North East Scotland

Summary
Mr A, who had Alzheimer's disease (the most common cause of dementia), was admitted to a specialist ward at Royal Cornhill Hospital for assessment and treatment.  He had been displaying very challenging behaviour, and was no longer safe to be looked after at home.  He was sectioned under the Mental Health (Scotland) Act, and he remained in this hospital for the next ten months.  During this time his behaviour became more stable and he was transferred to a dementia assessment ward at Glen O'Dee Hospital.  This move was against the wishes of Mr A's partner and welfare power of attorney, Ms C.  Mr A died six weeks after being transferred, following a rapid deterioration in his physical condition.

Ms C raised concerns about a range of aspects of the nursing care that Mr A received in both hospitals.  In relation to his time at Royal Cornhill Hospital, she was concerned about Mr A's risk of falls and the staff response to this, his skin care, his oral health care, and provision of social activities for Mr A. She also raised concerns about communication with Mr A’s relatives, particularly with Ms C, given her position as his welfare power of attorney and his Named Person under the Mental Health (Scotland) Act.

In relation to the care and treatment Mr A had in Glen O’Dee Hospital, Ms C complained about the forms of restraint used to keep Mr A safe from falls, the lack of sufficient encouragement and assistance to mobilise him, and the impact of this on his skin care.  In relation to Mr A’s medical care, she was concerned that Mr A developed a sore throat that was not properly assessed, and this led him to stop eating and drinking.

When Ms C complained to the board, they identified no significant failings with the care and treatment given to Mr A, either in Royal Cornhill Hospital or Glen O’Dee Hospital.

During my investigation I sought advice from a psychiatric nursing adviser and a psychiatric adviser, who both identified failings in Mr A’s care and treatment.

This case has raised significant failings, particularly in the most standard elements of nursing care: effective care planning; keeping a patient safe; monitoring their condition; providing appropriate food and nutrition; record-keeping; and communication with relatives.  Caring for Mr A was not always made easy by Mr A’s challenging behaviour, but the planning and communication around his care were all the more necessary because of his behaviour and incapacities.  I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.  I upheld all Ms C’s complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaint handling failed to identify these issues;
• provide an action plan setting out improvements identified in the above Significant Event Analysis, with explanation of how they would be met, along with changes that have already taken place since these events;
• remind staff of the need to ensure that changes to visiting hours are mutually agreeable to staff, patients and relatives, and are recorded wider staff awareness;
• conduct a nursing audit in the appropriate ward to assess the current practices in relation to record-keeping, food, fluid and nutrition and vital signs monitoring;
• provide evidence that any actions identified from the nursing audit are implemented in full;
• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaints handling failed to identify these issues;
• draw together the findings from both Significant Event Analyses to identify any shared issues on the continuum of care and in complaints handling, to be addressed by the Board; and
• apologise to Ms C for the failings identified in this report, both in relation to Mr A's care and treatment and in relation to the responses Ms C received to her complaints.

Summary
Mrs C's husband (Mr A) had been diagnosed with lung cancer and discharged to the care of his medical practice.  To help manage Mr A's pain at the end of his life, Mrs C was allowed to administer a controlled drug.  Despite this arrangement, Mrs C said that the practice failed to manage Mr A's pain reasonably and to make reasonable arrangements to ensure a sufficient amount of pain relief was available.  Mrs C also said that the practice failed to communicate with her in a reasonable way about administering pain relief and to keep accurate records.  Mrs C said that as a result of this, Mr A suffered intolerable pain before his death, which caused her extreme distress.

I took independent advice from a GP adviser.  The adviser considered that in relation to treatment decisions and pain management, the standard of care and treatment provided was reasonable.  Moreover, while there were administrative shortcomings in relation to record-keeping, these were not significant and had no detrimental clinical effect on Mr A's care.  I accepted that advice. With regard to the governance arrangements in relation to Mrs C's administration of the medication,  I found that there was effectively an informal arrangement between the practice and Mrs C which allowed Mrs C to administer a controlled drug without the practice first putting adequate safeguards in place or seeking guidance from a specialist.  I agreed with the adviser that it was of concern that GPs continued to prescribe a controlled drug after expressing concerns that Mrs C had administered the medication without clinical advice.  Furthermore, the practice failed to ensure that Mr A consented to the arrangement. I upheld this part of Mrs C's complaint and made recommendations.

