Health

Overview
Mr and Mrs C complained to NHS Lothian Health Board (the Board) on 24 October 2006 about the treatment and management of medical care provided to their late son (Master C) by the Board's Child and Family Mental Health Service (CAMHS) whilst he was a patient during 2000 and 2001. Mr and Mrs C also complained about the subsequent failure of the Board to provide adequate services for the treatment of his mental health in 2001. CAMHS was governed by Lothian Primary Care NHS Trust until 31 March 2004 and was the accountable body during the period of Master C's treatment in 2000-2001. NHS Lothian Health Board (the Board) was the accountable body thereafter who considered and responded to the complaints made by Mr and Mrs C, and subsequently to this office.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed in the care and treatment of Master C during the period 2000 - 2001 (upheld).

Redress and recommendations
The Ombudsman has considered all the information presented to this office, together with the action taken by the Board. It is clear the service failures identified in this report demonstrate systemic failures by the Board. It is evident that the service failures were as a result of poor policy and practice. The Ombudsman is satisfied that the Board, as a consequence of this complaint, demonstrated by the evidence presented to this office detailing improvements to CAMHS since 2001, have undertaken action to remedy the service failures identified in order to improve current services.

The Ombudsman recommends that the Board:

• (i) provides evidence that their patient discharge process for CAMHS is clear and robust and available to patients, parents and carers; and
• (ii) ensures their complaints policy reflects a clear process which outlines a structured, timely approach to gathering information from key personnel involved in the complaint.

Overview
The complainant (Miss C) complained about the care and treatment provided to her cousin (Miss A) by a medical practice (the Practice) before she died from liver cancer on 28 June 2010. The Practice had carried out a large number of liver function tests on Miss A from May 2004 onwards. These showed that her GGT (Gamma-glutamyltransferase – a liver enzyme) levels were high. Miss C complained about the lack of action taken by the Practice in response to the raised GGT levels.

Specific complaint and conclusion
The complaint which has been investigated is that the Practice failed or delayed to act on Miss A's abnormal test results (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) write to Miss C to apologise for the failure to investigate Miss A's abnormal GGT results; and
• (ii) take steps to ensure that in future they investigate cases where the patient has a persistently high GGT level to try to establish the cause.

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

Overview
The complainant (Mrs C) raised concerns about the care and treatment provided by a general practitioner from the out-of-hours service (the GP) to her husband (Mr C) on 2 August 2010. She complained that the GP failed to diagnose Mr C with ischaemic heart disease and admit him to hospital. Mr C died of a heart attack several hours after the GP's visit.

Specific complaint and conclusion
The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide reasonable care and treatment to Mr C on 2 August 2010 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that the failings identified in this report are raised with the GP during his next appraisal, to ensure that lessons have been learned from this case; and
• (ii) apologise to Mrs C for the failures identified in this report.

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

Overview
An MP (Mr C) complained on behalf of the aggrieved (Mr D and Ms B) that out-of-hours doctors employed by Ayrshire and Arran NHS Board (the Board) endangered their infant son (Baby A)'s life by failing, on a number of occasions, to diagnose his twisted bowel.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's diagnosis of Baby A's twisted bowel was unnecessarily delayed (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide training to General Practice and midwifery staff in their area on the assessment and treatment of neonates with bilious vomiting; and
• (ii) apologise to Mr D and Ms B for the failings identified in this report.

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

Overview
On 2 July 2010 an Independent Advice and Support Worker from the Citizens Advice Bureau (Ms C), complained to the Scottish Public Services Ombudsman about Highland NHS Board (the Board) on behalf of her client (Mr A). The complaint was that there had been a failure to identify why Mr A was not healing from a fracture of his left tibia and fibula, sustained whilst playing football in May 2008. Ms C complained that the pain Mr A suffered following his fracture was not assessed properly. She also complained that the clinicians involved in his care did not consider the possibility of any other underlying conditions that may have been present. Mr A was ultimately diagnosed as suffering from osteosarcoma of the left knee.

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

• (a) the Board did not appropriately investigate Mr A's failure to heal from his left tibia and fibula fracture (not upheld);
• (b) Mr A's ongoing pain was not assessed properly (upheld); and
• (c) the Board failed to consider the possibility of the presence of underlying conditions (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the procedures within orthopaedic related departments to ensure they have robust systems in place to identify red flag symptoms;
• (ii) draw the findings of this report to the attention of all clinical staff involved in Mr A's care and treatment throughout the period of 10 May 2008 to 12 May 2009, so that they can learn from it; and
• (iii) provide Mr A with a full apology for the failures identified in this report.

