South of Scotland

Overview
The complainant (Mrs C) raised a number of concerns that following a telephone discussion with the practice receptionist (the Receptionist), she and her husband (Mr C), her son (Mr A) and daughter (Miss D) were de-registered from the dentist's (Dentist 1's) list of patients.

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

• (a) Dentist 1 unreasonably de-registered Mrs C, Mr C, Mr A and Miss D without explanation (upheld);
• (b) Dentist 1 inappropriately said that she did not require to provide any explanation (not upheld); and
• (c) Mr A's appointments on 23 March 2011 and 20 April 2011 which fell within the period Dentist 1 remained liable to provide treatment (until 8 June 2011) were unjustifiably cancelled (upheld).

Redress and recommendation
The Ombudsman recommends that Dentist 1:

• (i) Dentist 1 apologise to Mr A for cancelling his appointment on 23 March 2011 without establishing its purpose.

Dentist 1 has accepted the recommendation and will act on it accordingly.

Overview
The complainant (Ms C) raised concerns about the treatment that she received from Dumfries and Galloway NHS Board (the Board) prior to the birth of her son (Baby A). She also complained about the treatment Baby A received after he was born.

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

• (a) the Board failed to diagnose that Ms C had pre-eclampsia, despite her showing clear symptoms (not upheld);
• (b) the Paediatrician's arrival was excessively delayed, despite Ms C and her family's concerns over Baby A's breathing (upheld);
• (c) the Paediatrician failed to properly prioritise Baby A (upheld);
• (d) the Midwife failed to recognise that there were problems with Baby A feeding when she gave him formula milk (not upheld);
• (e) the Board failed to diagnose Persistent Pulmonary Hypertension of the Newborn despite Baby A showing clear symptoms (upheld);
• (f) the Doctor treating Baby A did not know how to increase the oxygen when this was requested by the Consultant (not upheld); and
• (g) Ms C was refused entry into neonatal when Baby A was admitted and she was not called when he received a heart massage (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind midwifery staff of the importance of maintaining consistent records of babies' physiological observations;
• (ii) present Baby A's case, and Adviser 2's comments, to Neonatal staff to highlight any learning points that can be taken from this case; and
• (iii) apologise to Ms C and Mr B for the issues highlighted 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 that this brother (Mr A) had been inappropriately cared for and treated in Highland NHS Board (the Board) hospitals between February and October 2010.

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

• (a) delayed in diagnosing Mr A's cancer, including a delay in Mr A being reviewed by Gastroenterology (upheld);
• (b) inappropriately discharged Mr A from Caithness General Hospital on 9 June 2010 (upheld); and
• (c) did not adequately communicate to Mr A the details of his diagnosis and prognosis (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review endoscopy waiting times, taking into account SIGN and NICE guidance, and report on what steps will be taken to address capacity issues to avoid delays such as that identified in this case;
• (ii) explain how cancelled endoscopies will be treated as adverse events;
• (iii) review the circumstances of Mr A's admission and discharge on 8 and 9 June 2010, with a specific focus on the potential for an inter-hospital transfer, and discharge criteria, and report on the lessons learned;
• (iv) review admission clerking and medical record-keeping at Hospital 1, to ensure it is in line with current standards; and
• (v) remind consultants of their responsibility to inform patients personally of their test results and likely consequences, and to note this in the medical records.

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

Overview
The complainant Ms C raised a complaint that, as a result of substandard care at Raigmore Hospital, she developed a large pressure sore during a period of recuperation following an operation.

Specific complaint and conclusion
The complaint which has been investigated is that Highland NHS Board (the Board) failed to prevent a pressure sore developing following Ms C's operation on 4 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence of current audit and monitoring in relation to pressure sore prevention and treatment. This should include relevant national initiatives, Clinical Quality Indicators and patient safety data;
• (ii) provide the Ombudsman with the current education and training programmes for the prevention and management of pressure sores;
• (iii) draw the report to the attention of nursing staff involved in Ms C's care; and
• (iv) provide a full apology to Ms C for the failures identified within this report.

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

Overview
The complainant (Mr C) complained about the care and treatment provided to his sister-in-law (Mrs A) while she was in the care of Dumfries and Galloway NHS Board (the Board). He alleged that the Board failed to provide appropriate mental health care for Mrs A during a period when she was physically unwell.

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

• (a) Mrs A's anti-depressant medication, phenelzine, was stopped without reasonable psychiatric consultation in April 2010 (upheld);
• (b) keyhole surgery was undertaken inappropriately on Mrs A in April 2010 (not upheld);
• (c) following surgery for bowel cancer in April 2010, Mrs A was sent home without reasonable aftercare instructions, which led to further health problems and the need for her bowel to be extended (upheld); and
• (d) Mrs A was unreasonably able to acquire the means and opportunity to self-harm in Dumfries and Galloway Infirmary and Crichton Royal Hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the fact that no proper advice was given to Mrs A pre and post-operatively;
• (ii) when presented with patients for surgery with known mental health issues for which they take medication, ensure that the circumstances are discussed with the patient, the GP and clinicians involved;
• (iii) ensure that all relevant discussions with the patient, GP and clinicians (and any subsequent outcomes) are recorded properly;
• (iv) give consideration to the terms of their permission forms for operations, given the failures with regard to Mrs A;
• (v) apologise to Mr C for their failure to provide Mrs A with adequate aftercare instructions in April 2010;
• (vi) review their procedures to ensure that such an occurrence does not occur again;
• (vii) apologise to Mr C for the insufficient care they took to prevent Mrs A from accessing the means to harm herself; and
• (viii) where patients have expressed thoughts of suicide, carry out (and fully record and act on) risk assessments.

