Health

Overview
The complainant (Mrs C) raised concerns that there was a delay by clinicians at Royal Aberdeen Children's Hospital (the Hospital) in diagnosing that her daughter, (Miss A), who had pneumococcal meningitis in August 2007, was profoundly deaf. Miss A had been reviewed at the Child Hearing Assessment Clinic on a regular basis but it took until January 2010 for the diagnosis to be made.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay in the diagnosis of Miss A's hearing loss (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share the contents of this report with the various clinicians involved in Miss A's care and treatment and consider carrying out Evoked Response Audiometry hearing tests at an earlier stage in children who have suffered meningococcal disease; and
• (ii) apologise to Mrs C for the delay in reaching a definitive diagnosis on Miss A's hearing loss.

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

Overview
The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her late mother (Mrs A) during an admission to Queen Margaret Hospital in Dunfermline (the Hospital) between 12 April 2010 and her death on 5 May 2010.

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

• (a) failed to continue with antibiotic treatment after the course of Amoxicillin (an antibiotic) was completed at 22:00 on 1 May 2010, despite Mrs A's rapidly deteriorating condition (upheld);
• (b) failed to act on the concerns Mrs C raised on 2 May 2010 (upheld);
• (c) were unaware that Mrs A was expectorating thick green sputum (matter coughed up from the lungs) on 1 May 2010, when this is documented in the medical records (upheld);
• (d) failed to inform Mrs C about Mrs A's deteriorating condition (upheld);
• (e) failed to ensure that oral medication administered to Mrs A when she was in a semi-conscious state did not remain in her mouth from 08:00 on 5 May 2010 until Mrs C pointed this out at 14:00 on 5 May 2010 (not upheld);
• (f) failed to provide an Incident Report regarding when Mrs A was inappropriately handled and spoken to (upheld);
• (g) failed to ensure complaint (f) was investigated (upheld);
• (h) disagreed about the cause of death after the Death Certificate was issued and registered (not upheld); and
• (i) made inconsistent statements in their original complaint response to those made at a face-to-face meeting - specifically about the presence of infection (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide me with an update regarding their implementation of the measures described in their letter to my office dated 24 March 2011;
• (ii) review the means by which the clinical judgements of HAN members who see patients independently are monitored;
• (iii) conduct a review of information handover from team to team, with a view to identifying how this can be strengthened;
• (iv) consider Adviser 2's comments on the failings in Mrs A's nursing care and draw up and implement an action plan to address these failings;
• (v) apologise to Mrs C for the failure to investigate complaint (f) properly;
• (vi) ensure that serious complaints are appropriately recorded and investigated;
• (vii) inform me of the outcome of their discussions with regard to completing death certificates and tell me what measures they have taken to ensure that, in future, the cause of death listed on a death certificate is accurate; and
• (viii) ensure that clinical records are thoroughly reviewed as part of their investigation process and prior to providing responses to complaints.

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

Overview
The complainant (Miss C) raised a number of concerns that in August 2010, the Board failed to properly identify her late father (Mr A)'s health complications, provide adequate post-operative nursing care and failed to communicate with her about his care.

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

• (a) medical staff failed to properly identify health complications leading to Mr A's death (upheld);
• (b) Mr A did not receive adequate nursing care post-operatively on 18 and 19 August 2010 (upheld); and
• (c) nursing staff failed to communicate adequately with Miss C regarding Mr A's care (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence of the measures in place to address the failures identified within this report in the MEWS system;
• (ii) confirm to the Ombudsman that they will raise this report with the junior doctor in their annual appraisal;
• (iii) bring this report to the attention of the relevant staff; and
• (iv) apologise to Miss C for the failures identified.

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

Overview
The complainant (Mrs C) raised a number of concerns about delays and failures in the care and treatment provided to her mother (Mrs A) by a medical practice (the Practice) between November 2009 and August 2010. Mrs C was also dissatisfied with aspects of the Practice response to her complaints.

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

• (a) the care and treatment which the Practice provided to Mrs A between late 2009 and August 2010 was inadequate (upheld);
• (b) the Practice did not take reasonable action in response to information provided about planned investigations of Mrs A's health (not upheld); and
• (c) the Practice response to Mrs C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A for their failure to reasonably assess and oversee her care and treatment in 2009 and 2010;
• (ii) ensure that their GP records accurately reflect and define patients' symptoms and consultants' findings as part of the on-going diagnostic process; and
• (iii) apologise to Mrs A and Mrs C for the failure to adequately address the complaint.

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

Overview
The complainant (Mrs C) raised a number of concerns about the treatment her adult son (Mr A) received at hospital (Hospital 1) following an attempted suicide at her home on 17 August 2010. Her complaints included that Mr A was inadequately supervised in a general ward and that he had the opportunity to make a further suicide attempt. Mrs C also complained that despite her request that Mr A should remain in Hospital 1 he was transferred to another hospital (Hospital 2) which was in another health board area where Mr A normally lived.

