Health

Overview
The complainant (Mr C) complained about the care and treatment provided to his sister-in-law (Mrs A) while she was in the care of Dumfries and Galloway NHS Board (the Board). He alleged that the Board failed to provide appropriate mental health care for Mrs A during a period when she was physically unwell.

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

• (a) Mrs A's anti-depressant medication, phenelzine, was stopped without reasonable psychiatric consultation in April 2010 (upheld);
• (b) keyhole surgery was undertaken inappropriately on Mrs A in April 2010 (not upheld);
• (c) following surgery for bowel cancer in April 2010, Mrs A was sent home without reasonable aftercare instructions, which led to further health problems and the need for her bowel to be extended (upheld); and
• (d) Mrs A was unreasonably able to acquire the means and opportunity to self-harm in Dumfries and Galloway Infirmary and Crichton Royal Hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the fact that no proper advice was given to Mrs A pre and post-operatively;
• (ii) when presented with patients for surgery with known mental health issues for which they take medication, ensure that the circumstances are discussed with the patient, the GP and clinicians involved;
• (iii) ensure that all relevant discussions with the patient, GP and clinicians (and any subsequent outcomes) are recorded properly;
• (iv) give consideration to the terms of their permission forms for operations, given the failures with regard to Mrs A;
• (v) apologise to Mr C for their failure to provide Mrs A with adequate aftercare instructions in April 2010;
• (vi) review their procedures to ensure that such an occurrence does not occur again;
• (vii) apologise to Mr C for the insufficient care they took to prevent Mrs A from accessing the means to harm herself; and
• (viii) where patients have expressed thoughts of suicide, carry out (and fully record and act on) risk assessments.

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

Overview
The Complainant (Miss C) complained on behalf of her friend (Mrs A) who underwent surgery for an inguinal hernia at the Western General Hospital in March 2010. Miss C raised concerns about delays to Mrs A's operation, which she felt could have been avoided. She also raised complaints about the service that Mrs A received from Lothian NHS Board (the Board) when she was in hospital.

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

• (a) Mrs A's operation was unnecessarily delayed (upheld);
• (b) Mrs A's special medical requirements were not made known to ward staff prior to her admission to Ward 23 (upheld);
• (c) cleanliness and staff hygiene practices in Ward 23 were poor (not upheld);
• (d) food service on the ward was poor (upheld);
• (e) the Board discharged Mrs A without ensuring that she had access to adequate support outwith the hospital (upheld); and
• (f) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care with a view to identifying any lessons that can be learned from her case;
• (ii) review their procedures for reporting CT scan results back to the referring clinician;
• (iii) review their procedures for tracking the progress of patients whose treatment has been referred to a different consultant;
• (iv) take steps to ensure that nursing staff maintain patient records in line with the Nursing and Midwifery Council's Record Keeping and Guidance for Nurses and Midwives;
• (v) take steps to satisfy themselves that the steady decline in the cleanliness monitoring score between September 2009 and March 2010 was not indicative of an endemic deterioration in cleanliness and hygiene standards on Ward 23; and
• (vi) provide training to staff on Ward 23 regarding nutrition, communication and record-keeping.

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

Overview
Mr and Mrs C complained to NHS Lothian Health Board (the Board) on 24 October 2006 about the treatment and management of medical care provided to their late son (Master C) by the Board's Child and Family Mental Health Service (CAMHS) whilst he was a patient during 2000 and 2001. Mr and Mrs C also complained about the subsequent failure of the Board to provide adequate services for the treatment of his mental health in 2001. CAMHS was governed by Lothian Primary Care NHS Trust until 31 March 2004 and was the accountable body during the period of Master C's treatment in 2000-2001. NHS Lothian Health Board (the Board) was the accountable body thereafter who considered and responded to the complaints made by Mr and Mrs C, and subsequently to this office.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed in the care and treatment of Master C during the period 2000 - 2001 (upheld).

Redress and recommendations
The Ombudsman has considered all the information presented to this office, together with the action taken by the Board. It is clear the service failures identified in this report demonstrate systemic failures by the Board. It is evident that the service failures were as a result of poor policy and practice. The Ombudsman is satisfied that the Board, as a consequence of this complaint, demonstrated by the evidence presented to this office detailing improvements to CAMHS since 2001, have undertaken action to remedy the service failures identified in order to improve current services.

The Ombudsman recommends that the Board:

• (i) provides evidence that their patient discharge process for CAMHS is clear and robust and available to patients, parents and carers; and
• (ii) ensures their complaints policy reflects a clear process which outlines a structured, timely approach to gathering information from key personnel involved in the complaint.

