Health

Overview
The complainant (Mrs C) complained about the transfer of her son (Mr A) to the Intensive Psychiatric Care Unit (the IPCU) at Carseview Centre (the Centre), Ninewells Hospital (Hospital 1), Dundee, on 8 January 2008. Mr A had been transferred from the Forensic Unit (the Unit), Murray Royal Hospital, Perth, where he was being treated under a Compulsory Treatment Order (CTO). She also complained that, on 16 January 2008, Mr A was granted a period of escorted leave within the vicinity of the Centre, from where he was able to abscond. Mrs C complained that when Mr A returned to the IPCU that same evening, he was not provided with adequate physical care and treatment. Mr A died in the early hours of 17 January 2008.

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

• (a) Tayside NHS Board (the Board)'s decision making processes to transfer Mr A from the Unit to the IPCU at Hospital 1 were unclear (upheld);
• (b) the decision taken to allow escorted leave from the IPCU was inappropriate for Mr A on 16 January 2008 (upheld); and
• (c) Mr A's physical care and treatment was inadequate on his return to the IPCU from a period of unescorted leave on 16 January 2008 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) urgently review their procedures for the transfer of patients under a CTO to ensure that non urgent transfers are properly categorised and dealt with as such; and that decisions are properly recorded;
• (ii) ensure that, where there is a statutory right of appeal against the decision to transfer, the appropriate persons are formally notified of that right;
• (iii) ensure that every consideration is given for the named person to have the opportunity to provide their views formally and for these views to be recorded and considered as part of the decision making process;
• (iv) ensure that decisions taken about the level of leave allowed during any episode of care and the level of escorts are explained and understood by the patient and their relatives (where appropriate) and a full record is made of these;
• (v) consider the introduction of a locally based alert system within the vicinity, which would enable staff to draw attention to potential incidents sooner than the time taken to return to the ward;
• (vi) review the escort arrangement at the IPCU for accompanied time out, to ensure that the arrangement is clinically appropriate in terms of the risk assessment for the patient;
• (vii) provide training to ensure the adequate medical examination, nursing observation and assessment of vital signs within the IPCU, when managing a patient recently having consumed an illicit substance;
• (viii) ensure that there is appropriate consideration for review of the procedure or protocol for referring a patient to the local Accident and Emergency department for further consideration of physical care and treatment when they admit to having consumed illicit substances;
• (ix) remind staff of their professional responsibilities towards the care and treatment of a patient received into their care with or without prior advice provided by other professional disciplines;
• (x) conduct an audit to ensure full compliance of the use of assessment tools and measures and completion of monitoring charts and vital signs monitoring charts;
• (xi) ensure that this report is shared with all staff involved in Mr A's care when he returned to the IPCU on 16 January 2008, so that they can learn from the findings of this report; and
• (xii) provide an apology 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 (Mr C) made a complaint about Grampian NHS Board (the Board). Mr C complained about the care and treatment he received for wounds and pressure sores; and the attitude of a Consultant Plastic Surgeon (Consultant 1). Mr C also complained about the Board's handling of his complaint.

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

• (a) Consultant 1 did not care for and treat Mr C's wounds and pressure sores appropriately (upheld);
• (b) Consultant 1 did not understand and direct the vacuum assisted closure (VAC) treatment of Mr C's wounds appropriately (upheld);
• (c) Consultant 1's attitude towards Mr C was inappropriate and he discriminated against Mr C because of his age and disability (not upheld); and
• (d) the Board's handing of Mr C's complaint, including the investigation, was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their approach to team care for wounds and pressure sores such as Mr C's, to ensure a cohesive plan of management;
• (ii) review their protocols for the use of VAC treatment to ensure that it is used appropriately in conjunction with other treatments for relief of pressure sores pre-operatively;
• (iii) remind staff of the importance of good record-keeping;
• (iv) review their processes to ensure they obtain responses from relevant staff when investigating complaints; and review their processes for recording the investigation of complaints; and
• (v) apologise to Mr C for the failings identified in this report.

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

Please note that this report contained typographical errors in three of the recommendation dates.  The three recommedation completion dates that were recorded as 2010 should have been 2011.

The SPSO has apologised for these errors.

Overview
The complainant (Mrs C) raised a number of concerns that her adult son (Mr A) had received inadequate treatment when he presented at the Accident and Emergency Department at Hairmyres Hospital (the Hospital) on the evening of 7 February 2010 and that it was inappropriate to discharge him from the Hospital. Mr A subsequently presented at the Hospital in the early hours of 8 February 2010 and died after an unsuccessful attempt to resuscitate him.

