North East Scotland

Overview
The complainant (Ms C), who is an advice caseworker, raised a number of concerns on behalf of her client (Ms A), about the treatment which Ms A had received at the Department of Urogynaecology at the Southern General Hospital, Glasgow (the Department). Ms A had undergone surgery in 2007 and since then has suffered with incontinence, urinary infections, loss of lower body sensation, vaginal discharge and severe pain.

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

• (a) proper informed consent was not obtained prior to surgery (upheld);
• (b) the clinical treatment which was provided was inadequate (not upheld); and
• (c) following surgery, staff failed to take prompt action to establish the cause of Ms A's concerns (upheld).
   

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

• (i) review their consent process, to ensure that patients have enough time to digest the information provided by staff and in information leaflets and that sufficient space is available on the consent forms to list what has been discussed;
• (ii) share this report with the staff involved and ask them to reflect on the advisers' comments about considering alternative procedures prior to surgery; 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 (Ms C), who was aged 33, was admitted to the Southern General Hospital in the area of Greater Glasgow and Clyde NHS Board (the Board) in September 2007 and October 2007 with possible cauda equina syndrome (CES). She complained that the decision not to operate near the start of the first admission seriously compromised her condition and that, despite ongoing symptoms and inability to manage her daily life, her discharge home did not include adequate follow-up support.

Specific complaint and conclusion
The complaint which has been investigated is that surgery should have been done near the start of the first hospital admission, there was inadequate communication with Ms C about the nature and outcome of her condition and the after-discharge support was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for not having operated earlier;
• (ii) reflect on this report's conclusions and take appropriate action in respect of each;
• (iii) satisfy themselves that the consultant in question has an appropriate understanding of CES; and
• (iv) update the Ombudsman's office on the main audit findings and main plans regarding after-discharge support.

Overview
The complainant (Mr C) raised concerns about the care and treatment which his late wife (Mrs C), who had severe Multiple Sclerosis, received from Greater Glasgow and Clyde NHS Board (the Board) during her time in hospital for treatment of her painful right hip. Mr C complained that, whilst in hospital, the Board failed to feed his wife, who required to be fed via a percutaneous endoscopic gastrostomy tube, in a sufficiently upright position, which caused food to pass into her lungs. Mr C said he believed that the Board failed to notice that his wife had then developed a chest infection and provide necessary treatment and that this had resulted in her death.

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

• (a) the Board did not feed Mrs C in a sufficiently upright position (not upheld); and
• (b) the Board failed to notice that Mrs C had developed a chest infection and treat it in time (partially upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for failing to notice that Mrs C had developed a chest infection on 16 February 2007 and provide appropriate treatment at that time and for failing to produce a care pathway for Mrs C when the course of her treatment changed;
• (ii) feed back the adviser 's views on what he considers would have been the appropriate course of treatment for Mrs C on 16 February 2007, to the staff involved in cases of this type and in Mrs C's care, in particular;
• (iii) provide training to staff to ensure that, in all appropriate cases, where the direction of a patient's treatment changes, a new care pathway is devised - this could be by introducing a multi-disciplinary record or audit of documentation;
• (iv) ensure the staff involved in Mrs C's care are made aware of the need to record accurate information on patient mobility in their records;
• (v) review their current policy on the use of special mattresses and beds, incorporating the NHS QIS standards and flowchart; and
• (vi) provide feedback to the staff involved in Mrs C's care on the importance of seeking guidance from a more senior member of the medical team on appropriate treatment and/or to ask technical staff for assistance, in cases where the accuracy of medical equipment, such as a pulse oximeter, is in question.

Overview
The Ombudsman received a complaint from a member of the public (Mrs C). Mrs C complained that her husband (Mr C) had not received the appropriate treatment further to a telephone call to the out-of-hours emergency medical services provided jointly between the NHS 24 and Greater Glasgow and Clyde NHS Board (the Board), during which time it is stated by the family they had been unable to get the service to accept their description of Mr C's illness. He had been out early in the evening and returned home complaining of a headache. Initially, Mr C had been advised to take medication available in the house, rest and let NHS 24 know if there was no improvement. He was admitted to the Southern General Hospital the following morning and died eight days later of subarachnoid haemorrhage. Mrs C complained that there was a delay of 12 hours without treatment for her husband.

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

• (a) NHS 24 failed to provide proper care and treatment to Mr C (upheld); and
• (b) the Board failed to provide proper care and treatment to Mr C (upheld).
   

