South of Scotland

Report no:

202200588
Date:

August 2023
Body:

Ayrshire and Arran NHS Board
Sector:

Health

The complainant (C) had a family history of breast cancer and was referred to the high risk/family history service for monitoring. C attended appointments with the high risk/family history service to have regular mammogram scans carried out. In 2019, C had symptoms in their left breast. They received a mammogram scan from the symptomatic service and appropriate investigations were carried out to establish the nature of the symptoms in C’s left breast which was confirmed to be a cyst. At this time, C’s right breast was reported as normal. In 2021, a mammogram scan identified abnormalities in the right breast which led to the diagnosis of advanced (stage 3) cancer. C was told that there were abnormalities present in the right breast on the scan in 2019.

C complained that the Board did not follow up on these abnormalities at the time. In light of C’s complaint the Board carried out an internal review, which C was unhappy with as they thought the review would be independent.

The Board said that mammogram scans are reviewed by two consultant radiologists or consultant radiographers who report independently to ensure there are two clinical opinions. The Board’s response to C’s complaint indicated that the abnormalities were considered and discussed at the time but it was decided that they should not be biopsied.

I took independent clinical advice from a consultant radiologist with specific experience in breast radiology (the Adviser). The Adviser highlighted that the Board’s response did not match the medical records, specifically that the abnormalities were not discussed in 2019 and that these were missed. The Adviser said that it was reasonable for the Board to carry out an internal review but the conclusions reached by the review were not reasonable.

I found that the Board failed to provide reasonable care and treatment to C as abnormalities were missed in 2019. Therefore, the opportunity for early diagnosis was missed. I found that the internal review was unreasonable due to the conclusions reached and that the Board did not appear to be holding appropriate meetings in line with relevant standards. I do not consider that the Board demonstrated they have learned from what happened in this case.

My investigation identified some issues with the way in which the Board investigated and responded to C’s complaint. As mentioned above, I found the medical records did not support the Board’s response. On seeing a draft version of this report, the Board clarified that the abnormalities were not identified or discussed in 2019, and that they were referring to a meeting that was held in 2021. I considered that this should have been made clearer in the complaint response. I found the Board’s handling of C’s complaint to be unreasonable.

As such, I upheld C’s complaints.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for C:

Complaint number	What we found	What the organisation should do	What we need to see
(a) and (b)	Calcifications present in 2019 were missed and not biopsied. Therefore, an opportunity to make an early diagnosis was missed. If the calcifications were biopsied in 2019 a diagnosis of cancer would have been achieved. An appropriate internal review was not carried out as the conclusion reached in relation to the impact of the failings was unreasonable. The Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings. Information included in the final response to C’s complaint was not supported by the medical records.	Apologise to C for: the failure to identify and biopsy calcifications in 2019, the opportunity to make an early diagnosis, and the significant, detrimental impact this has had on C and their prognosis the failure to carry out an appropriate internal review; and for the failures in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.	A copy or record of the apology By: 31 August 2023

Complaint number

What we found

What the organisation should do

What we need to see

(a) and (b)

Calcifications present in 2019 were missed and not biopsied. Therefore, an opportunity to make an early diagnosis was missed.
If the calcifications were biopsied in 2019 a diagnosis of cancer would have been achieved.
An appropriate internal review was not carried out as the conclusion reached in relation to the impact of the failings was unreasonable.
The Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings.
Information included in the final response to C’s complaint was not supported by the medical records.

Apologise to C for:

the failure to identify and biopsy calcifications in 2019, the opportunity to make an early diagnosis, and the significant, detrimental impact this has had on C and their prognosis
the failure to carry out an appropriate internal review; and
for the failures in complaint handling.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

A copy or record of the apology

By: 31 August 2023

We are asking the board to improve the way they do things:

Complaint number	What we found	What should change	What we need to see
(a)	Calcifications present in 2019 were missed and not biopsied. Therefore, an opportunity to make an early diagnosis was missed. If the calcifications were biopsied in 2019 a diagnosis of cancer would have been achieved.	When mammograms are undertaken on patients presenting with issues in one breast, radiologists should consider and fully report on the findings in both breasts. There should be appropriate consideration given to carrying out a biopsy when abnormalities such as definite and sizeable calcification are present on a mammogram and the decision in this regard recorded.	Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again. Evidence that learning is reflected in policy and guidance By: 2 September 2023
(b)	The internal review that was carried out in this case was unreasonable as the conclusion reached in relation to the impact of the failings was incorrect. The Board failed to reasonably demonstrate that as an organisation they learned from what happened in this case. The Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings.	An urgent meeting (or meetings) held in line with the Standards to discuss a sample of breast radiology cases from 2021 to date (at least six per year, pro rata for the current year). These cases should be selected in line with the Standards i.e. that are clinically important and have an educational message that would benefit their colleagues. The meeting(s) should be chaired by an independent person external to the Board, with the appropriate level of expertise and experience. This is to provide assurance about the independence of the meeting(s). The meeting(s) should record the outcome on each case in line with the Standards, including any “good spots” and learning points and/ or follow-up action identify and share any learning encourage constructive discussion and reflection produce a consensus on structured learning outcomes, learning points, and follow-up actions, supported by an overall, clear implementation plan.	This office and the complainant should be informed of the results of the radiology meetings any learning points and action plan to implement and share findings (as appropriate) Meeting held by: 31 October 2023 Results of meeting and (as relevant) any action plan by: 1 November 2023
(b)	We found that the Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings.	Systems and arrangements should be in place to support all radiology staff and ensure radiology education and learning meetings are held in line with the Standards. Assurance that the Board will follow the Standards consistently in the future.	Evidence the Board has in place an action plan to ensure that the Standards are in place for all radiology staff. Evidence of how the Board will ensure the Standards will continue to be met in the future. Evidence that the Board has communicated the outcome with the complainant. By: 2 September 2023

Complaint number

What we found

What should change

What we need to see

(a)

Calcifications present in 2019 were missed and not biopsied. Therefore, an opportunity to make an early diagnosis was missed.
If the calcifications were biopsied in 2019 a diagnosis of cancer would have been achieved.

When mammograms are undertaken on patients presenting with issues in one breast, radiologists should consider and fully report on the findings in both breasts.

There should be appropriate consideration given to carrying out a biopsy when abnormalities such as definite and sizeable calcification are present on a mammogram and the decision in this regard recorded.

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again.
Evidence that learning is reflected in policy and guidance
By: 2 September 2023

(b)

The internal review that was carried out in this case was unreasonable as the conclusion reached in relation to the impact of the failings was incorrect.
The Board failed to reasonably demonstrate that as an organisation they learned from what happened in this case.
The Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings.

An urgent meeting (or meetings) held in line with the Standards to discuss a sample of breast radiology cases from 2021 to date (at least six per year, pro rata for the current year). These cases should be selected in line with the Standards i.e. that are clinically important and have an educational message that would benefit their colleagues.

The meeting(s) should be chaired by an independent person external to the Board, with the appropriate level of expertise and experience. This is to provide assurance about the independence of the meeting(s).

The meeting(s) should

record the outcome on each case in line with the Standards, including any “good spots” and learning points and/ or follow-up action
identify and share any learning
encourage constructive discussion and reflection
produce a consensus on structured learning outcomes, learning points, and follow-up actions, supported by an overall, clear implementation plan.

This office and the complainant should be informed of

the results of the radiology meetings
any learning points and action plan to implement and share findings (as appropriate)

Meeting held by:

31 October 2023

Results of meeting and (as relevant) any action plan by:

1 November 2023

(b)

We found that the Board’s practice of excluding breast radiology cases from radiology education and learning meetings does not appear to be in line with the Standards for Radiology Events and Learning meetings.

Systems and arrangements should be in place to support all radiology staff and ensure radiology education and learning meetings are held in line with the Standards.

Assurance that the Board will follow the Standards consistently in the future.

Evidence the Board has in place an action plan to ensure that the Standards are in place for all radiology staff.
Evidence of how the Board will ensure the Standards will continue to be met in the future.
Evidence that the Board has communicated the outcome with the complainant.

By: 2 September 2023

We are asking the board to improve their complaints handling:

Complaint number	What we found	Outcome needed	What we need to see
(a)	We found that information included in the final response to C’s complaint was not supported by the medical records.	Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be: accurate in their findings and conclusions, clear, and supported by relevant evidence, such as, medical records.	Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again. Evidence that demonstrates how the Board ensure decisions are accurate and based on available evidence. By: 2 September 2023

Complaint number

What we found

Outcome needed

What we need to see

(a)

We found that information included in the final response to C’s complaint was not supported by the medical records.

Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. They should be: accurate in their findings and conclusions, clear, and supported by relevant evidence, such as, medical records.

Evidence that the findings of this investigation have been fed back to relevant staff in a supportive way for learning and improvement and to avoid a similar mistake being made again.