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

• (a) the treatment provided to Mr A at the Accident and Emergency Department at the Hospital on 7 February 2010 was inadequate (upheld); and
• (b) the decision to discharge Mr A from the Accident and Emergency Department at the Hospital on 7 February 2010 was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider the Manchester Triage Scale in their review of ways to introduce an assessment method to establish the clinical needs of patients attending Accident and Emergency; and
• (ii) apologise to Mrs C that staff failed to stress the importance to Mr A of a hospital admission although he was keen to go home.

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

Overview
The complainant (Mrs C) is an Independent Advice Support Services Case Worker with the Citizen's Advice Bureau. She raised a number of concerns about the Scottish Ambulance Service (SAS) on behalf of a client (Mrs A). Mrs A said that when she was out walking with her young great grandson in November 2009, she fell and broke her leg. She said a passer-by called for an ambulance (she said three calls were made) but that it took over an hour to arrive. Meanwhile, she was left in the cold. When the ambulance arrived, she was given pain relief and thus was not fully aware. Mrs A was aggrieved because her great grandson was left in the care of a person she did not know. She also complained that an inflatable splint used on her injured leg was faulty. Thereafter, Mrs C complained that the SAS failed to respond properly to the complaint she made on behalf of Mrs A.

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

• (a) there was delay in responding to the 999 call (not upheld);
• (b) the inflatable splint was faulty (upheld);
• (c) the crew inappropriately handed Mrs A's three-year-old great grandson to an unknown person while she was incapacitated (upheld); and
• (d) there was a failure to handle Mrs C's complaints appropriately, in that there was delay and failure to respond to all of the complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the SAS:

• (i) make an addition to their Child Protection Code of Practice, to take into account circumstances where children are left in their care by virtue of the fact that the responsible adult has been taken ill or involved in an accident. In this regard, they may wish to refer to the Scottish Government's Guidance on Looked after Children (Scotland) Regulations 2009;
• (ii) apologise to Mrs A for any distress caused as a result of allowing her great grandson to be left in the care of a stranger;
• (iii) provide to him a copy of the internal auditors' report on the introduction of the pilot complaints procedure and that he is kept advised of any recommendations made;
• (iv) keep him advised of the progress of the introduction of the new complaints procedure and that he receives a copy of the new complaints handling procedure; and
• (v) apologise to Mrs C (and Mrs A) for the way in which the formal complaint was handled.

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

Overview
On 2 February 2010, I received a complaint from the complainant (Ms C) against Lothian NHS Board (the Board). The complaint concerned the care and treatment her grandfather (Mr A) received in the Maple Villa Care Home, Livingston (the Care Home) prior to his death. Mr A suffered from Alzheimer's disease and the Care Home is a specialist dementia unit catering for patients with particularly challenging aspects of that condition. Mr A resided there from 2004 until July 2009. On 24 July 2009 he was admitted to St John's Hospital, Livingston, where he died three days later. Ms C said that on his admission he was severely dehydrated, had a urinary tract infection and bedsores.

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

• (a) provide Mr A with proper nutrition (upheld);
• (b) provide Mr A with general personal care (upheld);
• (c) take action to prevent bedsores (not upheld);
• (d) provide any form of stimulus to Mr A as a patient suffering from Alzheimer's disease (upheld); and,
• (e) communicate adequately with the family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make a written apology to Ms C for their failures with regard to Mr A and for the misinformation given;
• (ii) emphasise to staff in the Care Home the necessity of following adopted procedures and the proper completion of standardised forms;
• (iii) monitor procedures in the Care Home for a period of four months;
• (iv) provide evidence to the Ombudsman of the range of structured recreational or diversional activity now available to residents in the Care Home and emphasise to staff the importance of such;
• (v) emphasise to their staff the benefit to all parties of clear communication; and
• (vi) ensure that, on each new admission, the Care Home take steps to discuss and record the level and means of communication required with families; and provide evidence to the Ombudsman that this is happening.

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

Overview
The complainant (Mr C) contacted the Ombudsman about multiple concerns relating to the post-operative care he received following the extraction of a wisdom tooth at Dundee Dental Hospital. Mr C believes that, given his past medical history, his care was substandard and that Tayside NHS Board (the Board) failed to consider his symptoms adequately, resulting in him being admitted to Ninewells Hospital for nine days.