Mrs C also said that the practice did not respond reasonably to her complaints. I found that the practice's handling of Mrs C's complaints was reasonable and so did not uphold this complaint.

Redress and recommendations
The Ombudsman recommends that the practice:

• ensure the GPs who instructed Mrs C in relation to breakthrough medication and the other GPs who subsequently issued prescriptions for oxycodone seek support from the board's clinical support group, in relation to responsibilities for prescribing and consent under GMC (General Medical Council) guidance;
• ensure the relevant GPs discuss the findings of this investigation at their annual appraisal;
• ensure the relevant GPs familiarise themselves with the GMC guidance as a priority;
• draft a protocol in conjunction with the board to support patients and/or carers to administer prescribed subcutaneous medication by injections; and
• apologise for the failings this investigation identified.

Summary
Miss C complained on behalf of her aunt (Mrs A), a tenant of the council.  Mrs A lived in a property formerly tied to her husband's employment.  After her husband's retirement and subsequent death, the council did not take steps to offer a tenancy to Mrs A, meaning that Mrs A lived in the property for over six years without a written tenancy agreement, until the council offered her a Scottish Secure Tenancy. Once Mrs A signed the agreement, the council made arrangements to survey the property and identify outstanding repair works.

A number of issues were noted, including a leaking roof and dampness, and the council undertook to carry out repairs.  However, Mrs A was not satisfied with the condition of the property and wished to move to a smaller property.  Miss C contacted the council on behalf of Mrs A to make enquiries about moving and to seek updates on repair works.  Miss C was not satisfied with the time it had taken the council to arrange for the repair works and she complained to the council.

Miss C had expressed concern that her aunt's property was not wind and watertight and was not suitable for her aunt to live in.  Miss C complained further that the council took an unreasonable length of time to complete the repair works.  Miss C also said that the council's communication regarding the repair works was poor.  The council said that while progress in completing the repairs might have seemed slow to Mrs A, there were reasons for the delays, and that overall the council acted reasonably in relation to the works.

The council explained to me that they transferred their housing stock and housing management staff to Glasgow Housing Association in 2003.  The council said that this transfer did not involve tied houses, and therefore did not include the property Mrs A resided in.  The council said that they should have taken steps to normalise Mrs A's succession to a tenancy in 2007 but added that this did not happen because of the lack of housing management staff.  I considered that the council's failure to make suitable provisions for the management of tied houses was unacceptable and that this failure contributed to the circumstances about which Miss C complained.

Regarding the council's responsibilities to Mrs A once the tenancy commenced, I was critical of their failure to undertake an inspection before the tenancy commenced.  I also noted that once the survey was undertaken, the council unreasonably failed to consider whether the property was acceptable accommodation in terms of the tolerable standard (a statutory standard for quality of housing).  I was concerned that serious health and safety issues were outstanding for several months from the beginning of the tenancy and I considered that it was unreasonable that the council failed to consider whether Mrs A should have been offered alternative accommodation until the repairs had been completed.  I was also critical of the time it took the council to start the repair works and I noted a number of delays that I considered to have been avoidable.  I concluded that the council had failed to meet a number of their statutory responsibilities as a social landlord as well as their responsibilities in terms of the tenancy agreement.  In view of this, I upheld Miss C's complaint and made two recommendations.

I also considered the council's communication with Mrs A and Miss C.  I noted that the council had not told Mrs A about the works that would be undertaken and how long it would be before completion of these works.  I was also critical that the council failed to provide a single point of contact for information and queries about the repairs, and I found a number of instances where the council had failed to respond to Miss C's emails.  In this respect I concluded that the council had acted unreasonably.  I upheld Miss C's complaint and made two further recommendations.

Redress and recommendations
The Ombudsman recommends that the council:

• issue a written apology to Mrs A for the significant delay in repairing her rented property;
• abate (refund) Mrs A's rent in full for the period between 1 May 2014 and the date the major repair works were completed;
• issue a written apology to Mrs A for failing to provide reasonable updates on the works; and
• issue a written apology to Miss C for the communication failings identified in this investigation.

