North East Scotland

Overview

The complainant (Mrs C) complained about the Greater Glasgow and Clyde NHS Board (the Board)'s delay in dealing with her complaint concerning the circumstances pertaining when she required to view her son's body in the Royal Alexandra Hospital (the Hospital)'s mortuary.

Specific complaint and conclusion

The complaint which has been investigated is that the Board delayed in dealing with Mrs C's complaint concerning the circumstances pertaining when she required to view her son's body in the Hospital's mortuary (upheld).

Redress and recommendations

The Ombudsman recommends that the Board re-emphasise to staff the importance of following the stated complaints procedure and that, in the event of investigations over-running target dates, the complainant must be contacted on day 20 and fully advised.  Further, that complainants' agreement to an extension should be sought and after 40 days, where they do not agree, complainants should be advised of their right to raise the matter with the Ombudsman.

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

Overview

Mrs C raised a number of serious concerns about the failure of staff at Ninewells Hospital (the to diagnose and treat her husband when he was admitted with heart failure.  Mr C died within 24 hours of being admitted to the Hospital.  Mrs C also raised a concern about a change in Mr C's medication shortly before his death.  A final complaint concerned the time taken by the Board to respond to Mrs C's complaint and the failure to fully address her concerns.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)       failure to diagnose and provide treatment for Mr C's heart failure (upheld);
• (b)       inappropriate change in medication (not upheld); and
• (c)       failure in complaint handling (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        undertake a review of the operation and knowledge of the two Chest Pain Protocols at the Hospital and consider the adoption of a single unified protocol;
• (ii)       review the events in this complaint at an MAU multi-disciplinary meeting to ensure lessons are learned from the failure to recognise the seriousness of Mr C's condition and to react promptly and appropriately to his deterioration;
• (iii)      apologise in writing to Mrs C for their failure to provide an adequate or timely response to her complaint; and
• (iv)      ensure that their complaints handling process both acknowledges any errors identified  and uses these to drive service improvement.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the delay in diagnosing his sister's stroke and admitting her to hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) NHS 24 failed to make a correct diagnosis despite evidence to indicate that Mrs D had suffered a stroke (not upheld);
• (b) NHS 24 failed to give this case a high priority (not upheld);
• (c) NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance (not upheld);
• (d) the GP failed to stay with the patient whilst waiting for the ambulance (upheld);
• (e) the GP failed to give the case a high priority (upheld);
• (f) the GP failed to provide a referral note to the hospital (not upheld); and
• (g) the ambulance took an unreasonable time to attend (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on what lessons can be learned from this case;
• (ii) consider how to communicate these lessons to Practitioners; and
• (iii) advise her of their conclusions.

The Ombudsman recommends that the Service:

• (iv) issue a further apology to Mr C and his nephew Mr D in respect of the additional delays in responding to the call from the GP;
• (v) issue an apology for the incorrect information detailed in their earlier response to the complaint; and
• (vi) consider reviewing their procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the delay in diagnosing his sister's stroke and admitting her to hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) NHS 24 failed to make a correct diagnosis despite evidence to indicate that Mrs D had suffered a stroke (not upheld);
• (b) NHS 24 failed to give this case a high priority (not upheld);
• (c) NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance (not upheld);
• (d) the GP failed to stay with the patient whilst waiting for the ambulance (upheld);
• (e) the GP failed to give the case a high priority (upheld);
• (f) the GP failed to provide a referral note to the hospital (not upheld); and
• (g) the ambulance took an unreasonable time to attend (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on what lessons can be learned from this case;
• (ii) consider how to communicate these lessons to Practitioners; and
• (iii) advise her of their conclusions.

The Ombudsman recommends that the Service:

• (iv) issue a further apology to Mr C and his nephew Mr D in respect of the additional delays in responding to the call from the GP;
• (v) issue an apology for the incorrect information detailed in their earlier response to the complaint; and
• (vi) consider reviewing their procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

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

Overview

Ms C complained about the care and treatment provided to her mother, Mrs A, in Ninewells Hospital (the hospital).  Mrs A was admitted to the hospital to have a dialysis tube inserted but following the procedure a complication arose and Mrs A died.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)       that the incorrect procedure was used (not upheld); and
• (b)       failure to diagnose a complication (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Ms C for the distress caused to her and the rest of Mrs A's family by failure to diagnose the complication; and
• (ii)       ensure that staff on wards which receive patients who have undergone tunnelled line insertion are aware of the possibility of this known complication and can recognise the symptoms of perforation of a major blood vessel.

