Health

Overview
The complainant (Mrs C) raised a number of concerns against Greater Glasgow and Clyde NHS Board (the Board) that her late father (Mr A) had been inappropriately cared for by nursing staff in Dunrod F Ravenscraig Hospital (the Hospital) from 2 February 2011 up to his death on 24 April 2011.

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

• (a) nursing staff unreasonably failed to monitor and maintain Mr A's fluid levels (not upheld);
• (b) nursing staff unreasonably failed to deal with incontinence issues (not upheld);
• (c) nursing staff unreasonably failed to maintain a reasonable level of hygiene for Mr A (upheld);
• (d) there were inadequate transfer systems and documentation in place (upheld);
• (e) there was poor communication from staff (not upheld);
• (f) nursing staff unreasonably failed to pass on information to the relevant Social Work team when Mr A was transferred and this delayed the process of establishing a suitable nursing home for him to go to (not upheld);
• (g) inadequate attention was paid to Mr A's dignity by ensuring that his clothing was appropriately attended to (upheld); and
• (h) the investigation of Mrs C's complaint to the Board was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feed back the learning from this to nursing staff to avoid similar situations recurring;
• (ii) provide him with an update on the actions they have taken to ensure such an incident does not recur;
• (iii) ensure that communication between family members and staff are appropriately recorded;
• (iv) ensure that measures are taken to feed back the learning from this to complaints investigation staff to avoid similar situations recurring; and
• (v) 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 (Mr and Mrs C) lost their son (Baby A) following his premature birth on 5 January 2011. Their complaint concerns the care and treatment provided at Caithness General Hospital, Wick (Hospital 1) and Raigmore Hospital, Inverness (Hospital 2) during and after Mrs C's pregnancy. Mr and Mrs C believe that they received a poor standard of care from both Hospital 1 and Hospital 2 and said that the loss of Baby A has had a devastating effect on their lives.

Specific complaints and conclusions
The complaints which have been investigated are that Highland NHS Board (the Board):

• (a) unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld);
• (b) inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld);
• (c) unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld);
• (d) unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld);
• (e) inappropriately placed Baby A in what looked like a cardboard box (not upheld); and
• (f) unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that each operator at Hospital 2 is compliant with the RCOG Green Top Guideline No 8 on amniocentesis;
• (ii) review the amniocentesis consent form and patient information sheet used at Hospital 2, so as to take account of the five good practice points referred to in paragraph 17; 20
• (iii) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (a);
• (iv) review the local guidance at Hospital 1 and Hospital 2 concerning suspected fetal abnormalities discovered on any obstetric ultrasound scan. Where an abnormality is suspected there should be a clear pathway for specialised fetal medicine assessment and no delay in referral of the patient to a specialised hospital department;
• (v) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (c);
• (vi) provide evidence of the review of the guidelines for staff referred to in the letter from Doctor 3 to Mr and Mrs C dated 21 April 2011;
• (vii) reflect on the Adviser's comments about examination options after a stillbirth/late miscarriage where the baby has a structural abnormality; and
• (viii) review Hospital 2's post mortem patient information sheet and consent form, so as to include the four examination options listed in paragraph 74.

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

Overview
The complainant (Ms C) complained about the lack of communication with her family after her mother (Mrs A) was admitted to the Emergency Department in the Victoria Infirmary in Glasgow (the Hospital). Mrs A was 84 years old and had a history of dementia. The family were not told that Mrs A's condition in the Hospital had deteriorated. Mrs A subsequently died and Ms C considers that the family lost the opportunity of being with Mrs A at the end of her life.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's lack of communication with the family just before Mrs A's death was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a written apology to Ms C for the failure to inform her of the deterioration in her mother's condition; and
• (ii) provide him with an action plan and / or steps in place to ensure communication with relatives and carers is addressed within the Emergency Department.

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

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 complainant (Ms C) raised a concern that undue pressure was put on her to take prophylactic antibiotics during her labour by staff at the Southern General Hospital.

Specific complaint and conclusion
The complaint which has been investigated is that Ms C was unreasonably bullied into taking prophylactic antibiotics (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) bring this report to the attention of relevant staff including the second registrar to ensure lessons are learned and highlight the relevant guidelines and guidance on group B streptococcus and consent;
• (ii) review the guidance on group B streptococcus to clarify the limited circumstances where a child protection order should be considered;
• (iii) consider a multi-disciplinary approach involving obstetricians and paediatricians when a patient refuses treatment in similar situations; and
• (iv) apologise to Ms C.

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

Overview
The complainant (Mrs C) raised a number of concerns that her sister, Ms A, reported to her GP practice (the Practice) symptoms of increasing chest, neck and back pain which were not properly investigated. Strong analgesia had little or no effect but the practice continued to issue prescriptions for morphine without physically assessing Ms A. In late December 2011 Ms A was referred to hospital by a GP from NHS 24 where bone cancer was diagnosed. Shortly following the diagnosis, in early January 2012, one of Ms A's vertebra in her neck collapsed and she is now paralysed from the neck down. She has been told that her cancer is terminal and in May 2012 was told that she only has months to live.

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

• (a) unreasonably failed to make timely and appropriate investigations to establish the cause of the symptoms reported by Ms A (upheld);
• (b) unreasonably failed to make any referrals for specialist opinions in view of Ms A's symptoms (upheld); and
• (c) inappropriately issued prescriptions for morphine without physically assessing Ms A (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issues a written apology for the failings identified in this report;
• (ii) carry out a Significant Event Audit (SEA) on this case;
• (iii) carry out a review of a case note sample to assess the quality of examinations conducted and the information recorded; and
• (iv) completes the review of how acute prescriptions are issued and put a robust monitoring system in place.

