Health

Overview
A Member of Parliament (Mr D) raised a complaint on behalf of a constituent (Ms C). It was first raised within Lothian NHS Board (the Board) on 25 July 2007. The complaint focused on the lack of consent on 2 March 2007 for additional clinical procedures to be undertaken during a pre-arranged surgical procedure. In her view, Ms C had not been given adequate time to fully consider the options and the attendant risks before consenting fully to the potential, additional surgery. It subsequently took 17 months to resolve her complaint at the local resolution stage of the NHS complaints procedure before the matter was referred to the Ombudsman's office on 27 July 2009.

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

• (a) the Board's actions in relation to obtaining consent from Ms C for the removal of her left fallopian tube during a laparoscopic adhesiolysis and left salpingostomy were unsatisfactory (upheld); and
• (b) the Board delayed in responding to Ms C's complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the decisions taken to carry out additional surgery without her clear understanding of the potential outcomes;
• (ii) ensure elective surgical consent forms are clearly set out and appropriately understood and signed by the patient or their representative;
• (iii) apologise to Ms C and her representative for the delays experienced in the handling of their complaint; and
• (iv) ensure the revised internal complaints procedure provides all the necessary components set out in the NHS complaints procedure to guarantee a consistent approach to complaint handling within the Board.

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

Overview
The complainant (Ms C) raised a complaint against the Scottish Ambulance Service (the Service) about the length of time it took for a paramedic response unit (the PRU) and accident and emergency vehicle to attend an emergency call-out when her brother, Mr A, collapsed with chest pains at her home. Mr A later died in hospital.

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

• (a) the PRU took an unreasonable length of time to attend (not upheld); and
• (b) the accident and emergency vehicle took an unreasonable length of time to attend (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i) undertake the actions outlined at paragraph 19 of this report and provide him with evidence that these have taken place;
• (ii) review their current system for the allocation of back-up accident and emergency vehicles to PRUs, to ensure that the risk of unnecessary delay is minimised;
• (iii) consider introducing a system to record all calls from paramedics' mobile phones to the Emergency Medical Dispatch Centre; and
• (iv) apologise to Ms C for the failings identified in this report.

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

Overview
The Complainant (Mr C) had Peyronie's disease and underwent surgery to correct it. He complained that the operation that was carried out was not the one that had been discussed prior to surgery and that it was not carried out properly. Mr C subsequently encountered a number of complications that resulted in further corrective surgery. Mr C also complained that Greater Glasgow and Clyde NHS Board (the Board) failed to offer appropriate aftercare following his operation.

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

• (a) provide the correct treatment for Mr C's Peyronie's disease (not upheld);
• (b) warn Mr C of the potential complications of the procedure that was carried out (upheld); and
• (c) provide adequate aftercare following Mr C's surgery (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide patients with information relating to the potential complications of surgery, in writing, at the point of gaining their consent;
• (ii) advise patients of the fact that the surgery provided may differ to that proposed prior to surgery and that they keep a record that this advice has been given; and
• (iii) remind staff of the importance of recording any advice, medication or supplies provided to patients.

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

Overview
The complainants (Mr and Mrs C) raised concerns regarding the processes followed, in assessing Mr C, by Clinical Psychology and the Specialist Sexual Abuse Service (the Service) within Greater Glasgow and Clyde NHS Board (the Board). They were unhappy with the content of the reports that were produced and with the fact Mr C was not asked to provide clarity on aspects of the reports which they felt were inaccurate and misleading.

Specific complaint and conclusion
The complaint which has been investigated is that the process of the assessment within Clinical Psychology was inappropriate in that Mr C was denied the opportunity of providing supporting information and, as a result, the reports produced were inaccurate and Mr C's reputation was damaged (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure that there are clear triggers in place for referring child safety concerns for prompt assessment by individuals with the relevant expertise;
• (ii) ensure that all mental health staff receive appropriate training relating to their child protection duties and obligations. This should be routinely covered in clinical supervision and staff should have access to the relevant guidance;
• (iii) highlight to all mental health staff the importance of explicit record-keeping surrounding child protection. This should include not only the reasoning for decisions but the rationale underpinning them and all verbal referrals should be followed up using the appropriate inter-agency form;
• (iv) ensure that, where appropriate, child protection concerns are communicated to the patients concerned prior to making a referral. When not informing patients, clear and specific reasons for not doing so should be recorded;
• (v) ensure that patients are notified of the outcome of mental health assessments as soon as is practicable; and
• (vi) remind mental health and complaint handling staff of the importance of taking steps to clarify any uncertainty at an early stage, particularly where a child safety concern may exist.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the care and treatment received by his late wife (Mrs C) at Wishaw General Hospital (the Hospital), in the area of Lanarkshire NHS Board (the Board). Mrs C was admitted to the Hospital on the evening of 14 January 2008 with a perforated ulcer, having been sent home from Accident and Emergency (A&E) earlier that day with an incorrect diagnosis of gallstones. Thereafter, Mrs C remained in the Hospital where she passed away on 25 April 2008.