Summary
Mr A, who was suffering from lung cancer, had an operation at Aberdeen Royal Infirmary to remove his lung.  During the operation, Mr A suffered from hypoxia (a deprivation of oxygen).  He was transferred to intensive care but did not regain consciousness and died one week later.  Mr A's daughter (Miss C) complained about the care and treatment provided to her father.

In investigating, I took independent medical advice from a consultant anaesthetist, as well as considering the board's own investigation of the complaint.

Miss C complained that the consultant anaesthetist failed to provide a reasonable level of care to Mr A prior to and during his surgery.  The adviser said that surgery should not have proceeded when it became apparent there was a problem with monitoring carbon dioxide levels in Mr A's blood, and that it was concerning that the consultant anaesthetist had needed advice on methods to maintain blood oxygen levels and treat hypoxia.  The adviser also noted that the board's own investigation had acknowledged shortcomings in the communication between the surgeon and the consultant anaesthetist during surgery, and that the consultant anaesthetist had not been assertive enough in their decision-making.  I considered that the performance of the consultant anaesthetist fell below the reasonable level of care from a specialist doctor who has achieved consultant grade.

Miss C also complained that her father's suitability for surgery was not appropriately assessed.  The adviser said that the tests used for Mr A were generally acknowledged to have limitations and other tests should have been considered which may have prompted more investigation ahead of surgery.  The board said that their investigations found no problems with Mr A's pre-operative assessment.  I found this to be inaccurate and I was critical of the board for failing to identify that the assessment could have been more robust and to act upon this accordingly.  I also found that the failings in the
pre-operative assessment meant that neither Mr A nor his family were able to have an informed discussion about the risks of surgery.

The board acknowledged that there were significant failures in their post-operative communication with the family.  It was obvious to staff how unwell Mr A was after his operation, but despite this, it was not until around 36 hours later that someone from the surgical team properly discussed matters with the family.  This was the most distressing part of this case.  All other issues relate to technical problems, and the difficulties of high risk surgery, but this issue relates to the basics of human kindness and interaction with a family in distress.  This contributed significantly to a breakdown in trust between Mr A's family and some medical staff.  Although the board recognised that the communication was inadequate, I was not convinced that they have taken sufficient action to ensure this does not happen again.

I upheld all of Miss C's complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• provide evidence of the actions taken by the consultant anaesthetist to improve their non-technical skills and their subsequent appraisals;
• provide evidence that the consultant anaesthetist has continued to practice without significant subsequent complaints or concerns being raised;
• provide evidence that the consultant anaesthetist has revalidated with the General Medical Council, if this has been achieved as part of the five year cycle since this operation;
• review its pre-operative assessment procedure for lung cancer surgery, to ensure that cardiopulmonary exercise tests and echocardiograms are included for appropriate patients;
• review their lung cancer pre-operative assessment procedures to ensure FEV1 and the Diffusing capacity of the lung for Carbon Monoxide DLCO are calculated prior to surgery in order that post-operative lung function is taken into account;
• review their consent procedure for lung cancer surgery to ensure that it informs the patient what level of risk the operation will incur for them;
• review their procedures to include a requirement for a member of the surgical or anaesthetic team to speak to either the patient or their family at the first available opportunity following an adverse incident that requires admission to Intensive Care Unit;
• review the findings of the Anaesthetic Department Morbidity and Mortality meeting to identify if, and why medical staff declined to support the consultant anaesthetist in his meeting with the family; and
• remind staff that notes are taken of any meetings with family or patients following adverse events.

Summary
Ms C had been referred to a consultant plastic surgeon then to a consultant general surgeon to undergo a surgical procedure on her buttocks.  She has suffered from internal and peri-anal abscesses for a number of years and had previously undergone treatment to drain these on a number of occasions.  Ms C said that she had been assured that she would not suffer from any issues with continence following the operation, as this was a significant concern for her prior to undergoing surgery.  Following the operation, Ms C found that she was incontinent.  As a result she had to undergo a colostomy procedure, which has had a significant impact on her personal life, resulting in her having to give up work.