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

Overview
The complainant (Mr C) complained about a significant pressure ulcer he developed after being admitted to Perth Royal Infirmary (the Hospital). Mr C said that the pressure ulcer affected his quality of life because he had to endure an extended period of bed rest.

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

• (a) Mr C was provided with inadequate care and treatment which allowed him to develop a pressure ulcer (upheld); and
• (b) there was a failure to deal with his complaint appropriately (upheld).

Redress and recommendation
The Ombudsman recommends that Tayside NHS Board:

• (i) ensure their tissue viability training programme provides education and training for the assessment, grading and treatment of pressure ulcers in line with national guidance;
• (ii) undertake an audit of wards within the Hospital to ensure pressure ulcer care and management is in line with national guidance and best practice; and
• (iii) provide details of the outcome of their review of their complaints procedure to ensure investigations are evidence based and undertaken without undue delay.

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

Overview
The complainant, Mr C, raised a number of concerns about the care and treatment given to his father (Mr A) during the final days of his life.

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

• (a) nursing staff at Bannockburn Hospital (Hospital 1) failed to recognise that Mr A's condition was such that he required appropriate medical assistance (not upheld);
• (b) two out-of-hours doctors who separately attended Mr A assessed and treated him inappropriately. In particular, they failed to recognise his poor condition and arrange for a transfer to Stirling Royal Infirmary (upheld);
• (c) the decision making, care and communication of nursing staff in relation to the provision of palliative care for Mr A was inappropriate (upheld);
• (d) nursing staff inappropriately refused to provide even the most basic of medical records to a medically qualified relative, despite him having Mr C's consent as next of kin with welfare power of attorney (not upheld);
• (e) a staff nurse refused to allow a medically qualified relative to speak to Mr A's on call consultant and the on call consultant failed to recognise the importance of having this conversation (not upheld);
• (f) an inappropriate care and treatment plan was agreed between the staff nurse and the on call consultant pending the arrival of an out-of-hours doctor (not upheld);
• (g) during his stay in Hospital 1, Mr A's consultant failed to make himself available to meet with Mr C, who was next of kin with welfare power of attorney. This was despite Mr C's best efforts (not upheld); and
• (h) during Mr A's stay in Hospital 1 there was an unacceptable level of care with regard to his possessions, which resulted in the unacceptable loss of his spectacles for some weeks and his hearing aid which was never recovered (not upheld).

Redress and recommendations
The Ombudsman recommends that Forth Valley NHS Board:

• (i) complete a critical incident review regarding this situation, if they have not done so already;
• (ii) consider the practicality of having routine discussions regarding care escalation for patients admitted to Hospital 1 and other similar units;
• (iii) consider the means by which it can be ensured that severe illness is promptly recognised in such units, by use of a Scottish Early Warning Score or similar scoring system;
• (iv) consider a strategy for determining the appropriate limits of care as soon as a patient in Hospital 1 or similar unit becomes acutely unwell and where there has been no anticipatory care discussion;
• (v) emphasise to staff in Hospital 1 the importance of keeping full and proper records, including notes of conversations and telephone conversations; and
• (vi) remind Hospital 1 staff of the Do Not Attempt Cardiopulmonary Resuscitation Policy and provide evidence that they have done so.

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

Overview
The complainant (Mr C) had difficulties with his dentures and sought help from his general dental practitioner at his dental practice (the Practice). He was referred to Edinburgh Dental Institute (the Institute)'s Department of Restorative Dentistry (Restorative Dentistry); however, he was advised he would be unable to receive treatment from there, and was referred back to the Practice. Mr C was not satisfied by NHS Lothian - University Hospitals Division (the Board)'s response to his complaint about this.

Specific complaint and conclusion
The complaint which has been investigated is that in late 2011, the Board unreasonably refused to give Mr C an appointment at the Institute's Restorative Dentistry, or to inform him of alternative options to conventional dentures (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a full apology to Mr C for the failings identified in this report;
• (ii) urgently arrange for Mr C to be examined by the Department of Restorative Dentistry;
• (iii) draw this report to the attention of the Consultant within the Department of Restorative Dentistry; and
• (iv) in light of the findings of this case the Board take steps to ensure that the services referred to as being provided to patients under the Institute's Guidelines for the Referral of Patients to the Department of Restorative Dentistry are being provided.

Overview
The complainant (Ms C) raised a number of concerns about the diagnosis of her brother (Mr A)'s cancer. She complained that the health centre Mr A attended (the Practice) situated in the Greater Glasgow and Clyde NHS Board area, failed to take Mr A's complaints of back pain and reduced mobility seriously and that their lack of proactive investigation of his symptoms meant that Mr A's diagnosis was delayed. Ms C also complained about the Practice's handling of her formal complaint.

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

• (a) provided Mr A with inadequate care and treatment during the months prior to his death on 26 January 2011 (upheld); and
• (b) dealt inadequately with Ms C's subsequent complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) consider Mr A's case with a view to improving their procedures for proactively ensuring the completion of diagnostic investigations which have been identified as necessary for their patients;
• (ii) draw all GPs' attention to the Adviser's comments regarding record-keeping;
• (iii) review the outcome of this complaint alongside their complaint procedure to avoid similar situations recurring;
• (iv) apologise to Ms C and her family for the failings identified in this report.

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