Health

Overview
The complainant (Ms C) raised a number of complaints with Grampian NHS Board (the Board) about the care and treatment she received whilst being treated as an in-patient at Brodie Ward (the Ward) at the Royal Cornhill Hospital (the Hospital) in Aberdeen in 2010. She was dissatisfied by the Board's response to her complaints.

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

• (a) the care and treatment provided to Ms C on her admission to the Ward of the Hospital on 5 February 2010 was inadequate; (upheld)
• (b) the observations levels to which Ms C was subjected and the locking of the Ward door at night were inappropriate; (upheld)
• (c) there were communication issues during Ms C's stay on the Ward: including that she had difficulty in speaking to her named nurse; and that she was given inappropriate 'advice' on self-harming by a Staff Nurse (Staff Nurse 1); (upheld)
• (d) inadequate care and treatment was provided to Ms C after she took an overdose on 24 February 2010; (upheld)
• (e) it was unreasonable that on the occasions that Ms C expressed a desire to leave hospital she was 'threatened' with formal detention; (upheld)
• (f) the action taken following the incidents on 1 and 4 March 2010 was inappropriate and inadequate; (upheld)
• (g) staff on the Ward had an unreasonable approach to weight/body mass index (BMI) policy; (upheld) and
• (h) the Board unreasonably delayed in responding to the complaint made by Ms C on 25 May 2010. The Chief Executive did not respond until almost four months later on 6 September 2010. (upheld)

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman that interim care plans are developed for patients on admission to the Ward, and that all appropriate documentation within patient records is being completed;
• (ii) develop a search policy to provide guidance to staff on the issues of patient dignity and safety;
• (iii) review their observation policy to take cognisance of the shortcomings identified, and ensure that the observation policy leaflet for patients is finalised and distributed to all patients on the Ward;
• (iv) review their policy in relation to door locking on the Ward at night to take into consideration the additional issues highlighted;
• (v) provide evidence to the Ombudsman of staff training in relation to communication with mental health patients, which should include guidance on ensuring professional and appropriate record-keeping by staff in relation to patients;
• (vi) develop a policy to reflect the Mental Welfare Commission's guidance in relation to short term detention, for staff use and guidance and ensure this is distributed to staff;
• (vii) undertake an audit to ensure incidents are being recorded appropriately on Datix;
• (viii) ensure staff are aware of their responsibilities in relation to patient confidentiality;
• (ix) develop policy for staff to advise of appropriate steps to take in relation to patient measurements, in conjunction with the Quality Improvement Scotland guidelines;
• (x) ensure that complainants are kept up to date in relation to the progress of their complaints, and are given full information about the options available to them;
• (xi) provide evidence to the Ombudsman that the Board operates a rights and values based approach in relation to the care of patients within the Adult Mental Health Directorate;
• (xii) draw this report to the attention of all the staff involved in Ms C's care; and
• (xiii) provide a full apology to Ms C for all of the failings identified within this report.

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

Overview
The complainants, Mr C and Ms C, raised a number of concerns about Ms C's unplanned homebirth of their daughter (Baby A), and her death. The complainants believe that the loss of Baby A was totally avoidable and blame Highland NHS Board (the Board) for what happened.

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

• (a) the Board failed to provide adequate advice, care and treatment before, and during, the birth of Baby A (upheld);
• (b) the Board failed to provide adequate care and treatment to Mr and Ms C following the birth (upheld);
• (c) the Board failed to keep adequate and timely records of the birth and aftercare provided to Ms C (upheld);
• (d) the Serious Untoward Incident report failed to investigate and report adequately on all the issues regarding the birth and aftercare and the Chief Executive's response failed to investigate the matter adequately or to make any recommendations to avoid a recurrence (not upheld); and
• (e) the Board incorrectly stated that Baby A was stillborn (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board: Completion date

• (i) make a full and sincere apology for the failures identified in Complaint (a); and
• (ii) emphasise to all midwifery staff the necessity of compliance with the relevant rules in relation to the completion of notes.

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

Overview
The complainant (Ms C) complained on the behalf of the aggrieved (Mr and Mrs A) about the care and treatment received by Mrs A from Western Isles NHS Board (the Board) in December 2010. Mrs A was taken to Uist and Barra Hospital (the Hospital) with abdominal pains. Two days later Mr A was advised Mrs A was suffering from acute renal failure, was dying and no further treatment could be provided for her. However, Mrs A was subsequently able to be airlifted to the mainland for treatment. She went on to make a full recovery.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not provide reasonable care and treatment to Mrs A between 5 and 9 December 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide an updated version of the action plan to evidence that all of the identified actions have been implemented;
• (ii) provide further details about planned training for medical staff at the Hospital, which should include refresher training on the causes of opiate toxicity and enhanced training in relation to venous access;
• (iii) conduct a random case note review at the Hospital; and
• (iv) provide a full apology to Mr and Mrs A for the failings identified in this report.

Overview
The complainant (Mrs C) raised concerns on behalf of her mother (Mrs A) regarding the treatment that she received from Greater Glasgow and Clyde NHS Board (the Board). Mrs A attended Victoria Hospital (the Hospital) after breaking her ankle. She was treated for this but subsequently experienced severe pain and blistering around the ankle. Mrs A was later found to have a second fracture, which had previously been undetected. Mrs C complained about the Board's failure to diagnose the second fracture and about the initial treatment that Mrs A received, which she believed caused her blistering.