Evidence that demonstrates how the Board ensure decisions are accurate and based on available evidence.

By: 2 September 2023

Feedback

Points to note

In this case, the complainant was given the impression that an independent review would be carried out as part of the complaints investigation process. However, it was an internal review that was carried out. Whilst it was reasonable for an internal review to be carried out, I consider that better and clearer communication about this in advance of the review would have been beneficial for the complainant. This would likely have set the complainant’s expectations about what action the Board would be taking and what type of outcome they could expect.

I would ask that the Board reflect on this point and consider this feedback when handling similar situations in the future.

Complaints handling – responding to an SPSO investigation

When organisations are notified of our intention to investigate a complaint they are asked to provide all information relevant to the complaint, including any relevant policies or procedures.

It is disappointing that the Board provided information about radiology meeting standards only once my draft report was issued for comment, and further information only when provided with details about adjustments made to my report in light of that information. This information was relevant to the complaint and particularly important to our investigation of head of complaint (b). This information could have, and should have, been provided at an earlier stage.

I draw the Board’s attention to this point and ask that when responding to enquiries by my office in the future they ensure all relevant available information is provided at the start of our investigation.

In this case, the failure to do this resulted in avoidable delay in finalising my report, and I ask the Board also to reflect on the impact this would have on the complainer and the Board’s own staff.

Report no:

202101928
Date:

May 2023
Body:

A Medical Practice in the Ayrshire and Arran NHS Board area
Sector:

Health

The complainant (C) complained to my office about the care and treatment provided to their late parent (A) by their GP practice (the Practice) after A presented at the Practice in August 2019, with shortness of breath and chest pain. A was subsequently diagnosed with severe Chronic Obstructive Pulmonary Disease (COPD, a lung condition that causes breathing difficulties) and lung cancer. A very sadly died in late 2020.

C complained that the Practice failed to provide reasonable care and treatment to A when they presented with chest pain. In particular that the Practice did not perceive A’s condition as being serious and urgent and the significant deterioration in A’s health was not investigated.

In responding to the complaint, the Practice considered that A’s symptoms were taken seriously and that appropriate investigations were undertaken including excluding cardiac causes for their symptoms.

I sought independent advice on this complaint from a GP (the Adviser). I found that:

The Scottish Referral Guidelines for Suspected Cancer (the Guidelines), in particular, the section relating to lung cancer, should have been taken into account by the clinicians at the Practice from the outset when treating A.
There was a failure by the Practice to recognise the seriousness of the symptoms A presented and to refer them urgently as required under the Guidelines. I considered this was a significant failing in care.
While a referral was made to the respiratory physicians, I was extremely critical that this was not made on an urgent basis.
While the Practice subsequently conducted a Significant Event Analysis (SEA), it was limited and did not fully address what had occurred in A’s case. There was no mention of the Guidelines in the SEA report. I was particularly critical of this.

Taking account of the evidence and the advice received, I upheld the complaint. I also considered there was a failure by the Practice to provide C with a full and informed response in relation to certain aspects of their complaint and in particular to take into account the Guidelines.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Practice to do for C:

Complaint number	What we found	What the organisation should do	What we need to see
(a)	Under (a) we found: There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral. The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer. There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.	Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.	A copy or record of the apology. By: 26 June 2023

Complaint number

What we found

What the organisation should do

What we need to see

(a)

Under (a) we found:

There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.
The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.
There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.

Apologise to C for the failings identified.

The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

A copy or record of the apology.

By: 26 June 2023

We are asking the Practice to improve the way they do things:

Complaint number	What we found	What should change	What we need to see
(a)	Under complaint (a) we found: There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.	Patient symptoms should be appropriately identified and managed. Symptoms or features suggestive of cancer should result in the appropriate referral being made in line with relevant guidance.	Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails. Evidence that training needs in relation to the application of relevant guidance have been identified and addressed. Evidence of how the findings of this case have been used as a reflective training tool for relevant staff. By: 24 July 2023
(a)	The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.	Local and Significant adverse event reviews should be reflective and learning processes that considers events against relevant standards and guidelines, to ensure failings are identified and any appropriate learning and practice improvements are made.	Evidence that the Practice have reviewed their systems and processes for reviewing significant events to ensure it is a fully reflective and learning process that supports the staff involved to identify learning and improvement. By: 24 August 2023

Complaint number

What we found

What should change

What we need to see

(a)

Under complaint (a) we found:

There was a failure to recognise the significance of A’s symptoms when they presented at the Practice between August 2019 and September 2020, to make an urgent referral.

