Health

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.

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late mother (Mrs A) by the Medical Centre she attended for several years (the Practice), leading up to her death from cancer in June 2010. Mrs C is supported in her complaint by Mrs A's husband (Mr A) and her sister (Mrs D).

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

• (a) did not listen to the concerns raised (not upheld);
• (b) failed to carry out adequate tests and investigations (upheld); and
• (c) did not take adequate steps to help with the diagnosis of Mrs A's cancer (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) undertake a significant event review of Mrs A's care and treatment from March 2010 onwards and consider lessons that can be learned for future practice;
• (ii) ensure that Practice records comply with NHS record-keeping guidelines; and
• (iii) apologise for the failures identified in this report.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the treatment that Mrs C's mother (Mrs A) received when staying in the Southern General Hospital (the Hospital) between 6 October 2009 and 4 February 2010. They complained that staff of Greater Glasgow and Clyde NHS Board (the Board) failed to monitor Mrs A's condition properly or provide her with effective treatment. Mr and Mrs C raised further concerns about staff communication, record-keeping, a lack of patient dignity and a failure to provide stimulation for patients with dementia.

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

• (a) there was a failure to provide the appropriate care and treatment to Mrs A between 6 October 2009 and 4 February 2010 (upheld);
• (b) the nursing notes contained inaccurate and inconsistent information along with unprofessional language (upheld);
• (c) there was poor communication between ward team members and the family (upheld); and
• (d) the handling of the complaint was poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A's family for the issues highlighted in this report; and
• (ii) provide the Ombudsman with a report on the improvements made within the older people's unit as a result of their action plan, including details of how the National Dementia Strategy is being implemented by the Hospital.

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

Overview
The complainant (Mrs C) raised concerns that there was a delay by clinicians at Royal Aberdeen Children's Hospital (the Hospital) in diagnosing that her daughter, (Miss A), who had pneumococcal meningitis in August 2007, was profoundly deaf. Miss A had been reviewed at the Child Hearing Assessment Clinic on a regular basis but it took until January 2010 for the diagnosis to be made.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay in the diagnosis of Miss A's hearing loss (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share the contents of this report with the various clinicians involved in Miss A's care and treatment and consider carrying out Evoked Response Audiometry hearing tests at an earlier stage in children who have suffered meningococcal disease; and
• (ii) apologise to Mrs C for the delay in reaching a definitive diagnosis on Miss A's hearing loss.

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

Overview
The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her late mother (Mrs A) during an admission to Queen Margaret Hospital in Dunfermline (the Hospital) between 12 April 2010 and her death on 5 May 2010.

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

• (a) failed to continue with antibiotic treatment after the course of Amoxicillin (an antibiotic) was completed at 22:00 on 1 May 2010, despite Mrs A's rapidly deteriorating condition (upheld);
• (b) failed to act on the concerns Mrs C raised on 2 May 2010 (upheld);
• (c) were unaware that Mrs A was expectorating thick green sputum (matter coughed up from the lungs) on 1 May 2010, when this is documented in the medical records (upheld);
• (d) failed to inform Mrs C about Mrs A's deteriorating condition (upheld);
• (e) failed to ensure that oral medication administered to Mrs A when she was in a semi-conscious state did not remain in her mouth from 08:00 on 5 May 2010 until Mrs C pointed this out at 14:00 on 5 May 2010 (not upheld);
• (f) failed to provide an Incident Report regarding when Mrs A was inappropriately handled and spoken to (upheld);
• (g) failed to ensure complaint (f) was investigated (upheld);
• (h) disagreed about the cause of death after the Death Certificate was issued and registered (not upheld); and
• (i) made inconsistent statements in their original complaint response to those made at a face-to-face meeting - specifically about the presence of infection (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide me with an update regarding their implementation of the measures described in their letter to my office dated 24 March 2011;
• (ii) review the means by which the clinical judgements of HAN members who see patients independently are monitored;
• (iii) conduct a review of information handover from team to team, with a view to identifying how this can be strengthened;
• (iv) consider Adviser 2's comments on the failings in Mrs A's nursing care and draw up and implement an action plan to address these failings;
• (v) apologise to Mrs C for the failure to investigate complaint (f) properly;
• (vi) ensure that serious complaints are appropriately recorded and investigated;
• (vii) inform me of the outcome of their discussions with regard to completing death certificates and tell me what measures they have taken to ensure that, in future, the cause of death listed on a death certificate is accurate; and
• (viii) ensure that clinical records are thoroughly reviewed as part of their investigation process and prior to providing responses to complaints.

