North East Scotland

Overview
The complainant (Mrs C) complained about the treatment for a nut allergy provided to her daughter (Miss C) by a GP (the GP), prior to her daughter's death from anaphylaxis. In particular, Mrs C complained that an EpiPen (an auto injector of adrenaline) had not been prescribed to Miss C. Mrs C also complained about the tone and manner of the GP when she telephoned four days after her daughter's death.

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

• (a) the care and treatment provided to Miss C by her GP for a nut allergy prior to her death from anaphylaxis was inadequate (upheld); and
• (b) the tone and manner of the GP when she telephoned four days after Miss C's death were inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that:

• (i) the GP write to Mrs C to apologise for failing to discuss the letter of 1 August 2007 with her.

The Practice has accepted the recommendation to issue an apology and will act on it accordingly.

Further Action
Faced with the lack of national guidance on adrenaline auto injector prescription, there is a danger of inconsistency in approach with potentially devastating consequences. Introducing national guidance could be a safeguard against this. A national paediatric allergy network that has been set up could take this forward and build upon the work already done by Greater Glasgow and Clyde NHS Board. The Ombudsman will draw this matter to the attention of the Scottish Government Health and Social Care Directorate.

Overview
The complainant (Mr C) raised a number of concerns about the treatment which his late wife (Mrs C) received when she attended Aberdeen Royal Infirmary (the Hospital) as a day patient on 18 March 2010. Mrs C fell and fractured her hip while receiving chemotherapy treatment but the fracture was not identified on x-ray and she was discharged home. Mrs C received a telephone call from a consultant oncologist at the Hospital (the Consultant) on 22 March 2010 and was told that she had to return to hospital as the fracture had been identified when he had reviewed the x-ray. Mrs C was admitted to the Hospital that day but her condition deteriorated and she died on 26 March 2010.

Specific complaint and conclusions
The complaint which has been investigated is that the care and treatment which Mrs C received at the Hospital on 18 March 2010 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) bring this report to the attention of the On-call doctor's clinical supervisor and determine whether there is a training requirement for the interpreting of x-rays; and
• (ii) formally apologise to Mr C for the On-call doctor's failure to correctly interpret the x-ray on 18 March 2010.

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

Overview
The complainant (Mrs C) complained about the transfer of her son (Mr A) to the Intensive Psychiatric Care Unit (the IPCU) at Carseview Centre (the Centre), Ninewells Hospital (Hospital 1), Dundee, on 8 January 2008. Mr A had been transferred from the Forensic Unit (the Unit), Murray Royal Hospital, Perth, where he was being treated under a Compulsory Treatment Order (CTO). She also complained that, on 16 January 2008, Mr A was granted a period of escorted leave within the vicinity of the Centre, from where he was able to abscond. Mrs C complained that when Mr A returned to the IPCU that same evening, he was not provided with adequate physical care and treatment. Mr A died in the early hours of 17 January 2008.

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

• (a) Tayside NHS Board (the Board)'s decision making processes to transfer Mr A from the Unit to the IPCU at Hospital 1 were unclear (upheld);
• (b) the decision taken to allow escorted leave from the IPCU was inappropriate for Mr A on 16 January 2008 (upheld); and
• (c) Mr A's physical care and treatment was inadequate on his return to the IPCU from a period of unescorted leave on 16 January 2008 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) urgently review their procedures for the transfer of patients under a CTO to ensure that non urgent transfers are properly categorised and dealt with as such; and that decisions are properly recorded;
• (ii) ensure that, where there is a statutory right of appeal against the decision to transfer, the appropriate persons are formally notified of that right;
• (iii) ensure that every consideration is given for the named person to have the opportunity to provide their views formally and for these views to be recorded and considered as part of the decision making process;
• (iv) ensure that decisions taken about the level of leave allowed during any episode of care and the level of escorts are explained and understood by the patient and their relatives (where appropriate) and a full record is made of these;
• (v) consider the introduction of a locally based alert system within the vicinity, which would enable staff to draw attention to potential incidents sooner than the time taken to return to the ward;
• (vi) review the escort arrangement at the IPCU for accompanied time out, to ensure that the arrangement is clinically appropriate in terms of the risk assessment for the patient;
• (vii) provide training to ensure the adequate medical examination, nursing observation and assessment of vital signs within the IPCU, when managing a patient recently having consumed an illicit substance;
• (viii) ensure that there is appropriate consideration for review of the procedure or protocol for referring a patient to the local Accident and Emergency department for further consideration of physical care and treatment when they admit to having consumed illicit substances;
• (ix) remind staff of their professional responsibilities towards the care and treatment of a patient received into their care with or without prior advice provided by other professional disciplines;
• (x) conduct an audit to ensure full compliance of the use of assessment tools and measures and completion of monitoring charts and vital signs monitoring charts;
• (xi) ensure that this report is shared with all staff involved in Mr A's care when he returned to the IPCU on 16 January 2008, so that they can learn from the findings of this report; and
• (xii) provide an apology 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 (Mr C) made a complaint about Grampian NHS Board (the Board). Mr C complained about the care and treatment he received for wounds and pressure sores; and the attitude of a Consultant Plastic Surgeon (Consultant 1). Mr C also complained about the Board's handling of his complaint.

