Health

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment provided to his wife (Mrs C) in the weeks leading up to her death in June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Highland NHS Board (the Board) failed to:

• (a) obtain properly informed consent for an operation (upheld);
• (a) manage a 'Do Not Attempt Resuscitation' order properly (upheld); and
• (b) provide reasonable care and treatment to Mrs C from 2004 onwards (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake an audit of operative consent and reflect if further action is needed in light of the results of the audit; and
• (ii) undertake an audit of the use of 'Do Not Attempt Resuscitation' orders and reflect if further action is needed in light of the results of the audit.

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

Overview

The complainants (Mr and Mrs C) raised concerns on behalf of their son (Mr A) about the decision by the Scottish Ambulance Service (the Service) not to send an ambulance for their son and the way the Service handled their complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Service's decision not to send an ambulance jeopardised Mr A's safety (upheld); and
• (a) the Service mishandled the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i) acknowledges to Mr and Mrs C that the wrong decision had been made and apologises for the distress the decision had caused;
• (ii) writes to her outlining the steps it has taken to implement the new guidance so that the assurances can be given to the Ombudsman that the relevant Service personnel, local authorities and organisers of private hire events are clear on the Service’s role; and
• (iii) apologises to Mr and Mrs C for its handling of the complaint.

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

Overview

The complainant (Mr C) raised concerns about the treatment that he received for his urological condition and the fact that he was not appropriately referred for surgery.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Fife NHS Board (the Board) failed to refer Mr C for surgery (upheld);
• (a) the Board did not provide timely follow-up after Mr C's supra-pubic catheterisation (not upheld); and
• (b) unnecessary investigations were carried out prior to Mr C's referral to another hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for failing to list him for surgery; and
• (ii) take steps to ensure that patients are followed up when required.

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

Overview

The complainant (Mr C)'s GP referred him to a Consultant Urological Surgeon at the Southern General Hospital (the Hospital).  After tests, however, Mr C was referred on to a clinic for the treatment of sexual and reproductive health problems (the Clinic).  Mr C's complaints concern his treatment at the Hospital and the confusion surrounding his referral to the Clinic.

Specific complaints and conclusions

The complaints which have been investigated are that Mr C's treatment:

• (a) at the Hospital was unreasonable (partially upheld); and
• (b) at the Clinic was unreasonable (upheld).

Redress and recommendations

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

• (i) apologise to Mr C for the shortcomings identified in this report;
• (ii) offer Mr C an appointment to have a full assessment with the new consultant at the Hospital;
• (iii) audit the Clinic's system of dealing with referrals to ensure it is now working properly and advise her of the outcome; and
• (iv) offer Mr C an appointment to begin therapy with a named counsellor and a further follow-up appointment with the Clinic Consultant.

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

Overview

The complainant (Mrs C) raised a number of concerns relating to her husband (Mr C)'s admission to Ninewells Hospital, Dundee (the Hospital), his treatment during his stay and the way in which her complaint was handled by Tayside NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's belongings were never recorded on his admission to the Hospital (upheld);
• (a) no response was made to Mr C's cardiac monitor sounding an alarm at various points during his stay in the ward and it was entirely ignored during the night (no finding);
• (b) Mr C was given contradictory information about how he could get his cardiac monitor reset (no finding);
• (c) Mr C's pressing of the call button was not answered for one hour (no finding);
• (d) staff on duty in the ward were not appropriately qualified (not upheld); and
• (e) there were inadequacies in the handling of Mrs C's complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to comply with the 'Patients' Funds and Property Procedure' when admitting patients to the ward;
• (ii) ensure that all staff, especially bank nurses, are reminded of the importance of accurate record-keeping; and
• (iii) take action to remind appropriate staff of the need to comply with the relevant procedures, in relation to investigating and responding to complaints within the required timescales.

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

Overview
The complainant (Miss C) raised a number of concerns about the care and treatment received by her mother (Mrs A) in Stobhill Hospital (the Hospital) prior to her death on 11 July 2007.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) despite having suffered Transient Ischaemic Attacks (TIA), Mrs A was discharged without having had a scan to determine the exact cause of her symptoms; in particular, she should not have been discharged after her second TIA (not upheld);
(b) Mrs A was prescribed aspirin, which Miss C said was unsafe (not upheld); and
(c) there was a delay in the Greater Glasgow and Clyde NHS Board (the Board) informing the family that Mrs A had contracted MRSA (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) stress to nursing staff the importance of comprehensive note taking;
(ii) formally apologise to Miss C for the delay in advising that Mrs A had contracted MRSA; and
(iii) emphasise to staff the importance of good communication in keeping family members advised of a patient's changing condition and of recording such conversations in the appropriate clinical notes.

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

Overview
The complainant (Mr C) was referred to an orthopaedic consultant (Consultant 1) at Ninewells Hospital for treatment to his knee and foot.  Before a date for surgery could be arranged, personal circumstances meant that Consultant 1 had to take an extended period of absence from work, at short notice.  Mr C complained that his surgery was unacceptably delayed, as Tayside NHS Board (the Board) did not make adequate arrangements to progress the treatment of Consultant 1’s patients during his absence.

Specific complaint and conclusion
The complaint which has been investigated is that Mr C was subjected to an unacceptably long wait for operations on his foot and knee (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board considers Mr C’s overall treatment plan, and the time taken up by administration, when reviewing their procedures in line with the Scottish Government’s revised waiting time targets.

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

Overview
The complainant (Mrs C) was concerned about the way in which a ward closure in Lynebank Hospital (the Hospital) was handled.  Her niece (Ms A) was resident on the ward.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the closure of a ward in which Ms A was resident was poorly handled (upheld); and
(b) the response to Mrs C's complaint about this matter was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that Fife NHS Board:
(i) apologise to Ms A and Mrs C's husband for the limited time available to prepare for and consult about the move between wards;
(ii) draw on the experience of this ward transfer to review the way in which such moves are planned in future; and
(iii) review the way in which such decisions are documented.

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

Overview
Mrs C complained that there had been a significant delay in diagnosing her late husband (Mr C)'s kidney condition and, further, that he had not been told he was suffering from kidney problems for some months.  Mr C had been treated as an emergency by Crosshouse Hospital in February 2005.  He attended his GP Practice (the Practice) over the following months before being admitted as an in-patient to Ayr Hospital on 19 January 2006 where, sadly, he died on 30 January 2006.  Mrs C said that Mr C had been diagnosed with a serious kidney condition while being treated as an out-patient in June 2005 but that this had never been communicated to him.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) there was a delay in diagnosing Mr C's kidney condition and his treatment for this was inadequate (not upheld); and
(b) information about Mr C's kidney condition was not appropriately communicated to him (not upheld).

Redress and recommendations
The Ombudsman has made no recommendations.

Overview
The complainant (Mr C) raised a number of concerns about the cleanliness of his room in the Royal Infirmary of Edinburgh (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that Mr C's room in the Hospital was not adequately cleaned during his stay (upheld to the extent that any evidence to back up Lothian NHS Board's (the Board) position had been mislaid and that the Board's response to Mr C was not adequately evidenced).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) remind the relevant cleaning contractor of the importance of good record keeping; and
(ii) ensure that they obtain all of the available evidence when investigating a complaint and verify any statements provided during the course of the investigation.

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