Health

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her husband (Mr C) by Forth Valley NHS Board (the Board) at Stirling Royal Infirmary (the Hospital) from 3 April 2006 until his death on 27 July 2006. Mrs C also raised concerns about the way in which the Board handled her complaint.

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

• (a) the Consultant's actions denied Mr C the opportunity to make informed choices about treatment and end of life care and the Board failed to follow the Liverpool Care Pathway (upheld);
• (b) the Board failed to acknowledge the failings of the Consultant or to make changes or improvements to address the failings (upheld); (c) there was an unnecessary and lengthy delay in the Board's handling of the complaint (upheld);
• (d) the notes taken at a meeting with the Board's representatives did not fully and accurately detail the depth of Mrs C's concerns and the outcome she wished to achieve (upheld); and
• (e) Mrs C's request for a meeting with the Consultant was refused unreasonably (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake an external peer review in the Hospital, to include: • the procedures relating to the management of biopsies, including communicating biopsy results; the current strategy for the policy of Living and Dying Well, with particular reference to the implementation of the Liverpool Care Pathway and the role of consultants; the education and training of staff, particularly consultants, relating to end of life care;
• (ii) ensure that the failings identified in this report are raised with the Consultant during his next appraisal, to ensure lessons have been learned from this case;
• (iii) provide evidence about how feedback from complaints is used as part of the consultant appraisal process;
• (iv) review their procedures to ensure they investigate complaints fully, in accordance with the NHS Complaints Procedure, with particular reference to timescales; and
• (v) 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 (Ms C) raised a number of concerns about the way the relevant medical history of her late partner (Mr A) was initially obtained by Borders NHS Board (Board 1) and provided to Lothian NHS Board (Board 2). She also complained that prior to the decision to operate, Board 2 failed to obtain a full medical history from Mr A and that had they done so, the operation may not have proceeded.

Specific complaint and conclusions
The complaint which has been investigated is that Board 1 and Board 2 failed to ensure all the relevant medical history was obtained prior to the decision to operate on Mr A. There are two elements to this:

• (a) Board 1 failed to ensure all relevant medical history was provided to Board 2 (not upheld); and
• (b) Board 2 failed to ensure a full medical history was obtained during the consultation prior to surgery (upheld).

Redress and recommendations
The Ombudsman recommends that Board 1:

• (i) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Ombudsman recommends that Board 2:

• (ii) apologise to Ms C for the failures identified;
• (iii) ensure Consultant 2 reflects on this report so he can review his practice on taking patients' medical history, including when it would be appropriate to request full medical records; and
• (iv) revise their respective policies in relation to existing medical records protocols to ensure that in appropriate cases, all health professionals have direct access to patients' records.

The Board 1 and Board 2 have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Ms C) raised concerns on behalf of her client (Mrs B) that a Scottish Ambulance Service crew failed to recognise the seriousness of her daughter (Ms A's) condition when they responded to Mrs B's emergency telephone call. This resulted in a delay in transferring Ms A from Mrs B's home to the hospital with fatal results. Ms C was also dissatisfied with how the Scottish Ambulance Service (the Service) had dealt with this complaint.

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

• (a) failed to provide appropriate care and treatment to Mrs B's daughter (upheld); and
• (b) delayed in investigating the matter and failed to keep Mrs B updated (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i) review the protocol for ambulance crews to ensure it gives clear guidance to staff about the relative roles of different crew members in the assessment of patients;
• (ii) assess this protocol to demonstrate and evaluate that it is properly understood by ambulance crew;
• (iii) ensure that measures are undertaken to feedback the learning from this incident to avoid similar situations recurring;
• (iv) review their methods for learning from complaints and introduce comprehensive, dated action plans for follow-up action specific to each complaint;
• (v) introduce a method of ensuring that any wider learning from complaints is fully integrated into the governance structure of the Service; and
• (vi) issue Ms C and Mrs B with a formal written apology for the failures identified in this report.

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

Overview
The complainants, Mr and Ms C, raised a number of concerns about the midwifery care and treatment provided to Ms C from 15 January 2009, prior to her admission to the Southern General Hospital (the Hospital) on 17 January 2009. Following admission later that day, their baby daughter (Baby C) was stillborn.

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

• (a) the ward based telephone assessment procedure was inadequate (upheld); and
• (b) there was a failure to identify the changing presentation of Ms C prior to admission (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) conduct an audit of the telephone triage system introduced in January 2010, to ensure its effectiveness;
• (ii) remind midwifery staff of the need to fully record and document all telephone contacts to ensure continuity of care when more than one telephone contact is made and more than one member of staff has been involved in handling the calls;
• (iii) conduct an audit to ensure appropriate midwifery staffing levels are being maintained;
• (iv) consider amending the Review to take into account the Adviser's comments at paragraph 24; and
• (v) provide a full apology to Mr and Ms C for the failures identified in this report.

