Health

Overview
The complainant, an advocacy worker (Ms C), complained on behalf of the aggrieved (Miss A) in relation to the care and treatment she received at Paisley Maternity Hospital, in the area of Greater Glasgow and Clyde NHS Board (the Board). Ms C conveyed Miss A's dissatisfaction with the management of her pain during the birth of her daughter on 11 December 2007. Through the course of my investigation, I also identified concerns relating to the quality of the written records of Miss A's care.

Specific complaint and conclusion
The complaint which has been investigated is that the management of Miss A's pain was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) highlight the issues raised in this report to all staff in the maternity unit, particularly anaesthetic staff, emphasising the importance of keeping clear, detailed and consistent records;
• (ii) offer Miss A an early appointment to be seen in an obstetric anaesthetic clinic, in line with the Adviser's comments at paragraph 23; and
• (iii) apologise to Miss A 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 she received at the Royal Alexandra Hospital (the Hospital) in the area of Greater Glasgow and Clyde NHS Board (the Board). Mrs C sustained a fall on 16 June 2007 in which she fractured her tibia and fibula and upon admission to the Hospital, she was seen by an orthopaedic consultant who treated the fracture conservatively by placing Mrs C's leg in a cast. Mrs C complained about the fact that she was not treated operatively and about the standard of follow-up care she received in the Fracture Clinic.

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

• (a) the decision to treat Mrs C's fracture conservatively was inappropriate (not upheld); and
• (b) the standard of follow-up treatment was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board should:

• (i) apologise to Mrs C for the failings identified in this report;
• (ii) highlight the issues raised in this report to all relevant orthopaedic staff;
• (iii) remind clinical staff of the importance of documenting their discussions with consultants; and
• (iv) encourage consultants to consider taking a more proactive role in complex cases.

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

Overview
The complainant (Ms C) raised a number of concerns about the diagnosis of diabetes and aftercare offered to her by her GP practice (the Practice).

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

• (a) the Practice failed to follow recognised procedures in reaching a diagnosis that Ms C was suffering from diabetes (upheld);
• (b) the Practice did not arrange for appropriate follow-up for Ms C following the diagnosis of diabetes (upheld);
• (c) the Practice's communication with Ms C regarding her diagnosis and test results was inadequate (upheld); and
• (d) the Practice's response to Ms C's complaint was inappropriate (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) put in place a protocol to ensure that diabetes is diagnosed in line with recognised practices;
• (ii) put in place a protocol to ensure that newly diagnosed diabetics receive appropriate follow-up care;
• (iii) take steps to ensure they deal with complaints in line with the NHS complaints procedure; and
• (iv) write to Ms C with an apology for the failures identified in this report, including those relating to complaint handling and the content of the letter sent to Ms C on 14 July 2008.

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

Overview
The complainant (Mrs C) complained that her son (Mr A)'s General Practitioner (GP 1) failed in his duty of care by not referring Mr A for an immediate ultrasound scan when he presented with severe pain and swelling in his left testicle. She also complained that a medical practice (the Practice) failed to meet the requirements of their Practice Complaints Procedure in the way they dealt with her complaint.

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

• (a) GP 1 failed in his duty of care by not referring Mr A for an immediate ultrasound scan (not upheld); and
• (b) the Practice failed to meet the requirements of their Practice Complaints Procedure in the way they handled Mrs C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) formally apologise to Mrs C for the failure to follow the Practice Complaints Procedure, and
• (ii) take steps to ensure that Practice staff who deal with complaints are fully conversant with the time standards within the Practice Complaints Procedure and respond in accordance with these time standards.

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

Please note that this Report contained typographical errors in Annex 1. It should read:

The General Practitioner who examined Mr A and recorded 'lump is Right epididymis'.

The SPSO has apologised to the complainant for this error.

