Health

Overview
The complainant (Mrs C) complained that Greater Glasgow and Clyde NHS Board (the Board) did not correctly diagnose her misplaced vertebra when she attended the Western Infirmary with back pain and 'neurological symptoms'. She was further concerned that the Board did not offer treatment once her condition was diagnosed. Mrs C was also disappointed by the Board's handling of her complaint.

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

• (a) the Board failed to correctly diagnose the severity of Mrs C's spinal problems (not upheld);
• (b) the Board failed to treat Mrs C's spinal symptoms (not upheld); and
• (c) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider reviewing Mrs C's case with a view to identifying any aspects of the communication between consultants and her GP that could be improved; and
• (ii) consider how NHS Scotland's publication: Can I help you? Learning from comments complaints and suggestions should be taken into account when making decisions on complaint time limits.

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

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment his late mother (Mrs A) received while a patient in Ward 8 (the Ward) of the Royal Victoria Hospital, Edinburgh (the Hospital). Mrs A died, aged 82-years-old, on 7 May 2007 in the Hospital. The complaint is brought by Mr C on behalf of himself, his sister (Mrs D) and other family members. Mr C and his family were also unhappy with the way in which Lothian NHS Board (the Board) dealt with their complaint.

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

• (a) Mr C and his family were given conflicting reasons by nursing staff for Mrs A's move to a two bedded room in the Ward (upheld);
• (b) the language used by nursing staff about Mrs A was inappropriate (upheld);
• (c) the attitude of a staff nurse on the Ward was unacceptable (no finding);
• (d) the attitude of nursing staff towards mobilising Mrs A was reprimanding in manner and unreasonable (not upheld);
• (e) the temperature in the Ward was high and uncomfortable (upheld);
• (f) the conditions in the two bedded room contributed to the speed of Mrs A's decline in the final days of her life (not upheld); and
• (g) the Board failed to handle the complaint from Mr C and his family appropriately (partially upheld).
   

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

• (i) issue Mr C, Mrs D and their family with a formal written apology for the failings identified in heads of complaint (a), (b), (e) and (g) of this report; and
• (ii) audit and update the Action Plan in one year and share the findings with the Ombudsman's office.

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

Overview
The complainant (Ms C), who is an advice caseworker, raised a number of concerns on behalf of her client (Ms A), about the treatment which Ms A had received at the Department of Urogynaecology at the Southern General Hospital, Glasgow (the Department). Ms A had undergone surgery in 2007 and since then has suffered with incontinence, urinary infections, loss of lower body sensation, vaginal discharge and severe pain.

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

• (a) proper informed consent was not obtained prior to surgery (upheld);
• (b) the clinical treatment which was provided was inadequate (not upheld); and
• (c) following surgery, staff failed to take prompt action to establish the cause of Ms A's concerns (upheld).
   

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

• (i) review their consent process, to ensure that patients have enough time to digest the information provided by staff and in information leaflets and that sufficient space is available on the consent forms to list what has been discussed;
• (ii) share this report with the staff involved and ask them to reflect on the advisers' comments about considering alternative procedures prior to surgery; 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), who was aged 33, was admitted to the Southern General Hospital in the area of Greater Glasgow and Clyde NHS Board (the Board) in September 2007 and October 2007 with possible cauda equina syndrome (CES). She complained that the decision not to operate near the start of the first admission seriously compromised her condition and that, despite ongoing symptoms and inability to manage her daily life, her discharge home did not include adequate follow-up support.

Specific complaint and conclusion
The complaint which has been investigated is that surgery should have been done near the start of the first hospital admission, there was inadequate communication with Ms C about the nature and outcome of her condition and the after-discharge support was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for not having operated earlier;
• (ii) reflect on this report's conclusions and take appropriate action in respect of each;
• (iii) satisfy themselves that the consultant in question has an appropriate understanding of CES; and
• (iv) update the Ombudsman's office on the main audit findings and main plans regarding after-discharge support.

Overview
The complainant (Mr C) raised concerns about the care and treatment which his late wife (Mrs C), who had severe Multiple Sclerosis, received from Greater Glasgow and Clyde NHS Board (the Board) during her time in hospital for treatment of her painful right hip. Mr C complained that, whilst in hospital, the Board failed to feed his wife, who required to be fed via a percutaneous endoscopic gastrostomy tube, in a sufficiently upright position, which caused food to pass into her lungs. Mr C said he believed that the Board failed to notice that his wife had then developed a chest infection and provide necessary treatment and that this had resulted in her death.