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

Overview
An MP (Mr C) complained on behalf of the aggrieved (Mr D and Ms B) that out-of-hours doctors employed by Ayrshire and Arran NHS Board (the Board) endangered their infant son (Baby A)'s life by failing, on a number of occasions, to diagnose his twisted bowel.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's diagnosis of Baby A's twisted bowel was unnecessarily delayed (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide training to General Practice and midwifery staff in their area on the assessment and treatment of neonates with bilious vomiting; and
• (ii) apologise to Mr D and Ms B for the failings identified in this report.

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

Overview
On 2 July 2010 an Independent Advice and Support Worker from the Citizens Advice Bureau (Ms C), complained to the Scottish Public Services Ombudsman about Highland NHS Board (the Board) on behalf of her client (Mr A). The complaint was that there had been a failure to identify why Mr A was not healing from a fracture of his left tibia and fibula, sustained whilst playing football in May 2008. Ms C complained that the pain Mr A suffered following his fracture was not assessed properly. She also complained that the clinicians involved in his care did not consider the possibility of any other underlying conditions that may have been present. Mr A was ultimately diagnosed as suffering from osteosarcoma of the left knee.

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

• (a) the Board did not appropriately investigate Mr A's failure to heal from his left tibia and fibula fracture (not upheld);
• (b) Mr A's ongoing pain was not assessed properly (upheld); and
• (c) the Board failed to consider the possibility of the presence of underlying conditions (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the procedures within orthopaedic related departments to ensure they have robust systems in place to identify red flag symptoms;
• (ii) draw the findings of this report to the attention of all clinical staff involved in Mr A's care and treatment throughout the period of 10 May 2008 to 12 May 2009, so that they can learn from it; and
• (iii) provide Mr A with a full apology for the failures 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 regarding the treatment that her father (Mr A) received following admission to Ayr Hospital (the Hospital). Mrs C complained that staff of Ayrshire and Arran NHS Board (the Board) failed to explain the severity of Mr A's condition to family members and that, as a result of this, his family were not with him at his bedside when he died. Mrs C raised further complaints regarding the condition that Mr A's body was in when the family were allowed in to see him and the Board's handling of her formal complaint.

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

• (a) the Board failed to explain properly the nature of Mr A's condition to his family (upheld);
• (b) the Board failed to allow family members access to Mr A during the final hours of his life (upheld);
• (c) the Board failed to respect Mr A's dignity (upheld);
• (d) information provided by the Board in response to Mrs C's complaint was inaccurate (upheld); and
• (e) the clinical records were inaccurate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures for handing over the care of patients between consultants, with a view to ensuring that all relevant information has been shared with family members;
• (ii) review the communication between the consultants and nursing staff in Mr A's case, with a view to identifying any failures in communication from consultant to nurse to family members;
• (iii) give further consideration to Mrs C's comments on the presentation of Mr A's body and take such steps as they feel appropriate to prevent similar upset in the future;
• (iv) take steps to ensure that advice provided to patients' family members is accurately recorded in the clinical records; and
• (v) take steps to ensure that statements relied upon to respond to complaints are checked against documented evidence for accuracy.

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment provided to his mother-in-law (Mrs A) by Borders NHS Board (the Board) and the communication between health care professionals who treated Mrs A and with Mrs A's family. He also raised concerns about the way the Board handled his complaint.

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

• (a) provide reasonable care and treatment to Mrs A leading up to her fall on 28 February 2009 and following her operation on 1 March 2009 to repair her hip (upheld);
• (b) ensure reasonable communication between the health care professionals who treated Mrs A and with Mrs A's family (upheld);and
• (c) deal with Mr C's complaint according to the NHS Complaints Procedure (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence that they have audited staff awareness of the Falls Prevention Strategy and Bed Rail Policy; the knowledge and skills of staff relevant to their effective implementation; and take action to address any knowledge and skill gaps identified by the audit;
• (ii) consider amending the Falls Prevention Strategy and Bed Rail Policy in light of the information in this report;
• (iii) ensure staff are aware of the failures identified in this report in meeting the needs of patients with dementia and to implement training to address this, particularly in rehabilitative care and communication; and
• (iv) apologise to Mr C for the failures identified in this report.

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

Overview
The complainant (Ms C) raised a number of concerns about the way the relevant medical history of her late partner (Mr A) was initially obtained by Borders NHS Board (Board 1) and provided to Lothian NHS Board (Board 2). She also complained that prior to the decision to operate, Board 2 failed to obtain a full medical history from Mr A and that had they done so, the operation may not have proceeded.

Specific complaint and conclusions
The complaint which has been investigated is that Board 1 and Board 2 failed to ensure all the relevant medical history was obtained prior to the decision to operate on Mr A. There are two elements to this:

• (a) Board 1 failed to ensure all relevant medical history was provided to Board 2 (not upheld); and
• (b) Board 2 failed to ensure a full medical history was obtained during the consultation prior to surgery (upheld).

Redress and recommendations
The Ombudsman recommends that Board 1:

• (i) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Ombudsman recommends that Board 2:

• (ii) apologise to Ms C for the failures identified;
• (iii) ensure Consultant 2 reflects on this report so he can review his practice on taking patients' medical history, including when it would be appropriate to request full medical records; and
• (iv) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Board 1 and Board 2 have accepted the recommendations and will act on them accordingly.