Health

Overview
The complainant (Mr C) had carpal tunnel release surgery performed on his left hand in June 2006. Unfortunately, post-operatively, he suffered pain, numbness and swelling in his hand. Mr C raised concerns about the way the operation was performed and also that he was not referred back to the operating surgeon to be re-examined as soon as possible after he complained of adverse symptoms. He has subsequently been told that he has permanent nerve damage.

Specific complaint and conclusion
The complaint which has been investigated is that Lothian NHS Board (the Board) did not provide reasonable care and treatment to Mr C during and following his operation for carpal tunnel syndrome (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reinforce with staff the importance of referring patients back for a consultant review as soon as possible if there are complications or adverse symptoms which need attention; and
• (ii) apologise to Mr C for the failings identified in this report.

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

Overview
The complainant (Mr C) complained that his wife (Ms A) had not received appropriate care and treatment when they both attended the Obstetric Triage Department, Simpson's Centre for Reproductive Health (the Centre), prior to the birth of their baby daughter (Baby A), and that Baby A suffered severe medical complications as a result.

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

• (a) the Centre failed to detect problems with Ms A's pregnancy and failed to carry out appropriate tests when she attended the Centre on 15 and 16 June 2008 (upheld);
• (b) the Centre failed to take Mr C and Ms A's concerns and questions into account on 15 and 16 June 2008 (upheld);
• (c) the Centre failed to give Mr C and Ms A correct advice on 15 and 16 June 2008 or to ensure that adequate follow-up support was in place and offered to Mr C and Ms A on 16 June 2008 (upheld); and
• (d) on 23 June 2008 there was a time lapse of more than 30 minutes (the recommended practice) from the decision to perform an emergency lower uterine caesarean section to the start of this procedure (upheld).

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

• (i) inform him of the measures being undertaken to address the issues raised within paragraphs 26, 27 and 28;
• (ii) inform him of the measures being undertaken to address the inadequate level of staff interface and communication with Mr C and Ms A at the Centre;
• (iii) inform him of the measures they take to ensure that the practice (when presented with a patient with reduced foetal movement) is adhered to, with reference to NICE Antenatal Guidelines 2008;
• (iv) inform him of the measures undertaken to ensure that the delay which occurred in this case, from decision to 'knife to skin', does not recur in a similar situation; and
• (v) issue Mr C and Ms A with a formal written apology for the inadequate standard of care and treatment Mr C and Ms A received on 15, 16 and 23 June 2008, prior to the birth of Baby A, as identified in heads of complaint (a), (b), (c) and (d).

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

Overview
The complainants (Mr and Mrs C) complained that Lothian NHS Board (the Board) did not re-test Mr C for Huntington's disease (HD) when new, more accurate, testing was introduced in 1993. Mr C had previously been diagnosed as a likely sufferer of the condition, but received a negative result when re-tested in October 2007. Mr and Mrs C said that their belief that the condition would affect Mr C, and potentially their daughters, caused a great deal of anxiety and led them to make certain life choices. They complained that, had re-testing been provided routinely upon the introduction of more accurate tests in 1993, much of the stress placed on the family would have been avoided and different decisions made about their daughters' future.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not act reasonably in failing to re-test Mr C for HD following the introduction of more accurate tests (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind clinicians of the importance of open discussions of available new genetic tests with affected patients in order to enable them to make informed choices; and
• (ii) remind clinicians of the importance of recording such discussions, including relevant information given to patients.

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

Overview
The complainant (Mr C), a caseworker at a Citizens Advice Bureau, raised a complaint on behalf of Mr A about the care and treatment of his late wife (Mrs A) by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to identify that Mrs A had a broken femur, following falls at Stobhill Hospital (the Hospital) in December 2008 and despite concerns about her mobility being raised by her family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the need to carry out and record medical assessments in line with policy;
• (ii) provide him with the results of the audit referred to in paragraph 10; and
• (iii) consider implementing the Adviser's suggestions in paragraph 18.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the treatment his late father (Mr A) received during his admission to Ninewells Hospital (the Hospital). Mr C feels that Tayside NHS Board (the Board) failed to assess Mr A's creatine kinase (CK) level early enough and that the treatment he received for high potassium levels fell short of what could be reasonably expected. Mr C believes that the Board's failure to treat Mr A appropriately resulted in his premature death.