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

• (a) the Board did not feed Mrs C in a sufficiently upright position (not upheld); and
• (b) the Board failed to notice that Mrs C had developed a chest infection and treat it in time (partially upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for failing to notice that Mrs C had developed a chest infection on 16 February 2007 and provide appropriate treatment at that time and for failing to produce a care pathway for Mrs C when the course of her treatment changed;
• (ii) feed back the adviser 's views on what he considers would have been the appropriate course of treatment for Mrs C on 16 February 2007, to the staff involved in cases of this type and in Mrs C's care, in particular;
• (iii) provide training to staff to ensure that, in all appropriate cases, where the direction of a patient's treatment changes, a new care pathway is devised - this could be by introducing a multi-disciplinary record or audit of documentation;
• (iv) ensure the staff involved in Mrs C's care are made aware of the need to record accurate information on patient mobility in their records;
• (v) review their current policy on the use of special mattresses and beds, incorporating the NHS QIS standards and flowchart; and
• (vi) provide feedback to the staff involved in Mrs C's care on the importance of seeking guidance from a more senior member of the medical team on appropriate treatment and/or to ask technical staff for assistance, in cases where the accuracy of medical equipment, such as a pulse oximeter, is in question.

Overview
The Ombudsman received a complaint from a member of the public (Mrs C). Mrs C complained that her husband (Mr C) had not received the appropriate treatment further to a telephone call to the out-of-hours emergency medical services provided jointly between the NHS 24 and Greater Glasgow and Clyde NHS Board (the Board), during which time it is stated by the family they had been unable to get the service to accept their description of Mr C's illness. He had been out early in the evening and returned home complaining of a headache. Initially, Mr C had been advised to take medication available in the house, rest and let NHS 24 know if there was no improvement. He was admitted to the Southern General Hospital the following morning and died eight days later of subarachnoid haemorrhage. Mrs C complained that there was a delay of 12 hours without treatment for her husband.

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

• (a) NHS 24 failed to provide proper care and treatment to Mr C (upheld); and
• (b) the Board failed to provide proper care and treatment to Mr C (upheld).
   

Redress and recommendations
The Ombudsman recommends that:

• (i) NHS 24 provide an apology to Mrs C and her family for the delay in transferring the necessary clinical details to the correct out-of-hours service;
• (ii) NHS 24 conduct an evaluation into a review of the improvements introduced by NHS 24 as a result of this complaint;
• (iii) NHS 24 ensure call handlers' basic training is developed enough to ensure staff are able to determine how to manage information they are given when a call is made from a service user, and the mechanism to transfer vital clinical information between services is reviewed to avoid mistakes in transmission arising;
• (iv) NHS 24 ensure the algorithms are fit for purpose in so far as they are able to capture the appropriate detailed information to assist the nurses to make the appropriate decisions;
• (v) the Board provide an apology to Mrs C and her family for the delay in picking up on the clinical symptoms described by Mr C and his family;
• (vi) the Board undertake a further review of the triage doctor's clinical practice in order to ensure their understanding of the signs and symptoms of a subarachnoid haemorrhage; and
• (vii) the Board ensure the triage doctor reflects on the lessons of the case, shares it with his appraiser during his next appraisal and is aware of the possibilities of rare diagnoses such as subarachnoid haemorrhage for future work.

NHS 24 and the Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) raised a number of concerns regarding the standard of cleanliness in Ward 17 of Ninewells Hospital (the Hospital). He complained that Tayside NHS Board (the Board) failed to maintain an adequate standard of cleanliness in the ward and that their systems for monitoring cleanliness were flawed. Mr C also complained that, when he visited the Hospital, patient records were left unattended in areas accessible by the public.

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

• (a) cleanliness standards at the Hospital were poor (no finding);
• (b) staff at the Hospital failed to adhere to the Board's hygiene policies (no finding);
• (c) the Board's procedures for monitoring cleanliness were ineffective (not upheld); and
• (d) the Board failed to securely store patient records (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) invite Mr C to a meeting at the Hospital to discuss his concerns about cleanliness and infection control; and
• (ii) instruct their Caldecott Guardian to review the procedures for transferring clinical records between the Orthopaedic Out-patient Clinic reception area and clinical staff to ensure the security of clinical records at all times.

