Health

Overview

The complainant (Mrs C) was unhappy with the care provided to her late father (Mr A) by Greater Glasgow and Clyde NHS Board (the Board). Mr A was admitted to the Western Infirmary (Hospital 1) on 5 January 2008, as he had been diagnosed with bladder and prostate cancer and his condition was deteriorating. On the following day, it was recorded that he had two pressure sores and that his heel was red and soft. Mr A was transferred to ward 3A in Gartnavel General Hospital (Hospital 2) on 7 January 2008. He was then transferred to the Beatson West of Scotland Cancer Centre (Hospital 3) on 15 January 2008 and discharged on 24 January 2008. During this time, he contracted Noro virus (more commonly known as winter vomiting virus). On 28 January 2008, he was readmitted to Hospital 1 and was transferred to Hospital 2 on the following day. He was discharged again on 5 February 2008. He was then readmitted to Hospital 1 on 9 February 2008, but was transferred to Hospital 2 on the following day. Tests completed showed that Mr A had contracted MRSA and Clostridium difficile. Mr A was referred to the palliative care team on 20 February 2008. Sadly, he died later that day.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to effectively manage Mr A's pressure sores (upheld);
• (b) Mr A contracted MRSA and other infections because the infection control measures were inadequate (not upheld);
• (c) there was a delay in referring Mr A to the palliative care team (upheld); and
• (d) there was a lack of continuity in the nursing care provided to Mr A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar improvement tool to examine the reason why Mr A received inadequate treatment for his pressure ulcers;
• (ii) ensure that the policies in place reflect current national best practice standards for pressure ulcer assessment, prevention and treatment and that robust systems are in place to review, monitor and report adherence;
• (iii) confirm that the learning from report 200702913, published by the Ombudsman in June 2009, is being transferred across the Board region;
• (iv) ensure that there are steps in place to verify that staff are able to diagnose patients who might benefit from palliative care and then make timely referrals to palliative care teams;
• (v) take immediate steps to implement the Liverpool Care Pathway or similar end of life care planning system;
• (vi) continue to review and monitor the nursing care in Ward 3A in Hospital 2. This should include an examination of the clinical leadership and management; the patient experience; and the quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the implementation of the Scottish Government policy for Senior Charge Nurses - Leading Better Care;
• (vii) ask the Director of Nursing to verify that appropriate education and development is in place to ensure that nursing staff throughout the Board are aware of and adhere to national standards in relation to pressure ulcers, control of infection and end of life care;
• (viii) ensure that systems are in place to review and monitor standards of all aspects of nursing documentation in line with professional standards;
• (ix) ensure that patient transfer policies exist and are used in the best interests of patients, ensuring that communication and continuity of care is paramount; and
• (x) make a full and detailed apology to Mrs 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) raised a number of concerns about the care and treatment provided by Tayside NHS Board (the Board) to his father (Mr A) in the months before his death in October 2007. Mr C also complained about delays in diagnoses and treatment of Mr A and the handling of his complaint about these matters.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) delayed in diagnosing Mr A (upheld);
• (b) failed to provide timely treatment following diagnosis (not upheld);
• (c) did not provide adequate care to Mr A in the respiratory ward (the Ward) of Ninewells Hospital, Dundee (upheld); and
• (d) failed to handle Mr C's complaint appropriately (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ask the consultant responsible for Mr A's care in the Ward to apologise to Mr C for any contribution he may have made to the misunderstanding with Mr A about visiting him on 28 September 2007;
• (ii) apologise to Mr C for the failure to provide adequate care to Mr A as identified in this report; and
• (iii) review the current arrangements for selecting patients for consultant out of hours review, including processes for communication and handover between doctors.