I took independent advice from a consultant colorectal surgeon, who said that incontinence was a well-recognised side-effect of the procedure Ms C had.  Ms C said that she would never have consented to the procedure had she been made aware of this risk.  I found Ms C's medical notes documented that this was an area of great concern to her, therefore I consider that it was unreasonable that this was not discussed with her and documented prior to surgery, nor did the consent form that she signed mention this as a possible risk of the surgery.

The board accepted that the forms Ms C signed had not documented incontinence as a risk of the surgery.  However, they did dispute whether Ms C was ever given an assurance that there was no risk of this complication from the procedure.  I do not accept that this removes the responsibility from the board in this regard.  Under General Medical Council guidelines, the medical staff responsible for her care had an obligation to ensure that Ms C was able to give informed consent, particularly as she had identified a particular concern before the operation.

I also found that the board failed to respond appropriately to Ms C's complaint about the cause of her incontinence.  Whilst it is possible that the incontinence is a result of a progression of Ms C's on-going condition, it is also possible that it was a result of a complication of the surgery.  Given this, the board's failure to provide adequate information to her before the procedure and later in their complaints responses was unreasonable, so I upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• review the consent forms used for this type of surgery to ensure they accurately reflect the potential complications;
• remind staff of the importance of identifying and documenting that issues of importance to patients have been discussed during the consent process; and
• apologise unreservedly to Ms C for the failings identified in this report.

Summary
Ms C, who works for the Patient Advice and Support Service, brought the complaint on behalf of Ms A. It concerned the delay in Ms A's son's diagnosis with Hodgkin's Lymphoma (a cancer that develops in the lymphatic system).I decided to issue a public report because of the significant personal injustice suffered by the child and his family in delaying the diagnosis. I was also concerned that this case highlighted a potential systemic failure at the GP practice to recognise a 'red flag' symptom of cancer.

The child was taken to the practice in May 2013 with a painful swelling on the left side of his neck. He was seen by a doctor who took blood for testing and prescribed an antibiotic. The child returned to the practice later that month and was seen by a different doctor. A chest x-ray referral form was completed and a note made that blood tests were to be repeated in one month as some of the earlier results were abnormal. Further antibiotics were prescribed.

However, no appointment was made with the practice for the further blood tests and no chest x-ray appointment was allocated to the child at the local hospital. The child returned to the practice in October 2013 when he was seen again by the first doctor who immediately referred him for a chest x-ray and for further blood tests. Further consultations took place regarding the child's continuing pain and though a referral was made, it was not an urgent referral and the child was advised to wait for a forthcoming appointment in early November. After this appointment and following further investigation, he was diagnosed with Hodgkin's Lymphoma.

I took independent medical advice on this complaint from a GP adviser. They referred to the Scottish referral guidelines for suspected cancer and commented that they would expect a doctor to be aware of the significance of a left supraclavicular (above the collarbone) node and its potential as a sign of an underlying cancer. They said it would have been reasonable practice to refer the child at an earlier stage and considered that this delay suggested a lack of clinical knowledge on the part of the practice doctors. Although it was considered beneficial to carry out blood tests and an x-ray, the adviser said that this should not have delayed the referral being sent when the child first presented with a lump.

This case also highlighted the way referrals were processed by the practice at that time. The practice were unable to say whether the letter requesting an x-ray had been lost at the practice and never posted; lost by Royal Mail; or lost within the records office at the local hospital. They apologised for the delay in the child receiving his x-ray acknowledged that ideally, the referral should have been followed up. They said that there had not been a robust system for following up referrals or test requests.

The practice explained that in order to prevent such incidents happening again, the process had been changed so that the referring doctor now gives the referral letter to the patient and instructs them to go directly to the hospital. They also advised that a register had been introduced on their computer system for the daily recording of all referrals and test requests. They said that this is checked each week and updated with results or other information received, with any entry that has not been actioned for more than two weeks being flagged for immediate attention. They considered that the new system worked well and would prevent a recurrence of the circumstances the child experienced. I asked the adviser about the new system introduced by the practice to monitor referral and test requests and they commended it and agreed that this would adequately address the issue of the chest x-ray request that arose in this case.

