Health

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.

Overview
The complainant (Mrs C) was unhappy with the support given to her son (Master A) by a District Nursing Team (DNT), from January to June 2010. She was also unhappy with Grampian NHS Board (the Board)'s handling of her complaint. Master A, who was five years old at the time of the events complained about, was diagnosed with Type 1 diabetes in August 2006. He had a history of asthma, allergies and eczema.

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

• (a) gave Master A instructions on self-administering insulin without Mrs C's consent or knowledge, or that of Master A's Paediatric Diabetes Care Team (upheld); and
• (b) failed to handle Mrs C's complaint properly (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the misunderstanding and confusion caused by the DNT's poor record-keeping;
• (ii) obtain signed consent from parents/carers where healthcare staff want a child to self-administer insulin;
• (iii) look into having a single named point of contact for parents/carers in relation to all of a child's diabetes care and treatment; and
• (iv) review how complaints are dealt with by the Moray Community Health and Social Care Partnership, to ensure that the Complaints Handling Procedures are followed.

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

Overview
The complainant (Mr C) raised a number of concerns about the standard of care and treatment provided to his son (Mr A) by Tayside NHS Board (the Board)'s Mental Health Service during the 13 months prior to his death by suicide in July 2010. Mr C also raised concerns about the communication between health staff and Mr A's family during this period.

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

• (a) did not provide Mr A with appropriate care and treatment for his depression (upheld); and
• (b) failed to communicate effectively with Mr A's parents (Mr and Mrs C) or consult with them regarding Mr A's treatment and progress (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make the use and review of the risk screening tool to complement and inform the risk assessment process mandatory for all patient assessments following a self-harm / suicide attempt;
• (ii) review their process for conducting RCAs to ensure a degree of independence;
• (iii) revise procedures in responding to Ombudsman's investigations to ensure no documents are omitted or withheld;
• (iv) review their practice with respect to the involvement of family and others, to ensure it is in line with the good practice contained in the NES framework;
• (v) review their process for involving families in SIRs and RCAs; and
• (vi) issue Mr C with a formal written apology for the failures identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns that following a telephone discussion with the practice receptionist (the Receptionist), she and her husband (Mr C), her son (Mr A) and daughter (Miss D) were de-registered from the dentist's (Dentist 1's) list of patients.

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

• (a) Dentist 1 unreasonably de-registered Mrs C, Mr C, Mr A and Miss D without explanation (upheld);
• (b) Dentist 1 inappropriately said that she did not require to provide any explanation (not upheld); and
• (c) Mr A's appointments on 23 March 2011 and 20 April 2011 which fell within the period Dentist 1 remained liable to provide treatment (until 8 June 2011) were unjustifiably cancelled (upheld).

Redress and recommendation
The Ombudsman recommends that Dentist 1:

• (i) Dentist 1 apologise to Mr A for cancelling his appointment on 23 March 2011 without establishing its purpose.

Dentist 1 has accepted the recommendation and will act on it accordingly.

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.