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

• (a) there was a delay in testing CK level (upheld); and
• (b) the Board failed to treat Mr A's elevated potassium levels appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures patients with new and significant muscular weakness, as was found in this case, who are taking statins, should have their CK level checked on admission;
• (ii) the Board issue an apology to the family of Mr A and accept that there was a failure to provide urgent medical treatment;
• (iii) the Board evaluate existing policy in relation to the usage of 12 lead electrocardiograms when determining cardiac risks and provide Mr C and the Ombudsman with the evidence and outcome of this review; and
• (iv) the Board apologise to the complainant and review the way this complaint was handled to see if there are any lessons to be learned for the future handling of complaints.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns that, during four attendances at Ninewells Hospital (Hospital 1) during July and August 2007, Tayside NHS Board (the Board) had not taken their concerns for the health of their infant daughter (Child C) seriously, that Child C had not been adequately examined and that her condition had not been investigated appropriately. They were also concerned that the Board's handling of their subsequent complaints was not adequate due to the time taken to respond to the complaints. They also felt the quality of the review the Board undertook was poor and the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the written evidence. Following Child C's final attendance, the Board sent a letter to Child C's GP. Mr and Mrs C complained that this letter contained inaccurate and unnecessary comments, and that sending it was inappropriate.

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

• (a) the Board did not appropriately examine, diagnose and treat Child C at four attendances in July and August 2007 (partially upheld to the extent that further investigations of Child C's condition should have been undertaken in August 2007 and she should have been admitted on 16 August 2007);
• (b) the Board did not respond appropriately to Mr and Mrs C's complaint of 24 August 2007 (partially upheld to the extent that the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the available written evidence); and
• (c) the Board's letter of 3 September 2007 to Child C's GP was inappropriate in the circumstances (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr and Mrs C that further investigations of Child C's condition were not undertaken and that she was not admitted on 16 August 2007;
• (ii) review the decision-making in this case with the appropriate Board staff at their next appraisals; and
• (iii) apologise to Mr and Mrs C that the conclusion that Child C's clinical condition had changed between 16 August 2007 and 17 August 2007 was not supported by the available written evidence.

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

Overview
The complainant (Mrs C) raised a number of concerns about the lack of psychology and other adolescent mental health services available to her daughter (Miss A) by Tayside NHS Board (the Board). In particular Mrs C was concerned that a failure to provide Miss A with appropriate services led to an escalation of Miss A's depression and subsequent eating disorder which ultimately contributed to her death by suicide in 2007. Mrs C also complained that her attempts to raise her concerns with the Board received a patchy and slow response that did not recognise the ongoing importance of the concerns she was raising.

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

• (a) provide Miss A with access to appropriate psychology services (upheld);
• (b) provide Miss A with access to appropriate eating disorder services (upheld); and
• (c) handle Mrs C's complaint in a timely and appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise in writing to Mrs C for all the failures identified in this report;
• (ii) review the current service provision of family therapy to adolescents with eating disorders; and
• (iii) consider the introduction of an Integrated Care Pathway designed around the NHS Quality Improvement Scotland and NICE guidelines on the management of anorexia.

Overview
The complainant (Ms C) raised a number of concerns about her treatment by Tayside NHS Board (the Board), following the delivery of her first child by emergency caesarean. Ms C said that she suffered major blood loss after her discharge from hospital and had to be re-admitted. Ms C explained that the Board tried various procedures to control her bleeding which proved unsuccessful and eventually carried out a hysterectomy. Ms C said she wanted to know why 'a healthy 24 year old woman goes into hospital to have her first baby and comes out unable to have any more children and nearly dies in the process'.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment Ms C received from the Board, following the delivery of her first child, was inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board ensure that, in future, good contemporaneous notes are made following delivery by caesarean section.