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

Overview
The complainant (Mr C)'s father (Mr A) was admitted to Queen Margaret Hospital (the Hospital) after falling and breaking his left hip. Mr C raised a number of concerns relating to the care and treatment that Mr A received during his stay at the Hospital. He complained that Fife NHS Board (the Board) failed to maintain adequate standards of ward cleanliness, resulting in Mr A picking up two hospital-acquired infections. He also complained about the nursing care Mr A received, noting that his father had fallen four times whilst staying at the Hospital, on one occasion fracturing his right hip. Mr A died at the Hospital. Mr C raised further concerns regarding the Board's failure to contact his family in time for them to be with Mr A at the time of his death.

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

• (a) there was a lack of care and compassion by the nursing staff on Ward 14 when Mr A fell four times (upheld);
• (b) there was a lack of cleanliness in Ward 14 (not upheld);
• (c) there was a lack of concern from nursing staff in Ward 20 when Mr A's family highlighted that his blood pressure reading appeared high (not upheld);
• (d) Mr A contracted MRSA twice (not upheld);
• (e) the Board failed to inform Mr A's family of the rapid decline in his clinical condition or to contact them prior to his death (upheld); and
• (f) the Board failed to remove a catheter tube from Mr A's body (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the circumstances surrounding Mr A's falls with a view to identifying, and rectifying, underperformance in the practical implementation of their falls management and dementia care policies and procedures; and
• (ii) review the circumstances leading to Mr C's complaint and consider introducing measures to improve communication with patients' families.

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

Please note that this Report contained a typographical error in paragraph 2. It should read:

5 October 2009.

Overview
The complainant (Mrs C) made a complaint about the care and service provided to her husband (Mr C) by the Scottish Ambulance Service (the Service) in transporting Mr C to and from an Endoscopy out-patient appointment at Crosshouse Hospital in Kilmarnock. Mrs C also complained about the care and treatment provided to Mr C by Ayrshire and Arran NHS Board (the Board) while waiting for his out-patient appointment at the Hospital.

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

• (a) the care and service provided to Mr C by the Service were not reasonable (upheld); and
• (b) the care and treatment provided to Mr C by the Board was not reasonable (upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i) remind all crews in the South West Division to contact their Area Service Office and await instructions if cancellations on their patient list would mean that other patients would be transported to hospital several hours before their appointment time; and
• (ii) remind all crews in the South West Division of the importance of passing on relevant information about a patient's needs following an outbound journey, such as whether a stretcher facility is required for a return journey, to their Area Service Office.

The Ombudsman recommends that the Board:

• (iii) ensure that a record is made of the time a patient is admitted for their procedure and also of all advice given to patients on admission by nursing staff. This requirement should be incorporated into the new guidance;
• (iv) remind nursing staff of the importance of treating people as individuals, even in a very busy unit, as set out in the NMC Code; and
• (v) provide him with evidence of audit and evaluation of the first six months' operation of the new guidance and action plan for dealing with vulnerable adults arriving for Endoscopy appointments.

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

Overview
The complainant (Mrs C) complained about the treatment for a nut allergy provided to her daughter (Miss C) by a GP (the GP), prior to her daughter's death from anaphylaxis. In particular, Mrs C complained that an EpiPen (an auto injector of adrenaline) had not been prescribed to Miss C. Mrs C also complained about the tone and manner of the GP when she telephoned four days after her daughter's death.

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

• (a) the care and treatment provided to Miss C by her GP for a nut allergy prior to her death from anaphylaxis was inadequate (upheld); and
• (b) the tone and manner of the GP when she telephoned four days after Miss C's death were inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that:

• (i) the GP write to Mrs C to apologise for failing to discuss the letter of 1 August 2007 with her.

The Practice has accepted the recommendation to issue an apology and will act on it accordingly.

Further Action
Faced with the lack of national guidance on adrenaline auto injector prescription, there is a danger of inconsistency in approach with potentially devastating consequences. Introducing national guidance could be a safeguard against this. A national paediatric allergy network that has been set up could take this forward and build upon the work already done by Greater Glasgow and Clyde NHS Board. The Ombudsman will draw this matter to the attention of the Scottish Government Health and Social Care Directorate.

Overview
The complainant (Mr C) raised a number of concerns about the treatment which his late wife (Mrs C) received when she attended Aberdeen Royal Infirmary (the Hospital) as a day patient on 18 March 2010. Mrs C fell and fractured her hip while receiving chemotherapy treatment but the fracture was not identified on x-ray and she was discharged home. Mrs C received a telephone call from a consultant oncologist at the Hospital (the Consultant) on 22 March 2010 and was told that she had to return to hospital as the fracture had been identified when he had reviewed the x-ray. Mrs C was admitted to the Hospital that day but her condition deteriorated and she died on 26 March 2010.

