Health

Overview
The complainant (Ms C) complained on the behalf of the aggrieved (Mr and Mrs A) about the care and treatment received by Mrs A from Western Isles NHS Board (the Board) in December 2010. Mrs A was taken to Uist and Barra Hospital (the Hospital) with abdominal pains. Two days later Mr A was advised Mrs A was suffering from acute renal failure, was dying and no further treatment could be provided for her. However, Mrs A was subsequently able to be airlifted to the mainland for treatment. She went on to make a full recovery.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not provide reasonable care and treatment to Mrs A between 5 and 9 December 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide an updated version of the action plan to evidence that all of the identified actions have been implemented;
• (ii) provide further details about planned training for medical staff at the Hospital, which should include refresher training on the causes of opiate toxicity and enhanced training in relation to venous access;
• (iii) conduct a random case note review at the Hospital; and
• (iv) provide a full apology to Mr and Mrs A for the failings identified in this report.

Overview
The complainant (Mrs C) raised concerns on behalf of her mother (Mrs A) regarding the treatment that she received from Greater Glasgow and Clyde NHS Board (the Board). Mrs A attended Victoria Hospital (the Hospital) after breaking her ankle. She was treated for this but subsequently experienced severe pain and blistering around the ankle. Mrs A was later found to have a second fracture, which had previously been undetected. Mrs C complained about the Board's failure to diagnose the second fracture and about the initial treatment that Mrs A received, which she believed caused her blistering.

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

• (a) the Board failed to diagnose Mrs A's os calcis fracture in good time (upheld);
• (b) the Board's treatment of Mrs A's broken ankle was inappropriate (upheld); and
• (c) the Board's complaint handling was poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) present Mrs A's case and this report's findings to Orthopaedic, A&E and complaint handling staff at a suitable staff forum, such as a mortality and morbidity meeting;
• (ii) review their procedures for assessing patients' suitability for discharge to ensure that social and medical considerations are given the appropriate consideration; and
• (iii) consider providing further training to staff on patient discharge eligibility assessment.

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

Overview
The complainant (Ms C) raised concerns about delays and failures in the care and treatment provided to Mr A when he attended a medical practice (the Practice) on a number of occasions between December 2010 and February 2011 due to bowel problems and, from 11 February 2011 onwards, pain in his groin. Mr A had an ultrasound and CT scan in March 2011. He was diagnosed with diverticular disease and had to undergo emergency surgery. He had an abscess drained, repairs to his bladder and a section of his bowel removed. He was discharged with a stoma bag.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay by the Practice's GPs in fully investigating and diagnosing Mr A's condition (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr A for the delay in fully investigating and diagnosing his condition;
• (ii) carry out a Significant Event Audit on this case;
• (iii) carry out a review of a sample of case notes to assess the quality of the recording of examination findings; and
• (iv) ensure that revision of common abdominal conditions, including diverticulitis, forms part of the Continuing Professional Development of all GPs involved in this case.

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

Overview
The complainant (Mr C) raised concerns about the failure by the medical practice (the Practice) to diagnose that he had Crohn's disease. He said that the Practice failed to carry out appropriate investigations, despite his regular visits complaining about stomach problems.

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

• (a) over a five-year period from April 2005, the Practice unreasonably failed to diagnose that Mr C had Crohn's disease (upheld); and
• (b) the Practice failed to respond properly to Mr C's letter of complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr C for the failure to carry out further investigations and/or make a referral when he attended with ongoing bowel symptoms in March and April 2009;
• (ii) apologise to Mr C for the failure to take steps to try to obtain his full medical records in order that they could respond to his complaint in full; and
• (iii) make relevant staff aware of our finding on this matter.

Overview
The complainant (Mrs C) complained about the care, treatment and diagnosis her daughter (Ms A) received at an out-of-hours service at Peterhead Hospital (Hospital 1) in May 2011. Mrs C also complained about the responses she received from NHS Grampian (the Board) in relation to her complaints.

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

• (a) the out-of-hours doctor (the Doctor) incorrectly explained that Ms A had not presented with photophobia despite her complaining of this to a nurse, and shielding her eyes with her hood (not upheld);
• (b) the Doctor inappropriately failed to mention in his letter of response to Mrs C's complaint that Ms A had presented with a headache (upheld);
• (c) the Doctor unreasonably reached an incorrect diagnosis (not upheld); and
• (d) the Chief Executive issued a dismissive response to Mrs C's complaint which reflected the lack of investigation into her concerns (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman that they have reviewed their complaints handling procedure in relation to complaints about its out-of-hours service, to ensure a proactive approach is taken; and
• (ii) issue a full apology to Mrs C for the failures identified within this report.

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

Overview
The complainant (Ms C) raised a number of concerns on behalf of Mr A's family that Mr A was not admitted to an in-patient facility for mental health and that there were failures in communication between the medical and mental health teams treating Mr A.

