Health

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment provided to his mother, Mrs A at Monklands Hospital (the Hospital) and the Beatson Oncology Centre (the Centre).  The Hospital is managed by Lanarkshire NHS Board (Board 1).  The Centre is managed by Greater Glasgow and Clyde NHS Board (Board 2).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unacceptable delay in the Hospital making a correct diagnosis (upheld);
• (b) the Hospital's decision to operate on Mrs A was incorrect (upheld);
• (c) Mrs A's prognosis was not adequately explained to the family by either the Hospital or the Centre (partially upheld); and
• (d) Mr C's complaints about the conditions in the Hospital ward were not dealt with appropriately (upheld).

Redress and recommendations

The Ombudsman recommends that Board 1 apologise to Mr C for the delay in making the diagnosis and for making the incorrect decision to operate.

The Ombudsman recommends that both Boards apologise to Mr C for the fact that Mrs A's prognosis was not adequately explained to the family and review the way that a poor prognosis is explained to patients and their families.

The Ombudsman will send a copy of this report to SIGN for their consideration when Guideline 61 on post-menopausal bleeding is reviewed later this year.

Overview

The complainant (Mr C) raised a number of concerns about the treatment he received when he attended the Accident and Emergency Department at Stirling Royal Infirmary (the Hospital) on 24 June 2007, following a road traffic accident.

Specific complaint and conclusions

The complaint which has been investigated is that Mr C received inadequate treatment when he attended the Accident and Emergency Department at the Hospital on two occasions on 24 June 2007, following a road traffic accident (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board:

• (i) apologise to Mr C for the failings identified in this report;
• (ii) share this report with the Senior House Officer so that she can reflect on her actions; and
• (iii) consider using the circumstances of this complaint in an anonymised form as a learning tool for junior staff working in Accident and Emergency.

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 which her late mother, Mrs A, received at the Royal Infirmary of Edinburgh (the Hospital) in August 2007.  Mrs C complained that there were delays in carrying out a CT scan and for Mrs A to be seen by a dietician.  She also complained that there were communication problems with the staff.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a delay in carrying out a CT scan following Mrs A’s admission to the Hospital (upheld);
• (b) it was inappropriate for staff to assume Mrs A was suffering from bowel cancer and this compromised her treatment plan (not upheld);
• (c) there was a delay in Mrs A being seen by a dietician and to ensure she received an adequate level of nutrition (upheld); and
• (d) the level of communication with Mrs A’s family was inadequate (upheld).

Redress and recommendations

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

• (i) give consideration to whether communication links between clinical and radiology staff require review in view of the findings in this report;
• (ii) conduct a review of the current procedures for requesting a CT scan at the weekend, to ensure that patient care is not compromised, should the status of the request be downgraded;
• (iii) conduct an audit of the clinical and nursing records in the ward, to ensure that they are completed in accordance with the guidance issued by the regulatory bodies such as the General Medical Council and the Nursing and Midwifery Council;
• (iv) reflect on Adviser 1’s comments about the lack of urgency in the clinical investigation and consider whether the degree of patient orientation or clinical leadership at ward level is appropriate;
• (v) review their policies for nutritional assessments and dietetic referrals and consider whether nursing staff would benefit from the implementation of a robust education programme related to meeting the nutritional needs of older people in hospital, with clear links to Food, Fluid and Nutritional Care Standards (NHS Quality Improvement, Scotland NHS Scotland September 2003);
• (vi) should provide evidence of clinical benchmarking of ‘Communication’, which is clearly linked to Standard 8 Clinical standards for older people in acute care (Clinical Standards Board for Scotland October 2002), to ensure that this aspect of practice is audited and there is demonstrable evidence of improvement in this aspect of care delivery; and
• (vii) issue Mrs C an apology for the failings which have been identified in this report.

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

Overview

The complainants raised a number of concerns about the care of their late mother (Mrs A) while she was a patient at Stobhill Hospital, Glasgow and Glasgow Royal Infirmary between January and August 2007.  In particular, they raised concerns about unnecessarily prolonged admission due to acquired infections, quality of food, lack of mental and social therapy, management of hearing aids, communication with family members and information about MRSA.

Specific complaints and conclusions

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide appropriate care to Mrs A between 14 January 2007 and her death on 31 August 2007 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) give consideration to the introduction of recorded, validated mental tests on admission for older people (whether the patient is considered confused or not) by way of a base-line assessment to assist in future diagnosis;
• (ii) review policy for handling of hearing aids and assistance available particularly in light of Mrs A’s experience;
• (iii) advise her of the action plan resulting from the November 2007 audit of Ward 45, Ward 46, and Ward 47 at Stobhill Hospital, Glasgow, and
• (iv) advise her of the action plan resulting from the Rehabilitation and Assessment Directorate review of the ‘patient day’.

