North East Scotland

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment given to his wife (Mrs C), after she was admitted as a voluntary patient to Crathes Ward (Ward 1) of the Royal Cornhill Hospital, Aberdeen (the Hospital).  He said that although she was experiencing suicidal thoughts, the means by which she could attempt to end her life were not removed from her.  He was also concerned that she was not placed under an appropriate level of observation and that she did not receive her required medication.

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

• (a) failed timeously to remove Mrs C's personal belongings for safe keeping (upheld);
• (b) failed to keep Mrs C under an appropriate level of observation (upheld); and
• (c) failed to ensure that Mrs C had an adequate supply of medication (upheld).

Redress and recommendations

The Ombudsman recommends that Grampian NHS Board:

• emphasise to staff on Ward 1 that when suicidal intent has been indicated, they must take action to mitigate the risk;
• ensure that action in this regard should be properly documented and timed;
• make a formal apology to Mr and Mrs C for their failures in this matter;
• take steps to ensure that their processes of risk assessment and risk assessment planning are robust and transparent; and
• ensure that transfer procedures take due account of medication issues, to ensure that any required medication is prescribed/given without undue delay.

Overview
The complainant (Mrs C) raised concerns about Grampian NHS Board (the Board)'s handling of her husband (Mr C)'s hip replacement operation.  Equipment problems caused complications during the procedure.  Following surgery, Mr C developed delirium.  Although this largely resolved with time, he was required to remain in hospital for several months following his surgery.

Specific complaint and conclusion
The complaint which has been investigated is that staff at Dr Gray's Hospital (the Hospital) in Elgin failed to conduct Mr C's hip replacement operation on 31 October 2012 in a reasonable and appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• conduct a review of the equipment available in their theatres to ensure that their surgical teams have access to any instruments which might be required in the course of an operation; and
• share my findings with their surgical staff for discussion at a suitable learning forum, with particular reference to the appropriateness of decisions made during Mr C's operation.

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

Overview
The complainant (Miss C) raised a number of concerns that her sister (Ms A) had been provided with inadequate care and treatment in that the symptoms with which she was presenting between October and November 2011 were not appropriately investigated and treated. 

A Critical Incident Review (CIR) of the events surrounding Ms A's care and treatment was held in May 2012 by Tayside NHS Board (the Board) following Ms A's death in April 2012.  Miss C complained that the Board failed to provide the family with a copy of the CIR report despite repeated requests and failed to arrange a meeting with the family.

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

• (a) between October and November 2011, staff at Ninewells Hospital failed to provide Ms A with appropriate medical treatment in view of the symptoms with which she presented (upheld); and
• (b) staff at the Board failed to provide the family with a copy of the CIR report despite them making repeated requests and failed to take steps to arrange a meeting with the family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provide evidence that appropriate action was taken to address the mis-reporting of the Magnetic  Resonance Imaging scan of 10 October 2011;
• (ii)  ensure that future Radiology Discrepancy and Complications Meetings are minuted and the minutes appropriately circulated;
• (iii)  review the application of the 'three day guidance' to ensure that staff appropriately assess patients before referring back to their GP and where necessary provide refresher training;
• (iv)  ensure that staff on the Acute Medical Unit are reminded of the need to be proactive in addressing patients pain;
• (v)  continue to work towards producing a care pathway to improve the treatment of patients who present with un-resolving and/ or deteriorating symptoms, including improved communication with primary care providers (GPs);
• (vi)  remind staff dealing with complaints about the usefulness of meetings at an early stage of the complaints process as per their Complaints Management Procedure; and
• (vii)  issue a written apology to Ms A's family 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 her husband (Mr C)'s care and treatment when he was admitted to the Emergency Department of Aberdeen Royal Infirmary on 19 November 2012. 

She said that despite being assessed at 09:20 for transfer to the Acute Medical Assessment Unit he was not transferred there until 20:18.  In the meantime, he had been lying on a trolley.  Once transferred, Mrs C said that there was a delay in him seeing a doctor and that his condition continued to decline.  Regrettably, Mr C died at noon the next day and Mrs C further complained about Mr C's appearance when she arrived in hospital after his death.

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

• (a) the care and treatment given to Mr C on his admission to hospital in November 2012 were unreasonable (upheld);
• (b) Grampian NHS Board (the Board) unreasonably asked Mrs C to sign Mr C's death certificate before she had been given a chance to see him (upheld); and
• (c) the Board unreasonably failed to properly lay out Mr C before Mrs C saw him (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the fact that Mr C was not examined further by the medical team whilst he was still in the Emergency Department;
• provide a plan detailing the changes they have made to prevent such a recurrence (that is, missing target times and a failure to assess and treat in a timely manner);
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
• emphasise to all staff in the Emergency Department the importance of keeping accurate and timely clinical records;
• advise me of the steps they have taken to ensure that staff are aware of their responsibilities in similar circumstances and to be alert to the sensitivities of family members;
• take steps to ensure that this does not happen again and emphasise to all appropriate staff the necessity of preserving a patient's dignity in death; and
• be sensitive to the needs of close family members in such matters and advise appropriate staff accordingly.