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

Overview

Mr C has complained about the care and treatment provided to his late mother (Mrs A) prior to and during her last hospital stay in a hospital (the Hospital) within the Shetland NHS Board (the Board) area. Mr C's mother was admitted to the Hospital on 8 March 2005 and discharged to her care home in the afternoon of 9 March 2005. Mrs A died later in the evening of 9 March 2005. Mr C has also complained that Mrs A should have remained in hospital longer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the reasons for medication, prescribed for Mrs A's suspected clinical condition at the time, were unclear (partially upheld, to the extent that the reason why medication was prescribed in the community for Mrs A's suspected condition was clear and appropriate but the reasons for the prescribing decisions made following admission to the Hospital were not clear and appropriate);
• (b) medical and nursing staff failed to assess and record the treatment and care requirements adequately throughout this particular episode of care (partially upheld, in relation to the actions of the Hospital);
• (c) Mrs A was not provided with an acceptable level of fluids during her stay in the Hospital (upheld); and
• (d) Mrs A should have remained in the Hospital longer (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care, so they can reflect on the findings relevant to the prescription of medication when Mrs A was admitted to the Hospital and identify clear and explicit indications for the use of prescribed and administered medication;
• (ii) ensure thorough assessment, recording and treatment is undertaken for the ongoing care of a patient when health remains compromised and discharge is being considered;
• (iii) ensure nursing staff are appropriately trained to record baseline observations and understand the reasons for recording them;
• (iv) ensure a fluid intake and output record is kept for an unwell patient, where feeding and drinking assistance is required; and explanations are recorded when there is a delay in supporting the early, prompt intake of fluids;
• (v) remind staff of the importance of encouraging fluid intake, when a patient is unable to attend to that aspect of care independently;
• (vi) ensure full consideration is given to any potential discharge plan, when observations continue to indicate a level of patient distress or compromise;
• (vii) ensure appropriate family members are given an opportunity to contribute to the discharge planning process of an unwell relative; and
• (viii) provide Mr C with a full formal apology for the failures in care identified in this report.

Overview

The aggrieved (Mrs A) raised a concern that her husband (Mr A)'s prostate cancer was not detected in 2003/2004 when he attended a number of hospital appointments. Mrs A considered both that the cancer could have been detected at that earlier stage and that it should have been detected then.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr A with all appropriate care and treatment in 2003/2004 and as a consequence missed an opportunity to secure an earlier diagnosis of prostate cancer (upheld).

Redress and recommendation

The Ombudsman recommends that the Board review the Urology Department protocol for the assessment and management of men with new lower urinary tract symptoms bearing this case in mind.

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

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment that her late father (Mr A) had received from his GP Practice (the Practice) before his death.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice delayed in examining Mr A after his family contacted them stating that he had chest pain on 28 June 2007 (upheld); and
• (b) the action taken to 'flag' Mr A's notes that he had special requirements was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for the delays in examining Mr A on 28 June 2007;
• (ii) organise a review of their triage systems and ensure that the revised procedures are communicated effectively to staff;
• (iii) apologise to Mrs C for the failure to effectively flag Mr A's notes; and
• (iv) consider how they can effectively flag the electronic records of a patient with significant health problems.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment of her mother (Mrs A). Mrs A was resident in a care home and two Doctors (Doctor 1 and Doctor 2) from Ayrshire and Arran NHS Board (the Board) had visited her in the final hours of her life.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's care and treatment of Mrs A in the final hours of her life was not reasonable (partially upheld to the extent that some aspects of Mrs A's care and treatment were not reasonable).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) encourage Doctor 1 to reflect on the case at their next appraisal, with particular reference to: assessment of unfamiliar patients as part of the Ayrshire Doctors On Call team; the factors to be considered in reaching a decision on the admission to hospital of frail elderly patients; the discussion and recording of admission criteria with carers and relatives; and the dosage of antibiotics in relation to Scottish Intercollegiate Guidance Network guidance; and
(ii) encourage Doctor 2 to reflect on the case at their next appraisal, with particular reference to: the discussion and recording of terminal diagnoses with carers and relatives; andthe use of symptomatic measures in terminal care.

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

Overview
The complainant (Mr C) and his sister raised a number of concerns about the care and treatment provided to their sister (Ms A) by Mental Health Services within Ailsa Hospital (Hospital 1), Ayrshire and Arran NHS Board (the Board) in February 2006. Ms A sustained a major spinal injury as a result of a fall from a window after her discharge from Ayr Hospital (Hospital 2) on 14 February 2006. Ms A never recovered, her condition deteriorated and she died in January 2007. Following the submission of Mr C's complaint to the Ombudsman's office the Board undertook a further review of Mr C's concerns and at a meeting with Mr C a number of issues were explained and apologies given for the failings in communication with Ms A's family which had been identified. Mr C was satisfied with much of this but remain concerned about the treatment provided to his sister. These are the issues investigated in this report.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Ms A's treatment at Hospital 1 during January and February 2006 was ineffective and she was discharged inappropriately (not upheld); and
(b) Ms A was treated and discharged inappropriately from Hospital 2 following her attendances at the Accident and Emergency Department on 10 and 13 February 2006 (not upheld).

