Health

Overview
The complainant (Mr C)'s wife (Mrs C) was admitted to the Western General Hospital (the Hospital). Mrs C is paraplegic and uses a wheelchair. Whilst in the Hospital, she developed pressure ulcers which ultimately required her to go into permanent residence in hospital. Mr C complained about the failure of Lothian NHS Board (the Board) to prevent her pressure ulcers. He also raised concerns about their staff's communication with Mrs C and questioned the appropriateness of the initial decision to discharge her from the Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that care and treatment at the Hospital regarding the pressure ulcers and discharge home, including communication, were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide training to their staff on the proper implementation of their pressure ulcer policies, including the completion of all relevant documentation in the clinical records;
• (ii) apologise to Mr and Mrs C for the issues highlighted in this report; and
• (iii) provide this office with evidence of the action taken to implement the action plan with particular reference to ensuring a multi-disciplinary assessment of patients' suitability for discharge.

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

Overview
The complainant (Mrs C) complained about the care and treatment provided to her husband (Mr C) following his admission to the Royal Alexandra Vale of Leven Hospital (the Hospital). Mr C was 90 years old and was admitted because he was suffering pains in his legs; prior to his hospital admission he was living independently with no other immediate health concerns. Mr C developed pneumonia in hospital and while being treated for this developed diarrhoea, kidney failure, a pressure ulcer and severe oral thrush. Mr C subsequently died. Mrs C felt the Hospital staff's lack of timely action had contributed to Mr C's death.

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

• (a) staff did not diagnose the cause of pain in Mr C's legs (not upheld);
• (b) staff did not reasonably respond to Mr C's dehydration (upheld);
• (c) there was an unreasonable delay in carrying out an x-ray or scan following the diagnosis of a chest infection on 25 March 2012 (not upheld);
• (d) staff did not reasonably respond to Mr C's complaints of pain in his back on 1 April 2012 (not upheld); and
• (e) staff did not reasonably respond to the development of thrush in Mr C's mouth (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff at the Hospital of the need to communicate with patients and their relatives and carers to ensure they are kept fully informed about their care and treatment, and of the importance of a proactive approach in this regard;
• (ii) conduct an audit to ensure the timely assessment of all acute admissions by consultant medical staff;
• (iii) review the implementation of the fluid balance chart policy, with an emphasis on the identification of the appropriate point for staff to escalate concerns to clinical staff;
• (iv) ensure junior medical staff at the Hospital receive full training on the management of elderly and acutely ill patients with the aim of preventing kidney failure;
• (v) conduct a significant incident review with regards to the period of care from 27 March to 3 April 2012;
• (vi) issue a reminder to all medical staff at the Hospital to ensure that nursing staff are given timely notice of changes to patients' medication;
• (vii) advise staff at the Hospital that, where possible, patients and their families and carers must be able to discuss care and treatment with a named point of contact within the medical team; and
• (viii) give a formal apology to Mrs C for the shortcomings identified in this report and for the distress she has suffered.

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

Overview
The complainant (Mrs C) together with other members of her family raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) concerning the care and treatment their mother (Mrs A) received while a patient in the Victoria Infirmary, Glasgow between September and November 2010. Mrs A died in hospital on 13 November 2010.

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

• (a) the care and treatment provided to Mrs A, including the management of her pressure ulcer and the use of a Certificate of Incapacity, was inadequate (upheld);
• (b) the implementation and application of the Liverpool Care Pathway (LCP) was inadequate (not upheld); and
• (c) communication between board staff and Mrs A's family was unreasonably poor, in particular a meeting with Mrs A's Consultant on 26 October 2010, and a telephone conversation between Mrs A's son and a medical registrar on 1 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence that the Board's current policies and procedures regarding the prevention, management, monitoring, education and training of pressure ulcers is in line with national guidance and best practice;
• (ii) take steps to put in place an action plan to address the shortcomings identified in this report in relation to pressure ulcer management and share this action plan with both the Ombudsman and Mrs C;
• (iii) review how in-patient units communicate with each other about the decision making capacity of patients requiring procedures as in-patients, to ensure that a patient who is being managed under the terms of the Adults With Incapacity (Scotland) Act 2000, is known to be so by any other team undertaking a procedure that would normally require written consent;
• (iv) consider whether the use of treatment plans (recommended for patients with complex care needs) might support the effective use and validity of Certificates of Incapacity in terms of Section 47 of the Adults With Incapacity (Scotland) Act 2000;
• (v) review how clinicians document the fact that capacity may be lacking for one specific intervention but present for other investigations and treatments if they believe this to be the case;
• (vi) ensure that family and carers are appropriately involved and informed of the consideration of use of the Adults With Incapacity legislation in the care of a patient and to document this clearly on the Certificate of Incapacity;
• (vii) apologise to Mrs C and other members of the family for the failings identified in complaint (a);
• (viii) with reference to our adviser's comments under paragraph 84 of this report, consider auditing the precise location of death of their in-patients and whether any system of prioritisation for single rooms across units might minimise this;
• (ix) seek to ensure that any discussion that a member of staff has with a patient's family is recorded in the patient's medical records; and
• (x) apologise to Mrs C and other members of the family for the failings identified in complaint (c).

