Health

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her mother (Mrs A) about the care and treatment her late father (Mr A) received while a patient in the Golden Jubilee National Hospital, Clydebank (the Hospital). Mr A had been referred to the Hospital following a diagnosis of lung cancer and died there, several days after surgery.

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

• (a) there were unreasonable shortcomings in Mr A's care and treatment in the Hospital (upheld); and
• (b) there has been an unreasonable lack of clarity by the Hospital in explaining why Mr A died (upheld).

Redress and recommendations
The Ombudsman recommends that the Hospital:

• (i) apologise to Mrs A and her family for the failings identified in complaint (a);
• (ii) consider a review of the wording of the consent form a patient signs prior to surgery, so as to include the main operative risks;
• (iii) reflect on the comments of Adviser 1, in relation to the advice given on treatment options and the carrying out of a preoperative physiological assessment;
• (iv) reflect on the comments of Adviser 1, in relation to Mr A's postoperative nutritional management;
• (v) revise their nursing action plan, so as to address the failings identified in this report;
• (vi) apologise to Mrs A and her family for the failings identified in complaint (b); and
• (vii) consider obtaining a copy of the post mortem report, where a patient dies and a post mortem is instructed by the Procurator Fiscal, so as to inform the clinicians who cared for the patient and to be able to discuss the findings with the patient's family, if required.

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

Overview
The complainant (Mrs C) underwent reconstructive breast surgery following treatment for breast cancer. She complained to Grampian NHS Board (the Board) that the surgeon and the surgical procedure were both changed at short notice. She had had a different procedure explained to her by a different surgeon at a consultation prior to the surgery. Mrs C said she had not had sufficient time to consider the changes prior to undergoing the surgery. She also complained that the outcome of the surgery was unacceptable.

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

• (a) it was unreasonable to change the surgeon and the surgical procedure Mrs C was to undergo at short notice, without giving her sufficient time to consider the changes or make a fully informed decision (upheld); and
• (b) the outcome of Mrs C's surgery was unacceptable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure this case is discussed with the Registrar at his next appraisal;
• (ii) consider the issue of consent, and provide evidence to the Ombudsman that the General Medical Council's guidelines are being followed in relation to obtaining informed consent from patients for surgical procedures;
• (iii) take steps to ensure that a similar situation does not occur in the Plastic Surgery Department when cases are re-assigned to cover consultant leave;
• (iv) bring this report to the attention of all staff involved in Mrs C's care, to prevent a recurrence of similar issues; and
• (v) provide 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 (Mrs C) raised a number of concerns about the care, treatment and subsequent discharge of her husband (Mr C), who has dementia, following his admittance to the Accident and Emergency Department (the Department) of Victoria Hospital (the Hospital) on 6 January 2011.

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

• (a) the care and treatment of Mr C in the Department on 6 January 2011 was not reasonable (upheld);
• (b) the arrangements for Mrs C to deal with Mr C's personal hygiene in the Department were unreasonable (upheld);
• (c) the time taken to admit Mr C to a ward from the Department was unreasonable (upheld);
• (d) the responses to Mrs C's telephone calls to the Department for information about Mr C were unreasonable (upheld);
• (e) the arrangements for Mr C's discharge on 7 January 2011 were unreasonable (upheld);
• (f) Mrs C was not provided with reasonable information upon Mr C's discharge (upheld); and
• (g) Mr C's mental health condition and Mrs C's role as his carer, next of kin and holder of power of attorney over him were not reasonably taken into account during his admission (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind nursing staff within the Department of their responsibilities with regards to patients' personal hygiene and that it is not appropriate to rely on visitors to undertake this for them;
• (ii) provide evidence to the Ombudsman that staff within the Department have undergone training in relation to the importance of good communication with patients and their families;
• (iii) review their policy in relation to ensuring appropriate discharge arrangements for patients, taking into account any vulnerabilities and risk factors;
• (iv) remind nursing staff of the importance of treating patients with dignity at all times;
• (v) review their policy in relation to providing discharge information to patients with dementia and their relatives and carers as part of the implementation of Scotland's National Dementia Strategy;
• (vi) provide evidence that, as part of the implementation of Scotland's National Dementia Strategy, staff within the Department and the Ward are given ongoing training in relation to the importance of acknowledging dementia and recognising the role of carers and next of kin; and
• (vii) provide a full formal apology to Mr and Mrs C for all of the failings identified within this report.