Specific complaints and conclusions
The complaint which has been investigated is that the Board failed to diagnose and treat Mr C's haematoma adequately, resulting in a prolonged hospital admittance (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the pre-operative planning for dental patients with pre-existing disease and/or drug history to ensure that effective treatment plans are available in the event of post-operative complications. This should include a review of their post-operative information packs given to patients to ensure that they provide detailed instructions to patients on Warfarin therapy; and
• (ii) apologise to Mr C for their failure to carry out effective pain control.

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

Overview
The complainant (Mr C) made a complaint about Grampian Health Board (the Board) on behalf of the aggrieved (Mrs A). Mrs A was admitted to Aberdeen Royal Infirmary (the Hospital) after collapsing in a supermarket on 17 February 2009. On the following day, it was recorded that she was very agitated, confused and that she was shouting. Later that day, nurses recorded that they were unable to give the prescribed intravenous antibiotics because Mrs A refused them. The records show that she was subsequently given two doses of haloperidol (an antipsychotic drug) by intramuscular injection 'to settle'.

Specific complaints and conclusion
The complaint which has been investigated is that Mrs A was injected with haloperidol against her will on 18 February 2009 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in the Hospital to include:  the assessment, treatment and care of people with confusion, delirium or behavioural disturbance; the use of the Adults with Incapacity legislation; the use of both physical restraint and restraint by medicines;
• (ii) review the means by which medical and nursing staff are trained in the assessment and management of acute agitation or confusion, including appropriate use of the Adults with Incapacity legislation and documentation;
• (iii) review and disseminate their 'Guidance for Rapid Tranquilisation of Psychiatric Emergencies in Psychiatric Hospitals, General Hospitals and Accident and Emergency Departments' document;
• (iv) remind all clinical staff in the Hospital to carefully document indications for the use of sedative medication, the patient's consent to such treatment and the use of any form of restraint to administer such medication;
• (v) provide me with details of the findings and the action plan created as a result of the above recommendations and provide updates where relevant;
• (vi) ensure that the findings in this report are communicated to the staff involved in Mrs A's care and treatment; and
• (vii) issue an apology to Mrs A for the failings identified in this report.

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

Overview
The complainant (Ms C) raised concerns about the treatment she had received when she attended the Accident and Emergency (A&E) unit at the Royal Infirmary of Edinburgh in the area of Lothian NHS Board (the Board) following an injury to her leg.

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

• (a) the diagnosis provided by the Board was not reasonable (upheld); and
• (b) the care provided in Hospital 1 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) should give consideration to implementing the Ottawa knee decision rules when assessing A&E patients if these are not already in place;
• (ii) should apologise for the shortcomings in the care provided which are highlighted in this report; and
• (iii) devise/review their pain management guidelines and ensure that all A&E clinical staff are aware of the guidelines.

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

Overview
The complainant, Ms C, raised a number of concerns about the care and treatment that her late father (Mr A) received at Crosshouse Hospital Kilmarnock (the Hospital), in the area of Ayrshire and Arran NHS Board (the Board). Ms C considered that poor standards of care had led to Mr A's premature death.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment which Mr A received at the Hospital was inadequate and brought about his death prematurely (I upheld the complaint that the care and treatment were inadequate.  However, I did not find that poor standards of care had led to Mr A's premature death).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman's office with a specimen copy of the new in-patient admissions booklet;
• (ii) provide the Ombudsman's office with a report on the findings of the audit of the Abbreviated Mental Test section of the patient medical admission form;
• (iii) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in this report;
• (iv) reflect on the comments of the specialist Advisers in paragraphs 15 and 22 of this report; and
• (v) issue an apology to Ms C and her family for the failings 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 her late father (Mr A) received from Ninewells Hospital (the Hospital) after he was admitted on 20 April 2008 with collapse and expressive dysphasia (difficulty in using language). Mrs C is also aggrieved about the length of time it took for Tayside NHS Board (the Board) to respond to her complaints.

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

• (a) there was inadequate monitoring of blood pressure (upheld);
• (b) there was lack of intervention to increase blood pressure (upheld);
• (c) the reintroduction of blood pressure and cardiac medications all at once was inappropriate (not upheld);
• (d) there was a delay in the swallow assessment and nasogastric tube being inserted (not upheld); and
• (e) there was a delay in the Board responding to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review its policy regarding the monitoring of patients with acute stroke who are given treatment that may cause unexpected and precipitous falls in blood pressure;
• (ii) provide ongoing evidence, such as Scottish patient safety reports, which demonstrates consistency and continuity of care for those patients being transferred between wards or units; and
• (iii) review the need for a protocol in the stroke unit regarding the immediate management of patients with acute stroke who suffer sudden, severe and symptomatic falls in blood pressure.

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