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

Overview
The complainant (Mr C) raised concerns regarding the care and treatment received by his late mother (Mrs A) at the Royal Infirmary of Edinburgh (the Hospital). Mrs A underwent surgery on 27 June 2007 for the removal of a pelvic cyst and a hysterectomy and Mr C was unhappy with the level of information provided prior to the surgery; the appropriateness of the decision to operate; the handling of the surgical complications and the timing of Mrs A's discharge. The specific points of complaint are listed below.

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

• (a) the consent process was not properly carried out and there was insufficient communication with regard to operative risks (partially upheld to the extent that the doctor obtaining consent did not have the appropriate level of seniority and experience);
• (b) the surgical decision-making process was inappropriate (upheld);
• (c) the surgical complications were not dealt with appropriately (upheld); and
• (d) Mrs A was discharged prematurely from the Hospital (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure that the process of obtaining patient consent is carried out by a clinician with an appropriate level of seniority and experience, ideally the doctor who will be carrying out the surgery;
• (ii) review their procedures to ensure that there is consultant involvement in decisions to proceed to surgery and in decisions regarding the type of surgery to be carried out;
• (iii) reflect on the delay in identifying Mrs A's intra-abdominal bleed and implement an action to prevent similar future failures;
• (iv) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective; and
• (v) apologise to Mr C for the failings identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns that her mother (Mrs A) had not been reasonably cared for or treated by medical staff at St John's Hospital (the Hospital) or her GP practice (the Practice) in the months before her death, and that the responses to Mrs C's enquiries and complaints by Lothian NHS Board (the Board) and the Practice had not been appropriate and had been unnecessarily distressing to her.

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

• (a) the Board did not provide reasonable care and treatment to Mrs A between May 2007 and February 2008 (partially upheld to the extent that the investigation, diagnosis, care and treatment of Mrs A from November 2007 to February 2008 was not reasonable);
• (b) the actions taken by the Board in response to Mrs C's complaints about the care and treatment of Mrs A were not reasonable (upheld);
• (c) Mrs A did not receive adequate care and treatment from the Practice between November 2007 and February 2008 (partially upheld to the extent that the Practice did not reasonably address or follow-up the symptoms that Mrs A displayed which can be linked to cancer, that the Practice's prescription of pills rather than other forms of treatment to Mrs A was not reasonable, that the Practice did not reasonably take into account changes in Mrs A's condition and that the level of information recorded in Mrs A's notes was not comprehensive); and
• (d) the Practice's responses to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing (partially upheld to the extent that, although the Practice appropriately responded to some of Mrs C's enquiries and complaints, some of the Practice's responses, or lack of responses, to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A's family that the chest x-ray of 26 November 2007 was mis-reported and that this led to a delay in the diagnosis of Mrs A's cancer;
• (ii) remind medical staff that letters to GPs should be dictated immediately after consultations with patients;
• (iii) encourage the practice of discussing patients with atypical clinical features at multi-disciplinary meetings;
• (iv) take steps to assure themselves of the quality of their chest x-ray reporting service;
• (v) apologise to Mrs C that the investigation of her complaints did not uncover the mis-reporting of the chest x-ray of 26 November 2007; and
• (vi) ensure that investigations of similar complaints in the future consider the possibility that x-rays, scans, test results or similar may have been mis-reported.

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A's family for those aspects of her care and treatment that were not reasonable;
• (ii) produce a plan for reviewing their adherence to national guidelines. This plan should be minuted and form part of the Practice's clinical governance meetings. The minutes should be inspected by the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these issues;
• (iii) ensure that national guidelines are readily available to all practitioners;
• (iv) undertake a review of clinical record-keeping using the Royal College of General Practitioners (Scotland) template on section 3D (2) of the Revalidation Toolkit. The review should be discussed with the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these areas;
• (v) apologise to Mrs C that their responses to her enquiries and complaints were inappropriate and unnecessarily distressing; and
• (vi) review their complaints handling procedure to ensure that complainants are given direct answers to reasonable direct questions, that individual circumstances, distress and stated preferences are reasonably taken into account when suggesting meetings with correspondents and complainants, that it is made clear to correspondents how to set in motion the Practice's complaints procedure and that avoidable errors are reasonably eliminated, taking into account the individual circumstances of a complaint.

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