Health

Overview
The complainant Mr C , was unhappy with the care provided to his late mother, Mrs A. Mrs A had been admitted to the Victoria Infirmary (the Hospital) following a fall. Shortly after her admission, the Hospital identified an outbreak of the winter vomiting virus in the ward to which Mrs A had been admitted (Ward A). While there, Mrs A was diagnosed with an infection and her condition deteriorated. Sadly, Mrs A died a few days after moving from Ward A to Ward B. Mr C said he was concerned about the care and treatment provided to Mrs A and that he and his family had been distressed by the way Mrs A had been cared for after it became clear she was unlikely to recover. He said Mrs A had been moved into an open ward (Ward B) and the curtains around her bed left open. Mr C also raised complaints about matters relating to the closure of Ward A and stated that the Hospital had failed to ensure the public was aware there was an outbreak of infection. He also said he had been concerned about the general level of hygiene in and around Ward A.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the care and treatment provided to Mrs A was inadequate (upheld);
(b) there was insufficient care taken by staff handling an outbreak of infection in Ward A (upheld);
(c) the level of hygiene in and around the ward was inadequate (no finding);
(d) there were significant failures in communication about the effect on Mrs A of the infection and the serious nature of Mrs A's condition (upheld);
(e) there was a failure to ensure Mrs A's dignity (upheld); and
(f) the Board did not respond appropriately to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) use a root cause analysis or similar tool to examine the reasons for the clinical failures identified in treating Mrs A’s diarrhoea and managing her fluid intake;
(ii) provide clear evidence over the next 12 months that the new policy on professional standards of record-keeping is having significant improvements on the quality of documentation;
(iii) provide the Ombudsman with evidence that the initiatives underway on infection control should prevent a recurrence of the failings identified in this report;
(iv) use this complaint as part of their own ongoing programmes to improve cleanliness and, in particular, consider how hygiene standards can be tracked and monitored and how visitors and patients can be encouraged to feel they can approach staff about any concerns they have;
(v) share with the Ombudsman the results of patient and staff surveys on communication over the next 12 months and the audit of communication following report 200600345 and any action taken as a result;
(vi) keep the Ombudsman informed of the progress of implementation of the Liverpool Care Pathway over the next 12 months;
(vii) provide evidence of the actions being taken to ensure individual patient dignity until the Hospital is closed;
(viii) ensure that guidance to complaint handling staff emphasises the need for full disclosure of relevant information; and
(ix) make a full, detailed apology to Mr C and his family for the failings identified in this report.

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

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment, which she had received from Greater Glasgow and Clyde NHS Board (the Board) during the period April 2003 to October 2005.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care following Ms C's operation on 18 April 2003 (upheld).

Redress and recommendation
The Ombudsman has no recommendations to make on these issues because he is satisfied that the Board have made changes that address the concerns raised in this report.

Overview
The complainant (Miss C) raised a number of concerns regarding the treatment her late mother (Mrs A) received at Wishaw General Hospital (the Hospital). Miss C was unhappy with the level of nursing care which Mrs A received, specifically in relation to a fall she suffered in the early hours of the morning following her admission. Miss C also raised concerns regarding numerous cancellations of the proposed surgery to address damage suffered to Mrs A's femur during her fall.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the standard of nursing care provided was inadequate (upheld); and
(b) the decisions to cancel surgery were unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board (the Board):
(i) undertake an urgent investigation into the nursing staff's failure to follow the correct procedure when administering a controlled substance;
(ii) implement an action to address the failure to assess Mrs A's pain, using the Modified Early Warning System tool;
(iii) implement a formal bed move policy which restricts any avoidable movement of vulnerable patients;
(iv) clarify their policy on nursing confused patients, providing a copy of a relevant risk assessment for patients' mental capacity, along with an appropriate nursing action plan, to be adopted following a diagnosis of confusion;
(v) remind staff of the importance of frequent vital observations, particularly after incidents where patients have sustained head injuries;
(vi) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in this report;
(vii) apologise to Miss C for the failings which have been identified in this report; and
(viii) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective.

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

Overview

The complainant (Mrs C) raised a number of concerns about the dental treatment she received from her dentist (the Dentist) on 25 January 2008, which led to her attending her local hospital in great pain and with a swollen face. Mrs C's care was then taken over by a consultant oral and maxillofacial surgeon who told her that the numbness in her face could take up to six weeks to heal or it could be permanent.

