North East Scotland

Overview
The complainant (Mr C) raised a number of concerns about the standard of care and treatment provided to his son (Mr A) by Tayside NHS Board (the Board)'s Mental Health Service during the 13 months prior to his death by suicide in July 2010. Mr C also raised concerns about the communication between health staff and Mr A's family during this period.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:

• (a) did not provide Mr A with appropriate care and treatment for his depression (upheld); and
• (b) failed to communicate effectively with Mr A's parents (Mr and Mrs C) or consult with them regarding Mr A's treatment and progress (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make the use and review of the risk screening tool to complement and inform the risk assessment process mandatory for all patient assessments following a self-harm / suicide attempt;
• (ii) review their process for conducting RCAs to ensure a degree of independence;
• (iii) revise procedures in responding to Ombudsman's investigations to ensure no documents are omitted or withheld;
• (iv) review their practice with respect to the involvement of family and others, to ensure it is in line with the good practice contained in the NES framework;
• (v) review their process for involving families in SIRs and RCAs; and
• (vi) issue Mr C with a formal written apology for the failures identified in this report.

Overview
The complainant (Ms C) raised a number of concerns about how The Robert Gordon University (the University) dealt with her admission to the University, examinations, assessment for a learning difficulty, and graduation. Ms C was also concerned about how the University had handled her complaint.

Specific complaints and conclusions
The complaints which have been investigated are that the University:

• (a) failed to consider Ms C for a place in second year in 2005 (upheld);
• (b) scheduled a sitting of final examinations: in August 2009, when they were aware Ms C could not sit them; and in January 2010, which was unreasonably late (not upheld);
• (c) failed to inform Ms C of the requirement to register for graduation prior to the deadline (upheld);
• (d) failed to assess Ms C for a learning difficulty (upheld);
• (e) failed to deal with Ms C's complaints appropriately (not upheld); and
• (f) between June and September 2010, delayed providing the documentation necessary to validate Ms C's qualification in her home country (upheld).

Redress and recommendations
The Ombudsman recommends that the University:

• (i) ensure there is formal administration and record-keeping for dealing with advanced entry applications across the institution, to prevent this situation from happening again;
• (ii) remind School Offices of the need to be proactive in assisting students who have exceptional examination arrangements, to ensure that information on graduation registration is sent to them in good time;
• (iii) review the Disability and Dyslexia Office's (DDS) recording of, and follow-up to, requests from academic staff to contact students for assessment;
• (iv) in order to avoid confusion, formalise their practice on offering DDS screening to students in the final semester of their final year, incorporating the revised turnaround time for receiving assessment reports from Allied Health Professionals;
• (v) clarify their understanding of the documents to be provided, and the specific requirements for such documents, for validation of the BSc (Hons) Nutrition and Dietetics in Ms C's home country; and
• (vi) apologise to Ms C for the failings identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns about the prescription of antipsychotic drugs to her aunt (Miss A) during her admission to hospital in September 2009 and that the prescribing chain of command of the drugs was not clear.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:

• (a) wrongly prescribed haloperidol to Miss A from 15 until 25 September 2009 (not upheld); and
• (b) failed to provide clarity surrounding the prescribing chain of command (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) carry out an audit of their practice on implementation of the Adults with Incapacity Act with particular reference to consent and report to the Ombudsman on the findings;
• (ii) amend its guidance on managing patients with delirium to include the requirements of the Adults with Incapacity Act;
• (iii) share this report with staff to ensure they complete documentation properly and meet the communication needs of patients with cognitive or sensory (or both) impairment; and
• (iv) apologise to Mrs C for the failures identified in this report.

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

Overview

• (a) during Ms C’s labour she was not listened to (upheld);
• (b)  clinical staff wrongly asked Ms C to get off the bed to allow them to clean up a gush of amniotic fluid (upheld); and
• (c)  the prolapsed cord could have been diagnosed much quicker (not upheld).

Overview
The complainant (Mr C) had a large odontogenic keratocyst removed from his jaw in October 2008. His maxillofacial consultant (the Consultant) reviewed Mr C in February 2009 and recommended that he be reviewed every six months because the cyst was aggressive and had a high rate of recurrence. The Consultant saw Mr C again in September 2009, but his appointment in March 2010 was cancelled. The Consultant saw Mr C in September 2010. It was identified that he needed surgery as the cyst had recurred.

