Health

Overview

The complainant (Mr C) alleged that the prescription of Pramipexole medication was inappropriate in his care and treatment for Parkinson's disease. He also complained that there was a failure in the follow-up care provided for him in the early part of 2006.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was inappropriately prescribed Pramipexole after his care transferred to the Southern General Hospital (the Hospital) in June 2005 (not upheld); and
• (b) there was a failure of appropriate support and monitoring of Mr C's condition during the early part of 2006 (partially upheld to the extent that it is possible alternative support services could have been considered as part of Mr C's care).

 Redress and recommendations

The Ombudsman recommends that the Board:

•  (i) ensure that clear agreements, in writing if possible, are made between patients, clinicians and where appropriate, family members, about the plan of care and a patient's responsibility regarding the information expected from them during treatment; and
• (ii) remind clinical colleagues of the potential referral opportunities which may be available to augment aspects of patient care and to discuss these with colleagues and patients as appropriate.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the clinical treatment that his father (Mr A) received whilst under the care of Greater Glasgow and Clyde NHS Board (the Board).  He believed that staff at Glasgow’s Victoria Infirmary failed to give due consideration to Mr A’s previous medical history and that, had they done so, his death in December 2006 could have been avoided.  Mr C also complained that the medication prescribed for another of Mr A’s conditions was unsuitable and that it potentially contributed to his deterioration.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board inappropriately treated Mr A with Methotrexate (not upheld);
• (b) the Board failed to take adequate note of Mr A’s past medical history when treating him (upheld);
• (c) the Board failed to proactively seek information relating to Mr A’s past medical history (upheld);
• (d) the Board inappropriately reduced Mr A’s steroid dosages before the full extent of his illness was known (upheld); and
• (e) Mr A’s death certificate did not accurately reflect the cause of death (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) formally apologise to Mr C and his family;
• (ii) remind all staff of the importance of sourcing and reviewing historical clinical records;
• (iii) review their record-keeping practices and introduce procedures to ensure the prompt identification, sourcing and provision of historical clinical records;
• (iv) considers ways to promptly source specific records relating to relevant information raised by patients and their families; and
• (v) ask the clinical team to review the circumstances of this case to see if there are any lessons that can be learned regarding the diagnosis and treatment of organising pneumonia.

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

Overview

The complainant (Mr C) raised concerns about Tayside NHS Board (the Board) on behalf of his wife (Mrs C) about the fact that her contact details were not updated in her medical records and that this resulted in mail being sent to the wrong address.  He also raised concerns that the Board failed to respond to his complaint until he contacted them to follow this up.

Specific complaints and conclusions

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

• (a) update their records of Mrs C's address and GP practice despite being notified of these on several occasions (upheld); and
• (b) efficiently respond to Mr C's complaint (not upheld).

Redress and recommendations

The Board have already taken steps to remedy the failings identified and the Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the treatment she received at Wishaw General Hospital after she was diagnosed with cancer in 2006.

Specific complaint and conclusion

The complaint which has been investigated is that a consultant inappropriately told Mrs C that, '[T]here is no doubt at all that all the cancer has been removed and currently you are cured', in a letter dated 16 March 2006.  Mrs C subsequently had a recurrence of the cancer (upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board) apologise to Mrs C for inappropriately telling her that, '[T]here is no doubt at all that all the cancer has been removed and currently you are cured'.

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

Overview

The complainant (Mr C) was diagnosed as having multiple sclerosis (MS) in an Edinburgh Hospital in September 1973.  The consultant who made the diagnosis decided not to tell Mr C of his condition.  Mr C found out that he had MS in May 2005 after referral to a neurologist but only discovered his earlier diagnosis in September 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's GP practice failed to inform him of a longstanding diagnosis of MS (not upheld); and
• (b) Mr C's MS was not identified or taken into account when he was receiving treatment from Fife NHS Board (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) attended the Royal Infirmary of Edinburgh (Hospital 1) for spinal surgery.  Complications of surgery left him with nerve damage and restricted mobility.  Mr C complained that staff of Lothian NHS Board (the Board) carried out his surgical procedure incorrectly and that hygiene standards and staff attitudes were poor during his stay at Hospital 1.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to perform Mr C's spinal surgery correctly (upheld);
• (b) hygiene standards at Hospital 1 were poor (upheld); and
• (c) the Board's staff acted unprofessionally when dealing with Mr C (no finding)

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) introduce a policy of carrying out appropriate diagnostic scans prior to any exploratory surgery;
• (ii) formally apologise to Mr C; and
• (iii) remind all ward staff of the procedure to be followed in the event of a linen shortage.

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

Overview

The complainant (Mrs C) raised a number of concerns, alleging that the community dentist (Dentist 1) fitted a denture which had been incorrectly prepared.  Also, she was unhappy about the clinical decision which was taken to proceed with treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the community dentist (Dentist 1) proceeded with treatment using an incorrectly prepared denture (upheld); and
• (b) Mrs C subsequently disagreed with the decision taken, to continue with treatment without regard to the stressful circumstances which applied (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) identify and evaluate the measures which are now in place to prevent this occurring again;
• (ii) consider the use of a pre-extraction appointment to ensure full understanding of a treatment plan;
• (iii) draw up guidelines to consider management and consent when a patient is under particular stress;
• (iv) consider the development of a pro-forma to jointly support all clinicians' agreement that the denture made is correctly prepared; and
• (v) ensure that a full apology is made to Mrs C for the distress and discomfort caused as a result of the treatment option followed in this particular case.

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 of her 64-year-old husband (Mr C) on Ward 58, a high dependency unit in the Western General Hospital (the Hospital), Edinburgh.  He had been transferred there on 1 August 2006 after several weeks on other wards in the Hospital and had a cardiac arrest there on 5 August 2006.  Sadly, he died later that day in an intensive care unit of the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C’s care and treatment from 1 to 5 August 2006 on Ward 58 were below a reasonable standard (upheld); and
• (b) Lothian NHS Board (the Board)’s complaint handling time was not in accordance with the NHS Complaints Procedure (upheld).

Redress and recommendation

The Ombudsman recommends that the Board put in place rigorous measures to address each of the five shortcomings arising from the leaking central line.

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

Overview

The complainant, Mr C, complained about the lack of clinical follow-up for his ear, nose and throat complaint and that a Consultant Surgeon (the Consultant) did not refer him for a further clinical opinion.  He also complained that Greater Glasgow and Clyde NHS Board (the Board) took over three months to respond to his formal complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) no action was taken for seven months to identify the cause of the symptoms of Mr C’s condition (not upheld);
• (b) the Consultant did not refer Mr C to another specialist for an opinion (upheld); and
• (c) the NHS took over three months to respond to the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind the Consultant of the importance of clear communication with patients, to assist their understanding of any potential diagnosis or otherwise, when symptoms are still present;
• (ii) ensure that staff clearly record the outcome of a clinical decision regarding a second opinion; and
• (iii) review their internal procedure for investigating and resolving complaints and consider ways to improve their response times to complaints.

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

Overview

The complainants, Mr C and Ms A, raised a number of concerns that, following a routine laparoscopy investigation for an infertility problem at Stirling Royal Infirmary (the Hospital) on 9 August 2005, Ms A was admitted as an emergency patient to the Hospital on 12 August 2005 and received inadequate care and treatment.  Thereafter, Mr C and Ms A also complained that Forth Valley NHS Board (the Board) had not treated Mr C and Ms A either appropriately or fairly as patients of their Infertility Service (the Service).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms A received inadequate care and treatment from the Hospital (not upheld); and
• (b) the Board's infertility service made matters worse (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.