The Board have accepted the recommendations and have acted on them.

Overview

The complainants (Mr and Mrs C) raised a number of concerns that their relative, Mrs A (Mrs C's sister, Mr C's sister-in-law), had suffered as a result of a break in the skin of her left heel not being adequately monitored and treated.  They also raised concerns regarding a potential communication breakdown between two hospitals when Mrs A was transferred from one hospital to the other.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       staff failed to inform Mrs A that she was suffering from a potential pressure sore on her left heel (upheld);
• (b)       staff at Western Infirmary, Glasgow (Hospital 1) failed to treat the potential pressure sore (no finding);
• (c)       Hospital 1 failed to advise Drumchapel Hospital (Hospital 2) about the potential pressure sore at the time of transfer (not upheld); and
• (d)       Hospital 2 failed to diagnose and treat the sore for approximately ten days after Mrs A's admission (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board reiterate to the staff involved the importance of making clear notes after assessments.

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

Overview

The complainant (Ms C), who owns and manages a care home, complained that The Scottish Commission for the Regulation of Care (the Care Commission) refused to accept her complaint about the performance and competence of two members of staff under their complaints procedure.

Specific complaint and conclusion

The complaint which has been investigated is that the Care Commission failed to accept Ms C’s complaint about the performance and competence of two members of their staff, which disregarded the requirements of the Regulation of Care (Scotland) Act 2001 and the Care Commission’s complaints procedure (upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the nursing care afforded to her late father (Mr A) during an admission at the Royal Alexandra Hospital, Paisley (the Hospital) from February 2004 to January 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr A's fluid intake was inadequately monitored and there was a delay in commencing IV fluids (upheld); and
• (b)  there was poor communication between nursing staff and relatives (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for the failure to chart fluid intake adequately and to consider commencing IV fluids earlier.

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

Overview

The complainant (Mr C) raised a number of concerns that doctors at the GP Practice (the Practice) failed to take action when his brother (Mr A) reported headaches following his discharge from hospital in April 2005.  Sadly Mr A sadly died on 9 July 2005 after suffering an aneurysm (dilation of an artery, vein or the heart).

Specific complaint and conclusion

The complaint which has been investigated is that the treatment provided by the Practice following Mr A’s discharge from hospital was inadequate (not upheld). 

Redress and recommendations

The Ombudsman recommends that the Practice take note of the Adviser’s comments in regard to record-keeping.

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

Overview

The complainant, Mr C raised a number of concerns associated with the removal of two facial lesions.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr C was not told that the procedure undertaken on 8 July 2005 involved a large scale biopsy (not upheld);
• (b)  Mr C was told that a basal cell carcinoma (BCC) was being removed from his lip whereas his notes refer to it being a squamous cell carcinoma (SCC) (not upheld);
• (c)  the procedure to Mr C's lip was undertaken without proper investigation, which involved increased risk (not upheld);
• (d)  there was belated acknowledgement that the words lip and lid had been transposed, and an insincere apology was offered (partially upheld);
• (e)  Mr C had not been seen by a dermatologist or skin cancer specialist (not upheld);
• (f)  the Board failed to admit errors or variations to Mr C's medical notes (not upheld);
• (g)  the surgeon involved failed to communicate with Mr C properly (not upheld);
• (h)  there were delays associated with Mr C's appointment times (not upheld); and
• (i)  there were delays in responding to Mr C's complaint (not upheld).

Redress and recommendation

The Ombudsman recommends that;

• (i)  in addition to discussing with the patient any surgical procedure, its possible outcomes and common complications, the Board should consider whether written information, reiterating information given, would enhance informed consent for the patient;
• (ii)  a further apology is made to Mr C, to acknowledge the Board's initial failure to apologise to him in a timely manner; and
• (iii)  the Board look to reducing the timescales between the dates of dictation, typing and issue of correspondence.

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