Overview
The complainant (Mrs C) raised a number of concerns that sub-standard ultrasound equipment or human error meant that a pregnancy she conceived during her fifth cycle of Intra Uterine Insemination (IUI) treatment was not detected. Mrs C complained that this resulted in the pregnancy being destroyed during the sixth cycle of IUI treatment.

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

• (a) it was unreasonable that Mrs C's pregnancy was not detected on 30 and 31 August 2011 (not upheld);
• (b) the scanning equipment used on 30 and 31 August 2011 was not of a reasonable standard (upheld); and
• (c) it was inappropriate that no record was made of the irregular pain and discomfort Mrs C experienced during the procedure carried out on 1 September 2011 (not upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• (i) issue a written apology for the failing identified; and
• (ii) review the IUI recording form to incorporate space for recording symptoms reported by the patient.

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

Overview
The complainant (Mrs C) questioned the care and treatment given to her late husband (Mr C) on 3 October 2011. Mr C died early the next day.

Specific complaints and conclusions
The complaints which have been investigated are that staff at the Accident and Emergency (A&E) Department of Borders General Hospital (the Hospital):

• (a) failed to thoroughly assess and treat Mr C during his first attendance on 3 October 2011 (upheld); and
• (b) unreasonably discharged Mr C home on 3 October 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise sincerely to Mrs C for their failures concerning the care and treatment given to Mr C; and
• (ii) apologise to Mrs C for unreasonably discharging Mr C on the evening of 3 October 2011.

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

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.

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.

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.

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Greater Glasgow and Clyde NHS Board – Acute Services Division (the Board).

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

• (a) staff failed to provide Mr C with timely and adequate pain relief when he reported problems with his catheter (upheld);
• (b) staff inappropriately discharged Mr C from hospital when he was suffering from a high temperature and wound infection (not upheld);
• (c) staff failed to ensure that an adequate home care package was in place on discharge from hospital, including palliative care, or provide advice about agencies which could assist if required (upheld);
• (d) the level of communication between staff and Mr C's family was inadequate (upheld); and
• (e) on 15 and 16 July 2011, Out-of-Hours Service GPs failed to adequately assess Mr C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make Mrs C a formal apology for their shortcoming in this matter and for the distress she and her family have suffered;
• (i) emphasise to all the staff involved, the importance of keeping full and timely notes;
• (ii) review the circumstances of complaint (a) and demonstrate to the Ombudsman that they have a programme in place to prevent such a situation occurring again;
• (iii) make specific apology to Mrs C for failing to make proper arrangements for Mr C's care and support on his discharge from hospital;
• (iv) in the wards concerned, review the procedures for patients' discharge to satisfy themselves that appropriate action is taken;
• (v) make a specific apology for their failure to communicate adequately; and
• (vi) taking into account the failures in communication, the Board should demonstrate to the Ombudsman the action to prevent such a situation occurring again.

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

Overview
The complainant (Ms C) complained that Greater Glasgow and Clyde NHS Board (the Board) failed to take appropriate action when her family reported that her daughter (Miss A) was suffering from mental health problems. Miss A subsequently jumped from a window in her fourth-floor flat. She suffered serious injuries to her lower body.

Specific complaint and conclusion
The complaint which has been investigated is that Community Psychiatric Nurses (CPNs) failed to take appropriate action to safeguard Miss A when it was reported that she was suffering from mental health problems (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a written apology to Ms C for the failure to carry out a reasonable telephone assessment when they spoke to Miss A and for the failure to raise concerns with a Mental Health Officer;
• (ii) review how risk is assessed and recorded in relation to telephone assessments in such circumstances to try to ensure as far as possible that patients assessed over the telephone receive the same quality of assessment as those spoken to face-to-face; and
• (iii) clarify to relevant staff the criteria or threshold regarding when concerns should be raised with a Mental Health Officer.

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