Patient symptoms should be appropriately identified and managed.

Symptoms or features suggestive of cancer should result in the appropriate referral being made in line with relevant guidance.

Evidence that this decision has been shared and discussed with relevant staff in a supportive manner. This could include minutes of discussions at a staff meeting or copies of internal memos/emails.

Evidence that training needs in relation to the application of relevant guidance have been identified and addressed.

Evidence of how the findings of this case have been used as a reflective training tool for relevant staff.

By: 24 July 2023

(a)

The SEA conducted by the Practice was limited and did not fully address what occurred in A’s case or take account of the relevant Scottish Referral Guidelines for Suspected Cancer.

Local and Significant adverse event reviews should be reflective and learning processes that considers events against relevant standards and guidelines, to ensure failings are identified and any appropriate learning and practice improvements are made.

Evidence that the Practice have reviewed their systems and processes for reviewing significant events to ensure it is a fully reflective and learning process that supports the staff involved to identify learning and improvement.

By: 24 August 2023

We are asking the Practice to improve their complaints handling:

Complaint number	What we found	Outcome needed	What we need to see
(a)	Under complaint (a) we found: There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole. The complaint response contained out of date contact details for the SPSO, including the address.	Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedures \| SPSO. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.	Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g., a record of a meeting with staff; or feedback given at one-to-one sessions). Evidence that the Practice’s complaint handling process is clearly signposted on its website and that information, including documentation (e.g., complaint leaflet and/ or template complaint response letter have been updated) in accordance with the model complaints handling procedure. Evidence that the website and documents properly signpost to the SPSO, including the current SPSO contact details. Evidence that relevant staff have or are scheduled to have appropriate complaint handling training. By: 24 July 2023

Complaint number

What we found

Outcome needed

What we need to see

(a)

Under complaint (a) we found:

There was a failure by the Practice to fully address the issues raised when responding to C’s complaint and evidence of a lack of learning from the complaint by the Practice as a whole.
The complaint response contained out of date contact details for the SPSO, including the address.

Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedures | SPSO. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning.

Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

Evidence that these findings have been fed back to relevant staff in a supportive manner that encourages learning, including reference to what that learning is (e.g., a record of a meeting with staff; or feedback given at one-to-one sessions).

Evidence that the Practice’s complaint handling process is clearly signposted on its website and that information, including documentation (e.g., complaint leaflet and/ or template complaint response letter have been updated) in accordance with the model complaints handling procedure.

Evidence that the website and documents properly signpost to the SPSO, including the current SPSO contact details.

Evidence that relevant staff have or are scheduled to have appropriate complaint handling training.

By: 24 July 2023

Feedback

Points to note

The Practice, when making an urgent cancer suspected referral, could have requested consideration of a CT scan. This would have allowed for A to be considered for a CT scan after their first chest x-ray was carried out. I encourage the Practice to share this and reflect on it for the future.

Report no:

201200492
Date:

June 2013
Body:

A Medical Practice in the Borders NHS Board area
Sector:

Health

Overview
The complainant (Mrs C) raised concerns about the inadequate care and treatment her daughter (Ms A) received at her previous medical practice (the Practice). The complaint concerns the lack of investigation into a lump on Ms A's neck and her symptom of tiredness. Ms A had several consultations with two GPs at the Practice, Doctor 1 and Doctor 2, between July and December 2010. When she registered with a different medical practice in early 2011 it was identified after further investigation that she had cancer of the thyroid. Ms A subsequently underwent treatment, including a thyroidectomy and radioactive iodine treatment.

Specific complaint and conclusion
The complaint which has been investigated is that Doctor 1 failed to adequately assess Ms A's reported symptoms of a lump in her neck and tiredness on 10 August 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that:

(i) Doctor 1 and Doctor 2 apologise to Ms A for the failings identified in this report; and
(ii) Borders NHS Board ensures that Doctor 1 and Doctor 2 reflect on the failings that have been identified in this report at their next appraisal.

Report no:

201203514
Date:

May 2013
Body:

Ayrshire and Arran NHS Board
Sector:

Health

Overview
Mr C, who is a prisoner, complained that the prison health centre was restricting his access to the NHS complaints procedure.

Specific complaint and conclusion
The complaint which has been investigated is that Mr C has been unreasonably denied access to the NHS complaints procedure (upheld).