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

Overview
The complainant (Mr C) raised his concerns that his optometrist (Optometrist 1) failed to provide reasonable care and treatment to him at his visit on 8 January 2008. Mr C considers that the prescription he was given was significantly different to that which should have been prescribed.

Specific complaint and conclusion
The complaint which has been investigated is that Optometrist 1 failed to provide reasonable care and treatment to Mr C at his visit of 8 January 2008 (upheld).

Redress and recommendations
The Ombudsman recommends that Optometrist 1:

• (i) provide patients with a warning (which should be recorded on their record cards) that a reduced power prescription may require some adjustment;
• (ii) review the way he communicates the possible implications of reducing a myopic prescription with a patient and records this communication in the clinical records; and
• (iii) review the way he operates his formal complaints procedure when providing NHS services to ensure that complaints are considered in line with the NHS complaints guidance. Optometrist 1 has viewed a draft of this report.

He has made clear that he does not accept the conclusion in the report but has accepted the recommendations and will act on them.

Overview
The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had not received reasonable care and treatment whilst under the care of Greater Glasgow and Clyde NHS Board (the Board) in early 2007. She was particularly concerned about the arrangements made for her husband to undergo a surgical procedure at another hospital and the administration of medicines to her husband. She also raised concerns about the action the Board took following her complaints about discussions between medical staff and Mr C's family.

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

• (a) the Board's requirement that Mr C attend Gartnavel Hospital at 09:00 on 11 January 2007 for a procedure that did not begin until 11:35 was unreasonable (no finding);
• (b) the Board's administration of steroids to Mr C during his admission in January 2007 was not reasonable (upheld); and
• (c) the Board did not take adequate action in response to Mrs C's complaints about discussions with Mr C's family on 12 January 2007 about his resuscitation (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C's family that the dosage of steroids was not increased following either the suspicion of sepsis or the incident of septic shock;
• (ii) take steps to ensure that medical staff are aware of the need to increase the dose of steroids following suspicion of sepsis or incidents of septic shock; and
• (iii) ensure that induction materials for medical staff clearly cover the specific requirements of the Board's resuscitation policy. This would serve to draw inductees' attention to the policy, and, specifically, its application in terms of provision of information to, and discussion with, patients, relatives and carers and provide evidence of this to the Ombudsman.

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

Overview
The complainants (Mr C and his partner Ms C) were unhappy about the care provided to Ms C during her pregnancy by Lanarkshire NHS Board (the Board). Sadly, Mr and Ms C's daughter (Baby A) was stillborn on 21 October 2007. Mr and Ms C considered a number of warning signs had been missed and, in particular, a scan at 36 weeks which showed the umbilical cord near Baby A's neck should have been followed up. They also complained about the postnatal care provided and that the response to their complaint was not adequate.

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

• (a) the care and treatment provided to Ms C during her pregnancy was inadequate (upheld);
• (b) there were failings to ensure appropriate support was provided following the death of Baby A (upheld); and
• (c) the response to Mr and Ms C's complaint was not adequate (partially upheld, to the extent that full information was not provided at the time of Mr and Ms C's complaint).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reassess the training provided to midwives on cardiotocographs, given the failure to recognise, record or follow up the deceleration correctly;
• (ii) review the use and purpose of the Board's telephone call records, given the failure to complete any record on 18 October 2007 and the presence on file of a badly completed record;
• (iii) apologise to Mr and Ms C for failing to recognise, record and respond appropriately to the deceleration;
• (iv) review their standard care pathway for bereaved parents, in light of the concerns raised in this report and the best practice examples elsewhere in NHS Scotland, and ensure that parents are given timely advice about counselling;
• (v) review the supervision arrangements for their ante-natal clinics taking into account the advice received in paragraph 17 and inform the Ombudsman of action taken as a result of this review;
• (vi) apologise to Mr and Ms C for failing to communicate with their GP, in line with their procedures, and for the time taken to provide them with information about counselling; and (vii) when responding to complaints, take into account the need to provide as full information as possible, particularly where interviews have been held with staff.