Overview
Mr C complained about the level of care provided to his daughter, Miss C, prior to her death in Ninewells Hospital, Dundee (the Hospital), on 1 April 2008. Miss C suffered from myotonic dystrophy, a condition in which generalised muscle weakness can be accompanied by a variety of other conditions, which in Miss C's case included learning difficulties. Miss C was admitted to the Hospital on 31 March 2008 for surgery on her parotid gland. Pre-operatively, she did not receive a formal assessment by a consultant anaesthetist. Post-operatively she was returned to the ward, where her initial observations included a period of low blood pressure. She was left to sleep overnight. Her vital signs were not recorded and she was not disturbed in the morning during a post-operative ward round. She was subsequently found to be unresponsive at around 10:30 and a cardiac arrest call was made at 10:58; however, it was not possible to resuscitate her. Her death was recorded at 11:17 that morning.

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

• (a) Miss C was not properly assessed at a formal pre-operative clinic prior to her surgery (upheld);
• (b) the care and treatment Miss C received post-operatively was inadequate (upheld); and
• (c) communications with Miss C's family were not appropriate (upheld).

Redress and recommendations
The Ombudsman recommends that Tayside NHS Board (the Board):

• (i) review the current interface arrangements in place between the ENT and Anaesthesia departments, to gain assurance that adequate communication, planning and multi team working arrangements are now in place with regard to pre-operative admissions; and advise him of the outcome of this review;
• (ii) provide a copy of the appropriate action plans which specifically contain details of how the Board will implement and meet the relevant policies, including:  NHS QIS quality indicators for people with learning difficulties (NHS QIS report 'Learning Disabilities' Quality Indicators February 2004); NHS QIS report 'Tackling Indifference', (Healthcare Services for People with Learning Disabilities. National Overview Report. December 2009);
• (iii) provide a copy of their education and training strategy, including the specific requirement relating to patients with learning disabilities;
• (iv) review and evaluate the current arrangements for pre-operative admission for people with learning disabilities and provide him with a report of the findings;
• (v) confirm the specific action taken to clarify the terms 'special nursing' and 'routine monitoring' to avoid ambiguity over what level of nursing support is required when caring for people with learning difficulties;
• (vi) provide assurance that policies and procedures are in place to ensure that the Nursing and Midwifery Council Code of Conduct and in particular the 'Guidance for record keeping' (2009) is implemented so that communication with patients' families is clear and unambiguous; and
• (vii) provide an explicit, unambiguous and meaningful apology to Miss C's family for all the failings identified in this report, detailing the steps they have put into place to ensure that a similar occurrence is not repeated.

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

Overview
The complainant (Mr C) was unhappy with the care provided to his late wife (Mrs C) by Lothian NHS Board (the Board). Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) on 18 August 2008, but was transferred to Liberton Hospital (Hospital 2) on 19 August 2008. She was given a course of antibiotics, but these were subsequently discontinued. Mrs C's condition deteriorated and she died in Hospital 2 on 26 August 2008.

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

• (a) provide appropriate treatment to Mrs C (upheld);
• (b) provide the correct course of antibiotics to Mrs C (upheld); and
• (c) communicate effectively with Mr C (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that their transfer protocol includes a requirement to consult with appropriate available relatives prior to transfer, when a patient is unable to give consent;
• (ii) provide guidance on documentation to all relevant staff at induction;
• (iii) adhere to their Incident Management Policy when a significant adverse event review is initiated, by ensuring that consideration is given to the inclusion of members with appropriate objectivity to the event;
• (iv) remind staff in Hospital 2 of the importance of assessing the competency of patients to make decisions to refuse treatment or medication where appropriate;
• (v) undertake an external peer review of the nursing care in Ward 1 in Hospital 2;
• (vi) provide him with details of the findings and action plan created as a result of the above recommendation and provide updates where relevant;
• (vii) ensure that the findings in this report are communicated to the staff involved in Mrs C's care and treatment; and
• (viii) issue an apology to Mr C for the failings identified in this report.