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

Overview

The complainant (Miss C) raised a number of concerns about the medical and nursing care and treatment of her 74-year-old mother (Mrs A) at Ninewells Hospital in the few months up to her death in a hospice in August 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A’s care from May to August 2006 was below a reasonable standard (partially upheld - only in respect of record-keeping).

Redress and recommendations

The Ombudsman recommends that Tayside NHS Board (the Board) provide the Ombudsman’s office with evidence of appropriate monitoring of the guidelines about long-term feeding lines for diabetic patients.

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

Overview

The complainants (Mr B and Mrs C) raised a number of concerns about the care and treatment of their late mother (Mrs A) during her final admission through Accident and Emergency at Inverclyde Royal Infirmary in February 2006.  They were also concerned about the manner in which their complaints had been dealt with by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) failed to provide appropriate care to Mrs A on 14 and 15 February 2006 (upheld); and
• (b) failed to respond promptly and appropriately to Mr B and Mrs C's complaints (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise in writing to Mr B and Mrs C for the failure to provide appropriate care to Mrs A and her family on the 14 and 15 February 2006 and the failure to respond to their complaints in a timely and effective manner.

The Ombudsman recognises that a number of other changes introduced by the Board and NHS Scotland avoid the need for further recommendation, although she notes with concern the time taken to introduce some of the changes and the negative impact several structural reorganisations had on this complaint.

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

Overview

The complainant, Mr C, broke his leg while playing rugby.  He complained about his treatment at Queen Margaret Hospital (the Hospital), where the Accident and Emergency doctor (the Doctor) diagnosed a soft tissue injury.  Mr C was also dissatisfied about how his complaint was handled.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's fracture was not diagnosed (upheld);
• (b) Mr C's indication of the location of the pain was ignored both by the Doctor and the bank radiographer (no finding);
• (c) different treatment would have been provided, had the fracture been diagnosed earlier (not upheld); and
• (d) Mr C's complaint was not handled adequately (upheld).

Redress and recommendations

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

• (i) share this report with the Doctor and the clinicians in the Accident and Emergency Department to allow them to reflect on it; and
• (ii) remind staff of the importance of obtaining information from all staff, including locum and bank staff, in relation to complaints; and
• (iii) remind staff to respond to complaints in a timely manner or to request an extension if they are unable to do so, in line with the NHS complaints procedure.

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

Overview

The complainant (Mrs C) raised a number of concerns about the level of nursing care which her late husband (Mr C) received at Borders General Hospital (the Hospital) during two admissions in 2006 and 2007.

Specific complaint and conclusions

The complaint which has been investigated is that, during two admissions to the Hospital in 2006 and 2007, staff failed to ensure that Mr C received an adequate level of nursing care (upheld).

Redress and recommendations

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

• (i) conduct an audit of the cleaning regime which is in use throughout the Hospital and advise her of the outcome;
• (ii) provide evidence of the systems in place to monitor and audit the nursing notes (which would include patient assessment and the care plan);
• (iii) remind staff of the importance to record incidents of injury to patients in the nursing records, in addition to completing incident reports;
• (iv) provide evidence that there are measures in place to monitor compliance with the Administration of Medicines Policy; and
• (v) share this report with the Senior Charge Nurse on the ward and consider, in light of the issues which have been raised, whether additional education and development is required.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment she received for a fractured arm at her community hospital (Hospital 1), following a fall on 24 October 2006.  Mrs C attended Hospital 1 from 24 October 2006 to 12 December 2006 but remained unhappy with the treatment she received and eventually referred herself to a major hospital (Hospital 2) for treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) further to Mrs C’s attendance at Hospital 1, from 25 October 2006, staff failed to arrange a follow-up x-ray (upheld); and
• (a) the management of Mrs C’s injury was inadequate (upheld).

Redress and recommendations

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

• (i) apologise to Mrs C for the failure to carry out a repeat x-ray; and
• (ii) develop a protocol for the management of patients who attend community hospitals with fractures, as suggested by the professional medical adviser.

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

Overview

The complainant (Mrs C) said that a neck injury prevented her from being able to lie in the conventional, fully recumbent, position in a dentist’s chair.  Her dentist (the Dentist) refused to treat her, as a back problem prevented him from working on patients that were not in the conventional position.  Mrs C had to find another dentist that would treat her in a more comfortable position.  Mrs C complained about the dental practice (the Practice)'s handling of her situation and the attitude of the Dentist and other staff at the Practice.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist unfairly refused to treat Mrs C (not upheld);
• (a) the Dentist failed to provide appropriate information to help Mrs C access the dental treatment that she required (no finding); and
• (b) the Practice’s complaint handling was poor (not upheld).

Redress and recommendations

The Ombudsman draws the Dentist’s attention to the General Dental Council Standards for Dental Professionals guidance, which suggests producing a public version of the Practice’s complaints procedure that can be prominently displayed and made easily available to patients.