Health

Overview
The complainant (Ms C) raised concerns about the care and treatment provided by her GP Practice (the Practice) over a two-year period in that the Practice failed to act on the 'red flag' symptoms she had of a brain tumour within a reasonable time and diagnose her condition.

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

• (a) the Practice failed to properly investigate Ms C's symptoms within a reasonable time; (upheld) and
• (b) the failure by the Practice to diagnose Ms C's condition was not reasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) review their practice to ensure they refer for specialist advice within a reasonable time;
• (ii) ensure their record-keeping complies with General Medical Council guidance;
• (iii) update their knowledge of diagnosis and management of persistent upper limb symptoms; and
• (iv) apologise to Ms C for the failures identified.

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

Overview
The complainant (Ms C) raised concerns about the treatment that she received from Dumfries and Galloway NHS Board (the Board) prior to the birth of her son (Baby A). She also complained about the treatment Baby A received after he was born.

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

• (a) the Board failed to diagnose that Ms C had pre-eclampsia, despite her showing clear symptoms (not upheld);
• (b) the Paediatrician's arrival was excessively delayed, despite Ms C and her family's concerns over Baby A's breathing (upheld);
• (c) the Paediatrician failed to properly prioritise Baby A (upheld);
• (d) the Midwife failed to recognise that there were problems with Baby A feeding when she gave him formula milk (not upheld);
• (e) the Board failed to diagnose Persistent Pulmonary Hypertension of the Newborn despite Baby A showing clear symptoms (upheld);
• (f) the Doctor treating Baby A did not know how to increase the oxygen when this was requested by the Consultant (not upheld); and
• (g) Ms C was refused entry into neonatal when Baby A was admitted and she was not called when he received a heart massage (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind midwifery staff of the importance of maintaining consistent records of babies' physiological observations;
• (ii) present Baby A's case, and Adviser 2's comments, to Neonatal staff to highlight any learning points that can be taken from this case; and
• (iii) apologise to Ms C and Mr B for the issues highlighted 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 about the prescription of antipsychotic drugs to her aunt (Miss A) during her admission to hospital in September 2009 and that the prescribing chain of command of the drugs was not clear.

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

• (a) wrongly prescribed haloperidol to Miss A from 15 until 25 September 2009 (not upheld); and
• (b) failed to provide clarity surrounding the prescribing chain of command (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) carry out an audit of their practice on implementation of the Adults with Incapacity Act with particular reference to consent and report to the Ombudsman on the findings;
• (ii) amend its guidance on managing patients with delirium to include the requirements of the Adults with Incapacity Act;
• (iii) share this report with staff to ensure they complete documentation properly and meet the communication needs of patients with cognitive or sensory (or both) impairment; 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.

Overview
In February 2010, the complainant (Mrs C)'s late mother (Mrs A) was admitted to Drumcarrow Lodge of Stratheden Psychiatric Hospital (the Hospital). She was hearing voices and suffering from hallucinations and paranoia. Mrs A was discharged from the Hospital on 31 May 2010 after her mental health problems had been resolved. However, Mrs C alleged that the Hospital paid scant regard to Mrs A's physical condition and did not assess this properly before her release. Mrs A died from heart failure on 5 June 2010 after an emergency admission to Ninewells Hospital, Dundee, on 2 June 2010. Mrs C submitted a formal complaint about the way the Hospital dealt with Mrs A's physical care and treatment but she alleged that the responses she received were unreasonable.

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

• (a) physical care and treatment of Mrs A, while she was a patient at the Hospital, were unacceptable (upheld); and
• (b) responses to Mrs C's complaints about Mrs A's physical care and treatment were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) offer Mrs C a full and sincere apology for their failures with regard to Mrs A's treatment;
• (ii) share this report with the team involved and with the Consultant Psychiatrist and remind him of his overall responsibilities in such cases;
• (iii) look into the process of issuing referral letters, to ensure that any failures to respond are chased up and into the fact that a letter appeared to have been signed by a trainee psychiatrist when she was on holiday;
• (iv) apologise to Mrs C for their failures with regard to the investigation of her complaint; and
• (v) review the rigour of their complaint handling process, with particular relevance to timescale and investigative thoroughness.

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 sister (Ms A), who had a diagnosis of Borderline Personality Disorder, after she was admitted to the Royal Edinburgh Hospital (Hospital 1) in September 2010. Mrs C was also unhappy with Lothian NHS Board's (the Board) responses to her complaints.