I am concerned that the events in this case suggest a gap in the clinical knowledge of both practice doctors who saw the child, as neither identified the significance of the supraclavicular lump.I appreciate that one of the doctors has now retired, but the other continues to practice. It is important that this matter is addressed without further delay as a learning priority, and I made a recommendation about this.

Redress and recommendations
The Ombudsman recommends that the practice:

• issue a written apology for the delays in appropriately referring the child to the board;
• ensure that the practicing doctor identifies the diagnosis and referral criteria for signs of cancer as a learning priority; and
• ensure that this case is discussed at the practicing doctor's next appraisal.

Summary
Mrs C had previously suffered from mouth cancer and was treated at Monklands Hospital.  After finding an ulcer in her cheek, she contacted the consultant previously in charge of her care, and was seen at Monklands Hospital again, where the ulcer was found to be cancerous.  Mrs C's case was discussed at the multi-disciplinary team (MDT) meeting, who decided to refer Mrs C to the Southern General Hospital for treatment.

However, this was not done until a week later.  The referral was by email from the consultant to his colleagues with details of Mrs C's (and other patients') cases, rather than a formal referral by letter.  It is not clear whether the email was received.  Around this time the head and neck / maxillofacial (the diagnosis and treatment  of diseases affecting the mouth, jaws, face and neck) consultants at the Southern General Hospital decided that, due to lack of capacity, they would no longer accept referrals of patients they considered could be treated locally (such as Mrs C).  It is unclear whether the management team instructed the consultants to do this, or whether the Southern General Hospital was required to accept Mrs C's referral under the existing funding arrangements.  Mrs C was not told that there was a problem with her referral.

Mrs C grew increasingly concerned about the delay, and phoned the consultant at Monklands Hospital several times over the next few weeks to follow this up.  Finally, about a month after the MDT, Mrs C emailed the consultant, outlining her strong concerns, and the consultant phoned the Southern General Hospital and arranged an urgent appointment for Mrs C.  Mrs C said that her treatment from Southern General Hospital staff was excellent from that point on.

Mrs C complained about the delay in the scan and the MDT meeting, as well as the delay in referring her to the Southern General Hospital.  Mrs C was concerned that the delay may have worsened her outcome, as she was initially told that surgery would be performed with the aim of providing a cure.  However, the surgery that she subsequently received significantly reduced her quality of life and gave her a low chance of surviving her cancer.  Mrs C also complained about the lack of communication from Monklands Hospital staff about what was happening.

My investigation found that the delay in arranging Mrs C's surgery was unreasonable, and outwith the national HEAT (Hospital Efficiency and Access Targets) standards.  I found it was unreasonable for the Monklands Hospital consultant to wait one week before referring Mrs C, and also that the email sent by the consultant was not an adequate referral.  I also found that there was a breakdown in the referral process between Monklands Hospital and the Southern General Hospital, which meant that no plans were made for Mrs C's surgery at either hospital until she followed this up repeatedly.  I am concerned that an important decision (not to accept certain referrals) could be made and implemented at NHS Greater Glasgow and Clyde without clear, recorded management approval.  I am also strongly critical of the poor communication between the consultants at both health boards, as they apparently discussed Mrs C's case without clearly agreeing who would be responsible for her treatment (both hospitals appeared to think the other would be responsible).  It was only through Mrs C's courage and perseverance in following up her own appointment that this matter was resolved.

I also found that Monklands Hospital staff failed to communicate reasonably with Mrs C about her treatment.  Staff did not return her calls on at least one occasion and, although the consultant phoned the Southern General Hospital to follow up the referral and offered to perform the surgery himself, no-one contacted Mrs C to explain what was being done or to check that the appointment had come through.

In reporting on this complaint, I outlined significant concerns about the way in which both boards provided information during my investigation.  NHS Lanarkshire failed to provide a key piece of evidence relating to this complaint until after my investigation was concluded.  NHS Greater Glasgow and Clyde also provided new evidence at a late stage, which directly contradicted information they had previously given during the investigation.  This caused unnecessary difficulties and delays in completing the investigation, and undoubtedly added to Mrs C's distress.  I also raised concerns at the lack of appreciation both boards have shown of the impact these events have had on Mrs C, and of the value of her complaint.  This case involves a patient who was left without any plans for her cancer surgery for several weeks, as the boards were unable to effectively communicate about, and resolve, an administrative disagreement over who was responsible for the surgery.  In this context, I am disappointed that the boards were not more proactive about acknowledging that Mrs C's experience was unacceptable, and acting to prevent a recurrence.