Redress and recommendations
Because of the action already taken by the Board to address failures in communication since the complaint was submitted to the Ombudsman's office, the Ombudsman has no recommendations to make.

Overview
The complainant (Mrs C) raised a number of concerns regarding the treatment that her father (Mr A) received from staff at Ninewells Hospital (the Hospital). She complained that, for a five day period following admission to the Hospital, her father was neglected by nursing staff, his condition left unmonitored and incorrect assumptions made regarding his mental state. Mrs C felt that inattention and poor record-keeping by staff of Tayside NHS Board (the Board) contributed to a deterioration in Mr A's condition, and to his death.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:
(a) incorrectly assumed that Mr A had dementia (not upheld);
(b) failed to treat Mr A appropriately for a five day period following his admission to the Hospital (upheld); and
(c) failed to appropriately monitor Mr A's fluid intake (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review their progress against the action plan and provide an updated version of the document;
(ii) provide details of the steps that they have taken to implement the Scottish Government's new Food, Fluid and Nutrition programme;
(iii) provide details of the steps that they have taken to achieve the Scottish Government's new Clinical Quality Indicators for Food, Fluid and Nutrition; and
(iv) formally apologise to Mrs C and her family for the distress and anxiety caused to them and Mr A during his stay at the Hospital.

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

Overview
The complainant (Mrs C) raised a number of concerns about the information provided to her about the extent of her late husband (Mr C)'s ill health and the operation of a Do Not Resuscitate (DNR) order. Mrs C was also concerned about the adequacy of steps taken to protect Mr C in hospital.

Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board) failed to:
(a) communicate adequately with Mrs C and in particular failed to follow the procedure for instituting and implementing a DNR order (upheld); and
(b) keep Mr C safe using appropriate restraint (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review the DNR policy, the use, and value added by the use of, the resuscitation box in the Unitary Patient Record; followed by an ongoing audit (or similar improvement methodology) to ensure that there is clarity about when the policy applies and whether it is sustained in practice. The audit should measure the completion of the DNR form and associated documentation in the patient record;
(ii) review how Cardio Pulmonary Resuscitation status is communicated at ward level, to ensure nursing staff are aware of the importance of robust communication at handover and transfer. The national 'Leading Better Care' policy may be helpful here;
(iii) consider including DNR orders in both induction and Basic Life Support staff training. This is already done in some parts of NHS Scotland and is endorsed by the Scottish Palliative Care Society;
(iv) review the mechanisms in place to ensure that communication between patients, their relatives and carers and staff is recognised as an important part of the patient experience; and
(v) develop a specific policy for the WanderGuard bracelet to ensure that its use complies with the Adults with Incapacity (Scotland) Act 2000 to ensure patients are treated with dignity and respect.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their baby daughter (Baby C) and Forth Valley NHS Board (the Board)'s failure to diagnose meningitis and hydrocephalus when she was seen by clinicians at Stirling Royal Infirmary (Hospital 1) on
20 September 2007.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care and treatment to Baby C on 20 September 2007 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr and Mrs C for the failings identified in this report;
(ii) carry out a root cause analysis of the inadequate assessment on
20 September 2007. This should explore why the obvious concerns of the GP were not addressed by the junior paediatricians. It should also establish whether the staff grade doctor involved in the decisions was sufficiently trained and experienced to be in this position of responsibility. The Board should then give consideration to further training for the relevant staff in light of the results of their analysis of the case. They should also provide Mr and Mrs C with a full and detailed explanation of their findings and the steps that will be taken to prevent recurrence; and
(iii) note the specialist medical adviser's comments that a cranial ultrasound scan should have been performed on 20 September 2007 to exclude a build up of fluid in the brain.

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