South of Scotland

Overview
The complainant (Mrs C) complained against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her husband (Mr A) received from Ayr Hospital (the Hospital), following his collapse on a public transport bus. Mr A subsequently became completely tetraplegic within a short period of time after he arrived at the Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that following Mr A's admission to the Hospital on 15 January 2010 there were unacceptable delays in his diagnosis and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feedback the learning from this event to all Accident and Emergency staff to ensure that similar situations will not recur;
• (ii) conduct a Significant Event Review of this case with an emphasis given to the misinterpretation the radiologist gave to the findings of the scan of 18 January 2010;
• (iii) ensure that all Accident and Emergency staff are familiar with and adhere to Nursing and Midwifery Council Guidelines on record-keeping;
• (iv) ensure that all Accident and Emergency staff are familiar with and adhere to Scottish Intercollegiate Guidelines Network Guidance on suspected head / neck injury;
• (v) review the procedure the Hospital follows should MRI scanning outside normal hours (08:00 to 17:00) and at weekends be urgently required;
• (vi) review the procedure for imaging to include image appraisal and the quality of films;
• (vii) review the provision and availability of collars; and
• (viii) apologise to Mrs C for the failures identified in this report.

Overview
The complainants, Mr C and Ms C, raised a number of concerns about Ms C's unplanned homebirth of their daughter (Baby A), and her death. The complainants believe that the loss of Baby A was totally avoidable and blame Highland NHS Board (the Board) for what happened.

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

• (a) the Board failed to provide adequate advice, care and treatment before, and during, the birth of Baby A (upheld);
• (b) the Board failed to provide adequate care and treatment to Mr and Ms C following the birth (upheld);
• (c) the Board failed to keep adequate and timely records of the birth and aftercare provided to Ms C (upheld);
• (d) the Serious Untoward Incident report failed to investigate and report adequately on all the issues regarding the birth and aftercare and the Chief Executive's response failed to investigate the matter adequately or to make any recommendations to avoid a recurrence (not upheld); and
• (e) the Board incorrectly stated that Baby A was stillborn (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board: Completion date

• (i) make a full and sincere apology for the failures identified in Complaint (a); and
• (ii) emphasise to all midwifery staff the necessity of compliance with the relevant rules in relation to the completion of notes.

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

Overview
The complainant (Ms C) complained on the behalf of the aggrieved (Mr and Mrs A) about the care and treatment received by Mrs A from Western Isles NHS Board (the Board) in December 2010. Mrs A was taken to Uist and Barra Hospital (the Hospital) with abdominal pains. Two days later Mr A was advised Mrs A was suffering from acute renal failure, was dying and no further treatment could be provided for her. However, Mrs A was subsequently able to be airlifted to the mainland for treatment. She went on to make a full recovery.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not provide reasonable care and treatment to Mrs A between 5 and 9 December 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide an updated version of the action plan to evidence that all of the identified actions have been implemented;
• (ii) provide further details about planned training for medical staff at the Hospital, which should include refresher training on the causes of opiate toxicity and enhanced training in relation to venous access;
• (iii) conduct a random case note review at the Hospital; and
• (iv) provide a full apology to Mr and Mrs A for the failings identified in this report.

Overview
The complainants, a firm of solicitors (Firm C), raised a number of concerns on behalf of its clients, a housing developer (Firm A), about the handling by Scottish Borders Council (the Council) of a planning application submitted for the development of a new secondary school.

Specific complaint and conclusion
The complaint which has been investigated is that the Council did not observe appropriate planning procedures with regard to the new school contained in the application and, in particular, to notify interested parties of significant changes (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) apologise for the failings identified.

Overview
The complainant (Ms C) raised concerns about delays and failures in the care and treatment provided to Mr A when he attended a medical practice (the Practice) on a number of occasions between December 2010 and February 2011 due to bowel problems and, from 11 February 2011 onwards, pain in his groin. Mr A had an ultrasound and CT scan in March 2011. He was diagnosed with diverticular disease and had to undergo emergency surgery. He had an abscess drained, repairs to his bladder and a section of his bowel removed. He was discharged with a stoma bag.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay by the Practice's GPs in fully investigating and diagnosing Mr A's condition (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr A for the delay in fully investigating and diagnosing his condition;
• (ii) carry out a Significant Event Audit on this case;
• (iii) carry out a review of a sample of case notes to assess the quality of the recording of examination findings; and
• (iv) ensure that revision of common abdominal conditions, including diverticulitis, forms part of the Continuing Professional Development of all GPs involved in this case.

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

Overview
The complainant (Mrs C) raised a number of concerns against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her late husband (Mr A) received at Crosshouse Hospital from his admission on 21 May 2010 up to his death on 23 May 2010.

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

• (a) failed to administer the prescribed anti-seizure and steroid medication (upheld);
• (b) failed to recognise and address Mr A's pain (not upheld);
• (c) failed to implement the Liverpool Care Pathway until 23 May 2010 (not upheld); and
• (d) failed to provide adequate care and attention on the night of 22 to 23 May 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feedback the learning from all aspects of this event to the medical team involved with Mr A's care, to understand the importance of avoiding similar situations recurring;
• (ii) review the process of pain scoring, its frequency and recording in this case and feedback the learning to nursing staff;
• (iii) complete a review of the LCP within the unit and feedback the learning to all medical and nursing staff within the unit;
• (iv) complete a full review of their medical staff cover for the night of 22 to 23 May 2010 to ensure such situations do not recur;
• (v) provide an update of their review on the use of pager numbers; and
• (vi) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainants, a firm of solicitors (Firm C), brought a complaint to my office on behalf of a number of clients. The complaint concerned the way in which Dumfries and Galloway Council (the Council) had reached its decision to identify a particular location as suitable for inclusion in the list of Small Building Groups suitable for limited housing development.