Redress and recommendations
The Ombudsman recommends that:

• (i) NHS 24 provide an apology to Mrs C and her family for the delay in transferring the necessary clinical details to the correct out-of-hours service;
• (ii) NHS 24 conduct an evaluation into a review of the improvements introduced by NHS 24 as a result of this complaint;
• (iii) NHS 24 ensure call handlers' basic training is developed enough to ensure staff are able to determine how to manage information they are given when a call is made from a service user, and the mechanism to transfer vital clinical information between services is reviewed to avoid mistakes in transmission arising;
• (iv) NHS 24 ensure the algorithms are fit for purpose in so far as they are able to capture the appropriate detailed information to assist the nurses to make the appropriate decisions;
• (v) the Board provide an apology to Mrs C and her family for the delay in picking up on the clinical symptoms described by Mr C and his family;
• (vi) the Board undertake a further review of the triage doctor's clinical practice in order to ensure their understanding of the signs and symptoms of a subarachnoid haemorrhage; and
• (vii) the Board ensure the triage doctor reflects on the lessons of the case, shares it with his appraiser during his next appraisal and is aware of the possibilities of rare diagnoses such as subarachnoid haemorrhage for future work.

NHS 24 and the Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant, Mr C, raised a number of concerns that his daughter, Ms C, was not treated appropriately by her Practice Teacher (Practice Teacher 2) while on placement for her University course. Mr C also complained that Glasgow Caledonian University (the University) failed to act in an appropriate manner when considering Mr C's complaint.

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

• (a) the conduct of Practice Teacher 2 towards Ms C was inappropriate (not upheld);
• (b) the University failed to respond to questions put to them by Mr C (not upheld);
• (c) the University passed a complaint from the Council about Ms C to the Scottish Social Services Council when there was no requirement for them to do so and did not refer a complaint made by Mr C about Practice Teacher 2 to the Scottish Social Services Council (not upheld);
• (d) the way in which the University considered Mr C's complaint and conducted their investigation was not in line with their procedures (partially upheld);
• (e) the University interviewed Ms C for a number of hours without telling her the purpose of the interview (not upheld).
   

Redress and recommendation
The Ombudsman recommends that the University consider reviewing their complaints procedures to take into account complaints where there are one or more aspects which concern allegations of bullying or harassment, to ensure that such allegations are properly considered under the relevant policy.

The University have accepted the recommendation and will act on it accordingly.

Overview
The complainant (Mrs C) raised a number of concerns about the care her son received from Social Work Services at Aberdeen City Council (the Council) through the Community Mental Health Team (CMHT) in the months prior to his death in 2006. Mrs C raised these concerns through the Council's complaints process, up to and including a Social Work Complaints Review Committee (CRC). The CRC made a number of resolutions (duly noted by the Council) but advised Mrs C that the actions and decisions of the CMHT were not a matter the CRC could consider. Mrs C complained to the Ombudsman's office about her original concerns and that the CRC had ruled the actions of the CMHT out of its remit. Mrs C was unhappy that it appeared that her complaints should rather have been addressed through the NHS complaints procedure but the Council had not advised her of this earlier.

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

• (a) the CRC failed to appropriately address Mrs C's complaints (not upheld); and
• (b) the Council failed to take adequate steps to collaborate with the NHS to ensure that Mrs C received a full response to her complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) ensure that guidance to CRC members and relevant staff clearly indicates the importance of careful drafting of the CRC minute, to ensure that a decision on each complaint considered is recorded and the basis for any recommendations is explained;
• (ii) apologise to Mrs C for their failure to follow-up with the NHS on the joint issues of her complaint;
• (iii) that guidance to CRCs and members of Council staff who support them is reviewed, to ensure that CRC minutes can fully reflect the conclusions reached and reasons for decisions made; and
• (iv) advise him of the development and progress of an action plan from within the working group towards a policy for managing joint complaints in partnership with the NHS.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the standard of cleanliness in Ward 17 of Ninewells Hospital (the Hospital). He complained that Tayside NHS Board (the Board) failed to maintain an adequate standard of cleanliness in the ward and that their systems for monitoring cleanliness were flawed. Mr C also complained that, when he visited the Hospital, patient records were left unattended in areas accessible by the public.

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

• (a) cleanliness standards at the Hospital were poor (no finding);
• (b) staff at the Hospital failed to adhere to the Board's hygiene policies (no finding);
• (c) the Board's procedures for monitoring cleanliness were ineffective (not upheld); and
• (d) the Board failed to securely store patient records (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) invite Mr C to a meeting at the Hospital to discuss his concerns about cleanliness and infection control; and
• (ii) instruct their Caldecott Guardian to review the procedures for transferring clinical records between the Orthopaedic Out-patient Clinic reception area and clinical staff to ensure the security of clinical records at all times.

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

Overview
The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had not received reasonable care and treatment whilst under the care of Greater Glasgow and Clyde NHS Board (the Board) in early 2007. She was particularly concerned about the arrangements made for her husband to undergo a surgical procedure at another hospital and the administration of medicines to her husband. She also raised concerns about the action the Board took following her complaints about discussions between medical staff and Mr C's family.

