Health

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, in the Vale of Leven Hospital (Hospital 1) between 26 August 2004 and 6 September 2004. Mrs A was subsequently admitted to Gartnavel General Hospital (Hospital 2) on 10 September 2004 but, sadly, died on 19 September 2004.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a renal ultrasound scan was not performed on admission to Hospital 1 and when one was done at Hospital 2 the results were not acted upon (upheld);
• (b) communication with Consultant 2 at Hospital 2 was inadequate (upheld);
• (c) Mrs A was inappropriately noted as having 'no medical issues' when allowed home on weekend pass (upheld);
• (d) Mrs A was discharged from Hospital 1 without appropriate action (upheld); and
• (e) the discharge letter was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) this case be discussed urgently with Consultant 1 and formally recorded at her next annual appraisal;
• (ii) the clinical team responsible for Mrs A's care in Hospital 1 consider and act on the lessons to be learned as a result of the failings identified in this report;
• (iii) Greater Glasgow and Clyde NHS Board (the Board) remind staff of the need for accurate records to be kept;
• (iv) the Board share with the Ombudsman a copy of the regular audit of communications which is presented to the NHS Board's Clinical Governance Committee; and
• (v) the Board apologise fully and formally to Ms C for the failings 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 quality and quantity of information provided to her late daughter (Miss C) following her diagnosis of epilepsy in April 2006. Mrs C considered that Miss C was denied an opportunity to fully understand the consequences of not taking her prescribed medication on a regular basis and that this may in turn have contributed to Miss C's premature death.

Specific complaint and conclusion

The complaint which has been investigated is that Fife NHS Board (the Board) failed to provide Miss C with adequate information thereby denying her appropriate care and management between April 2006 and her death in October 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide written information to patients following diagnosis on a proactive basis and in line with that recommended in SIGN 70;
• (ii) advise her when the epilepsy nurse-specialist is in post; and
• (iii) apologise to Mrs C that written information about Miss C's condition and changes in her drug regime were not made available to Miss C and that there is no evidence of an individualised decision being made not to tell Miss C about Sudden Unexpected Death in Epilepsy.

The Board have accepted and acted on recommendations (i) and (ii). Recommendation (iii) has not been accepted (see paragraph 48).

The Ombudsman will ask the Scottish Intercollegiate Guidance Network (SIGN) to consider the findings of this report as part of their on-going consideration of the review of the guidelines on Epilepsy in Adults (SIGN 70). Further, in light of the difference in views recognised in paragraph 48, the Ombudsman will ask that the Directorate of Health and Wellbeing consider the need for more research into patient views on information giving and into the possible risk factors for SUDEP and the use of this research to inform ethical guidance.

Overview

The complainant (Mrs C) raised a number of concerns about the services relating to travel provided to her daughter by her GP practice (the Practice).

Specific complaint and conclusion

The complaint which has been investigated is that the Practice failed to provide services relating to travel in accordance with the relevant regulations from February 2008 to date (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ceases immediately its policy for charging for all travel advice;
• (ii) as far as possible, refunds patients it has charged wrongly; and
• (iii) amends its policy in light of the regulations.

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 provided to her daughter (Ms A) who had mental health problems. Ms A's treatment was provided by Clinical Psychologists and was then transferred to a Community Psychiatric Nurse.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms A's treatment from the Clinical Psychologists was withdrawn inappropriately (not upheld); and
• (b) explanations provided to Mrs C and Ms A were inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Mrs C and Ms A for the failures identified in this report;
• (ii) remind staff that clinical decisions should be documented and of the importance of doing this; and
• (iii) remind staff that adequate explanations of clinical decisions need to be provided to patients.

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

Overview

The complainant (Mr C) raised a number of concerns about the response he received from Greater Glasgow Health Board (the Board) following an investigation by the Mental Welfare Commission for Scotland into the care and treatment which his late son (Mr A) received at Gartnavel Hospital, Glasgow (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the level of medical supervision for the senior house officer who decided on Mr A's mental health state and supervision status during the period 15 March 2001 to 21 March 2001 was inadequate (upheld);
• (b) the Board's response that a care plan was agreed by all staff was incorrect (upheld);
• (c) the charge nurse failed to act on an instruction in Mr A's medical notes that he was not allowed to leave the ward unless accompanied by members of staff (upheld); and
• (d) the Board have not accepted responsibility for failing in its duty of care or offered an appropriate apology (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) give consideration to amending the risk assessment tool to include issues such as impulsivity or when the patient's state of mind is unknown; and
• (ii) offer Mr and Mrs C a full apology for the failings in care which have been identified in this report.  The Ombudsman draws the Board's attention to the SPSO guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

