Health

Overview
The complainant (Mrs C) together with other members of her family raised a number of concerns with Greater Glasgow and Clyde NHS Board (the Board) concerning the care and treatment their mother (Mrs A) received while a patient in the Victoria Infirmary, Glasgow between September and November 2010. Mrs A died in hospital on 13 November 2010.

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

• (a) the care and treatment provided to Mrs A, including the management of her pressure ulcer and the use of a Certificate of Incapacity, was inadequate (upheld);
• (b) the implementation and application of the Liverpool Care Pathway (LCP) was inadequate (not upheld); and
• (c) communication between board staff and Mrs A's family was unreasonably poor, in particular a meeting with Mrs A's Consultant on 26 October 2010, and a telephone conversation between Mrs A's son and a medical registrar on 1 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence that the Board's current policies and procedures regarding the prevention, management, monitoring, education and training of pressure ulcers is in line with national guidance and best practice;
• (ii) take steps to put in place an action plan to address the shortcomings identified in this report in relation to pressure ulcer management and share this action plan with both the Ombudsman and Mrs C;
• (iii) review how in-patient units communicate with each other about the decision making capacity of patients requiring procedures as in-patients, to ensure that a patient who is being managed under the terms of the Adults With Incapacity (Scotland) Act 2000, is known to be so by any other team undertaking a procedure that would normally require written consent;
• (iv) consider whether the use of treatment plans (recommended for patients with complex care needs) might support the effective use and validity of Certificates of Incapacity in terms of Section 47 of the Adults With Incapacity (Scotland) Act 2000;
• (v) review how clinicians document the fact that capacity may be lacking for one specific intervention but present for other investigations and treatments if they believe this to be the case;
• (vi) ensure that family and carers are appropriately involved and informed of the consideration of use of the Adults With Incapacity legislation in the care of a patient and to document this clearly on the Certificate of Incapacity;
• (vii) apologise to Mrs C and other members of the family for the failings identified in complaint (a);
• (viii) with reference to our adviser's comments under paragraph 84 of this report, consider auditing the precise location of death of their in-patients and whether any system of prioritisation for single rooms across units might minimise this;
• (ix) seek to ensure that any discussion that a member of staff has with a patient's family is recorded in the patient's medical records; and
• (x) apologise to Mrs C and other members of the family for the failings identified in complaint (c).

Overview
The complainant (Mrs C) raised a number of concerns that sub-standard ultrasound equipment or human error meant that a pregnancy she conceived during her fifth cycle of Intra Uterine Insemination (IUI) treatment was not detected. Mrs C complained that this resulted in the pregnancy being destroyed during the sixth cycle of IUI treatment.

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

• (a) it was unreasonable that Mrs C's pregnancy was not detected on 30 and 31 August 2011 (not upheld);
• (b) the scanning equipment used on 30 and 31 August 2011 was not of a reasonable standard (upheld); and
• (c) it was inappropriate that no record was made of the irregular pain and discomfort Mrs C experienced during the procedure carried out on 1 September 2011 (not upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• (i) issue a written apology for the failing identified; and
• (ii) review the IUI recording form to incorporate space for recording symptoms reported by the patient.

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

Overview
The complainant (Mrs C) questioned the care and treatment given to her late husband (Mr C) on 3 October 2011. Mr C died early the next day.

Specific complaints and conclusions
The complaints which have been investigated are that staff at the Accident and Emergency (A&E) Department of Borders General Hospital (the Hospital):

• (a) failed to thoroughly assess and treat Mr C during his first attendance on 3 October 2011 (upheld); and
• (b) unreasonably discharged Mr C home on 3 October 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise sincerely to Mrs C for their failures concerning the care and treatment given to Mr C; and
• (ii) apologise to Mrs C for unreasonably discharging Mr C on the evening of 3 October 2011.

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

Overview
The complainant (Mrs C) raised concerns about the length of time it took for an accident and emergency vehicle to attend an emergency at home when her husband, Mr C, became gravely unwell and how the Scottish Ambulance Service (the Service) handled her complaint.

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

• (a) the delay in ambulance's arrival was unreasonable (upheld); and
• (b) the handling of the complaint was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i) report back to the Ombudsman on what additional support is provided to less experienced call handling staff;
• (ii) carry out a review involving the software provider to ensure that the software issue is re-assessed;
• (iii) review their complaints handling in light of the failings identified; and
• (iv) provide Mrs C with a full apology for the failures that occurred on 15 October 2010.

