The complaint concerned The City of Edinburgh Council’s response, in December 2001, to an enquiry from the complainants’ architectural agents which failed to disclose a condition attached to an amended planning consent of twenty years earlier, that the terraced dwelling house in which they resided should not be extended without the prior written approval of the planning authority.
West of Scotland
Overview
The complainant (Mr C) complained on behalf of his wife, Mrs C. He said that although Mrs C had an operation to her spine in June 2012, it was not until February 2013 that it was discovered that the operation had been undertaken in the wrong place. Mr C said that, as a consequence, his wife suffered unnecessary pain and discomfort which impacted significantly upon her life, particularly as Mrs C was recovering from radiotherapy treatment in respect of breast cancer.
Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment provided in connection with surgery on Mrs C's spine was unreasonable (upheld).
Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:
- ensure that the Consultant Neurosurgeon revisit her procedures for determining the level of surgery and consider doing two x-rays, one before incision and one with the wound open. Alternatively, do only one x-ray but with the wound open and the spinal elements clearly visible.
The Ombudsman recommends that Borders NHS Board:
- ensure that Hospital 2 review their procedures concerning the timely dispatch of radiology reports.
Overview
The complainant (Mrs C) expressed concern that her late husband (Mr C) had not been given enough information prior to giving his consent to open heart surgery. Mr C died during the operation, and Mrs C had said that, if they had been fully aware of the risks involved, Mr C would not have chosen to go ahead with the operation.
Specific complaints and conclusions
The complaint which has been investigated is that the consent process for cardiac surgery was not properly carried out in that Lothian NHS Board unreasonably failed to provide sufficient information about the potential complication of Mr C's heart being attached to the back of the sternum (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- ensure that staff refer to the General Medical Council Guidance, 'Consent: patients and doctors making decisions together' when agreeing and recording consent and risk for cardiac surgical procedures;
- ensure that unacceptable delays between patients' deaths and subsequent Audit Meetings do not occur in the future;
- ensure that Doctor 2 is reminded of the importance of record-keeping in all elements of care and treatment; and
- apologise to Mrs C for the failure to inform her and her husband adequately of the risks involved in his operation, and for the suffering that Mrs C has endured as a result of this failure.
The Board have accepted the recommendations and will act on them accordingly.
Overview
The complainant (Mrs C) alleged that the care and treatment given to her at St John's Hospital at Howden (the Hospital) during her admission of 18 to 21 November 2011 were below a reasonable standard.
Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment given to Mrs C at the Hospital during her admission of 18 to 21 November 2011 were below a reasonable standard (upheld).
Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):
- (i) formally apologise to Mrs C for all their failures in the provision of care and treatment to her during the period between 18 and 21 November 2011;
- (ii) satisfy themselves that proper reflection (see paragraph 20) is carried out by the staff concerned;
- (iii) review their process of written and electronic note taking to ensure that the 'story' of an untoward, unusual or exceptional event is clearly recorded and that steps taken to mitigate the situation are highlighted; and
- (iv) take steps to ensure that missed vital signs observations and missed medication administration are alerted appropriately.
The Board have accepted the recommendations and will act on them accordingly.
Overview
The complainant (Mr C) raised concerns about the loss of his clinical records and about the prescription of on-going medication for glaucoma by Lothian NHS Board (the Board)'s services delivered through the prison healthcare centre (the Healthcare Centre) at HMP Edinburgh (the Prison).
Specific complaint and conclusion
The complaint which has been investigated is that it was unreasonable that the Healthcare Centre lost Mr C's clinical records and did not prescribe his on-going medication (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- (i) issue a full apology to Mr C for the loss of his clinical records, for the potential impact that his lack of medication may have had on his eyesight, and for the poor handling of his complaints;
- (ii) confirms that the healthcare centre now uses electronic clinical records which include lists of prescribed drugs for prisoners, and the date this was implemented;
- (iii) confirms their review of the process of transferring clinical records from establishment to establishment, which they referenced in a letter to Mr C;
- (iv) confirms the scope and findings of the NHS LEAN review of the pharmacy process, and if this is not yet complete, what the timescales for the review are; and
- (v) provides evidence that they have reviewed their complaints handling procedure in relation to complaints about their prison healthcare service, to ensure a proactive approach is taken and to ensure they receive complaints timeously.
Overview
The complainant (Mrs C) raised a number of concerns that her father-in-law (Mr A) had been subjected unreasonably to a prolonged period of surgery because staff failed to ensure all surgical equipment was available before proceeding, and that a member of nursing staff failed to alert medical staff of a delay in Mr A's being able to move his legs following surgery. Mr A developed a serious complication and became paraplegic.