Specific complaint and conclusion

The complaint which has been investigated is that, on 25 January 2008, the Dentist provided Mrs C with an inadequate level of treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) apologises to Mrs C for the failings identified in this report; and
• (ii) reflects on the Adviser's comments in regard to the standard of radiographs, working length calculation and record-keeping.

The Dentist has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which he had received from clinicians for a finger injury following an assault on 10 June 2007. Mr C said that a consultant orthopaedic surgeon had failed to amputate a sufficient amount of the damaged finger and that this had hampered his ability to continue with his employment as an electrician. In addition, Mr C complained that another consultant orthopaedic surgeon had agreed to further amputate the finger if alternative therapy did not work but then subsequently denied that he had promised this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the clinicians failed to obtain informed consent prior to surgery (upheld);
• (b) the decision not to provide the level of amputation requested by Mr C was unreasonable (not upheld); and
• (c) the overall treatment provided by the clinicians was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board):

• (i) apologise to Mr C for not obtaining informed consent; and
• (ii) consider whether procedures require to be amended, so that the surgeon is available at the pre-assessment clinic to discuss the level of amputation which is planned and to take consent.

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

Overview

The complainant (Mr C) complained on behalf of his stepmother (Mrs A) about the assessment made of her condition on 15 October 2007, which led to Ayrshire and Arran NHS Board's (the Board) decision that she was not entitled to NHS Continuing Care, despite having qualified for a previous period in England. Mr C also complained that the benefits of moving to be closer to him as her only surviving relative were discounted by the Board and he also complained about how the Board handled the matter. Sadly, Mrs A died on 26 January 2008.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the assessment on 15 October 2007 was inadequate (not upheld);
• (b) the Board discounted the benefit of Mrs A's move to be closer to her family (not upheld); and
• (c) the Board failed to explain properly the decision not to award continuing care funding (upheld).

Redress and recommendations

The Ombudsman recommends that the Board;

• (i) apologise to Mr C for failing to explain the decision properly;
• (ii) undertake a retrospective assessment of Mrs A's eligibility for NHS Continuing Care from the point of her transfer to Scotland;
• (iii) consider whether they now have a preferred or standardised format for decisions relating to and documentation of assessments for NHS Continuing Care;
• (iv) consider what procedures they have in place to assess cross border transfers where there is no request or need for NHS Continuing Care;
• (v) consider what procedures they now have in place to ensure that all care home residents are routinely assessed at the point of entry and thereafter, with regard to their eligibility for NHS Continuing Care;
• (vi) consider under what circumstances they will consider retrospective requests for NHS Continuing Care; and
• (vii) review the instructions they give to their staff on the handling of assessments relating to extraordinary issues such as cross border patient movement.

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

Overview

The complainant, Mr C , was concerned that his late father (Mr A) had suffered serious pressure sores while in the Southern General Hospital (Hospital 1) following an operation on both his knees. Mr C felt that the decision to operate had not been taken appropriately and that the care provided while Mr A was in Hospital 1 was inadequate. Mr C was also unhappy about the way the Board had responded to concerns raised by him and his family.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the decision to operate was not appropriate, in that further tests should have been taken prior to the operation (upheld);
• (b) the post-operative care provided to Mr A was inadequate (upheld);
• (c) communication with Mr A and his family, concerning Mr A's care and treatment, was not adequate (upheld); and
• (d) the Board did not respond appropriately to the complaint raised by Mr C (partially upheld, to the extent that there was a delay in responding with no reasonable explanation given for this).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar tool to examine the reason why the pressure ulcers developed and why there was no proactive treatment once this occurred;
• (ii) provide the policy/guidance for the assessment and treatment of pressure ulcers, with particular reference to the referral to the specialist teams in tissue viability, pain and nutrition; undertake an audit to review the processes; and provide an action plan to address any shortcomings;
• (iii) undertake an audit of documentation to include nursing assessment, pain assessment and nursing care of Wards A and B;
• (iv) provide evidence of the education and training programme provided to nursing staff in relation to the assessment and care of pressure ulcers;
• (v) undertake an external peer review of the nursing care in Ward A, to include an examination of the clinical leadership and management, patient experience and quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the Scottish Government initiatives outlined in Leading Better Care;
• (vi) provide details of the action plan created as a result of the above recommendations and provide updates where relevant. Action plans should be specific, measurable, achievable, realistic and timely (SMART) and include robust quality indicators such as the Clinical Quality Indicator for Pressure Ulcer Prevention;
• (vii) as a priority, review the documentation provided to patients and provide the Ombudsman with the results of this;
• (viii) provide details of the audit made in response to report 200600345 and any action taken as a result;
• (ix) if not covered by that audit, undertake a specific audit of communication within Hospital 1, to include communication with families, and between staff;
• (x) reinforce to clinical staff the importance of responding to requests from complaint handling staff timeously; and
• (xi) make a full apology to Mr C and his family for the failings identified in this report.