Overview

The complainant (Mrs C) raised concerns about her husband's care and treatment at Dunoon General Hospital (Hospital 1) on 14 June 2006. She complained that medical staff did not consider a diagnosis of acute meningitis when they were considering her husband's diagnosis, and that his transfer to Inverclyde Royal Hospital (Hospital 2) was delayed. Following the decision to transfer her husband (Mr C), he became very unwell and, sadly, he died in Hospital 1 on 14 June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that: (a) an alternative diagnosis of acute meningitis was not considered when a diagnosis of stroke was given to the family on Wednesday 14 June 2006 (not upheld); and (b) there was a delay by Hospital 1 in arranging Mr C's transfer to Hospital 2 on 14 June 2006 (not upheld).

Redress and recommendations

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

• (i) ensure that the local redesign process currently being undertaken between the Board and the Scottish Ambulance Service covers the need for medical staff to have access to the most up-to-date details of inter-hospital transfer times and with all the relevant transportation matters clearly established at the time (of arranging the transfer); and
• (ii) review their acute unit transfers policy to take account of changing patterns of acute stroke management.

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

Overview

The complainant, Mr C, complained that treatment received by his late wife, Mrs C, was inadequate and that staff failed to diagnose that she was suffering from melanoma.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment Mrs C received from 2004 was inadequate and staff failed to diagnose that Mrs C was suffering from melanoma (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review their procedures, in line with the findings of this report, for the carrying out of biopsies on patients diagnosed with cancer and having a similar history to that of Mrs C;
• (ii) consider the findings of this report in relation to removing complaints from the NHS Complaints Procedure and consider subsequently reinstating them if dealing with future complaints resulting from similar circumstances; and
• (iii) write to Mr C with an apology for the distress caused by 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 the care and treatment she received while attending Inverclyde Royal Hospital (the Hospital) on 8 June 2006. She also complained that Greater Glasgow and Clyde NHS Board (the Board) failed to satisfactorily respond to her in good time, following the concerns she raised about the care and treatment she received from the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms C received inadequate care and treatment from the Hospital on 8 June 2006 (partially upheld to the extent that there were failings in obtaining consent and in communicating with her regarding the administering of the local anaesthetic (LA));
• (b) the Board's final response, dated 5 June 2007, did not address Ms C's complaint satisfactorily (upheld); and
• (c) the Complaints Department of the Board failed to respond to Ms C in good time, after she complained to them about the care and treatment she received at the Hospital she attended for recurring breast cancer surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the way in which the decision to administer the LA was communicated to Ms C;
• (ii) remind staff of the correct procedures to be followed when obtaining consent prior to surgery taking place;
• (iii) apologise to Ms C for their unsatisfactory final response to her complaint; and
• (iv) apologise to Ms C for the delay in responding to her complaint.

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

Overview

The complainant (Ms C) raised concerns that she and her two children were inappropriately removed from their GP practice (the Practice)'s list because her partner (Mr B) was removed for abusive behaviour.

Specific complaint and conclusion

The complaint which has been investigated is that Ms C and her children were inappropriately removed from the Practice's list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ensure that their policy on the removal of patients from their list complies with the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 and is within the spirit of the guidance available;
• (ii) ensure they have followed the Regulations and considered and followed alternative courses of action before removing a patient from their list; and
• (iii) apologise to Ms C for inappropriately removing her and her children from their list.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which his wife (Mrs C), who was suspected of having multiple sclerosis (MS), received from a consultant neurologist (Consultant 1) at Western Isles Hospital (the Hospital) between October 2006 and February 2007.  Mr C also complained about the behaviour of Consultant 1 and the Western Isles NHS Board (the Board)'s handling of the complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) between 18 October 2006 and 21 February 2007 Consultant 1 provided Mrs C with an inadequate level of treatment (not upheld);
• (b) Consultant 1 behaved inappropriately when he learned that Mrs C had made a complaint against him (upheld); and
• (c) the Board's handling of the complaint was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) Consultant 1 apologise to Mrs C for the comments he made about her in  his letter to the GP dated 22 August 2007; and that the Board:
• (ii) ensure that this report is shared with Consultant 1's appraiser and is discussed at Consultant 1's next annual appraisal;
•  (iii) carry out an audit to ensure that complaints are being dealt with in accordance with the timescales as stated in the NHS complaints procedure;
• (iv) remind staff who deal with complaints or are subject to complaints of their obligations to act in accordance with the guidance as stated in the NHS complaints procedure; and
• (v) apologise to Mr and Mrs C for the failings which have been identified in this report.

The Board have accepted recommendations (ii) to (v) and will act on them accordingly.  As at the date of issue of this report Consultant 1 has not accepted recommendation (i).