Specific complaints and conclusions
The complaints which have been investigated are that:
- Lothian NHS Board (the Board)'s delay in sourcing appropriate surgical equipment was unreasonable (upheld); and
- a nurse on duty unreasonably failed to report Mr A's inability to move his legs (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- provide a detailed action plan identifying the changes they have made to ensure a surgical safety checklist is completed by the surgical team in line with World Health Organisation guidelines;
- confirm the action plan also ensures that relevant guidance on consent is followed in relation to obtaining consent for surgical procedures;
- bring the failures in record-keeping to the attention of relevant staff and carry out regular audits to ensure compliance with guidelines;
- provide evidence that all relevant monitoring charts etc are in place for patients who receive an epidural to document normal return of motor function including a clear outline of actions to be taken if motor function has not returned with an expected timeframe;
- ensure that the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs;
- ensure protocols are in place which comply with Royal College of Anaesthetists guidelines on management of epidurals and demonstrate to the Ombudsman that they have been widely disseminated to and utilised by relevant staff; and
- apologise to Mrs C for the failures identified.
The Board have accepted the recommendations and will act on them accordingly.
Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their late son, Mr A, when he attended the Accident and Emergency (A&E) department of the Royal Infirmary of Edinburgh. Mr and Mrs C also complained that staff unreasonably failed to admit Mr A for further assessment, and that the handling of their subsequent complaint was inadequate.
Specific complaints and conclusions
The complaints which have been investigated are that:
- Lothian NHS Board (the Board) provided inadequate care and treatment to Mr A in A&E (upheld);
- the Board unreasonably failed to admit Mr A pending further assessment (not upheld); and
- the Board’s handling of Mr and Mrs C's complaint was inadequate (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- consult urgently with all relevant stakeholders to formulate an appropriate protocol for dealing with patients who attend A&E with substance misuse and co-morbid mental health illness;
- ensure that all staff dealing with complaints are reminded of the importance of keeping complainants informed and updated during the complaints process; and
- issue a written apology to Mr and Mrs 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 concerns about the care and treatment of his late mother (Mrs A) during a 12 week stay in three of Lothian NHS Board (the Board)’s hospitals. During this period, Mrs A developed pressure ulcers on the heels of both her feet and at the base of her spine. One of these pressure ulcers became very severe, and eventually became infected. This infection spread to Mrs A's bone, and ultimately led to her death, six weeks after discharge. Mr C has complained that, had she not developed pressure ulcers, she would have lived longer.
Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to take reasonable steps to prevent Mrs A developing pressure ulcers and they failed to adequately manage these (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- provide an update on the action that has been taken to implement recent recommendations from Health Improvement Scotland and my office on the care and treatment of patients in relation to the risk and treatment of pressure ulcers;
- conduct a peer review of the prevention, care and management of pressure ulcers in the ward in Hospital 2 where Mrs A stayed;
- develop an action plan for improvements identified through the peer review, including education and training, and share this with my office; and
- apologise to Mr C for the failures identified in this report in relation to Mrs A's care and treatment, for the pain and suffering experienced by Mrs A and for the inaccurate information provided to Mr C in the Board's initial response to his complaint.
The Board have accepted the recommendations and will act on them accordingly.
Overview
The complainant (Mr C) raised a number of concerns that his General Practitioners (GPs) failed to take timely action to fully investigate the symptoms he was reporting during five visits to his GP Surgery (the Practice) between August and November 2012. He complained that this led to a delay in the diagnosis of his testicular cancer.
Specific complaint and conclusion
The complaint which has been investigated is that the GPs failed to take the appropriate steps to diagnose Mr C's testicular cancer promptly (upheld).
Redress and recommendations
The Ombudsman recommends that the Practice:
- issues a written apology for the failings identified in this report; and
- ensures that GPs 1 and 3 reflect on their practice in relation to these events and discuss any learning points at their next appraisal.
The Practice have accepted the recommendations and will act on them accordingly.
Overview
The complainant (Mrs C) raised a number of concerns that treatment decisions, communication and level of support by healthcare professionals were not of a reasonable standard following her husband (Mr C)'s cancer diagnosis.
Specific complaints and conclusions
The complaints which have been investigated are that Lothian NHS Board (the Board):
- (a) failed to provide a reasonable standard of care and treatment to Mr C following his cancer diagnosis (upheld); and
- (b) failed to clearly communicate with Mrs C regarding Mr C's prognosis and provide an adequate level of support to help Mrs C cope with his illness (upheld).
Redress and recommendations
The Ombudsman recommends that the Board:
- provide a plan detailing the changes they have made to: prevent a recurrence of failing to store medical records securely; and meet Scottish government emergency department targets;
- 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;
- provide a plan detailing the changes they have made to prevent a recurrence of failings in their communication with Mr and Mrs C regarding chemotherapy treatment;
- ensure their responses to complaints are meaningful and appropriate in tone, use of language etc; and
- further apologise to Mrs C for the failures identified and offer to meet her to discuss in more detail the response she received to her complaint.
The Board have accepted the recommendations and will act on them accordingly.