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

• (a) the recorded primary cause of Mrs C's death was inaccurate (upheld);
• (b) Mrs C's Alzheimer's was managed inappropriately and she was not treated with respect (upheld);
• (c) Mrs C's nutrition and oral care were managed inappropriately (upheld); and
• (d) Mrs C's perforated ulcer should have been diagnosed earlier and her initial discharge from A&E was inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review Mrs C's death certificate in light of the discrepancy with the discharge letter and give the family a definitive answer;
• (ii) undertake an external review of nursing care in the wards on which Mrs C was treated following her release from intensive care. The review should consider the following:  treatment of Adults with Incapacity, including the assessment of ability to consent and administration of medication; and the use of bank and agency staff;
• (iii) clarify how their papers/standards 'Caring and Compassionate Practice' and 'Top Tips in caring for People with Dementia' are being monitored and measured, and how the education and training is being rolled out;
• (iv) provide evidence regarding the implementation of the national policy for Senior Charge Nurses ('Leading Better Care');
• (v) ensure that there are systems in place for assisting patients with feeding, as outlined in the NHS Quality Improvement Scotland 'Food Fluid and Nutritional Care in Hospitals' standards;
• (vi) ensure that there are systems in place for the provision of oral hygiene, including policies and procedures; education and training and audits;
• (vii) remind staff of the importance of detailed record-keeping, particularly in relation to doctors' recognition and appreciation of any abnormalities;
• (viii) remind complaint handling staff of the importance of providing an accurate response to complaints and, where possible, a detailed explanation of events; and
• (ix) apologise to Mr C 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 concerns regarding the orthopaedic treatment received by her husband (Mr A) at Crosshouse Hospital in the area of Ayrshire and Arran NHS Board (the Board). Mr A fractured his left ankle on 4 May 2007 and this was treated surgically on 8 May 2007. However, he had existing Peripheral Vascular Disease (a narrowing of the arteries) which contributed to his surgical wound failing to heal and he subsequently had to have his left leg amputated below the knee on 22 August 2008. Mrs C complained that Mr A's wound was managed inappropriately and that, as a result, his left leg was unnecessarily amputated. The specific complaints are listed below.

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

• (a) there was a failure to recognise Mr A's existing vascular condition and the decision to operate was inappropriate (upheld); and
• (b) Mr A's post-operative treatment was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) highlight this report to the relevant staff, particularly junior doctors, to ensure that they are aware of the deficiencies which have been identified; and
• (ii) apologise to Mr A for their failure to identify and take into account his vascular condition when deciding to operate on his ankle fracture, and for the delay in referring him for vascular review when his surgical wound failed to heal.

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

Overview
The complainant (Mrs C), a Senior Project Worker for an advocacy service, complained about the care and treatment of a member of the public (Mrs A) during an admission to St John's Hospital (the Hospital).

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

• (a) failed to prevent a male patient from entering Mrs A's room on a number of occasions (not upheld);
• (b) failed to explain what action they had taken to prevent a recurrence, when responding to the complaint (upheld);
• (c) inappropriately continued to barrier nurse Mrs A, despite a negative stool specimen being provided on 26 May 2009 (not upheld); and
• (d) stated, in response to Mrs A's complaint, that she was moved to Ward 17 for further assessment, whereas Mrs A had understood that she was simply being moved there because it was a safer environment (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that, in future complaint responses, they provide complainants with information regarding the action they intend to take to prevent recurrence of any problems identified; and
• (ii) consider Adviser 1 and Adviser 2's comments at paragraph 18 and revise their action plan in order to ensure that it is comprehensive.

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

Overview
Mrs C raised a complaint against Lothian NHS Board (the Board) regarding the care which her son, Mr A, had received when he was admitted by ambulance to the Accident and Emergency Department (the Department) at the Royal Infirmary of Edinburgh (the Hospital) complaining of chest pain. Mr A was discharged with a diagnosis of indigestion. Some weeks later, Mr A collapsed and died. A post mortem examination found that he had been suffering from acute heart disease.

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

• (a) the ECG performed by the ambulance crew was not available to or checked by the Department doctor (upheld); and
• (b) apart from an ECG, no other investigations were undertaken on Mr A when he arrived at the Hospital and local protocols and Scottish Intercollegiate Guidelines Network guidelines for patients presenting with chest pain were not adequately followed (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their current communication methods between ambulance staff and clinical staff (both verbally and documentary) in respect of patients who are admitted to the Department;
• (ii) remind clinical staff of the importance of ensuring that all ECGs are available for review by clinical staff for patients presenting with chest pain; that their findings are documented in the patient's clinical records; and the Board's audit procedures in relation to ECG sign off are followed;
  (iii) remind staff of the importance of seeking details of any family history of heart problems from patients presenting with chest pain and documenting this in the clinical records; and
• (iv) apologise to Mrs C 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 a number of concerns about the dental treatment she received from her dentist (the Dentist) in October and November 2008, which led to her attending her local hospital in great pain and with a swollen face.

Specific complaint and conclusion
The complaint which has been investigated is that, in October and November 2008, the Dentist provided Ms C with an inadequate level of treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Dentist:

• (i) apologises to Ms C for the failings identified in this report;
• (ii) reflects on the adviser's comments in regard to her technique in root canal treatment, in particular, in relation to working length calculation and the use of a rubber dam; and
• (iii) reflects on the adviser's comments with regard to record-keeping.

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

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment she received from Greater Glasgow and Clyde NHS Board (the Board) following treatment on 7 and 9 September 2008 for a medical termination of pregnancy (MTOP). Ms C also complained that she had received contradictory information regarding bleeding and that her complaint response from the Board contained inaccurate information.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not provide:

• (a) adequate care and treatment to Ms C after a MTOP (upheld);
• (b) clear written guidance to Ms C about the expected duration of bleeding after the MTOP (upheld); and
• (c) accurate information to Ms C in their complaint responses (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the inadequate care and treatment provided to her after the MTOP;
• (ii) devise a protocol for the management of retained products of conception following a MTOP; and
• (iii) apologise to Ms C for failing to provide her with accurate information in their complaint responses.

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