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• issue a written apology to Mrs C for the failings I found; and
• bring my findings to the attention of Consultant 1, for reflection as part of his next annual appraisal.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• issue a written apology to Mrs C for the failings I found;
• feedback my findings to all staff involved, for reflection and learning; and
• ensure there is a clear procedure for authorising and recording any decisions not to accept referrals, and that staff are aware of this.

The Ombudsman recommends that both boards:

• conduct a joint significant event analysis to investigate and address the cause(s) of the delay in Mrs C's referral, and share the results with my office and with Mrs C, if she wishes.

Summary
Mrs C complained about her late mother (Ms A)'s interaction with NHS 24, in particular their main out-of-hours telephone service, the Unscheduled Care Service (UCS), and Breathing Space, which is a confidential telephone service for people experiencing low mood, anxiety or depression, and also part of NHS 24.

Ms A suffered from anxiety and depression.  One week after attempting suicide, she telephoned Mrs C and told her she needed help as she could not cope.  Mrs C called NHS 24, describing Ms A as a risk to herself, and an NHS 24 call handler rang Ms A directly.  Ms A was extremely distressed during the call.  She told the call handler that she might harm herself again and that she wanted to be taken away under mental health legislation.  The call was initially classified as 'serious and urgent' but, when no nurse was available to speak to Ms A, a senior nurse advised the call handler to downgrade the call, which set a three hour call back from a nurse practitioner.  They also offered Ms A assistance from Breathing Space whilst she waited for the call back, which she accepted.  The Breathing Space adviser (the BSA) spoke and did breathing exercises with Ms A, but she was still tearful when the call ended.  A nurse practitioner called Ms A around two hours later but there was no answer and the call was closed.  Mrs C called the police a few days later as she had been unable to contact Ms A.  They forced entry to Ms A's home and found that she had completed suicide.  It is understood that she died from an overdose of medication.

In investigating Mrs C's complaints, I took independent advice from a nursing adviser, a mental health adviser and a GP adviser with experience of NHS 24 and out-of-hours work.

Mrs C said that the classification of Ms A's call meant that a suicidal woman needing immediate help instead received a three hour call back.  NHS 24's own investigation report noted that it was unclear why the call was downgraded, and that there seemed to have been a disregard of mental health concerns by the senior nurse.  They also found that following the transfer to Breathing Space, the call should have been closed down within the UCS.  The advice I received was that, given the information taken by the call handler, contact with Ms A should not have been broken.  Allocating a three hour call back and leaving the call open after transferring to Breathing Space was not reasonable and, therefore, I upheld this complaint.

Mrs C complained that the BSA had not used Applied Suicide Intervention Skills Training (ASIST) during the call with Ms A and took no action to help her.  NHS 24 said that ASIST techniques were not used as the BSA knew that a nurse practitioner would be calling Ms A to make a full clinical assessment of her symptoms.  My mental health adviser said that this explanation was not reasonable as the BSA knew about Ms A's suicide attempt yet did not explore sufficiently the risk of suicide during the call.  My adviser said that the support offered by the BSA was ineffective.  The call recording showed that Ms A became increasingly distressed and my adviser commented that they would have expected the BSA to continue speaking with Ms A until her distress had reduced, instead of ending the call.  I found that Breathing Space did not offer a reasonable service to Ms A so I upheld this complaint and made several recommendations.

Mrs C also complained that there was only one attempt to call Ms A back before closing the call, and that NHS 24 did not contact Ms A's GP.  My investigation found that NHS 24's procedure is to attempt to call patients up to two times before closing the call, unless there is a particular clinical concern.  However, there was enough evidence from Ms A's call to indicate a 'particular clinical concern' and I considered that further action should have been taken, including sharing information with Ms A's GP.  Therefore, I upheld this complaint.

This significant case has raised concerns about how effectively mental health crises are managed by the UCS.  The initial call handling is geared towards physical problems and gathering personal information.  However, the advice I have received highlighted that, for people experiencing mental health difficulties, this is ineffective and can exacerbate their symptoms.  More needs to be done to ensure that mental health is not treated with any less urgency than physical health, so I made a number of additional recommendations to address my wider concerns.

