North East Scotland

Overview

The complainant (Mrs C) raised concerns that her daughter (Baby C) had developed an infection in her leg after receiving her immunisations on 9 February 2006.  However, doctors at the practice (the Practice) told her on 20 February 2006 and 21  February 2006 that it was not an infection.  Mrs C took her daughter back to the Practice on 24 February 2006 and it was then that Baby C was referred to hospital for treatment to the infected wound.

Specific complaint and conclusion

The complaint which has been investigated iswas that there was a delay in diagnosing that Baby C had a leg infection and that as a result a hospital referral was required (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant Mr C raised a number of concerns regarding his dental treatment and the preparation and fitment of a dental bridge and a temporary denture.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the Dental Practice failed to provide Mr C with an appropriate bridge (not upheld);
• (b)  the dentist incorrectly drilled into the root of Mr C's tooth at an angle, leading to the tooth requiring extraction (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment of her husband (Mr C) at a number of hospitals in Greater Glasgow between June 2004 and his death from mesothelioma in September 2004.  Mrs C complained that Mr C was not given information about his prognosis and delays occurred which prevented his being given any useful treatment.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr C with timely and appropriate care and treatment between June and September 2004 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for communication failures;
• (ii)  consider using the events of this complaint to inform practise in communicating with patients affected by cancer; particularly when a number of different specialists are involved in care; and
• (iii)  gives consideration to improving written recording of discussions with patients and their elatives especially in situations where there are a number of clinicians involved in delivering care.

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

Overview

The complainant (Mr C) raised a number of concerns about Glasgow City Council (the Council)'s handling of a Statutory Notice issued in relation to the property he owns.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  by failing to issue a Statutory Notice in 1995, the Council concealed the condition of Mr C's property (not upheld);
• (b)  the decision not to issue a Statutory Notice in 1995 should have been taken by the full Council (not upheld);
• (c)  the Council failed to monitor the condition of Mr C's property between 1995 and 2004 (not upheld);
• (d)  the Property Enquiry Certificate (PEC) obtained by Mr C's solicitor when Mr C purchased the property was incomplete and, therefore, misleading (not upheld); and
• (e)  the Statutory Notice issued in 2004 in respect of Mr C's property was inaccurate, and his property was not in a serious state of repair (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained about the care and treatment provided to his wife (Mrs C) by both Grampian NHS Board and Highland NHS Board.  Mr C said that there was an unreasonable delay in diagnosing Mrs C's condition.  This led to a delay in her treatment and Mrs C died.

Specific complaint and conclusion

The complaint which has been investigated is that there was an unreasonable delay in diagnosing Mrs C's condition (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns that her ante-natal care had not been properly managed by NHS Greater Glasgow and Clyde NHS Board (the Board) and that in particular they had failed to provide adequate monitoring for potential gestational diabetes.  Ms C considered that but for this failure her daughter's stillbirth might have been prevented.

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a)  perform adequate urinalysis throughout Ms C's pregnancy (upheld);
• (b)  properly inform Ms C of an appointment (partially upheld);
• (c)  ensure Ms C's maternity records were available as needed (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board advise her of the outcome of their review of the guidance and protocol for management of gestational diabetes.

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

Overview 

The complainant (Mrs C) had concerns about some aspects of communication at the Western Infirmary, Glasgow (the Hospital), and about their decision to transfer her 84-year-old husband (Mr C) to a hospital near his home in England.  When Mr C was being transferred by ambulance from the WesternHospital Infirmary to the English hospital, his condition worsened, and she complained that the ambulance crew continued the journey, instead of stopping at another hospital on the way.  He died in the English hospital a few days later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) communication with the family and care at the GlHasgow hospital wereere inadequate (not upheld);
• (b) the ambulance crew's decision to continue the journey was inappropriate (not upheld but recommendations made for the Health Board and for the Scottish Ambulance Service);
• (c) the ambulance crew's record- keeping lacked detail (upheld);
• (d) the Glasgow hHospital should have operated (not upheld); and
• (e) the Glasgow hHospital should not have allowed the ambulance journey (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Health Board ensure that, where appropriate, 'Do Not Attempt Resuscitation' orders (DNARs) are communicated clearly, in writing, for ambulance crews and receiving hospitals;
• (ii) the Scottish Ambulance Service ensure that, where appropriate, ambulance crews obtain formal written DNAR information from referring hospitals; and
• (iii) the Scottish Ambulance Service ensure that record- keeping by ambulance crews during journeys is adequate.

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

Overview

The complainant (Mr C) had an AVF (arteriovenous fistula) in his spine.  When the Consultant Neuroradiologist clotted the blood vessels, some glue (embolic fluid) escaped into the central draining vein of the spinal cord which became blocked.  Mr C complained that his symptoms were worse after the procedure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was given insufficient information to allow him to make an informed choice of treatment; (upheld) and
• (b) the procedure was not adequately explained and he was not appropriately warned about possible complications (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review their current protocols for consent and recording of consent in line with 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive on 16 June 2006 especially for neurosurgical and radiological interventions;
• (ii) include details of procedures, alternatives and possible complications in leaflets and that they are given to patients as soon as the diagnosis is made;
• (iii) develop standard letters to be used until the leaflets are available;
• (iv) ensure that the fact that the relevant leaflet has been given to the patient is recorded in the patient's notes;
• (v) include information about embolisation and the possibility of complication occurring in the appropriate leaflet;
• (vi) ensure that Handbooks for Doctors and protocols on consent include detail on when, where and how to obtain informed consent; and
• (vii) apologise to Mr C for the failings in giving him information.

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

Overview

The complainant (Mr C) raised a number of concerns about the treatment his late mother, (Mrs A) received at the Victoria Infirmary, Glasgow in February 2006.  These included communication failures between staff and the relatives; inadequate care and treatment; and difficulties in reporting lost property.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff failed to ensure that Mrs A's nutritional intake was monitored and did not obtain a complete medical history (not upheld);
• (b)  staff failed to communicate adequately with Mrs A's family (upheld); and
• (c)  the procedure for reporting lost property was not adequately followed (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  ensure that this report is shared with the staff involved so that they are reminded of the importance of communication with relatives;
• (ii)  consider whether the procedure on change over of shifts for passing information to relatives about patients who have recently died is adequate; and
• (iii)  conducts a review of the availability of claim forms at ward level in the hospital and send Mr C a claim form and consider a request for reimbursement of Mrs A's glasses should he wish to pursue the matter.

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

Overview

The complainant Mr C raised a number of concerns about the treatment his wife (Mrs C) received at the Vale of Leven Hospital (the Hospital) during two admissions in September 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the treatment which Mrs C received was inadequate(not upheld);
• (b)  there was a delay in carrying out a CT scan (not upheld); and
• (c)  there was poor communication concerning the need to inform the Procurator Fiscal of Mrs C's death (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.