Redress and recommendations
The Ombudsman recommends that Ayrshire and Arran NHS Board:

(i) review the local process in place for the management of prison healthcare complaints to ensure that the handling of such complaints is brought into line with the good practice outlined in the Scottish Government Guidance 'Can I help you?';
(ii) take steps to ensure that NHS complaint forms are readily available for prisoners to access; and
(iii) provide prisoners with a reference number upon receipt of their feedback, comments and concerns or complaint.

Report no:

201104810
Date:

May 2013
Body:

Ayrshire and Arran NHS Board
Sector:

Health

Overview
The complainant (Mrs C) raised a number of concerns against Ayrshire and Arran NHS Board (the Board) about delays in diagnosing and treating her thyroid cancer at Crosshouse Hospital, Kilmarnock. Mrs C believed this was due to mistakes, confusion and poor communication and support by hospital staff and had felt 'massively let down' by what had happened to her.

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

(a) Mrs C was not given reasonable information, advice or support about the lump on her neck, and the possible risk of cancer, to allow her to make informed decisions about her treatment (upheld);
(b) nobody took reasonable steps to follow up, after the time Mrs C was timetabled for the operation, to ensure that the lump had not changed or to arrange a further operation date (upheld);
(c) staff unreasonably failed to carry out further tests when the lump was first discovered (not upheld); and
(d) the Board failed to provide a reasonable explanation of both the process which would be followed in relation to the scan offered in March/April 2011 and also the scan results themselves (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

(i) share the comments of the Adviser, in relation to complaint (a), with the relevant hospital staff to ensure that full information is given to a patient on the need for surgery and that this is documented in the patient's medical records;
(ii) issue Mrs C with a full and sincere apology for the failings identified in complaint (a);
(iii) consider changing their current practice so that where a patient cancels their surgery for a putative benign lesion, the hospital department concerned contacts the patient again, in a form that is documented, and records either the need for surgery or a follow-up appointment; and
(iv) issue Mrs C with a full and sincere apology for the failings identified in complaint (b).

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

Report no:

201201464
Date:

February 2013
Body:

Scottish Ambulance Service
Sector:

Health

Overview
The complainant (Mrs C) raised concerns about the length of time it took for an accident and emergency vehicle to attend an emergency at home when her husband, Mr C, became gravely unwell and how the Scottish Ambulance Service (the Service) handled her complaint.

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

(a) the delay in ambulance's arrival was unreasonable (upheld); and
(b) the handling of the complaint was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

(i) report back to the Ombudsman on what additional support is provided to less experienced call handling staff;
(ii) carry out a review involving the software provider to ensure that the software issue is re-assessed;
(iii) review their complaints handling in light of the failings identified; and
(iv) provide Mrs C with a full apology for the failures that occurred on 15 October 2010.

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

Report no:

201102952
Date:

February 2013
Body:

Highland NHS Board
Sector:

Health

Overview
The complainant (Mr C) raised a number of concerns against Highland NHS Board (the Board) regarding the care and treatment his late father (Mr A) received from Dr MacKinnon Memorial Hospital, Broadford. Mr C stated that the Board failed to provide adequate care and treatment for Mr A from 31 May 2010 up to his death on 4 June 2010.

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

(a) treat Mr A's constipation and subsequent complications appropriately (upheld); and
(b) communicate effectively with Mr A, Mr C and Mrs C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

(i) ensure that treatment is initiated by clinical staff in good time when a patient's condition deteriorates and appropriate details of this are recorded in their medical notes;
(ii) ensure that all relevant clinical details are recorded legibly by all doctors in the medical notes as and when they have reviewed a patient;
(iii) ensure that staff consider the reasons for abrupt changes in patients, to ensure that reasonable action is taken to limit the chances of further problems developing;
(iv) ensure that admission forms include prompts which assess a patient's cognitive function or capacity to participate in decision making;
(v) ensure that nursing admission notes are completed appropriately for every patient;
(vi) ensure that when a patient displays uncharacteristic behaviour, appropriate and timely cognisance is taken of this and any subsequent action required is recorded;
(vii) ensure that measures are taken to feed back the learning from this event to all staff, to ensure that similar situations will not recur;
(viii) conduct a review of end-of-life care, with specific reference to completion of Do Not Resuscitate forms;
(ix) ensure that DNAR discussions with family members are documented; and
(x) issue Mr C with a full and sincere apology for the failings identified in this complaint.

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

Report no:

201104965
Date:

January 2013
Body:

Highland NHS Board
Sector:

Health

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment given to her daughter (Ms A) prior to her death in October 2011.

