Health

Overview
The complainant (Mrs C) raised a number of concerns about the prescription of antipsychotic drugs to her aunt (Miss A) during her admission to hospital in September 2009 and that the prescribing chain of command of the drugs was not clear.

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

• (a) wrongly prescribed haloperidol to Miss A from 15 until 25 September 2009 (not upheld); and
• (b) failed to provide clarity surrounding the prescribing chain of command (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) carry out an audit of their practice on implementation of the Adults with Incapacity Act with particular reference to consent and report to the Ombudsman on the findings;
• (ii) amend its guidance on managing patients with delirium to include the requirements of the Adults with Incapacity Act;
• (iii) share this report with staff to ensure they complete documentation properly and meet the communication needs of patients with cognitive or sensory (or both) impairment; 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
In February 2010, the complainant (Mrs C)'s late mother (Mrs A) was admitted to Drumcarrow Lodge of Stratheden Psychiatric Hospital (the Hospital). She was hearing voices and suffering from hallucinations and paranoia. Mrs A was discharged from the Hospital on 31 May 2010 after her mental health problems had been resolved. However, Mrs C alleged that the Hospital paid scant regard to Mrs A's physical condition and did not assess this properly before her release. Mrs A died from heart failure on 5 June 2010 after an emergency admission to Ninewells Hospital, Dundee, on 2 June 2010. Mrs C submitted a formal complaint about the way the Hospital dealt with Mrs A's physical care and treatment but she alleged that the responses she received were unreasonable.

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

• (a) physical care and treatment of Mrs A, while she was a patient at the Hospital, were unacceptable (upheld); and
• (b) responses to Mrs C's complaints about Mrs A's physical care and treatment were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) offer Mrs C a full and sincere apology for their failures with regard to Mrs A's treatment;
• (ii) share this report with the team involved and with the Consultant Psychiatrist and remind him of his overall responsibilities in such cases;
• (iii) look into the process of issuing referral letters, to ensure that any failures to respond are chased up and into the fact that a letter appeared to have been signed by a trainee psychiatrist when she was on holiday;
• (iv) apologise to Mrs C for their failures with regard to the investigation of her complaint; and
• (v) review the rigour of their complaint handling process, with particular relevance to timescale and investigative thoroughness.

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

Overview
The complainant (Mrs C) complained about the care and treatment provided to her sister (Ms A), who had a diagnosis of Borderline Personality Disorder, after she was admitted to the Royal Edinburgh Hospital (Hospital 1) in September 2010. Mrs C was also unhappy with Lothian NHS Board's (the Board) responses to her complaints.

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

• (a) Ms A did not receive appropriate care and treatment from Hospital 1 during the period 13 September 2010 to 7 October 2010 (upheld); and
• (b) the Board have failed to provide satisfactory answers to Mrs C's questions about the matter (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospital 1, to include: the assessment of patients on admission; care-planning practice; the completion of risk management plans and proformas; and communication with the named person and relatives and their involvement and participation in decision-making. Practices in these areas should be audited against relevant professional body expectations; national standards, policies and codes of practice; and existing local policy intentions;
• (ii) provide him with details of the findings and the action plan created as a result of the above recommendation;
• (iii) ensure that the findings in this report are communicated to the staff involved in Ms A's care and treatment; and
• (iv) apologise to Mrs C and Ms A for the failures identified in this report.

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

Overview
The complainant (Mr C) raised a number of concerns that this brother (Mr A) had been inappropriately cared for and treated in Highland NHS Board (the Board) hospitals between February and October 2010.

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

• (a) delayed in diagnosing Mr A's cancer, including a delay in Mr A being reviewed by Gastroenterology (upheld);
• (b) inappropriately discharged Mr A from Caithness General Hospital on 9 June 2010 (upheld); and
• (c) did not adequately communicate to Mr A the details of his diagnosis and prognosis (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review endoscopy waiting times, taking into account SIGN and NICE guidance, and report on what steps will be taken to address capacity issues to avoid delays such as that identified in this case;
• (ii) explain how cancelled endoscopies will be treated as adverse events;
• (iii) review the circumstances of Mr A's admission and discharge on 8 and 9 June 2010, with a specific focus on the potential for an inter-hospital transfer, and discharge criteria, and report on the lessons learned;
• (iv) review admission clerking and medical record-keeping at Hospital 1, to ensure it is in line with current standards; and
• (v) remind consultants of their responsibility to inform patients personally of their test results and likely consequences, and to note this in the medical records.

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

Overview

• (a) during Ms C’s labour she was not listened to (upheld);
• (b)  clinical staff wrongly asked Ms C to get off the bed to allow them to clean up a gush of amniotic fluid (upheld); and
• (c)  the prolapsed cord could have been diagnosed much quicker (not upheld).

Overview
The complainant (Mr C) had a large odontogenic keratocyst removed from his jaw in October 2008. His maxillofacial consultant (the Consultant) reviewed Mr C in February 2009 and recommended that he be reviewed every six months because the cyst was aggressive and had a high rate of recurrence. The Consultant saw Mr C again in September 2009, but his appointment in March 2010 was cancelled. The Consultant saw Mr C in September 2010. It was identified that he needed surgery as the cyst had recurred.