Specific complaint and conclusions
The complaint which has been investigated is that the care and treatment which Mrs C received at the Hospital on 18 March 2010 was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) bring this report to the attention of the On-call doctor's clinical supervisor and determine whether there is a training requirement for the interpreting of x-rays; and
• (ii) formally apologise to Mr C for the On-call doctor's failure to correctly interpret the x-ray on 18 March 2010.

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

Overview
The complainant (Mrs C) complained about the transfer of her son (Mr A) to the Intensive Psychiatric Care Unit (the IPCU) at Carseview Centre (the Centre), Ninewells Hospital (Hospital 1), Dundee, on 8 January 2008. Mr A had been transferred from the Forensic Unit (the Unit), Murray Royal Hospital, Perth, where he was being treated under a Compulsory Treatment Order (CTO). She also complained that, on 16 January 2008, Mr A was granted a period of escorted leave within the vicinity of the Centre, from where he was able to abscond. Mrs C complained that when Mr A returned to the IPCU that same evening, he was not provided with adequate physical care and treatment. Mr A died in the early hours of 17 January 2008.

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

• (a) Tayside NHS Board (the Board)'s decision making processes to transfer Mr A from the Unit to the IPCU at Hospital 1 were unclear (upheld);
• (b) the decision taken to allow escorted leave from the IPCU was inappropriate for Mr A on 16 January 2008 (upheld); and
• (c) Mr A's physical care and treatment was inadequate on his return to the IPCU from a period of unescorted leave on 16 January 2008 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) urgently review their procedures for the transfer of patients under a CTO to ensure that non urgent transfers are properly categorised and dealt with as such; and that decisions are properly recorded;
• (ii) ensure that, where there is a statutory right of appeal against the decision to transfer, the appropriate persons are formally notified of that right;
• (iii) ensure that every consideration is given for the named person to have the opportunity to provide their views formally and for these views to be recorded and considered as part of the decision making process;
• (iv) ensure that decisions taken about the level of leave allowed during any episode of care and the level of escorts are explained and understood by the patient and their relatives (where appropriate) and a full record is made of these;
• (v) consider the introduction of a locally based alert system within the vicinity, which would enable staff to draw attention to potential incidents sooner than the time taken to return to the ward;
• (vi) review the escort arrangement at the IPCU for accompanied time out, to ensure that the arrangement is clinically appropriate in terms of the risk assessment for the patient;
• (vii) provide training to ensure the adequate medical examination, nursing observation and assessment of vital signs within the IPCU, when managing a patient recently having consumed an illicit substance;
• (viii) ensure that there is appropriate consideration for review of the procedure or protocol for referring a patient to the local Accident and Emergency department for further consideration of physical care and treatment when they admit to having consumed illicit substances;
• (ix) remind staff of their professional responsibilities towards the care and treatment of a patient received into their care with or without prior advice provided by other professional disciplines;
• (x) conduct an audit to ensure full compliance of the use of assessment tools and measures and completion of monitoring charts and vital signs monitoring charts;
• (xi) ensure that this report is shared with all staff involved in Mr A's care when he returned to the IPCU on 16 January 2008, so that they can learn from the findings of this report; and
• (xii) provide an apology 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 (Mr C) made a complaint about Grampian NHS Board (the Board). Mr C complained about the care and treatment he received for wounds and pressure sores; and the attitude of a Consultant Plastic Surgeon (Consultant 1). Mr C also complained about the Board's handling of his complaint.

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

• (a) Consultant 1 did not care for and treat Mr C's wounds and pressure sores appropriately (upheld);
• (b) Consultant 1 did not understand and direct the vacuum assisted closure (VAC) treatment of Mr C's wounds appropriately (upheld);
• (c) Consultant 1's attitude towards Mr C was inappropriate and he discriminated against Mr C because of his age and disability (not upheld); and
• (d) the Board's handing of Mr C's complaint, including the investigation, was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their approach to team care for wounds and pressure sores such as Mr C's, to ensure a cohesive plan of management;
• (ii) review their protocols for the use of VAC treatment to ensure that it is used appropriately in conjunction with other treatments for relief of pressure sores pre-operatively;
• (iii) remind staff of the importance of good record-keeping;
• (iv) review their processes to ensure they obtain responses from relevant staff when investigating complaints; and review their processes for recording the investigation of complaints; and
• (v) apologise to Mr C for the failings identified in this report.

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

Please note that this report contained typographical errors in three of the recommendation dates.  The three recommedation completion dates that were recorded as 2010 should have been 2011.

The SPSO has apologised for these errors.