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

Overview
The complainant (Mr C) raised a number of concerns against Highland NHS Board (the Board) regarding the care and treatment his late father (Mr A) received from Dr MacKinnon Memorial Hospital, Broadford. Mr C stated that the Board failed to provide adequate care and treatment for Mr A from 31 May 2010 up to his death on 4 June 2010.

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

• (a) treat Mr A's constipation and subsequent complications appropriately (upheld); and
• (b) communicate effectively with Mr A, Mr C and Mrs C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that treatment is initiated by clinical staff in good time when a patient's condition deteriorates and appropriate details of this are recorded in their medical notes;
• (ii) ensure that all relevant clinical details are recorded legibly by all doctors in the medical notes as and when they have reviewed a patient;
• (iii) ensure that staff consider the reasons for abrupt changes in patients, to ensure that reasonable action is taken to limit the chances of further problems developing;
• (iv) ensure that admission forms include prompts which assess a patient's cognitive function or capacity to participate in decision making;
• (v) ensure that nursing admission notes are completed appropriately for every patient;
• (vi) ensure that when a patient displays uncharacteristic behaviour, appropriate and timely cognisance is taken of this and any subsequent action required is recorded;
• (vii) ensure that measures are taken to feed back the learning from this event to all staff, to ensure that similar situations will not recur;
• (viii) conduct a review of end-of-life care, with specific reference to completion of Do Not Resuscitate forms;
• (ix) ensure that DNAR discussions with family members are documented; and
• (x) issue Mr C with a full and sincere apology for the failings identified in this complaint.

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 given to her daughter (Ms A) prior to her death in October 2011.

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

• (a) staff discharged Ms A from hospital on 12 August 2011 despite her suffering from a wound infection and temperature (not upheld);
• (b) during the period 14 August to 21 September 2011, staff failed to provide an adequate level of care and treatment to Ms A (upheld); and
• (c) during the period 14 August to 21 September 2011, staff failed to ensure that Ms A received an adequate level of fluid and nutrition (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for their failures with regard to Ms A's care and treatment;
• (ii) bring the findings of this complaint to the attention of the consultant physician concerned for discussion at his next appraisal;
• (iii) apologise for their failure to properly address Ms A's nutritional status and to follow NHS Standards; and,
• (iv) emphasise to appropriate staff the necessity of following existing standards with regard to food and nutrition and to satisfy themselves that these standards are met.

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 late husband (Mr C) by Greater Glasgow and Clyde NHS Board – Acute Services Division (the Board).

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

• (a) staff failed to provide Mr C with timely and adequate pain relief when he reported problems with his catheter (upheld);
• (b) staff inappropriately discharged Mr C from hospital when he was suffering from a high temperature and wound infection (not upheld);
• (c) staff failed to ensure that an adequate home care package was in place on discharge from hospital, including palliative care, or provide advice about agencies which could assist if required (upheld);
• (d) the level of communication between staff and Mr C's family was inadequate (upheld); and
• (e) on 15 and 16 July 2011, Out-of-Hours Service GPs failed to adequately assess Mr C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make Mrs C a formal apology for their shortcoming in this matter and for the distress she and her family have suffered;
• (i) emphasise to all the staff involved, the importance of keeping full and timely notes;
• (ii) review the circumstances of complaint (a) and demonstrate to the Ombudsman that they have a programme in place to prevent such a situation occurring again;
• (iii) make specific apology to Mrs C for failing to make proper arrangements for Mr C's care and support on his discharge from hospital;
• (iv) in the wards concerned, review the procedures for patients' discharge to satisfy themselves that appropriate action is taken;
• (v) make a specific apology for their failure to communicate adequately; and
• (vi) taking into account the failures in communication, the Board should demonstrate to the Ombudsman the action to prevent such a situation occurring again.

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

Overview
The complainant (Ms C) complained that Greater Glasgow and Clyde NHS Board (the Board) failed to take appropriate action when her family reported that her daughter (Miss A) was suffering from mental health problems. Miss A subsequently jumped from a window in her fourth-floor flat. She suffered serious injuries to her lower body.