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

• (a) Consultant 1 did not care for and treat Mr C's wounds and pressure sores appropriately (upheld);
• (b) Consultant 1 did not understand and direct the vacuum assisted closure (VAC) treatment of Mr C's wounds appropriately (upheld);
• (c) Consultant 1's attitude towards Mr C was inappropriate and he discriminated against Mr C because of his age and disability (not upheld); and
• (d) the Board's handing of Mr C's complaint, including the investigation, was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their approach to team care for wounds and pressure sores such as Mr C's, to ensure a cohesive plan of management;
• (ii) review their protocols for the use of VAC treatment to ensure that it is used appropriately in conjunction with other treatments for relief of pressure sores pre-operatively;
• (iii) remind staff of the importance of good record-keeping;
• (iv) review their processes to ensure they obtain responses from relevant staff when investigating complaints; and review their processes for recording the investigation of complaints; and
• (v) apologise to Mr C for the failings identified in this report.

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

Please note that this report contained typographical errors in three of the recommendation dates.  The three recommedation completion dates that were recorded as 2010 should have been 2011.

The SPSO has apologised for these errors.

Overview
The complainants (Mr and Mrs C) brought a complaint on behalf of their son, (Mr A), concerning allegations of misconduct made against him by the University of Dundee (the University). They complained that the University's investigation into his alleged misconduct was not conducted in accordance with the correct procedure, or in a manner that was fair and unbiased. They also felt that the conclusions of the investigation were unfairly punitive on Mr A.

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

• (a) the University did not follow their own process in reaching their decision on the allegations against Mr A (upheld);
• (b) the University failed to take into account Mr A's special needs when carrying out their investigation (not upheld); and
• (c) the punishment decided upon by the University was not commensurate with the allegations made against Mr A (not upheld).

Redress and recommendations
The Ombudsman recommends that the University:

• (i) review their actions on Mr A's case prior to the commencement of the Ordinance 40 process with a view to improving the transparency of their information gathering in cases of potential academic dishonesty;
• (ii) introduce measures to ensure that students are aware of the evidence submitted to the Boards of Internal and External Examiners for consideration;
• (iii) introduce a policy of formally stating the allegation being made against a student at the commencement of the Ordinance 40 process;
• (iv) apologise to Mr A and his family for the failings identified in this report prior to the commencement of the Ordinance 40 process;
• (v) introduce a policy of recording their consideration of students' special circumstances in all disciplinary cases; and
• (vi) remind staff chairing hearing panels that their decisions should be based solely on the evidence presented for consideration.

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

Overview
The complainant (Mr C) contacted the Ombudsman about multiple concerns relating to the post-operative care he received following the extraction of a wisdom tooth at Dundee Dental Hospital. Mr C believes that, given his past medical history, his care was substandard and that Tayside NHS Board (the Board) failed to consider his symptoms adequately, resulting in him being admitted to Ninewells Hospital for nine days.

Specific complaints and conclusions
The complaint which has been investigated is that the Board failed to diagnose and treat Mr C's haematoma adequately, resulting in a prolonged hospital admittance (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the pre-operative planning for dental patients with pre-existing disease and/or drug history to ensure that effective treatment plans are available in the event of post-operative complications. This should include a review of their post-operative information packs given to patients to ensure that they provide detailed instructions to patients on Warfarin therapy; and
• (ii) apologise to Mr C for their failure to carry out effective pain control.