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

• (a) failed to review Mr C within six months as recommended by the Consultant (upheld);
• (b) delayed in notifying him of the re-scheduled appointment (upheld); and
• (c) failed to handle his complaint adequately (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) take steps to make relevant staff aware that the views of clinical staff must be taken into account when they are considering deferring the follow-up of a patient and that this should be clearly documented;
• (ii) ensure that relevant staff are aware that they should not jeopardise the health of patients in order to meet a Government target; and
• (iii) apologise to Mr C for the failings identified in relation to complaint (a).

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

Overview
The complainant Ms C raised a complaint that, as a result of substandard care at Raigmore Hospital, she developed a large pressure sore during a period of recuperation following an operation.

Specific complaint and conclusion
The complaint which has been investigated is that Highland NHS Board (the Board) failed to prevent a pressure sore developing following Ms C's operation on 4 October 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence of current audit and monitoring in relation to pressure sore prevention and treatment. This should include relevant national initiatives, Clinical Quality Indicators and patient safety data;
• (ii) provide the Ombudsman with the current education and training programmes for the prevention and management of pressure sores;
• (iii) draw the report to the attention of nursing staff involved in Ms C's care; and
• (iv) provide a full apology to Ms C for the failures identified within this report.

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

Overview
The complainant (Mr C) complained that, as a result of his GP Practice (the Practice) failing to act on his enquiries about a follow up chest scan, there was an 18 month delay in him receiving the scan. When the scan was eventually performed he was diagnosed with lung cancer, and underwent surgery shortly thereafter.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay between November 2008 and May 2010, caused by the Practice, in Mr C receiving an MRI scan (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) conduct a Significant Event Analysis on this case;
• (ii) ensure that the GP discuss this case with his appraiser at his next GP appraisal; and
• (iii) provides Mr C with a full apology for the failures identified within this report.

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

Overview
The complainant (Mr C) complained about the care and treatment provided to his sister-in-law (Mrs A) while she was in the care of Dumfries and Galloway NHS Board (the Board). He alleged that the Board failed to provide appropriate mental health care for Mrs A during a period when she was physically unwell.

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

• (a) Mrs A's anti-depressant medication, phenelzine, was stopped without reasonable psychiatric consultation in April 2010 (upheld);
• (b) keyhole surgery was undertaken inappropriately on Mrs A in April 2010 (not upheld);
• (c) following surgery for bowel cancer in April 2010, Mrs A was sent home without reasonable aftercare instructions, which led to further health problems and the need for her bowel to be extended (upheld); and
• (d) Mrs A was unreasonably able to acquire the means and opportunity to self-harm in Dumfries and Galloway Infirmary and Crichton Royal Hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the fact that no proper advice was given to Mrs A pre and post-operatively;
• (ii) when presented with patients for surgery with known mental health issues for which they take medication, ensure that the circumstances are discussed with the patient, the GP and clinicians involved;
• (iii) ensure that all relevant discussions with the patient, GP and clinicians (and any subsequent outcomes) are recorded properly;
• (iv) give consideration to the terms of their permission forms for operations, given the failures with regard to Mrs A;
• (v) apologise to Mr C for their failure to provide Mrs A with adequate aftercare instructions in April 2010;
• (vi) review their procedures to ensure that such an occurrence does not occur again;
• (vii) apologise to Mr C for the insufficient care they took to prevent Mrs A from accessing the means to harm herself; and
• (viii) where patients have expressed thoughts of suicide, carry out (and fully record and act on) risk assessments.

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

Overview
The Complainant (Miss C) complained on behalf of her friend (Mrs A) who underwent surgery for an inguinal hernia at the Western General Hospital in March 2010. Miss C raised concerns about delays to Mrs A's operation, which she felt could have been avoided. She also raised complaints about the service that Mrs A received from Lothian NHS Board (the Board) when she was in hospital.

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

• (a) Mrs A's operation was unnecessarily delayed (upheld);
• (b) Mrs A's special medical requirements were not made known to ward staff prior to her admission to Ward 23 (upheld);
• (c) cleanliness and staff hygiene practices in Ward 23 were poor (not upheld);
• (d) food service on the ward was poor (upheld);
• (e) the Board discharged Mrs A without ensuring that she had access to adequate support outwith the hospital (upheld); and
• (f) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care with a view to identifying any lessons that can be learned from her case;
• (ii) review their procedures for reporting CT scan results back to the referring clinician;
• (iii) review their procedures for tracking the progress of patients whose treatment has been referred to a different consultant;
• (iv) take steps to ensure that nursing staff maintain patient records in line with the Nursing and Midwifery Council's Record Keeping and Guidance for Nurses and Midwives;
• (v) take steps to satisfy themselves that the steady decline in the cleanliness monitoring score between September 2009 and March 2010 was not indicative of an endemic deterioration in cleanliness and hygiene standards on Ward 23; and
• (vi) provide training to staff on Ward 23 regarding nutrition, communication and record-keeping.

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