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

Overview

The complainant (Ms C) complained about some aspects of care and treatment and communication with the family in respect of her mother, aged 80, who had been admitted to Aberdeen Royal Infirmary (the Hospital), a hospital in the area of Grampian NHS Board (the Board) in October 2007. She had been badly injured in a road traffic accident and, most sadly, never properly recovered full consciousness, dying in the Hospital about a fortnight later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) some aspects of the care and treatment were inadequate (upheld); and
• (b) communication with the family was inadequate (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise direct to Ms C for the shortcomings identified in this report;
• (ii) reflect on the medical lessons to be learnt from this case and consider appropriate action;
• (iii) ensure that, in future, they are able to evidence patients fluid levels, by retaining, for example, a record of daily fluid totals for a year after the event, in case needed;
• (iv) consider how to improve the record-keeping, including notes of discussions with patients and families, of medical staff in the ward in question, and take action accordingly;
• (v) consider any need for a wider audit of medical record-keeping; and
• (vi) reflect on the criticisms about complaint handling and consider appropriate action.

Overview

The complainant raised a number of concerns about the care and treatment of an 80-year-old woman (Mrs A), on behalf of Mrs A's son. Mrs A was admitted to the Royal Alexandra Hospital (the Hospital), in the area of Greater Glasgow and Clyde NHS Board (the Board), in September 2006 with stomach pain and constipation. The complainant said the admission should have been made several days earlier and that the inadequate treatment received in the Hospital might have contributed to Mrs A's death later that month in the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) out-of-hours doctors should have admitted Mrs A to the Hospital earlier (not upheld);
• (b) Mrs A's care and treatment in the Hospital were inadequate (upheld); and
• (c) the Board lost some of Mrs A's medical records (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that all appropriate healthcare professionals in the Board's hospitals are made aware of the appropriate management of constipation in older people; and
• (ii) reflect on the lessons learnt from this complaint and take appropriate action to help avoid a recurrence.

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

Overview

The complainant (Mrs C)'s 19-year-old son had a dental operation at St John's Hospital (the Hospital) in the area of Lothian NHS Board (the Board). His learning disability meant he did not have the mental capacity to make his own decisions about treatment or consent, nor to understand much of what was happening to him at the Hospital. Mrs C complained that she did not have the chance to withhold her consent to all the work being done at one session because she considered that the large volume of work should have been spread across more than one surgical session. She said that she had not been told before the operation of the possibility of so much work. She added that the amount of work done at the one session had caused her son such distress that, amongst other things, he had been chewing his lip, which she said had become an open, infected, sore.

Specific complaint and conclusion

The complaint which has been investigated is that informed consent to the operation was not properly sought (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to seek informed consent;
• (ii) satisfy themselves that relevant administrators and healthcare professionals at the Board have an appropriate knowledge and understanding of the Adults with Incapacity (Scotland) Act 2000, its Code of Practice and other relevant guidance;
• (iii) share lessons learnt from this case across their hospitals and disciplines;
• (iv) use the events of this case as part of their induction and other training programmes about consent and about communication with carers etc who have a legal say in decisions about the medical treatment of an adult with incapacity;
• (v) ensure that the Board's Consent Policy, in relation to obtaining consent in writing, is followed;
• (vi) advise clinicians across the Board's hospitals that recording only key points of consent discussions will not be sufficient in some cases; and
• (vii) consider revising their consent form in respect of adults with incapacity.