Health

Overview
This complaint was brought by the Citizens' Advice Bureau (CAB), acting on behalf of the complainant (Mrs C). Mrs C complained about the standard of care her late son (Mr A) received at the Victoria Infirmary, Glasgow in the area of Greater Glasgow and Clyde NHS Board (the Board). Mr A, a young man aged 27, had been admitted on 9 May 2007, following a referral from his GP, with various symptoms including urinary incontinence, a sore throat, a cough, shortness of breath and facial swelling. He had been dizzy for two days and had had diarrhoea and faecal incontinence the night before admission. He was discharged the following day and died suddenly four days later, alone, at home. The post mortem examination revealed heart muscle disease and evidence of heart failure and it is likely that Mr A died of a sudden irregularity of the speed or rhythm of the heart.

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

• (a) the standard of care Mr A received fell beneath the level expected of medical practitioners (upheld); and
• (b) the Board's responses to the complainant, when Mrs C sought an explanation for Mr A's death, were poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise directly to Mrs C for the serious failings identified in this report;
• (ii) reflect on the medical lessons to be learned from this case and consider appropriate action;
• (iii) produce an action plan, to include education and training, to address the equality, diversity and person-centred care failings identified in this report;
• (iv) apologise to Mrs C and the CAB for the shortcomings identified in this report in their correspondence with them;
• (v) reflect on their handling and investigation of complaints involving the sudden, unexpected death of a patient; and
• (vi) reflect on their handling and investigation of complaints where the family has involved an advocacy organisation such as Action Against Medical Accidents.

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

Overview
The complainant (Mrs C) raised concerns regarding the care and treatment received by her daughter (Miss A) when she attended the Royal Alexandra Hospital with back pain. Miss A was initially treated for a chest infection and referred for physiotherapy in respect of her back pain, however, she was subsequently diagnosed with a spinal infection and Mrs C complained that this was not diagnosed earlier. In addition, Mrs C raised her concerns that Miss A's anti-coagulant medication prevented surgical treatment of Miss A's infection.

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

• (a) there was a delay in referring Miss A for a Magnetic Resonance Imaging scan and, consequently, in diagnosing her spinal infection (upheld); and
• (b) the provision of anti-coagulant medication to Miss A prevented the possibility of surgical treatment of her spinal infection and a potentially more positive outcome (not upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Miss A for the delay in diagnosing her spinal infection;
• (ii) review their process in respect of identifying 'red flag' features in patients and taking relevant action upon identification of these; and
• (iii) ensure that complaints officers accurately reflect clinicians' feedback in their response to complaints.

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

Overview
The complainant (Mr C) complained about the Dental Practice (the Practice) he was registered with. In February 2009 Mr C complained that they failed to provide agreed treatment and were unprofessional in their behaviour toward him and in the service they provided.

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

• (a) Mr C was not appropriately treated by the Practice (upheld); and
• (b) the Practice failed to follow the NHS complaints procedure for Family Health Services (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) urgently implement policies to ensure that clinical information is appropriately recorded and protected, and policies and procedures are in place to safeguard all clinical information generated;
• (ii) take steps to ensure that all staff are aware of these policies and implement them in their working practice;
• (iii) take steps to identify all missing clinical information and to try to retrieve this;
• (iv) apologise to Mr C for the failures identified in this report;
• (v) urgently establishes a complaints procedure in line with the standards set out by the General Dental Council and the NHS complaints procedure; and
• (vi) apologise to Mr C for the poor handling of his complaint.

Overview
The complainant (Mr C) raised concerns regarding the orthopaedic treatment he received at Stirling Royal Infirmary (the Hospital). Mr C was involved in a motor cycle accident on 11 September 2007 and he sustained a fracture of his right tibia. He underwent an operation to treat this fracture on 12 September 2007 and he expressed concern with the standard of this surgical treatment.

Specific complaint and conclusion
The complaint which has been investigated is that a nail inserted in Mr C's right tibia was excessively long and resulted in Mr C suffering unnecessary pain and inconvenience (upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Mr C for the failings identified in this report.