The Board 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) that if a small mass found on his kidney in December 2005 had been regularly and appropriately checked, the delay to diagnose his renal cancer could have been prevented. Mr C also complained about the inadequate manner the Board dealt with his complaint about this.

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

• (a) delayed to diagnose Mr C's renal cancer (upheld); and
• (b) failed to address his complaint appropriately (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 medical staff, to understand the importance of avoiding similar situations recurring;
• (ii) review how hospital teams ensure that the results of patient investigations received after discharge are read and acted upon;
• (iii) conduct a Significant Events Review of this case;
• (iv) review their Complaints Management Procedures to ensure compliance, with reference to sections 5, 6 and 7; and
• (v) apologise for the failures identified in the report.

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

Overview
The complainant (Mr C) complained about the care his late father (Mr A) received at the Southern General Hospital (the Hospital) in February 2011. Mr C was concerned that the staff involved in Mr A's care had failed to consider and assess his cognitive function, or communicate with Mr C in relation to the plans for discharge, resulting in Mr A being inappropriately discharged. Mr A fell and was injured two days after being discharged home, and was re-admitted to the Hospital.

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

• (a) did not provide reasonable care and treatment to Mr A during his admission to the Hospital between 10 and 24 February 2011 (upheld);
• (b) did not reasonably consider whether Mr A was fit for discharge on 24 February 2011 (upheld);
• (c) did not dress Mr A in the outdoor clothes that had been provided for his journey home on 24 February 2011 (upheld); and
• (d) did not provide a reasonable response to Mr C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman of the implementation of a policy for the assessment of cognitive function of elderly patients, which should include documenting whether or not clinical staff find a patient has capacity to participate in decision making;
• (ii) provide the Ombudsman with a copy of the new discharge policy to demonstrate it states that relatives and carers must be engaged with during the planning for discharge process;
• (iii) ensure that their discharge policy and checklist contains a reminder that patients are dressed appropriately upon discharge;
• (iv) provide a full apology to Mr C for all of the failings identified within this report; and
• (v) review and clarify their policy in relation to the review of hip fracture patients by the DOME.

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

Overview
The complainant (Mrs C) raised a number of concerns about the treatment her late husband (Mr C) received whilst a patient at Hairmyres Hospital (the Hospital) in March 2010, after he was admitted on 10 March 2010 with shortness of breath. He developed pneumonia and MRSA, and Mrs C felt the Hospital were not caring for him adequately, in particular that staff did not properly recognise his needs (Mr C suffered from dementia). Mr C discharged himself against medical advice on 23 March 2010 and died at home on 2 April 2010.

Specific complaint and conclusion
The complaint which has been investigated is that during Mr C's admission to hospital in March 2010, there were unreasonable failings in his medical and nursing care and treatment in relation to pneumonia and medication (upheld).

Redress and recommendations
The Ombudsman recommends that the Lanarkshire NHS Board (the Board):

• (i) provide evidence on the implementation of Scotland's National Dementia Strategy and the Dementia Resource folder, including relevant action plans, in order to ensure: ongoing education and training for staff in the Hospital; and good communication with dementia patients and their families, involving family members in care when appropriate; and
• (ii) carry out a ward audit to ensure compliance with the Nursing and Midwifery Council's Standards for medicine management and record-keeping.

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

Overview
The complainant, Mrs C raised a number of concerns about the way in which her husband (Mr C) was cared for and treated while he was a patient in Queen Margaret Hospital, Dunfermline.

