North East Scotland

Overview

The complainant (Mr C) raised a number of concerns about aspects of the care and treatment of his mother (Mrs A) by NHS Greater Glasgow and Clyde (the Board) from May 2005 until her death in October 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  records were not knowingly available to staff or of sufficient quality (upheld);
• (b)  action taken to prevent falls was inadequate (not upheld);
• (c)  there was a lack of planned therapy for Mrs A (upheld); and
• (d)  there were delays in providing adequate pain relief (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  reflect on the lessons that emerge from the record-keeping issues in this case, consider whether the documentation should be changed or if the issue is rather about staff induction/training and advise her of the outcome of this consideration;
• (ii)  complete the work on a Bed Alarm Policy and submit a copy to SPSO when this is issued;
• (iii)  arrange for staff to reflect on the importance of good communication and involvement of patients and relatives in decisions about care and treatment and advise her of the steps taken to achieve this; and
• (iv)  consider how to address the needs of longer term patients for mental stimulation to enhance their quality of life and advise her of the outcome of this consideration.

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

Overview

The complainant’s representative raised a complaint against Argyll and Clyde NHS Board (the Board), on behalf of the complainant (Mrs C), about the treatment she received at the Royal Alexandra Hospital in respect of a top-up epidural to allow for the surgical removal of the retained placenta after the birth of her son in August 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  clinical errors by the consultant anaesthetist (Dr E) put Mrs C’s health at risk during her labour (not upheld); and
• (b)  Dr E’s recollection of the facts differs from those of Mrs C, who believes that Dr E is being untruthful (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  consider whether it needs to review when clinical risk reviews of incidents such as these are carried out; and
• (ii)  ensures that clinical staff are reminded of their responsibility to maintain detailed records, in particular, in respect of anaesthetic procedures.

The Board have accepted the recommendations and will act on them accordingly.  The Ombudsman asks that the Board notify her when the recommendations have been implemented.

Overview

The complainant raised a number of concerns about the care and treatment of his late sister (Miss C) by Greater Glasgow and Clyde NHS Board (the Board).  In particular he complained that Miss C had an operation to fuse her ankle joint which left her in considerable pain when it would have been clinically more appropriate to have amputated the foot; and also that on her final admission on 25 July 2005 to hospital she had been inappropriately admitted to orthopaedics which delayed diagnosis of the septicaemia which caused her death on 6 August 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  doctors did not take the clinically appropriate step to remove Miss C's foot from the ankle (not upheld); and
• (b)  Miss C was inappropriately admitted to an orthopaedic ward rather than a medical ward (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their procedures for ensuring an overall treatment plan with ongoing input from all the relevant specialisms where a patient has a number of underlying medical problems.

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

Overview

The complainant (Mrs C) complained that the GP Practice (the Practice)'s late diagnosis of her mother (Mrs A)'s colon cancer could have been avoided by their greater consideration of her symptoms.  Mrs A died in hospital in June 2003, about a month after diagnosis, aged 76.

Specific complaints and conclusions

The complaint which has been investigated is that the Practice should have investigated more fully than they did (upheld).

Redress and recommendations

The Ombudsman recommends that the GPs in question:

• (i)  apologise in writing to Mrs C, acknowledging that further investigation should have been done in mid 2002; and
• (ii)  inform the Ombudsman what steps they have taken and/or are taking to learn from, and try to avoid a recurrence of, this serious case, for example, by discussing it at their general practitioner appraisals and discussing other relevant cases with the clinical governance lead of the appropriate Community Health Partnership.

The Ombudsman is pleased that the Practice have accepted the recommendations and are taking action on them.

Overview

The complainant (Mr C) was concerned that North Glasgow Housing Association Ltd (the Association) unfairly excluded him from their offices, in response to a community website being set up by residents to highlight the lack of support they felt they were receiving from their landlord.  The website had originally been registered in Mr C Mr C's name but was subsequently registered to someone else.

Specific complaint and conclusion

The complaint which has been investigated is that the Association unfairly excluded Mr C Mr C from their offices, in response to a community website being set up by residents to highlight the lack of support they felt they received from their landlord (not upheld).