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

Overview
This complaint was brought by the Citizens' Advice Bureau (CAB), acting on behalf of the complainant (Mrs C). Mrs C complained about the standard of care her late son (Mr A) received at the Victoria Infirmary, Glasgow in the area of Greater Glasgow and Clyde NHS Board (the Board). Mr A, a young man aged 27, had been admitted on 9 May 2007, following a referral from his GP, with various symptoms including urinary incontinence, a sore throat, a cough, shortness of breath and facial swelling. He had been dizzy for two days and had had diarrhoea and faecal incontinence the night before admission. He was discharged the following day and died suddenly four days later, alone, at home. The post mortem examination revealed heart muscle disease and evidence of heart failure and it is likely that Mr A died of a sudden irregularity of the speed or rhythm of the heart.

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

• (a) the standard of care Mr A received fell beneath the level expected of medical practitioners (upheld); and
• (b) the Board's responses to the complainant, when Mrs C sought an explanation for Mr A's death, were poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise directly to Mrs C for the serious failings identified in this report;
• (ii) reflect on the medical lessons to be learned from this case and consider appropriate action;
• (iii) produce an action plan, to include education and training, to address the equality, diversity and person-centred care failings identified in this report;
• (iv) apologise to Mrs C and the CAB for the shortcomings identified in this report in their correspondence with them;
• (v) reflect on their handling and investigation of complaints involving the sudden, unexpected death of a patient; and
• (vi) reflect on their handling and investigation of complaints where the family has involved an advocacy organisation such as Action Against Medical Accidents.

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

Overview
The complainant (Mrs C) raised concerns regarding the care and treatment received by her daughter (Miss A) when she attended the Royal Alexandra Hospital with back pain. Miss A was initially treated for a chest infection and referred for physiotherapy in respect of her back pain, however, she was subsequently diagnosed with a spinal infection and Mrs C complained that this was not diagnosed earlier. In addition, Mrs C raised her concerns that Miss A's anti-coagulant medication prevented surgical treatment of Miss A's infection.

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

• (a) there was a delay in referring Miss A for a Magnetic Resonance Imaging scan and, consequently, in diagnosing her spinal infection (upheld); and
• (b) the provision of anti-coagulant medication to Miss A prevented the possibility of surgical treatment of her spinal infection and a potentially more positive outcome (not upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Miss A for the delay in diagnosing her spinal infection;
• (ii) review their process in respect of identifying 'red flag' features in patients and taking relevant action upon identification of these; and
• (iii) ensure that complaints officers accurately reflect clinicians' feedback in their response to complaints.

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

Overview
The complainant (Mr C) complained about the Dental Practice (the Practice) he was registered with. In February 2009 Mr C complained that they failed to provide agreed treatment and were unprofessional in their behaviour toward him and in the service they provided.

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

• (a) Mr C was not appropriately treated by the Practice (upheld); and
• (b) the Practice failed to follow the NHS complaints procedure for Family Health Services (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) urgently implement policies to ensure that clinical information is appropriately recorded and protected, and policies and procedures are in place to safeguard all clinical information generated;
• (ii) take steps to ensure that all staff are aware of these policies and implement them in their working practice;
• (iii) take steps to identify all missing clinical information and to try to retrieve this;
• (iv) apologise to Mr C for the failures identified in this report;
• (v) urgently establishes a complaints procedure in line with the standards set out by the General Dental Council and the NHS complaints procedure; and
• (vi) apologise to Mr C for the poor handling of his complaint.

Overview
The complainant (Mr C) raised concerns regarding the orthopaedic treatment he received at Stirling Royal Infirmary (the Hospital). Mr C was involved in a motor cycle accident on 11 September 2007 and he sustained a fracture of his right tibia. He underwent an operation to treat this fracture on 12 September 2007 and he expressed concern with the standard of this surgical treatment.

Specific complaint and conclusion
The complaint which has been investigated is that a nail inserted in Mr C's right tibia was excessively long and resulted in Mr C suffering unnecessary pain and inconvenience (upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Mr C for the failings identified in this report.

The Board have accepted the recommendation and will act on it accordingly.