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

• (a) Ms A did not receive appropriate care and treatment from Hospital 1 during the period 13 September 2010 to 7 October 2010 (upheld); and
• (b) the Board have failed to provide satisfactory answers to Mrs C's questions about the matter (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospital 1, to include: the assessment of patients on admission; care-planning practice; the completion of risk management plans and proformas; and communication with the named person and relatives and their involvement and participation in decision-making. Practices in these areas should be audited against relevant professional body expectations; national standards, policies and codes of practice; and existing local policy intentions;
• (ii) provide him with details of the findings and the action plan created as a result of the above recommendation;
• (iii) ensure that the findings in this report are communicated to the staff involved in Ms A's care and treatment; and
• (iv) apologise to Mrs C and Ms A for the failures identified in this report.

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

Overview
The complainant (Mr C) raised a number of concerns that this brother (Mr A) had been inappropriately cared for and treated in Highland NHS Board (the Board) hospitals between February and October 2010.

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

• (a) delayed in diagnosing Mr A's cancer, including a delay in Mr A being reviewed by Gastroenterology (upheld);
• (b) inappropriately discharged Mr A from Caithness General Hospital on 9 June 2010 (upheld); and
• (c) did not adequately communicate to Mr A the details of his diagnosis and prognosis (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review endoscopy waiting times, taking into account SIGN and NICE guidance, and report on what steps will be taken to address capacity issues to avoid delays such as that identified in this case;
• (ii) explain how cancelled endoscopies will be treated as adverse events;
• (iii) review the circumstances of Mr A's admission and discharge on 8 and 9 June 2010, with a specific focus on the potential for an inter-hospital transfer, and discharge criteria, and report on the lessons learned;
• (iv) review admission clerking and medical record-keeping at Hospital 1, to ensure it is in line with current standards; and
• (v) remind consultants of their responsibility to inform patients personally of their test results and likely consequences, and to note this in the medical records.

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

Overview

• (a) during Ms C’s labour she was not listened to (upheld);
• (b)  clinical staff wrongly asked Ms C to get off the bed to allow them to clean up a gush of amniotic fluid (upheld); and
• (c)  the prolapsed cord could have been diagnosed much quicker (not upheld).

Overview
The complainant (Mr C) had a large odontogenic keratocyst removed from his jaw in October 2008. His maxillofacial consultant (the Consultant) reviewed Mr C in February 2009 and recommended that he be reviewed every six months because the cyst was aggressive and had a high rate of recurrence. The Consultant saw Mr C again in September 2009, but his appointment in March 2010 was cancelled. The Consultant saw Mr C in September 2010. It was identified that he needed surgery as the cyst had recurred.

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

• (a) failed to review Mr C within six months as recommended by the Consultant (upheld);
• (b) delayed in notifying him of the re-scheduled appointment (upheld); and
• (c) failed to handle his complaint adequately (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) take steps to make relevant staff aware that the views of clinical staff must be taken into account when they are considering deferring the follow-up of a patient and that this should be clearly documented;
• (ii) ensure that relevant staff are aware that they should not jeopardise the health of patients in order to meet a Government target; and
• (iii) apologise to Mr C for the failings identified in relation to complaint (a).

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

Overview
The complainant Ms C raised a complaint that, as a result of substandard care at Raigmore Hospital, she developed a large pressure sore during a period of recuperation following an operation.

Specific complaint and conclusion
The complaint which has been investigated is that Highland NHS Board (the Board) failed to prevent a pressure sore developing following Ms C's operation on 4 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence of current audit and monitoring in relation to pressure sore prevention and treatment. This should include relevant national initiatives, Clinical Quality Indicators and patient safety data;
• (ii) provide the Ombudsman with the current education and training programmes for the prevention and management of pressure sores;
• (iii) draw the report to the attention of nursing staff involved in Ms C's care; and
• (iv) provide a full apology to Ms C for the failures identified within this report.

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

Overview
The complainant (Mr C) complained that, as a result of his GP Practice (the Practice) failing to act on his enquiries about a follow up chest scan, there was an 18 month delay in him receiving the scan. When the scan was eventually performed he was diagnosed with lung cancer, and underwent surgery shortly thereafter.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay between November 2008 and May 2010, caused by the Practice, in Mr C receiving an MRI scan (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) conduct a Significant Event Analysis on this case;
• (ii) ensure that the GP discuss this case with his appraiser at his next GP appraisal; and
• (iii) provides Mr C with a full apology for the failures identified within this report.

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