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

Overview
The complainant (Mr C) made a complaint about Grampian Health Board (the Board) on behalf of the aggrieved (Mrs A). Mrs A was admitted to Aberdeen Royal Infirmary (the Hospital) after collapsing in a supermarket on 17 February 2009. On the following day, it was recorded that she was very agitated, confused and that she was shouting. Later that day, nurses recorded that they were unable to give the prescribed intravenous antibiotics because Mrs A refused them. The records show that she was subsequently given two doses of haloperidol (an antipsychotic drug) by intramuscular injection 'to settle'.

Specific complaints and conclusion
The complaint which has been investigated is that Mrs A was injected with haloperidol against her will on 18 February 2009 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in the Hospital to include:  the assessment, treatment and care of people with confusion, delirium or behavioural disturbance; the use of the Adults with Incapacity legislation; the use of both physical restraint and restraint by medicines;
• (ii) review the means by which medical and nursing staff are trained in the assessment and management of acute agitation or confusion, including appropriate use of the Adults with Incapacity legislation and documentation;
• (iii) review and disseminate their 'Guidance for Rapid Tranquilisation of Psychiatric Emergencies in Psychiatric Hospitals, General Hospitals and Accident and Emergency Departments' document;
• (iv) remind all clinical staff in the Hospital to carefully document indications for the use of sedative medication, the patient's consent to such treatment and the use of any form of restraint to administer such medication;
• (v) provide me with details of the findings and the action plan created as a result of the above recommendations and provide updates where relevant;
• (vi) ensure that the findings in this report are communicated to the staff involved in Mrs A's care and treatment; and
• (vii) issue an apology to Mrs A for the failings 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 her late father (Mr A) received from Ninewells Hospital (the Hospital) after he was admitted on 20 April 2008 with collapse and expressive dysphasia (difficulty in using language). Mrs C is also aggrieved about the length of time it took for Tayside NHS Board (the Board) to respond to her complaints.

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

• (a) there was inadequate monitoring of blood pressure (upheld);
• (b) there was lack of intervention to increase blood pressure (upheld);
• (c) the reintroduction of blood pressure and cardiac medications all at once was inappropriate (not upheld);
• (d) there was a delay in the swallow assessment and nasogastric tube being inserted (not upheld); and
• (e) there was a delay in the Board responding to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review its policy regarding the monitoring of patients with acute stroke who are given treatment that may cause unexpected and precipitous falls in blood pressure;
• (ii) provide ongoing evidence, such as Scottish patient safety reports, which demonstrates consistency and continuity of care for those patients being transferred between wards or units; and
• (iii) review the need for a protocol in the stroke unit regarding the immediate management of patients with acute stroke who suffer sudden, severe and symptomatic falls in blood pressure.

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

Overview
The complainant (Mrs C), who is an advice worker, raised a number of concerns on behalf of her client (Ms A) about the treatment which she received following an admission to Dr Gray's Hospital (the Hospital) during the period 12 July 2008 to 14 July 2008. Ms A was readmitted to the Hospital on 16 July 2008 where it was found that she was suffering from cerebral lymphoma.

Specific complaint and conclusion
The complaint which has been investigated is that the treatment which Ms A received at the Hospital from 12 July 2008 to 14 July 2008 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the importance of good record-keeping;
• (ii) share this report with the staff concerned, in order that they can reflect on their actions; and
• (iii) apologise to Ms A for the failings which have been identified in this report.

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

Overview
The Complainant (Mr C) had Peyronie's disease and underwent surgery to correct it. He complained that the operation that was carried out was not the one that had been discussed prior to surgery and that it was not carried out properly. Mr C subsequently encountered a number of complications that resulted in further corrective surgery. Mr C also complained that Greater Glasgow and Clyde NHS Board (the Board) failed to offer appropriate aftercare following his operation.

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

• (a) provide the correct treatment for Mr C's Peyronie's disease (not upheld);
• (b) warn Mr C of the potential complications of the procedure that was carried out (upheld); and
• (c) provide adequate aftercare following Mr C's surgery (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide patients with information relating to the potential complications of surgery, in writing, at the point of gaining their consent;
• (ii) advise patients of the fact that the surgery provided may differ to that proposed prior to surgery and that they keep a record that this advice has been given; and
• (iii) remind staff of the importance of recording any advice, medication or supplies provided to patients.

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