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

Overview
The complainant (Mrs C) complained on behalf of her mother (Mrs A) to Grampian NHS Board (the Board) about the care and treatment her father (Mr A) received while a patient in Aberdeen Royal Infirmary (the Hospital) from 5 August to 23 September 2012.  Mr A had been admitted to the Hospital's Acute Stroke Unit after suffering a stroke at home.  Mr A died in the Hospital on 23 September 2012.

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

• Mr A's medical care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld); and
• Mr A's nursing care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• draw this report to the attention of all senior medical staff involved in Mr A's care;
• take steps to put in place an action plan to address the failings identified in this report;
• ensure that staff document relevant discussions they have with a patient's family or their carer;
• act upon the comments of Adviser 1 in relation to the introduction of a policy on the certification of a patient's death;
• draw to the attention of relevant staff, the importance of providing evidenced based complaints responses;
• share with relevant nursing staff the comments of Adviser 2 with regard to maintaining a patient's dignity;
• draw to the attention of relevant staff, Adviser 2's concerns about the Board's rationale for removing Mr A's pyjama bottoms; and
• apologise to Mrs A and her family for the failings identified in complaints (a) and (b).

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

Overview
The complainant (Mrs C) raised a complaint on behalf of Ms B about the care and treatment provided to her late mother (Mrs A) by Grampian NHS Board (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that staff at Dr Gray’s Hospital (Hospital 1) failed to provide Mrs A with appropriate care and treatment following her admission on 6 April 2012 with severe chest pain (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Ms B for the failures identified;
• reflect on the failure to examine Mrs A’s chest and ensure that measures are in place to prevent a similar occurrence in the future;
• undertake an audit of record-keeping within Ward 8 to ensure medical records are completed timeously and comprehensively and report back to the Ombudsman; and
• bring this report to the attention of relevant staff during their appraisals to ensure lessons have been learned from this case.

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

Overview
On 2 April 2013, the complainant (Miss C) telephoned her mother (Mrs A)'s medical practice (the Practice) and requested a house call Mrs A.  However, she said that when the GP (the Doctor) visited, she failed to examine Mrs A or ask her whether she was in pain.  Miss C said that the Doctor disregarded the symptoms she reported; refused to give Mrs A anything to help her sleep; and called her by an incorrect name.  Miss C complained that had Mrs A been examined and told treatment in hospital was necessary, the outcome for her could have been different.  Mrs A was subsequently taken to hospital where she died.

Specific complaint and conclusion
The complaint which has been investigated is that, in relation to a house call on 2 April 2013, the Doctor unreasonably failed to examine Mrs A, leading to a delay in admitting her to hospital for tests and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• ensures that the Doctor make a formal apology to Miss C for her failure in this matter; and
• ensures that the Doctor completes appropriate professional training so that she is fully appreciative of the seriousness of abdominal pain in the elderly and the importance of conducting a thorough history and examination.

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

Overview
The complainant (Ms C) who was an Advocate acting on behalf of Mrs A, raised a number of concerns that the care and treatment provided by his General Practitioner (GP) to Mrs A's husband (Mr A) were inappropriate.  Ms C also complained that Mr A’s medical practice (the Practice) failed to provide an adequate response to the complaint about Mr A's treatment.

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

• (a) the Practice failed to provide appropriate care and treatment for Mr A's reported symptoms of headaches; dizziness; and disorientation; in April and May of 2012 (upheld); and
• (b) the Practice failed to provide an adequate response to the complaint about Mr A's treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• conducts a Significant Event Analysis of these events and that any learning outcomes are discussed at the GP's annual appraisal;
• conducts a review of a sample of clinical records to assess whether they meet the standards recommended by the GMC.  Any learning outcomes to be addressed at the GP's annual appraisal and/or with appropriate training;
• conducts a review of the Practice's monitoring protocol for patients taking warfarin to ensure that it is fit for purpose;
• conducts a review and revision of its complaints procedure to ensure it complies with current NHS complaints handling guidance;
• ensures that all staff have received appropriate training on handling complaints; and
• issues a written apology to Mrs A for all the failings identified in this report.

