Mrs C and Mrs A, and together as the complainants), along with others, objected to the planning application.  The complainants subsequently raised concerns about the planning report relating to the proposed development and the role of the Council in facilitating discussions between themselves and the applicant.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a flawed report relating to the proposed development was submitted to the Development Quality Committee (not upheld); and
• (b) the Council failed to facilitate discussion between the applicant and neighbours (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council develops a written protocol that sets out the Council position and guides the actions of officials following deferral of a planning application to allow discussion between the parties involved.

Overview

The complainant (Mr C) is a tenant of the City of Aberdeen City Council (the Council).  He complained to the Ombudsman on 30 March 2007 about the Council's response to his reports regarding defects in the timing of the lighting in the stairway of his block.

Specific complaint and conclusion

The complaint which has been investigated is that the Council failed since March 2006 to rectify a problem with the timing of the communal lighting system in Mr C's block (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about the treatment his late mother (Mrs A) received from her General Practitioner (the GP) during 2006.  These included issues such as a failure by the GP to action treatment for Mrs A's reported concerns of nausea and weight loss and a failure to diagnose that she was suffering from fluid on her lungs.  In addition, Mr C complained that the GP failed to call an ambulance when Mrs A took ill at the Practice on 29 September 2006.  Mrs A was taken to hospital later the same day by ambulance from her home but sadly did not recover from a coma and died two weeks later.

Specific complaints and conclusions

The complaints which have been investigated are that the GP:

• (a) failed to provide treatment for Mrs A's reported concerns of nausea and weight loss and failed to diagnose that she was suffering from fluid on her lungs (not upheld); and
• (b) failed to call an ambulance when Mrs A took ill at the Practice on 29 September 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

Ms C was concerned her son (Mr A) had suffered from a deterioration in his mental illness in 2005 but that this had not been recognised by mental health professionals involved in his care.  As a result, his condition had not been correctly managed.  She believed that, if appropriate care and treatment had been provided, an alleged incident in June 2005 involving Mr A would not have occurred.  She was further unhappy that his contact with Community Psychiatric Nurses was reduced in July 2005 in response to a perceived risk to them.  Ms C was also unhappy about the response she had received from Greater Glasgow and Clyde NHS Board (the Board) following her complaints about this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the care and treatment given to Mr A during 2005 were inadequate (not upheld); and
• (b) there were failures in the handling of Ms C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Ms C for the failures identified in responding to her complaint.

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

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment she received from her dentist (the Dentist), and about his attitude in handling her complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist failed to provide Mrs C with dental treatment of a reasonable standard on 4 April 2006 in that he broke her tooth (not upheld);
• (b) the Dentist mishandled Mrs C's complaint (not upheld); and
• (c) the Dentist's attitude towards Mrs C was demeaning (no finding).

Redress and recommendations

The Ombudsman recommends that the Dentist ensures that appropriate records are kept, including x-ray, in respect of root canal treatment.

Overview

The complainant's (Misses C) raised a number of concerns that their late mother (Mrs C) had been inappropriately treated by a district nurse (Nurse 2) at a home visit.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Nurse 2 provided inadequate care and treatment leading to a loss of dignity for Mrs C (partially upheld);
• (b) there were communication failures between nursing staff (upheld); and
• (c) Tayside NHS Board had failed to deal with appropriately and investigate thoroughly Misses C's complaint (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.