Redress and recommendation

The Ombudsman recommends that the Association carry out a further review of their Customer Care Policy to ensure that it sets out the types of behaviour that are considered to be unacceptable and that, prior to deciding to restrict contact with a customer, those who are considered to be behaving inappropriately are explicitly warned of the consequences of continued inappropriate behaviour under the Customer Care Policy.

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

Overview

The complainant, Mr C, raised concerns that, following the withdrawal of part of his medication by the manufacturer, clinical staff failed to adequately assess his condition and provide him with suitable alternative medication or check his blood pressure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff failed to adequately assess Mr C following the withdrawal of his medication (not upheld);
• (b)  a staff grade doctor (the Staff Grade Doctor) inappropriately refused to check Mr C's blood pressure (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained that, during the review of their investigation into her complaint against a care home (the Care Home), The Scottish Commission for the Regulation of Care (the Care Commission) failed to take into account all relevant evidence and they used witness statements out of context.

Specific complaints and conclusions

The complaints which have been investigated are that, within their review process, the Care Commission:

• (a)  did not consider documentary evidence provided by Mrs C (not upheld); and
• (b)  did not refer to one of the witness's statements and used the remaining witnesses' statements out of context (not upheld).

Redress and recommendations

While the specific complaints brought by Mrs C are not upheld, the Ombudsman recommends that the Care Commission offer Mrs C an apology for their failure to confirm, during both their initial investigation and the review, that the documentary evidence, which she provided, had indeed been considered.

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

Overview

The complainant Mr C was concerned about the care and treatment provided to his late wife (Mrs C).  He said that a delay in the initial diagnosis of her cancer meant she had to attend the hospital daily for injections for suspected deep vein thrombosis.  He also said that he was unhappy about the care and treatment Mrs C had received following her admission to Inverclyde Royal Hospital (the Hospital) and felt that the communication both to Mrs C, her family and between the Hospital staff had been inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a delay in the initial diagnosis of Mrs C's condition (upheld);
• (b)  the treatment given to Mrs C was inappropriate (partially upheld); and
• (c)  there were significant failures of communication, concerning her treatment and care, both to Mrs C and her family and between the Hospital staff (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mr C and his family for the delay in diagnosis and share this report with the clinical staff responsible for Mrs C's care;
• (ii)  review their pain assessment and management procedures and ensure that these include a full explanation of the role and involvement of specialist or palliative care teams in the care of patients with non-surgical pain;
• (iii)  apologise to Mr C and his family for not fully explaining Mrs C's pain management regime and for any unnecessary pain that Mrs C suffered as a result of this;
• (iv)  review their policies and procedures to ensure that there is suitable monitoring of nutritional care and management;
• (v)  provide evidence that standards of communication have improved and, in particular, that there are policies and procedures in place to ensure that patients who are terminally ill and their families are fully supported and treated with appropriate dignity;
• (vi)  emphasise to staff responsible for responding to complaints the importance of doing so in a non-defensive and open manner; and
• (vii)  apologise to Mr C and his family for all the failures identified in record keeping and communication; for failing to provide adequate support to them and Mrs C during her final illness; for the confusion about the circumstances surrounding Mrs C's death; and for failing to respond with appropriate care and sensitivity to the concerns raised by Miss C on their behalf.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment her late mother (Mrs A) received at the Southern General Hospital, Glasgow in November and December 2005.  Her concerns included that Mrs A should have been treated in a High Dependency Unit; nursing staff failed to maintain Mrs A's oral and personal hygiene; staff failed to react when Mrs A's condition deteriorated; and poor communication.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mrs A received inadequate clinical treatment (not upheld);
• (b)  staff failed to provide Mrs A with basic nursing care (not upheld); and
• (c)  staff failed to communicate adequately with Mrs A's relatives (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns about clinical treatment and delays in appointments and results.

Specific complaints and conclusions

The complaints which have been investigated are that Greater Glasgow and Clyde NHS Board (the Board) failed to:

• (a)  perform the correct biopsy in the first instance (upheld);
• (b)  arrange timely follow-up (upheld); and
• (c)  report biopsy results in a timely manner (upheld).

Redress and recommendations

The Ombudsman recommends that the Board make a written apology to Ms C for all the identified failures.

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