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

(a) staff discharged Ms A from hospital on 12 August 2011 despite her suffering from a wound infection and temperature (not upheld);
(b) during the period 14 August to 21 September 2011, staff failed to provide an adequate level of care and treatment to Ms A (upheld); and
(c) during the period 14 August to 21 September 2011, staff failed to ensure that Ms A received an adequate level of fluid and nutrition (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

(i) apologise to Mrs C for their failures with regard to Ms A's care and treatment;
(ii) bring the findings of this complaint to the attention of the consultant physician concerned for discussion at his next appraisal;
(iii) apologise for their failure to properly address Ms A's nutritional status and to follow NHS Standards; and,
(iv) emphasise to appropriate staff the necessity of following existing standards with regard to food and nutrition and to satisfy themselves that these standards are met.

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

Report no:

201100845
Date:

November 2012
Body:

The Highland Council
Sector:

Local Government

Overview
The complainant (Mr C)'s son (Mr A) was a pupil at a school in the Highland Council (the Council)'s area. Mr A was unable to sit his Higher Physics examination due to a family bereavement. Assurances were given by his school (the School) that he would be awarded a grade based on his preliminary examination results. However, the evidence provided by the School in support of Mr A's performance did not comply with the requirements of the Scottish Qualifications Authority (SQA) and Mr A was awarded a lower grade. Mr C complained that the School did not use a prelim paper of the required standard and that they did not provide adequate evidence to the SQA in support of the subsequent appeal of Mr A's Higher Physics Result. Mr C also complained about the Council's handling of enquiries and complaints from him and his wife (Mrs C).

Specific complaints and conclusions

The complaints which have been investigated are that:

(a) the School did not use a paper of the required standard in conducting a prelim examination for Higher Physics in early 2010 (upheld);
(b) the School's submission of evidence of Mr A's performance in Higher Physics to the SQA in 2010 was not reasonable (upheld); and
(c) the Council did not respond reasonably to Mr and Mrs C's enquiries and complaints (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:
(i)	ensure that the School develops a procedure for checking all prelim examination papers for compliance with SQA standards;
(ii)	work with the SQA to increase their understanding of the SQA's standards and how SQA staff assess the suitability of prelim papers;
(iii)	conduct a review of the types of evidence that will be accepted by the SQA in support of appeals and absentee assessments;
(iv)	ensure that the SQA's comments on the marking of Mr A's prelim examination have been fed back to the Principal Teacher concerned; and
(v)	issue a formal written apology to Mr A for the failings highlighted in this report.

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

Report no:

201102612
Date:

November 2012
Body:

Highland NHS Board
Sector:

Health

Overview
The complainants (Mr and Mrs C) lost their son (Baby A) following his premature birth on 5 January 2011. Their complaint concerns the care and treatment provided at Caithness General Hospital, Wick (Hospital 1) and Raigmore Hospital, Inverness (Hospital 2) during and after Mrs C's pregnancy. Mr and Mrs C believe that they received a poor standard of care from both Hospital 1 and Hospital 2 and said that the loss of Baby A has had a devastating effect on their lives.

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

(a) unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld);
(b) inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld);
(c) unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld);
(d) unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld);
(e) inappropriately placed Baby A in what looked like a cardboard box (not upheld); and
(f) unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

(i) ensure that each operator at Hospital 2 is compliant with the RCOG Green Top Guideline No 8 on amniocentesis;
(ii) review the amniocentesis consent form and patient information sheet used at Hospital 2, so as to take account of the five good practice points referred to in paragraph 17; 20
(iii) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (a);
(iv) review the local guidance at Hospital 1 and Hospital 2 concerning suspected fetal abnormalities discovered on any obstetric ultrasound scan. Where an abnormality is suspected there should be a clear pathway for specialised fetal medicine assessment and no delay in referral of the patient to a specialised hospital department;
(v) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (c);
(vi) provide evidence of the review of the guidelines for staff referred to in the letter from Doctor 3 to Mr and Mrs C dated 21 April 2011;
(vii) reflect on the Adviser's comments about examination options after a stillbirth/late miscarriage where the baby has a structural abnormality; and
(viii) review Hospital 2's post mortem patient information sheet and consent form, so as to include the four examination options listed in paragraph 74.

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

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South of Scotland

Redress and Recommendations

The Ombudsman's recommendations are set out below:

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Complaints handling – responding to an SPSO investigation

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Redress and Recommendations

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