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

• (a) failed to act in a consistent and fair manner in assessing the criteria for identifying suitable locations (upheld);
• (b) failed to produce adequate reasoned justification for moving a location from the unsuitable list to the suitable list and, in doing so, ignored advice in the committee reports (upheld);
• (c) did not adhere to the governance advice provided by Council officers (not upheld);
• (d) failed to adequately advise the public of the proposed changes (not upheld);
• (e) failed to follow the established procedure of considering each location on its merits in favour of a 'block group' consideration (not upheld); and
• (f) failed to handle the complaint adequately (upheld).

Redress and recommendations
The Ombudsman recommends that the Council:

• (i) review the manner in which the case was handled to ensure public confidence in public administration and the planning system; and
• (ii) issue a full and clear apology to Firm C for the failings identified in the handling of the complaint.

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

Overview
The complainant (Mr C) raised a number of concerns against Highland NHS Board (the Board) that if a small mass found on his kidney in December 2005 had been regularly and appropriately checked, the delay to diagnose his renal cancer could have been prevented. Mr C also complained about the inadequate manner the Board dealt with his complaint about this.

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

• (a) delayed to diagnose Mr C's renal cancer (upheld); and
• (b) failed to address his complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feedback the learning from this event to all medical staff, to understand the importance of avoiding similar situations recurring;
• (ii) review how hospital teams ensure that the results of patient investigations received after discharge are read and acted upon;
• (iii) conduct a Significant Events Review of this case;
• (iv) review their Complaints Management Procedures to ensure compliance, with reference to sections 5, 6 and 7; and
• (v) apologise for the failures identified in the 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 treatment she received at Borders General Hospital (the Hospital) following cataract surgery. Mrs C had concerns that she had received insufficient information about the proposed surgery and choice of anaesthetic; that an inappropriate method of anaesthetic was used; and when problems occurred following the surgery there was a delay in her being referred for specialist assessment.

Specific complaints and conclusions
The complaints from Mrs C which I have investigated are that:

• (a) the information and advice provided to Mrs C before surgery was insufficient to allow her to make a fully informed decision or to give valid consent for surgery (not upheld);
• (b) the pre-operative assessment was inadequate in that Mrs C was not assessed by her surgeon prior to surgery and the assessment did not take full cognisance of the particular risks involved (not upheld);
• (c) the choice of sharp needle anaesthesia was inappropriate and unreasonable (upheld);
• (d) the post-operative care and treatment was inadequate. In particular, that there was an unreasonable and unexplained delay in referring Mrs C for a specialist opinion (upheld); and
• (e) the complaints handling by Borders NHS Board (the Board) was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the risks of carrying out sharp needle anaesthesia in patients with high myopia;
• (ii) apologise to Mrs C for perforating her eye during surgery;
• (iii) remind staff of the need to refer patients for specialist opinion as soon as the clinical situation has been identified;
• (iv) apologise to Mrs C for the delay in making a specialist referral; and
• (v) remind staff of the need to conduct a Critical Incident Review where an adverse incident has occurred in order to establish whether practices require to be amended.

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

Overview
The complainant (Mrs C) raised a number of concerns about the treatment her adult son (Mr A) received at hospital (Hospital 1) following an attempted suicide at her home on 17 August 2010. Her complaints included that Mr A was inadequately supervised in a general ward and that he had the opportunity to make a further suicide attempt. Mrs C also complained that despite her request that Mr A should remain in Hospital 1 he was transferred to another hospital (Hospital 2) which was in another health board area where Mr A normally lived.

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

• (a) failed to provide an acceptable standard of care to Mr A, an individual whose psychiatric problems had been highlighted to staff, who was suffering from extreme paranoia and who had recently attempted suicide (upheld);
• (b) failed to operate an effective or flexible transfer procedure and failed to ensure that the Bed Manager acted reasonably in response to Mrs C's requests that Mr A remain in Hospital 1 (upheld);
• (c) allowed some staff to act in a hostile way towards Mrs C after she had contacted the Mental Welfare Commission for advice (upheld);
• (d) failed to ensure satisfactory conditions in a psychiatric ward (not upheld); and
• (e) failed to ensure that Mr A's wounds were managed appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the Task and Finish Group to ensure that the Adviser's concerns about mental health assessment staff training and inadequate record-keeping are taken into account in their review of clinical processes etc;
• (ii) review hand-over procedures to ensure an adequate level of observation is maintained during that time;
• (iii) remind staff of their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003 in relation to transfer of patients to another hospital;
• (iv) conduct an audit/review systems for safe management of non-clinical sharps;
• (v) conduct an audit of wound care practice in the Mental Health Ward; and
• (vi) apologise to Mrs C and Mr A for the failings which have been identified in this report.

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