West of Scotland

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainants (Mrs C and Mrs D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at St Johns Hospital at Howden (the Hospital) between 19 December 2005 and 2 February 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Lothian NHS Board (the Board):

• (a) failed to provide adequate care and treatment to Mrs A (partially upheld); and
• (b) failed to properly plan for Mrs A's discharge (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that discussions take place within the clinical team on Ward 9 of the Hospital to agree the appropriate standard of practice with regards to the importance of a) thorough examination of a patient prior to discharge, with particular reference to patients with pre-existing medical problems and multiple medications, and b) recording of medical examination findings and the rational behind any changes to medications;
• (ii) consider the use of fully unified records, i.e. including therapy follow-up records with the joint medical/nursing records;
• (iii) consider regular (at least weekly) multi-disciplinary team meetings where discharge planning for complex cases, particularly for elderly patients, can be discussed, coordinated and recorded;
• (iv) consider that where family conflicts or carer anxieties are raised, case conference meetings are organised when the key disciplines and family and carers can meet to exchange information and plan discharges and that all family meetings are adequately recorded; and
• (v) consider whether current occupational therapist staffing levels in this area are sufficient to avoid the delays experienced by Mrs A.

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

Overview

The complainant, Mr C, complained that Viewpoint Housing Association Ltd (the Association) had implemented a decision to withdraw a meals service provided to his mother-in-law (Mrs A) contrary to the terms of her tenancy agreement.  He also complained that his complaint to the Association about this had not been adequately responded to.

Specific complaints and conclusions

The complaints which have been investigated are that the Association:

• (a) removed the provision of a full meals service contrary to the terms of Mrs A's tenancy agreement (upheld); and
• (b) failed to adequately respond to Mr C's complaint of March 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Association:

• (i) apologise to Mrs A for varying her agreement without adequate consultation;
• (ii) ensure that future tenant consultations are meaningful and properly recorded; and
• (iii) apologise to Mr C for their failure to adequately respond to his complaints.

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

Overview

The complainant (Mr C) claimed that West Lothian Council (the Council) failed to conduct the required consultation before installing traffic calming measures in his neighbourhood and that the Council failed to warn him of the aftermath of their installation as he reported that they were causing noise and vibration from traffic.

Specific complaint and conclusion

The complaint which has been investigated is that the installation of traffic calming measures took place after inadequate consultation with local residents and without warning of the possible consequences (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the manner in which Lothian NHS Board (the Board) had responded to complaints raised originally by her mother (Mrs A) and continued by Mrs C after Mrs A's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to deal with Mrs A and Mrs C's complaints in a timely and appropriate manner (upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for their failure to deal with the complaints raised by Mrs A or Mrs C in a timely or appropriate manner.

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

Overview

The complainant, Mrs C, who suffered from an anal fissure, was concerned that her general practitioner (the GP) waited too long before referring her to hospital and that the GP prescribed Proctosedyl (a cream which is used to reduce pain, inflammation and swelling in rectal lesions) for too long.

Specific complaints and conclusions

The complaints which have been investigated are that the GP:

• (a) waited too long before referring Mrs C to hospital (not upheld); and
• (b) prescribed Proctosedyl for too long (upheld).

Redress and recommendation

The Ombudsman recommends that the GP:

• (i) reacquaint herself with the use of topical steroids; and
• (ii) apologise to Mrs C for prescribing Proctosedyl for too long.

The GP has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) did not consider that Lothian NHS Board (the Board) had taken seriously, or learnt from, the death of his 46-year-old son (Mr A).

Specific complaint and conclusion

The complaint which has been investigated is that the Board's response to Mr A's death was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for: the failure to provide convincing evidence of a thorough investigation, with lessons learnt; the impression at various times that no action would be taken in response to his son's death; the poor quality of some of the complaint responses; and the delay in giving him a definitive response to a complaint meeting and letter of early 2005; and
• (ii) ensure that, where appropriate, this investigation drives further service improvement in future complaints.