Specific complaint and conclusion
The complaint which has been investigated is that Community Psychiatric Nurses (CPNs) failed to take appropriate action to safeguard Miss A when it was reported that she was suffering from mental health problems (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a written apology to Ms C for the failure to carry out a reasonable telephone assessment when they spoke to Miss A and for the failure to raise concerns with a Mental Health Officer;
• (ii) review how risk is assessed and recorded in relation to telephone assessments in such circumstances to try to ensure as far as possible that patients assessed over the telephone receive the same quality of assessment as those spoken to face-to-face; and
• (iii) clarify to relevant staff the criteria or threshold regarding when concerns should be raised with a Mental Health Officer.

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

Overview
The complainant (Mrs C) raised a number of concerns against Greater Glasgow and Clyde NHS Board (the Board) that her late father (Mr A) had been inappropriately cared for by nursing staff in Dunrod F Ravenscraig Hospital (the Hospital) from 2 February 2011 up to his death on 24 April 2011.

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

• (a) nursing staff unreasonably failed to monitor and maintain Mr A's fluid levels (not upheld);
• (b) nursing staff unreasonably failed to deal with incontinence issues (not upheld);
• (c) nursing staff unreasonably failed to maintain a reasonable level of hygiene for Mr A (upheld);
• (d) there were inadequate transfer systems and documentation in place (upheld);
• (e) there was poor communication from staff (not upheld);
• (f) nursing staff unreasonably failed to pass on information to the relevant Social Work team when Mr A was transferred and this delayed the process of establishing a suitable nursing home for him to go to (not upheld);
• (g) inadequate attention was paid to Mr A's dignity by ensuring that his clothing was appropriately attended to (upheld); and
• (h) the investigation of Mrs C's complaint to the Board was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feed back the learning from this to nursing staff to avoid similar situations recurring;
• (ii) provide him with an update on the actions they have taken to ensure such an incident does not recur;
• (iii) ensure that communication between family members and staff are appropriately recorded;
• (iv) ensure that measures are taken to feed back the learning from this to complaints investigation staff to avoid similar situations recurring; and
• (v) 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 complainants (Mr and Mrs C) lost their son (Baby A) following his premature birth on 5 January 2011. Their complaint concerns the care and treatment provided at Caithness General Hospital, Wick (Hospital 1) and Raigmore Hospital, Inverness (Hospital 2) during and after Mrs C's pregnancy. Mr and Mrs C believe that they received a poor standard of care from both Hospital 1 and Hospital 2 and said that the loss of Baby A has had a devastating effect on their lives.

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

• (a) unreasonably failed to follow Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines when carrying out Mrs C's amniocentesis procedure (upheld);
• (b) inappropriately carried out the amniocentesis procedure in Hospital 1, despite an earlier NHS Quality Improvement Scotland audit report suggesting this should not happen (not upheld);
• (c) unreasonably failed to inform Mr and Mrs C that Baby A had an abdominal wall defect which was detected at the time of the amniocentesis procedure (upheld);
• (d) unreasonably failed to inform Mr and Mrs C that Baby A was born with a beating heart and Mr and Mrs C were not given the opportunity to hold him (upheld);
• (e) inappropriately placed Baby A in what looked like a cardboard box (not upheld); and
• (f) unreasonably failed to arrange a consultant review to determine what went wrong and what implications this could have for a future pregnancy (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that each operator at Hospital 2 is compliant with the RCOG Green Top Guideline No 8 on amniocentesis;
• (ii) review the amniocentesis consent form and patient information sheet used at Hospital 2, so as to take account of the five good practice points referred to in paragraph 17; 20
• (iii) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (a);
• (iv) review the local guidance at Hospital 1 and Hospital 2 concerning suspected fetal abnormalities discovered on any obstetric ultrasound scan. Where an abnormality is suspected there should be a clear pathway for specialised fetal medicine assessment and no delay in referral of the patient to a specialised hospital department;
• (v) issue Mr and Mrs C with a full and sincere apology for the failings identified in Complaint (c);
• (vi) provide evidence of the review of the guidelines for staff referred to in the letter from Doctor 3 to Mr and Mrs C dated 21 April 2011;
• (vii) reflect on the Adviser's comments about examination options after a stillbirth/late miscarriage where the baby has a structural abnormality; and
• (viii) review Hospital 2's post mortem patient information sheet and consent form, so as to include the four examination options listed in paragraph 74.

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