The Board 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 provided to her aunt (Miss A) including failures in communication. Mrs C was also concerned about the way NHS Greater Glasgow and Clyde (the Board) dealt with her complaint.

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

• (a) the care and treatment provided to Miss A during her admission at Glasgow Royal Infirmary in January 2010 was not reasonable (upheld);
• (b) the Board's communication with Miss A's family was not reasonable (upheld); and
• (c) the Board did not deal reasonably with Mrs C's complaints (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure they deal with complaints in accordance with the NHS complaints procedure; and
• (ii) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Mrs C) made a complaint that her daughter (Mrs A) had not received reasonable care and treatment from Greater Glasgow and Clyde NHS Board - Acute Services Division (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to care properly for Mrs A at Inverclyde Royal Hospital, Greenock resulting in her developing a pressure ulcer (upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Mr C) raised a number of concerns about the prescription of antipsychotic drugs to his mother (Mrs A), failures in record-keeping and failures in communication by Greater Glasgow and Clyde NHS Board (the Board) from late 2008 until February 2010.

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

• (a) wrongly prescribed Mrs A with antipsychotic drugs from late 2008 to February 2010 (upheld);
• (b) failed to keep adequate medical records (upheld); and
• (c) failed to communicate properly with Mrs A's family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in Hospitals 1 and 2, on the implementation of the Adults with Incapacity Act and SIGN Guideline 86 for patients with dementia with particular reference to assessment of capacity within 72 hours of admission wherever practicable and report back to the Ombudsman on the findings;
• (ii) carry out an audit of their: record-keeping to ensure it is in accordance with the national guidelines with particular reference to care planning practice; practice relating to the storage of patients' medical records to ensure it accords with the Scottish Government Records Management: NHS Code of Practice (Scotland); and report back to the Ombudsman on the findings;
• (iii) develop a policy on meeting the communication needs of patients with dementia which includes having an identifiable and agreed relatives' communication or participation strategy as a core aspect of the care plan; and
• (iv) apologise to Mr C for the failures identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns regarding the treatment that her father (Mr A) received following admission to Ayr Hospital (the Hospital). Mrs C complained that staff of Ayrshire and Arran NHS Board (the Board) failed to explain the severity of Mr A's condition to family members and that, as a result of this, his family were not with him at his bedside when he died. Mrs C raised further complaints regarding the condition that Mr A's body was in when the family were allowed in to see him and the Board's handling of her formal complaint.

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

• (a) the Board failed to explain properly the nature of Mr A's condition to his family (upheld);
• (b) the Board failed to allow family members access to Mr A during the final hours of his life (upheld);
• (c) the Board failed to respect Mr A's dignity (upheld);
• (d) information provided by the Board in response to Mrs C's complaint was inaccurate (upheld); and
• (e) the clinical records were inaccurate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures for handing over the care of patients between consultants, with a view to ensuring that all relevant information has been shared with family members;
• (ii) review the communication between the consultants and nursing staff in Mr A's case, with a view to identifying any failures in communication from consultant to nurse to family members;
• (iii) give further consideration to Mrs C's comments on the presentation of Mr A's body and take such steps as they feel appropriate to prevent similar upset in the future;
• (iv) take steps to ensure that advice provided to patients' family members is accurately recorded in the clinical records; and
• (v) take steps to ensure that statements relied upon to respond to complaints are checked against documented evidence for accuracy.

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment provided to his mother-in-law (Mrs A) by Borders NHS Board (the Board) and the communication between health care professionals who treated Mrs A and with Mrs A's family. He also raised concerns about the way the Board handled his complaint.

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

• (a) provide reasonable care and treatment to Mrs A leading up to her fall on 28 February 2009 and following her operation on 1 March 2009 to repair her hip (upheld);
• (b) ensure reasonable communication between the health care professionals who treated Mrs A and with Mrs A's family (upheld);and
• (c) deal with Mr C's complaint according to the NHS Complaints Procedure (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence that they have audited staff awareness of the Falls Prevention Strategy and Bed Rail Policy; the knowledge and skills of staff relevant to their effective implementation; and take action to address any knowledge and skill gaps identified by the audit;
• (ii) consider amending the Falls Prevention Strategy and Bed Rail Policy in light of the information in this report;
• (iii) ensure staff are aware of the failures identified in this report in meeting the needs of patients with dementia and to implement training to address this, particularly in rehabilitative care and communication; and
• (iv) apologise to Mr C for the failures identified in this report.

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