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment provided to his son (Mr A) for mental health problems by Tayside NHS Board (the Board) prior to his death by suicide in July 2010. Mr C also raised concerns about the level of the family's involvement in the Board's Adverse Significant Incident review and their root cause analysis after Mr A's death.

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

• (a) mental health care and treatment from June 2009 until Mr A's death in July 2010 were below an acceptable standard (upheld); and,
• (b) the level of family involvement in the Board's Adverse Significant Incident review and their root cause analysis was below an acceptable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) take steps to ensure that systems are in place in order that the care of vulnerable people is co-ordinated effectively and with due urgency, to minimise the danger of people at risk inappropriately disengaging or being lost to follow up;
• (ii) take steps to ensure that systems are in place in order that therapeutic engagement is planned with the patient's full participation. One-to-one therapeutic time should be negotiated and agreed on an individual basis and solitary, withdrawn and /or difficult to engage patients should have access to a range of interventions matched to their needs and wishes. They should also be consistently encouraged to engage with agreed interventions;
• (iii) ensure that clinical observation practice is in line with national guidance;
• (iv) take steps to ensure that no patient is de facto detained;
• (v) take steps to ensure that the eligibility criteria for engagement with secondary community mental health services are sufficiently flexible to allow vulnerable people to access appropriate services in situations where the person does not wish to (or does not require to) go into hospital but has complex needs which may be receptive to psycho-social interventions and which require a greater intensity of input than can reasonably be provided in the primary care setting;
• (vi) take steps to ensure that systems are in place in order that people who are vulnerable and difficult to engage are proactively followed-up by community services and all reasonable and appropriate steps are taken to minimise the risk of scheduled appointments being missed;
• (vii) ensure that the care plans of vulnerable patients, especially those who are difficult to engage or have a history of defaulting from care, include steps to be taken when scheduled appointments are missed;
• (viii) take steps to ensure that discharge letters which promote the delivery and continuity of safe and effective care are timeously received by GPs;
• (ix) take steps to ensure that up-to-date training records are maintained which enable performance against national or internal training targets to be judged; and
• (x) issue a written apology to Mr C for the failings identified in this report.

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

Overview
The complainant (Mr C) raised a number of concerns with Grampian NHS Board (the Board) that the care given to his wife (Mrs C) and baby daughter (Baby C) at Aberdeen Maternity Hospital (the Hospital) was inadequate. Mrs C was admitted to the Hospital two weeks prior to Baby C's birth by caesarean section. Baby C died shortly after birth, having been born premature and very underweight. Mr C was particularly concerned about the refusal of medical staff to continue resuscitation on Baby C. It is of concern to me that a number of relevant and important clinical documents, including reference to the fact a post-mortem examination had been conducted, were not provided to my office by the Board until they were asked to highlight any factual errors in a draft version of this report. At this stage of our investigative process, the Board had already been asked, on two occasions, to provide all the relevant information they held. In addition, we had already obtained clinical advice, with my advisers providing comment on the clinical records and information as received. I am disappointed by the Board's decision not to provide such relevant information until this final fact checking stage. I expect all bodies to ensure that their responses to my office's enquiries are thorough and include all information which is of relevance to the complaints under investigation. The Board's omissions in this case undoubtedly hampered our investigations, caused increased stress and distress for the family involved, and are totally unacceptable, as well as unprofessional.

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

• (a) failed to adequately manage the later stages of Mrs C’s pregnancy including the birth of her baby (upheld);
• (b) failed to adequately assess the possible success of continued resuscitation (not upheld); and
• (c) failed to adequately communicate with Mr and Mrs C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider introducing guidelines for the management of small for gestational age foetuses, with reference to the Royal College of Obstetricians and Gynaecologists guidance of March 2013;
• (ii) undertake an assessment to ensure that the Obstetric Team has the correct training and equipment to perform assessments of extremely pre-term infants with abnormal umbilical blood flows, and prepare an action plan to address any shortcomings;
• (iii) provide evidence to demonstrate that following the death of a baby, full clinical examinations and investigations, including a post-mortem, are discussed with and offered to parents;
• (iv) demonstrate that the Board's guidelines about intrauterine death , which contain survival figures for babies of extreme prematurity, are referred to as appropriate by maternity and neonatal staff when discussing care with prospective parents;
• (v) remind all of the staff involved in Mrs C's care of the importance of obtaining signed consent forms for caesarean sections;
• (vi) issue a full apology to Mr and Mrs C for all of the failings identified in this report;
• (vii) draw this report to the attention of all neonatal, obstetric and maternity staff at the Hospital; and
• (viii) conduct a significant event analysis of Mrs C and Baby C's care from the point of Mrs C's admission until Baby C's delivery and treatment.