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

• (a) Greater Glasgow and Clyde NHS Board (the Board) failed unreasonably to admit Mr A to hospital (not upheld); and
• (b) there was no reasonable communication between the teams to whom Mr A was or should have been referred, including the Royal Alexandra Hospital, the intensive home treatment team, the community mental health team and the alcohol problems clinic (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the coordination of the relevant services to ensure the failures identified in this report are addressed; and
• (ii) apologise to the family.

Overview
The complainant (Mrs C) raised a number of concerns against Ayrshire and Arran NHS Board (the Board) regarding the care and treatment her late husband (Mr A) received at Crosshouse Hospital from his admission on 21 May 2010 up to his death on 23 May 2010.

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

• (a) failed to administer the prescribed anti-seizure and steroid medication (upheld);
• (b) failed to recognise and address Mr A's pain (not upheld);
• (c) failed to implement the Liverpool Care Pathway until 23 May 2010 (not upheld); and
• (d) failed to provide adequate care and attention on the night of 22 to 23 May 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that measures are taken to feedback the learning from all aspects of this event to the medical team involved with Mr A's care, to understand the importance of avoiding similar situations recurring;
• (ii) review the process of pain scoring, its frequency and recording in this case and feedback the learning to nursing staff;
• (iii) complete a review of the LCP within the unit and feedback the learning to all medical and nursing staff within the unit;
• (iv) complete a full review of their medical staff cover for the night of 22 to 23 May 2010 to ensure such situations do not recur;
• (v) provide an update of their review on the use of pager numbers; and
• (vi) 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 complainant (Mrs C) raised a number of concerns regarding the nursing care provided to her late mother (Mrs A) during an admission to the Royal Alexandra Hospital in Paisley (the Hospital) from 12 October 2010 until her death on 16 October 2010.

Specific complaint and conclusion
The complaint which has been investigated is that there were several unacceptable shortcomings in care during Mrs A's admission to the Hospital in October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) provide him with an update regarding their implementation of the introduction of the Liverpool Care Pathway;
• (ii) consider the Adviser's comments on the several failings in Mrs A's end of life nursing care and draw up and implement an action plan to address these failings;
• (iii) conduct a significant events review of this case; 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
The complainant (Mrs C) raised a number of concerns on behalf of her mother (Mrs A) about the care and treatment her late father (Mr A) received while a patient in the Golden Jubilee National Hospital, Clydebank (the Hospital). Mr A had been referred to the Hospital following a diagnosis of lung cancer and died there, several days after surgery.

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

• (a) there were unreasonable shortcomings in Mr A's care and treatment in the Hospital (upheld); and
• (b) there has been an unreasonable lack of clarity by the Hospital in explaining why Mr A died (upheld).

Redress and recommendations
The Ombudsman recommends that the Hospital:

• (i) apologise to Mrs A and her family for the failings identified in complaint (a);
• (ii) consider a review of the wording of the consent form a patient signs prior to surgery, so as to include the main operative risks;
• (iii) reflect on the comments of Adviser 1, in relation to the advice given on treatment options and the carrying out of a preoperative physiological assessment;
• (iv) reflect on the comments of Adviser 1, in relation to Mr A's postoperative nutritional management;
• (v) revise their nursing action plan, so as to address the failings identified in this report;
• (vi) apologise to Mrs A and her family for the failings identified in complaint (b); and
• (vii) consider obtaining a copy of the post mortem report, where a patient dies and a post mortem is instructed by the Procurator Fiscal, so as to inform the clinicians who cared for the patient and to be able to discuss the findings with the patient's family, if required.

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

Overview
The complainant (Mrs C) underwent reconstructive breast surgery following treatment for breast cancer. She complained to Grampian NHS Board (the Board) that the surgeon and the surgical procedure were both changed at short notice. She had had a different procedure explained to her by a different surgeon at a consultation prior to the surgery. Mrs C said she had not had sufficient time to consider the changes prior to undergoing the surgery. She also complained that the outcome of the surgery was unacceptable.

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

• (a) it was unreasonable to change the surgeon and the surgical procedure Mrs C was to undergo at short notice, without giving her sufficient time to consider the changes or make a fully informed decision (upheld); and
• (b) the outcome of Mrs C's surgery was unacceptable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure this case is discussed with the Registrar at his next appraisal;
• (ii) consider the issue of consent, and provide evidence to the Ombudsman that the General Medical Council's guidelines are being followed in relation to obtaining informed consent from patients for surgical procedures;
• (iii) take steps to ensure that a similar situation does not occur in the Plastic Surgery Department when cases are re-assigned to cover consultant leave;
• (iv) bring this report to the attention of all staff involved in Mrs C's care, to prevent a recurrence of similar issues; and
• (v) provide a full apology to Mrs C for the failures identified within this report.

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