Overview
The complainant (Miss C) complained about the care and treatment provided to her cousin (Miss A) by a medical practice (the Practice) before she died from liver cancer on 28 June 2010. The Practice had carried out a large number of liver function tests on Miss A from May 2004 onwards. These showed that her GGT (Gamma-glutamyltransferase – a liver enzyme) levels were high. Miss C complained about the lack of action taken by the Practice in response to the raised GGT levels.

Specific complaint and conclusion
The complaint which has been investigated is that the Practice failed or delayed to act on Miss A's abnormal test results (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) write to Miss C to apologise for the failure to investigate Miss A's abnormal GGT results; and
• (ii) take steps to ensure that in future they investigate cases where the patient has a persistently high GGT level to try to establish the cause.

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

Overview
The complainant (Mrs C) raised concerns about the care and treatment provided by a general practitioner from the out-of-hours service (the GP) to her husband (Mr C) on 2 August 2010. She complained that the GP failed to diagnose Mr C with ischaemic heart disease and admit him to hospital. Mr C died of a heart attack several hours after the GP's visit.

Specific complaint and conclusion
The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide reasonable care and treatment to Mr C on 2 August 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that the failings identified in this report are raised with the GP during his next appraisal, to ensure that lessons have been learned from this case; and
• (ii) apologise to Mrs C for the failures identified in this report.

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

Overview
An MP (Mr C) complained on behalf of the aggrieved (Mr D and Ms B) that out-of-hours doctors employed by Ayrshire and Arran NHS Board (the Board) endangered their infant son (Baby A)'s life by failing, on a number of occasions, to diagnose his twisted bowel.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's diagnosis of Baby A's twisted bowel was unnecessarily delayed (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide training to General Practice and midwifery staff in their area on the assessment and treatment of neonates with bilious vomiting; and
• (ii) apologise to Mr D and Ms B for the failings identified in this report.

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

Overview
On 2 July 2010 an Independent Advice and Support Worker from the Citizens Advice Bureau (Ms C), complained to the Scottish Public Services Ombudsman about Highland NHS Board (the Board) on behalf of her client (Mr A). The complaint was that there had been a failure to identify why Mr A was not healing from a fracture of his left tibia and fibula, sustained whilst playing football in May 2008. Ms C complained that the pain Mr A suffered following his fracture was not assessed properly. She also complained that the clinicians involved in his care did not consider the possibility of any other underlying conditions that may have been present. Mr A was ultimately diagnosed as suffering from osteosarcoma of the left knee.

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

• (a) the Board did not appropriately investigate Mr A's failure to heal from his left tibia and fibula fracture (not upheld);
• (b) Mr A's ongoing pain was not assessed properly (upheld); and
• (c) the Board failed to consider the possibility of the presence of underlying conditions (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the procedures within orthopaedic related departments to ensure they have robust systems in place to identify red flag symptoms;
• (ii) draw the findings of this report to the attention of all clinical staff involved in Mr A's care and treatment throughout the period of 10 May 2008 to 12 May 2009, so that they can learn from it; and
• (iii) provide Mr A with a full apology 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 about the care and treatment provided to her aunt (Miss A) including failures in communication. Mrs C was also concerned about the way NHS Greater Glasgow and Clyde (the Board) dealt with her complaint.

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

• (a) the care and treatment provided to Miss A during her admission at Glasgow Royal Infirmary in January 2010 was not reasonable (upheld);
• (b) the Board's communication with Miss A's family was not reasonable (upheld); and
• (c) the Board did not deal reasonably with Mrs C's complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure they deal with complaints in accordance with the NHS complaints procedure; and
• (ii) 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) made a complaint that her daughter (Mrs A) had not received reasonable care and treatment from Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to care properly for Mrs A at Inverclyde Royal Hospital, Greenock resulting in her developing a pressure ulcer (upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) raised a number of concerns about the prescription of antipsychotic drugs to his mother (Mrs A), failures in record-keeping and failures in communication by Greater Glasgow and Clyde NHS Board (the Board) from late 2008 until February 2010.

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

• (a) wrongly prescribed Mrs A with antipsychotic drugs from late 2008 to February 2010 (upheld);
• (b) failed to keep adequate medical records (upheld); and
• (c) failed to communicate properly with Mrs A's family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospitals 1 and 2, on the implementation of the Adults with Incapacity Act and SIGN Guideline 86 for patients with dementia with particular reference to assessment of capacity within 72 hours of admission wherever practicable and report back to the Ombudsman on the findings;
• (ii) carry out an audit of their: record-keeping to ensure it is in accordance with the national guidelines with particular reference to care planning practice; practice relating to the storage of patients' medical records to ensure it accords with the Scottish Government Records Management: NHS Code of Practice (Scotland); and report back to the Ombudsman on the findings;
• (iii) develop a policy on meeting the communication needs of patients with dementia which includes having an identifiable and agreed relatives' communication or participation strategy as a core aspect of the care plan; and
• (iv) apologise to Mr C for the failures identified in this report.

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