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

• (a) failed to provide an acceptable standard of care to Mr A, an individual whose psychiatric problems had been highlighted to staff, who was suffering from extreme paranoia and who had recently attempted suicide (upheld);
• (b) failed to operate an effective or flexible transfer procedure and failed to ensure that the Bed Manager acted reasonably in response to Mrs C's requests that Mr A remain in Hospital 1 (upheld);
• (c) allowed some staff to act in a hostile way towards Mrs C after she had contacted the Mental Welfare Commission for advice (upheld);
• (d) failed to ensure satisfactory conditions in a psychiatric ward (not upheld); and
• (e) failed to ensure that Mr A's wounds were managed appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the Task and Finish Group to ensure that the Adviser's concerns about mental health assessment staff training and inadequate record-keeping are taken into account in their review of clinical processes etc;
• (ii) review hand-over procedures to ensure an adequate level of observation is maintained during that time;
• (iii) remind staff of their responsibilities under the Mental Health (Care and Treatment) (Scotland) Act 2003 in relation to transfer of patients to another hospital;
• (iv) conduct an audit/review systems for safe management of non-clinical sharps;
• (v) conduct an audit of wound care practice in the Mental Health Ward; and
• (vi) apologise to Mrs C and Mr 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 (Mrs C) was unhappy with the support given to her son (Master A) by a District Nursing Team (DNT), from January to June 2010. She was also unhappy with Grampian NHS Board (the Board)'s handling of her complaint. Master A, who was five years old at the time of the events complained about, was diagnosed with Type 1 diabetes in August 2006. He had a history of asthma, allergies and eczema.

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

• (a) gave Master A instructions on self-administering insulin without Mrs C's consent or knowledge, or that of Master A's Paediatric Diabetes Care Team (upheld); and
• (b) failed to handle Mrs C's complaint properly (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the misunderstanding and confusion caused by the DNT's poor record-keeping;
• (ii) obtain signed consent from parents/carers where healthcare staff want a child to self-administer insulin;
• (iii) look into having a single named point of contact for parents/carers in relation to all of a child's diabetes care and treatment; and
• (iv) review how complaints are dealt with by the Moray Community Health and Social Care Partnership, to ensure that the Complaints Handling Procedures are followed.

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

Overview
The complainant (Mr C) raised a number of concerns about the standard of care and treatment provided to his son (Mr A) by Tayside NHS Board (the Board)'s Mental Health Service during the 13 months prior to his death by suicide in July 2010. Mr C also raised concerns about the communication between health staff and Mr A's family during this period.

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

• (a) did not provide Mr A with appropriate care and treatment for his depression (upheld); and
• (b) failed to communicate effectively with Mr A's parents (Mr and Mrs C) or consult with them regarding Mr A's treatment and progress (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make the use and review of the risk screening tool to complement and inform the risk assessment process mandatory for all patient assessments following a self-harm / suicide attempt;
• (ii) review their process for conducting RCAs to ensure a degree of independence;
• (iii) revise procedures in responding to Ombudsman's investigations to ensure no documents are omitted or withheld;
• (iv) review their practice with respect to the involvement of family and others, to ensure it is in line with the good practice contained in the NES framework;
• (v) review their process for involving families in SIRs and RCAs; and
• (vi) issue Mr C with a formal written apology for the failures identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns that following a telephone discussion with the practice receptionist (the Receptionist), she and her husband (Mr C), her son (Mr A) and daughter (Miss D) were de-registered from the dentist's (Dentist 1's) list of patients.

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

• (a) Dentist 1 unreasonably de-registered Mrs C, Mr C, Mr A and Miss D without explanation (upheld);
• (b) Dentist 1 inappropriately said that she did not require to provide any explanation (not upheld); and
• (c) Mr A's appointments on 23 March 2011 and 20 April 2011 which fell within the period Dentist 1 remained liable to provide treatment (until 8 June 2011) were unjustifiably cancelled (upheld).

Redress and recommendation
The Ombudsman recommends that Dentist 1:

• (i) Dentist 1 apologise to Mr A for cancelling his appointment on 23 March 2011 without establishing its purpose.

Dentist 1 has accepted the recommendation and will act on it accordingly.

Overview
The complainant (Ms C) raised concerns about the care and treatment provided by her GP Practice (the Practice) over a two-year period in that the Practice failed to act on the 'red flag' symptoms she had of a brain tumour within a reasonable time and diagnose her condition.

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

• (a) the Practice failed to properly investigate Ms C's symptoms within a reasonable time; (upheld) and
• (b) the failure by the Practice to diagnose Ms C's condition was not reasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) review their practice to ensure they refer for specialist advice within a reasonable time;
• (ii) ensure their record-keeping complies with General Medical Council guidance;
• (iii) update their knowledge of diagnosis and management of persistent upper limb symptoms; and
• (iv) apologise to Ms C for the failures identified.

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

Overview
The complainant (Ms C) raised concerns about the treatment that she received from Dumfries and Galloway NHS Board (the Board) prior to the birth of her son (Baby A). She also complained about the treatment Baby A received after he was born.

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

• (a) the Board failed to diagnose that Ms C had pre-eclampsia, despite her showing clear symptoms (not upheld);
• (b) the Paediatrician's arrival was excessively delayed, despite Ms C and her family's concerns over Baby A's breathing (upheld);
• (c) the Paediatrician failed to properly prioritise Baby A (upheld);
• (d) the Midwife failed to recognise that there were problems with Baby A feeding when she gave him formula milk (not upheld);
• (e) the Board failed to diagnose Persistent Pulmonary Hypertension of the Newborn despite Baby A showing clear symptoms (upheld);
• (f) the Doctor treating Baby A did not know how to increase the oxygen when this was requested by the Consultant (not upheld); and
• (g) Ms C was refused entry into neonatal when Baby A was admitted and she was not called when he received a heart massage (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind midwifery staff of the importance of maintaining consistent records of babies' physiological observations;
• (ii) present Baby A's case, and Adviser 2's comments, to Neonatal staff to highlight any learning points that can be taken from this case; and
• (iii) apologise to Ms C and Mr B for the issues highlighted in this report.

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