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

• (a) the Board's requirement that Mr C attend Gartnavel Hospital at 09:00 on 11 January 2007 for a procedure that did not begin until 11:35 was unreasonable (no finding);
• (b) the Board's administration of steroids to Mr C during his admission in January 2007 was not reasonable (upheld); and
• (c) the Board did not take adequate action in response to Mrs C's complaints about discussions with Mr C's family on 12 January 2007 about his resuscitation (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C's family that the dosage of steroids was not increased following either the suspicion of sepsis or the incident of septic shock;
• (ii) take steps to ensure that medical staff are aware of the need to increase the dose of steroids following suspicion of sepsis or incidents of septic shock; and
• (iii) ensure that induction materials for medical staff clearly cover the specific requirements of the Board's resuscitation policy. This would serve to draw inductees' attention to the policy, and, specifically, its application in terms of provision of information to, and discussion with, patients, relatives and carers and provide evidence of this to the Ombudsman.

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

Overview
The complainant (Mr C) was a post/graduate student at the University of Glasgow (the University) studying for a doctorate in a science subject. He complained about aspects of the supervision of his study and about the way his appeal and complaint were handled.

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

• (a) did not provide adequate supervision for Mr C's PhD (not upheld);
• (b) did not provide an agreed placement (not upheld);
• (c) did not appropriately consider concerns about a key reagent (not upheld);
• (d) did not handle an academic appeal properly (not upheld);
• (e) did not handle a complaint properly (upheld); and
• (f) did not maintain adequate records in relation to Mr C's progress (upheld).

Redress and recommendations
The Ombudsman recommends that the University:

• (i) reinforce the good practice of maintaining a written record of significant events, such as decisions about a student's placement;
• (ii) apologise to Mr C for shortcomings in their handling of his complaint;
• (iii) take steps to ensure that complainants are given clear and accurate advice about the status of their complaints; and
• (iv) considers whether there are situations where it should be obligatory that accurate records are kept of meetings when supervisors are discussing serious concerns about the progress of a student.

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

Overview

The complainant (Mrs C) was unhappy with the care provided to her late father (Mr A) by Greater Glasgow and Clyde NHS Board (the Board). Mr A was admitted to the Western Infirmary (Hospital 1) on 5 January 2008, as he had been diagnosed with bladder and prostate cancer and his condition was deteriorating. On the following day, it was recorded that he had two pressure sores and that his heel was red and soft. Mr A was transferred to ward 3A in Gartnavel General Hospital (Hospital 2) on 7 January 2008. He was then transferred to the Beatson West of Scotland Cancer Centre (Hospital 3) on 15 January 2008 and discharged on 24 January 2008. During this time, he contracted Noro virus (more commonly known as winter vomiting virus). On 28 January 2008, he was readmitted to Hospital 1 and was transferred to Hospital 2 on the following day. He was discharged again on 5 February 2008. He was then readmitted to Hospital 1 on 9 February 2008, but was transferred to Hospital 2 on the following day. Tests completed showed that Mr A had contracted MRSA and Clostridium difficile. Mr A was referred to the palliative care team on 20 February 2008. Sadly, he died later that day.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to effectively manage Mr A's pressure sores (upheld);
• (b) Mr A contracted MRSA and other infections because the infection control measures were inadequate (not upheld);
• (c) there was a delay in referring Mr A to the palliative care team (upheld); and
• (d) there was a lack of continuity in the nursing care provided to Mr A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar improvement tool to examine the reason why Mr A received inadequate treatment for his pressure ulcers;
• (ii) ensure that the policies in place reflect current national best practice standards for pressure ulcer assessment, prevention and treatment and that robust systems are in place to review, monitor and report adherence;
• (iii) confirm that the learning from report 200702913, published by the Ombudsman in June 2009, is being transferred across the Board region;
• (iv) ensure that there are steps in place to verify that staff are able to diagnose patients who might benefit from palliative care and then make timely referrals to palliative care teams;
• (v) take immediate steps to implement the Liverpool Care Pathway or similar end of life care planning system;
• (vi) continue to review and monitor the nursing care in Ward 3A in Hospital 2. This should include an examination of the clinical leadership and management; the patient experience; and the quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the implementation of the Scottish Government policy for Senior Charge Nurses - Leading Better Care;
• (vii) ask the Director of Nursing to verify that appropriate education and development is in place to ensure that nursing staff throughout the Board are aware of and adhere to national standards in relation to pressure ulcers, control of infection and end of life care;
• (viii) ensure that systems are in place to review and monitor standards of all aspects of nursing documentation in line with professional standards;
• (ix) ensure that patient transfer policies exist and are used in the best interests of patients, ensuring that communication and continuity of care is paramount; and
• (x) make a full and detailed apology to Mrs C for the failings identified in this report.

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