Specific complaints and conclusions
The complaints which have been investigated are that Grampian NHS Board (the Board):

• (a) failed to review Mr C within six months as recommended by the Consultant (upheld);
• (b) delayed in notifying him of the re-scheduled appointment (upheld); and
• (c) failed to handle his complaint adequately (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) take steps to make relevant staff aware that the views of clinical staff must be taken into account when they are considering deferring the follow-up of a patient and that this should be clearly documented;
• (ii) ensure that relevant staff are aware that they should not jeopardise the health of patients in order to meet a Government target; and
• (iii) apologise to Mr C for the failings identified in relation to complaint (a).

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

Overview
The complainant (Mrs C) raised concerns about the care and treatment provided by a general practitioner from the out-of-hours service (the GP) to her husband (Mr C) on 2 August 2010. She complained that the GP failed to diagnose Mr C with ischaemic heart disease and admit him to hospital. Mr C died of a heart attack several hours after the GP's visit.

Specific complaint and conclusion
The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide reasonable care and treatment to Mr C on 2 August 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that the failings identified in this report are raised with the GP during his next appraisal, to ensure that lessons have been learned from this case; and
• (ii) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her aunt (Miss A) including failures in communication. Mrs C was also concerned about the way NHS Greater Glasgow and Clyde (the Board) dealt with her complaint.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the care and treatment provided to Miss A during her admission at Glasgow Royal Infirmary in January 2010 was not reasonable (upheld);
• (b) the Board's communication with Miss A's family was not reasonable (upheld); and
• (c) the Board did not deal reasonably with Mrs C's complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure they deal with complaints in accordance with the NHS complaints procedure; and
• (ii) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Mrs C) made a complaint that her daughter (Mrs A) had not received reasonable care and treatment from Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to care properly for Mrs A at Inverclyde Royal Hospital, Greenock resulting in her developing a pressure ulcer (upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) raised a number of concerns about the prescription of antipsychotic drugs to his mother (Mrs A), failures in record-keeping and failures in communication by Greater Glasgow and Clyde NHS Board (the Board) from late 2008 until February 2010.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:

• (a) wrongly prescribed Mrs A with antipsychotic drugs from late 2008 to February 2010 (upheld);
• (b) failed to keep adequate medical records (upheld); and
• (c) failed to communicate properly with Mrs A's family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospitals 1 and 2, on the implementation of the Adults with Incapacity Act and SIGN Guideline 86 for patients with dementia with particular reference to assessment of capacity within 72 hours of admission wherever practicable and report back to the Ombudsman on the findings;
• (ii) carry out an audit of their: record-keeping to ensure it is in accordance with the national guidelines with particular reference to care planning practice; practice relating to the storage of patients' medical records to ensure it accords with the Scottish Government Records Management: NHS Code of Practice (Scotland); and report back to the Ombudsman on the findings;
• (iii) develop a policy on meeting the communication needs of patients with dementia which includes having an identifiable and agreed relatives' communication or participation strategy as a core aspect of the care plan; and
• (iv) apologise to Mr C for the failures identified in this report.

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

Overview
The complainants, Mr and Ms C, raised a number of concerns about the midwifery care and treatment provided to Ms C from 15 January 2009, prior to her admission to the Southern General Hospital (the Hospital) on 17 January 2009. Following admission later that day, their baby daughter (Baby C) was stillborn.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the ward based telephone assessment procedure was inadequate (upheld); and
• (b) there was a failure to identify the changing presentation of Ms C prior to admission (upheld).

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

• (i) conduct an audit of the telephone triage system introduced in January 2010, to ensure its effectiveness;
• (ii) remind midwifery staff of the need to fully record and document all telephone contacts to ensure continuity of care when more than one telephone contact is made and more than one member of staff has been involved in handling the calls;
• (iii) conduct an audit to ensure appropriate midwifery staffing levels are being maintained;
• (iv) consider amending the Review to take into account the Adviser's comments at paragraph 24; and
• (v) provide a full apology to Mr and Ms C for the failures identified in this report.

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