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

• (a) the Board failed to diagnose Mrs A's os calcis fracture in good time (upheld);
• (b) the Board's treatment of Mrs A's broken ankle was inappropriate (upheld); and
• (c) the Board's complaint handling was poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) present Mrs A's case and this report's findings to Orthopaedic, A&E and complaint handling staff at a suitable staff forum, such as a mortality and morbidity meeting;
• (ii) review their procedures for assessing patients' suitability for discharge to ensure that social and medical considerations are given the appropriate consideration; and
• (iii) consider providing further training to staff on patient discharge eligibility assessment.

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

Overview
The complainant (Ms C) raised concerns about delays and failures in the care and treatment provided to Mr A when he attended a medical practice (the Practice) on a number of occasions between December 2010 and February 2011 due to bowel problems and, from 11 February 2011 onwards, pain in his groin. Mr A had an ultrasound and CT scan in March 2011. He was diagnosed with diverticular disease and had to undergo emergency surgery. He had an abscess drained, repairs to his bladder and a section of his bowel removed. He was discharged with a stoma bag.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay by the Practice's GPs in fully investigating and diagnosing Mr A's condition (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr A for the delay in fully investigating and diagnosing his condition;
• (ii) carry out a Significant Event Audit on this case;
• (iii) carry out a review of a sample of case notes to assess the quality of the recording of examination findings; and
• (iv) ensure that revision of common abdominal conditions, including diverticulitis, forms part of the Continuing Professional Development of all GPs involved in this case.

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

Overview
The complainant (Mr C) raised concerns about the failure by the medical practice (the Practice) to diagnose that he had Crohn's disease. He said that the Practice failed to carry out appropriate investigations, despite his regular visits complaining about stomach problems.

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

• (a) over a five-year period from April 2005, the Practice unreasonably failed to diagnose that Mr C had Crohn's disease (upheld); and
• (b) the Practice failed to respond properly to Mr C's letter of complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr C for the failure to carry out further investigations and/or make a referral when he attended with ongoing bowel symptoms in March and April 2009;
• (ii) apologise to Mr C for the failure to take steps to try to obtain his full medical records in order that they could respond to his complaint in full; and
• (iii) make relevant staff aware of our finding on this matter.

Overview
The complainant (Mrs C) complained about the care, treatment and diagnosis her daughter (Ms A) received at an out-of-hours service at Peterhead Hospital (Hospital 1) in May 2011. Mrs C also complained about the responses she received from NHS Grampian (the Board) in relation to her complaints.

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

• (a) the out-of-hours doctor (the Doctor) incorrectly explained that Ms A had not presented with photophobia despite her complaining of this to a nurse, and shielding her eyes with her hood (not upheld);
• (b) the Doctor inappropriately failed to mention in his letter of response to Mrs C's complaint that Ms A had presented with a headache (upheld);
• (c) the Doctor unreasonably reached an incorrect diagnosis (not upheld); and
• (d) the Chief Executive issued a dismissive response to Mrs C's complaint which reflected the lack of investigation into her concerns (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman that they have reviewed their complaints handling procedure in relation to complaints about its out-of-hours service, to ensure a proactive approach is taken; and
• (ii) issue a full apology to Mrs C for the failures identified within this report.

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

Overview
The complainant (Ms C) raised a number of concerns on behalf of Mr A's family that Mr A was not admitted to an in-patient facility for mental health and that there were failures in communication between the medical and mental health teams treating Mr A.

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

• (a) Greater Glasgow and Clyde NHS Board (the Board) failed unreasonably to admit Mr A to hospital (not upheld); and
• (b) there was no reasonable communication between the teams to whom Mr A was or should have been referred, including the Royal Alexandra Hospital, the intensive home treatment team, the community mental health team and the alcohol problems clinic (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the coordination of the relevant services to ensure the failures identified in this report are addressed; and
• (ii) apologise to the family.

Overview
The complainant (Mrs C) raised a number of concerns against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her late husband (Mr A) received at Crosshouse Hospital from his admission on 21 May 2010 up to his death on 23 May 2010.

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

• (a) failed to administer the prescribed anti-seizure and steroid medication (upheld);
• (b) failed to recognise and address Mr A's pain (not upheld);
• (c) failed to implement the Liverpool Care Pathway until 23 May 2010 (not upheld); and
• (d) failed to provide adequate care and attention on the night of 22 to 23 May 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feedback the learning from all aspects of this event to the medical team involved with Mr A's care, to understand the importance of avoiding similar situations recurring;
• (ii) review the process of pain scoring, its frequency and recording in this case and feedback the learning to nursing staff;
• (iii) complete a review of the LCP within the unit and feedback the learning to all medical and nursing staff within the unit;
• (iv) complete a full review of their medical staff cover for the night of 22 to 23 May 2010 to ensure such situations do not recur;
• (v) provide an update of their review on the use of pager numbers; and
• (vi) 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 complainant (Mrs C) raised a number of concerns regarding the nursing care provided to her late mother (Mrs A) during an admission to the Royal Alexandra Hospital in Paisley (the Hospital) from 12 October 2010 until her death on 16 October 2010.

Specific complaint and conclusion
The complaint which has been investigated is that there were several unacceptable shortcomings in care during Mrs A's admission to the Hospital in October 2010 (upheld).

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

• (i) provide him with an update regarding their implementation of the introduction of the Liverpool Care Pathway;
• (ii) consider the Adviser's comments on the several failings in Mrs A's end of life nursing care and draw up and implement an action plan to address these failings;
• (iii) conduct a significant events review of this case; and
• (iv) apologise to Mrs C for the failures identified in this report.

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