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

• (a) there was a lack of urgency and avoidable delays in investigating Mr C's condition and providing him with a definitive diagnosis (upheld);
• (b) there were avoidable delays in chasing up test results from Royal Infirmary Edinburgh following Mr C's mediastinoscopy on 15 March 2010 (upheld);
• (c) there was unnecessary delay in referring Mr C to the Western General Hospital (not upheld);
• (d) it was unnecessary and inappropriate to move Mr C so often (upheld); and
• (e) staff attitude was unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that Fife NHS Board (the Board):

• (i) apologise to Mrs C for their delays in this matter;
• (ii) arrange for the Urology MDT cancer network to review this case and act upon any recommendations made;
• (iii) look at their monitoring and follow-up procedures with a view to making them more robust;
• (iv) formally apologise to Mrs C for moving Mr C 13/14 June 2010; and
• (v) consider their own bed transfer policy and practice with regard to the findings of this part of the complaint and to ensure that they are appropriate.

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

Overview
The complainant (Mrs C) raised a number of concerns about the investigation and diagnosis of her sister (Mrs A)'s breast cancer by Mrs A's GP practice (the Practice) from May 2010 until November 2010.

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

• (a) the Practice failed to investigate Mrs A's symptoms properly within a reasonable time (upheld);
• (b) the failure by the Practice to diagnose Mrs A's condition was not reasonable (not upheld); and
• (c) the Practice failed to refer Mrs A to hospital within a reasonable time (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) undertake a further Critical Event Analysis of Mrs A's care to consider their care of patients with cancer, particularly around presentations which may signal metastatic disease; and
• (ii) apologise to Mrs A and her family for the failures identified.

The Practice have confirmed they will act on the recommendations accordingly.

Overview
The complainant (Mrs C) raised a number of concerns about the treatment she received at Borders General Hospital (the Hospital) following cataract surgery. Mrs C had concerns that she had received insufficient information about the proposed surgery and choice of anaesthetic; that an inappropriate method of anaesthetic was used; and when problems occurred following the surgery there was a delay in her being referred for specialist assessment.

Specific complaints and conclusions
The complaints from Mrs C which I have investigated are that:

• (a) the information and advice provided to Mrs C before surgery was insufficient to allow her to make a fully informed decision or to give valid consent for surgery (not upheld);
• (b) the pre-operative assessment was inadequate in that Mrs C was not assessed by her surgeon prior to surgery and the assessment did not take full cognisance of the particular risks involved (not upheld);
• (c) the choice of sharp needle anaesthesia was inappropriate and unreasonable (upheld);
• (d) the post-operative care and treatment was inadequate. In particular, that there was an unreasonable and unexplained delay in referring Mrs C for a specialist opinion (upheld); and
• (e) the complaints handling by Borders NHS Board (the Board) was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the risks of carrying out sharp needle anaesthesia in patients with high myopia;
• (ii) apologise to Mrs C for perforating her eye during surgery;
• (iii) remind staff of the need to refer patients for specialist opinion as soon as the clinical situation has been identified;
• (iv) apologise to Mrs C for the delay in making a specialist referral; and
• (v) remind staff of the need to conduct a Critical Incident Review where an adverse incident has occurred in order to establish whether practices require to be amended.

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

Overview
The complainant (Mrs C) raised a number of concerns about the inadequate care and treatment her late mother (Mrs A) received from her GP Practice (the Practice).

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

• (a) failed to refer Mrs A to Liberton Day Hospital (the Hospital) following their 17 August 2010 consultation (not upheld);
• (b) failed to monitor the fluid on Mrs A?s lungs (upheld); and
• (c) failed to treat cellulitis adequately by only prescribing antibiotics, not arranging for attention by a district nurse and failing to follow up Mrs A?s condition, given her history of cellulitis (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) ensure that patients are appropriately monitored and the outcomes recorded during the course and administration of diuretics;
• (ii) conduct a Significant Event Analysis on this case; and
• (iii) provide Mrs C with a full apology for the failures identified within this report.

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