Redress and recommendations
The Ombudsman recommends that NHS 24:

• apologise to Mrs C for the allocation of a three hour call back;
• ensure that this complaint is included for discussion at the next appraisal of the Senior Nurse;
• ensure that all relevant staff are aware of the guidance on transferring calls to Breathing Space to avoid incorrect advice being offered to call handlers in future;
• apologise to Mrs C for the way this call was handled by Breathing Space;
• ensure that the findings of this report are discussed with the BSA for learning;
• ensure that Breathing Space staff are aware of when to use ASIST techniques;
• ensure that all Breathing Space staff are aware of the process to escalate calls;
• apologise to Mrs C for the failure to take appropriate action when Ms A could not be reached;
• ensure that this complaint is included for discussion at the next appraisal of the Nurse Practitioner;
• report to us on the implementation schedule of the new Patient Contact Management system system;
• and then again when the system goes live
• review their guidance for all staff on the management of suicidal thoughts and common mental health problems;
• review their procedures for triaging mental health difficulties, such as panic and depression, for patients who present in crisis; and
• review the questions used in the initial contact process to take mental health into account.

CSummary
Ms C was assessed as low risk during her pregnancy and it was, therefore, considered suitable for her to deliver her baby at the Community Midwifery Unit at Vale of Leven District General Hospital.  After going into labour she was admitted to the maternity unit but her labour was slow to progress.  Several hours after admission, an examination found that her baby was in a posterior position (when the back of the baby's skull is in the back of the mother's pelvis).  This meant that the delivery would be more complicated and would be likely to need a higher level of care than was available at the maternity unit.  Staff called an ambulance to transfer Ms C to the Royal Alexandria Hospital.  The ambulance service was particularly busy so the transfer took longer than expected.  There was also a delay in the ambulance team accessing the building as they did not know the maternity unit.  Ms C was given an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth) very shortly before she was transferred.  Her baby was unwell at birth and she was transferred to another hospital for specialist neo-natal treatment.

Mr and Ms C complained to the board that the maternity unit did not reasonably explain in advance the transfer arrangements to hospital from the unit in case of an emergency; did not provide a reasonable standard of maternity care; delayed making the decision to transfer Ms C to hospital; contributed to delays during the transfer process; and that the board did not handle their complaint in line with the complaints procedure.

The board conducted a Significant Incident Review following the complaint, identifying a number of failings in Ms C's care, and recommending improvements at the maternity unit.

I took independent midwifery advice on this complaint.  Regarding the information received about an emergency transfer to hospital from the maternity unit, it was clear that Ms C's understanding of the transport arrangements was not correct.  She had also not been given any written information.  The board acknowledged that Ms C should have been given clearer information, and they had amended a leaflet to include the transfer information.  However, my adviser noted that the leaflet should be provided to women before they have chosen where to give birth.

We found several failures in the maternity care provided to Ms C in the maternity unit.  This included a failure to properly assess her on admission or identify a clear plan of care; lack of monitoring throughout her labour; poor documentation, particularly of care planning and regarding handovers between staff; and also the episiotomy was undertaken inappropriately and possibly unnecessarily.  The poor standard of care put Ms C and her baby at unnecessary risk.

As a result of some of the failures above, the decision to transfer Ms C to hospital was delayed.  If her labour had been managed properly, she could have been transferred before it was an emergency.  I am critical that the board's SIR did not highlight this delay and that they have yet to apologise for it.

The delay in the ambulance arriving at the maternity unit was due to pressures on the ambulance service and therefore out of the board's hands.  However, the difficulties the crew experienced getting into the building were avoidable, and I am critical of the lack of action from the maternity unit staff.

The board clearly did not deal with Mr and Ms C's complaints within the timescales of their guidance (Guidance to Staff in Dealing with Complaints).  Additionally, the board's final response to their complaints was in the form of notes from meetings, rather than a formal letter clearly stating whether complaints were upheld and providing a meaningful apology.