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

Overview
The complainant (Miss C) raised a number of concerns that in August 2010, the Board failed to properly identify her late father (Mr A)'s health complications, provide adequate post-operative nursing care and failed to communicate with her about his care.

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

• (a) medical staff failed to properly identify health complications leading to Mr A's death (upheld);
• (b) Mr A did not receive adequate nursing care post-operatively on 18 and 19 August 2010 (upheld); and
• (c) nursing staff failed to communicate adequately with Miss C regarding Mr A's care (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence of the measures in place to address the failures identified within this report in the MEWS system;
• (ii) confirm to the Ombudsman that they will raise this report with the junior doctor in their annual appraisal;
• (iii) bring this report to the attention of the relevant staff; and
• (iv) apologise to Miss C for the failures identified.

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

Overview
The complainant (Mrs C) raised a number of concerns about delays and failures in the care and treatment provided to her mother (Mrs A) by a medical practice (the Practice) between November 2009 and August 2010. Mrs C was also dissatisfied with aspects of the Practice response to her complaints.

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

• (a) the care and treatment which the Practice provided to Mrs A between late 2009 and August 2010 was inadequate (upheld);
• (b) the Practice did not take reasonable action in response to information provided about planned investigations of Mrs A's health (not upheld); and
• (c) the Practice response to Mrs C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A for their failure to reasonably assess and oversee her care and treatment in 2009 and 2010;
• (ii) ensure that their GP records accurately reflect and define patients' symptoms and consultants' findings as part of the on-going diagnostic process; and
• (iii) apologise to Mrs A and Mrs C for the failure to adequately address the complaint.

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

Overview
The complainant (Mrs C) raised a number of concerns about the treatment her adult son (Mr A) received at hospital (Hospital 1) following an attempted suicide at her home on 17 August 2010. Her complaints included that Mr A was inadequately supervised in a general ward and that he had the opportunity to make a further suicide attempt. Mrs C also complained that despite her request that Mr A should remain in Hospital 1 he was transferred to another hospital (Hospital 2) which was in another health board area where Mr A normally lived.

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

• (a) failed to provide an acceptable standard of care to Mr A, an individual whose psychiatric problems had been highlighted to staff, who was suffering from extreme paranoia and who had recently attempted suicide (upheld);
• (b) failed to operate an effective or flexible transfer procedure and failed to ensure that the Bed Manager acted reasonably in response to Mrs C's requests that Mr A remain in Hospital 1 (upheld);
• (c) allowed some staff to act in a hostile way towards Mrs C after she had contacted the Mental Welfare Commission for advice (upheld);
• (d) failed to ensure satisfactory conditions in a psychiatric ward (not upheld); and
• (e) failed to ensure that Mr A's wounds were managed appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the Task and Finish Group to ensure that the Adviser's concerns about mental health assessment staff training and inadequate record-keeping are taken into account in their review of clinical processes etc;
• (ii) review hand-over procedures to ensure an adequate level of observation is maintained during that time;
• (iii) remind staff of their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003 in relation to transfer of patients to another hospital;
• (iv) conduct an audit/review systems for safe management of non-clinical sharps;
• (v) conduct an audit of wound care practice in the Mental Health Ward; and
• (vi) apologise to Mrs C and Mr A for the failings which have been identified in this report.

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