Health

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

Overview
The complainant (Miss C) attended the Royal Infirmary of Edinburgh, in the area of Lothian NHS Board (the Board), on two separate occasions in early 2009 with a history of abdominal pain and irregular menstrual bleeding. She complained about the management of her pain during these attendances.

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

• (a) Miss C's pain was managed inappropriately (upheld); and
• (b) the standard of record-keeping was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their systems for ensuring that patients' pain is properly assessed in Accident and Emergency and on the gynaecology ward and that patients' needs are met with timely pain management, and provide copies of audits regarding pain assessment and management. The review should consider triage arrangements for patients directly referred by their GP and also initiatives for meeting patients' needs if medical staff are not readily available to prescribe pain relief;
• (ii) ensure that, when handling complaints, all complainants' concerns are addressed and that responses refer to relevant standards and guidelines where appropriate;
• (iii) apologise to Miss C for their failure to manage her pain appropriately and for not fully addressing this issue when responding to her complaint. The apology should also acknowledge the inappropriate reference to Miss C using her mobile telephone; and
• (iv) provide evidence that appropriate strategies are in place to ensure that all nursing records meet the standards outlined by the Nursing and Midwifery Council.

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

Overview
The complainant (Ms C), who is an advice worker, raised a number of concerns on behalf of her client (Mrs A) about the treatment which she received for a swollen leg following her attendance at Borders General Hospital (the Hospital) on 11 December 2008 and 12 December 2008. Mrs A believed that she received an inadequate examination by a doctor (the Junior Doctor) on 11 December 2008 and that her care and treatment was not managed appropriately. Mrs A's leg continued to cause her problems and she returned to her general medical practice who referred her back to the Hospital on 18 December 2008 where an ultrasound scan revealed the presence of a deep vein thrombosis.

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

• (a) the Junior Doctor failed to carry out an appropriate assessment and examination of Mrs A on 11 December 2008 (upheld); and
• (b) the management of Mrs A on 11 December 2008 and 12 December 2008 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the Junior Doctor and ensure he has a documented discussion with his current clinical supervisor on the issue, which is filed in his training logbook;
• (ii) review the adequacy of the clinical supervision of junior doctors in the General Medical Unit; and
• (iii) apologise to the family of Mrs 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 (Mr C) has raised concerns about the time it has taken to receive an operation following a referral by his GP. He has also complained of Lothian NHS Board (the Board)'s failure to provide a clear explanation for the delay.

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

• (a) there was an unacceptable delay between referral for surgery and being offered an appointment (upheld); and
• (b) the Board failed to provide a clear and consistent explanation for the delayed appointment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) write to Mr C to apologise for their failure to provide him with surgery within their own targets of 12 weeks from referral;
• (ii) write to Mr C to apologise for their failure to provide him with an explanation for the delay in offering him an accurate date for surgery within their target period and also their failure to adhere to their 'guaranteed' date for surgery of 18 September 2009; and
• (iii) review the way they carry out and monitor referrals for surgery.

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

Overview
The complainant (Ms C), on behalf of her sister (Ms A), raised a number of concerns about the treatment which Ms A's late partner (Mr B) received from his general medical practice (the Practice) from 22 January 2009 to 26 January 2009. Mr B was admitted to hospital on 26 January 2009 with respiratory problems and multi-organ failure and died on 11 February 2009.

Specific complaint and conclusion
The complaint which has been investigated is that the Practice did not do enough to investigate the symptoms displayed by Mr B and failed to diagnose severe sepsis which had developed as a result of community acquired pneumonia (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant, Mr C, raised a number of concerns about the care and treatment provided to his mother, Mrs A, by Lanarkshire NHS Board (the Board). Mr C was concerned that there had been delays in Mrs A's treatment, incorrect diagnosis of her bowel problems, poor communication and poor complaints handling.

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

• (a) there was an unacceptable delay in performing triple heart bypass surgery on Mrs A (not upheld);
• (b) there was an incorrect diagnosis of Mrs A's bowel problems (not upheld);
• (c) there was inadequate communication between Monklands Hospital (Hospital 3) and Mrs A's General Practitioner and Hospital 3 and other hospitals involved in her care (upheld); and
• (d) the complaint to the Board raised by Mrs A's MSP was not handled properly (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A for the failures identified under head of complaint (b);
• (ii) remind their staff to ensure that written and typed notes are made contemporaneously after any clinical admission or out-patient visit; and
• (iii) apologise to Mrs A for the communication failures highlighted at paragraphs 43 to 45.

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

Overview
The complainant (Mrs C), who is an advice worker, raised a number of concerns on behalf of her client (Ms A) about the treatment which she received following an admission to Dr Gray's Hospital (the Hospital) during the period 12 July 2008 to 14 July 2008. Ms A was readmitted to the Hospital on 16 July 2008 where it was found that she was suffering from cerebral lymphoma.

Specific complaint and conclusion
The complaint which has been investigated is that the treatment which Ms A received at the Hospital from 12 July 2008 to 14 July 2008 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the importance of good record-keeping;
• (ii) share this report with the staff concerned, in order that they can reflect on their actions; and
• (iii) apologise to Ms 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 (Ms C) attended her dentist (the Dentist) with toothache. She believed the pain was coming from a particular tooth, but the Dentist removed the neighbouring tooth. She said the pain continued until a dentist at another dental practice removed the one which she considered should have been removed. She felt this was proof that the Dentist had taken out the wrong tooth.

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

• (a) the examination of Ms C's mouth was inadequate (upheld); and
• (b) the record-keeping was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Dentist:

• (i) apologises to Ms C for the shortcomings identified;
• (ii) ensures adequate investigation of patients with toothache; and
• (iii) improves his record-keeping to the standard described in this report.

The Dentist has accepted the recommendations and will act on them accordingly.