I upheld all of the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  ensure that the leaflet entitled 'Having your baby at the Vale of Leven CMU' is given to women before they have made a decision about where they would like to give birth, and revise the wording of the leaflet as appropriate; 30 November 2015
• (ii)  consider the need to review the NHS Greater Glasgow and Clyde Obstetric Guidelines, in line with National Institute for Health and Care Excellence Guidelines on Intrapartum Care (2014); 30 November 2015
• (iii)  reflect on the findings of this case, and consider whether the provision of aromatherapy at the Unit should be offered on a 24 hour basis; 30 November 2015
• (iv)  extend the use of the new tool for handover of care, so that it is applied to telephone handovers when transferring care from the Unit to Royal Alexandria Hospital; 30 November 2015
• (v)  consider implementing a system for staff rotations from the unit to Royal Alexandria Hospital on an annual basis, if this is not already in place; and 7 January 2016
• (vi)  apologise to Ms and Mr C for the failings identified in this report, and the distress this caused them and Baby C. 30 October 2015

Summary
Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) received from her medical practice over the two-year period before her death.  Mrs A first contacted the practice in November 2011 about her hip pain.  She was prescribed painkillers but the pain persisted, and an x-ray was taken in summer 2012 which suggested that she had osteoarthritis.  Mrs A's pain increased so, in October 2012, the practice made a referral for her to see an orthopaedic consultant (who specialises in the musculoskeletal system).

In January 2013, Mrs A reported to the practice her weight loss of ten kilograms over two to three weeks.  She saw the orthopaedic consultant, who thought that her pain was muscular and at the base of her spine, rather than caused by arthritis in her hip.  Mrs A received physiotherapy and stronger painkillers, neither of which helped to reduce her worsening pain.  She was re-referred to orthopaedics, and saw the consultant, who arranged a scan for the end of August 2013.  Before the scan, Mrs A's condition deteriorated further.  She was in regular contact with the practice, and prescribed different pain medications.  She found the scan very painful and did not get the results in the time-frame she was expecting.

Mrs A's mobility decreased in September 2013 until she was mostly bed-bound, and a home visit from the practice was requested.  The scan results showed an abnormality at the base of her spine and, in light of her deterioration, the practice arranged Mrs A's hospital admission.  She was told soon after that she had widespread secondary cancer to her hip and pelvic bone area.  She died in October 2013.

In investigating Mrs C's complaints, I obtained independent advice from a GP adviser.  She was concerned that Mrs A's pattern of contact with the practice, her symptoms and abnormal test results should have led to a referral for an assessment for a potential underlying problem.  The adviser said that Mrs A's rapid weight loss should have been investigated as it was unlikely to be only caused by nausea from her medication.  The Scottish Referral Guidelines for Suspected Cancer say that unexplained or persistent weight loss of over three weeks should be referred for investigation, which did not happen.  She also noted that Mrs A's haemoglobin level and liver function should have been rechecked after getting abnormal test results.

My adviser said that Mrs A's medical records showed her increased rate of contact with the practice during the two-year period before her death and, particularly, between July and September 2013.  She said that the practice should have been alert to this pattern of contact.  She also noted that over half of Mrs A's consultations in this period were over the telephone.  She recognised the established place in patient care for telephone contact, but she felt the symptoms Mrs A described (increasing pain, reduced function and increased weight loss) meant that she needed clinical re-examination.  She felt Mrs A's symptoms were sufficient for the practice to have considered an alternative diagnosis and further investigation.

In view of the clear medical advice I received about Mrs A's pattern of contact with the practice, her symptoms and her test results, I consider more could reasonably have been done by the practice to reassess her diagnosis and investigate other possible causes of her condition.  I upheld this complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  apologise to Mrs C for the shortcomings identified in this report; 28 October 2015
• (ii)  discuss this matter as a significant event within the Practice (with particular reference to Mrs A's pattern of contacts, the number of telephone consultations and Mrs A's increasing pain and immobility prior to her hospital admission); 25 November 2015
• (iii)  review and consider their use of telephone consultations to ensure they are not overly dependent on them; and 25 November 2015
• (iv)  ensure they are familiar with the Scottish Referral Guidelines for Suspected Cancer and also the Scottish Intercollegiate Guidelines Network Guidance for pain management. 25 November 2015