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

Overview
In early 2008, Ms A was diagnosed with osteomyelitis of the maxilla, following investigation at a private hospital. This is a condition where the main bone of the upper jaw (maxilla) has become inflamed and damaged by infection. Ms A had suffered from symptoms since at least 2004 and previously attended at both Borders NHS Board (Board 1) and Lothian NHS Board (Board 2) hospitals. She complained that, despite this, she had not been correctly diagnosed by the NHS and that, as a result, she had had to pay for private treatment. Ms A's complaint was brought to the Ombudsman's office by her MSP (Mr C).

Specific complaint and conclusion
The complaint which has been investigated is that Ms A was not investigated properly and that the diagnosis could have been made sooner by the NHS (upheld).

Redress and recommendations
The Ombudsman recommends that Board 1:

• (i) review their procedures for monitoring and auditing the referral process in light of the problems identified;
• (ii) remind clinicians involved of the need to consider carefully the information provided as part of the referral process;
• (iii) consider the best practice advice made by the Adviser to the Ombudsman; and
• (iv) provide him with reassurance that there has been an improvement in the time taken to review CT scans and discuss them with patients.  He also asks that Board 1notify him when the recommendations have been implemented.

The Ombudsman recommends that Board 2:

• (i) review their procedures for monitoring and auditing the referral process in light of the problems identified;
• (ii) remind clinicians involved of the need to consider carefully the information provided as part of the referral process;
• (iii) consider the best practice advice made by the Adviser to the Ombudsman;
• (iv) undertake a short, focussed audit of record-keeping in the Ear Nose and Throat clinic and the Dental Institute and put in place an action plan to deal with any problems identified; and
• (v) reimburse Ms A for the costs of the private treatment required to identify her condition.

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

Overview
The complainant (Mr C) had carpal tunnel release surgery performed on his left hand in June 2006. Unfortunately, post-operatively, he suffered pain, numbness and swelling in his hand. Mr C raised concerns about the way the operation was performed and also that he was not referred back to the operating surgeon to be re-examined as soon as possible after he complained of adverse symptoms. He has subsequently been told that he has permanent nerve damage.

Specific complaint and conclusion
The complaint which has been investigated is that Lothian NHS Board (the Board) did not provide reasonable care and treatment to Mr C during and following his operation for carpal tunnel syndrome (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reinforce with staff the importance of referring patients back for a consultant review as soon as possible if there are complications or adverse symptoms which need attention; and
• (ii) apologise to Mr C for the failings identified in this report.

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

Overview
The complainant (Mr C) complained that his wife (Ms A) had not received appropriate care and treatment when they both attended the Obstetric Triage Department, Simpson's Centre for Reproductive Health (the Centre), prior to the birth of their baby daughter (Baby A), and that Baby A suffered severe medical complications as a result.

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

• (a) the Centre failed to detect problems with Ms A's pregnancy and failed to carry out appropriate tests when she attended the Centre on 15 and 16 June 2008 (upheld);
• (b) the Centre failed to take Mr C and Ms A's concerns and questions into account on 15 and 16 June 2008 (upheld);
• (c) the Centre failed to give Mr C and Ms A correct advice on 15 and 16 June 2008 or to ensure that adequate follow-up support was in place and offered to Mr C and Ms A on 16 June 2008 (upheld); and
• (d) on 23 June 2008 there was a time lapse of more than 30 minutes (the recommended practice) from the decision to perform an emergency lower uterine caesarean section to the start of this procedure (upheld).

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):

• (i) inform him of the measures being undertaken to address the issues raised within paragraphs 26, 27 and 28;
• (ii) inform him of the measures being undertaken to address the inadequate level of staff interface and communication with Mr C and Ms A at the Centre;
• (iii) inform him of the measures they take to ensure that the practice (when presented with a patient with reduced foetal movement) is adhered to, with reference to NICE Antenatal Guidelines 2008;
• (iv) inform him of the measures undertaken to ensure that the delay which occurred in this case, from decision to 'knife to skin', does not recur in a similar situation; and
• (v) issue Mr C and Ms A with a formal written apology for the inadequate standard of care and treatment Mr C and Ms A received on 15, 16 and 23 June 2008, prior to the birth of Baby A, as identified in heads of complaint (a), (b), (c) and (d).

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

Overview
The complainants (Mr and Mrs C) complained that Lothian NHS Board (the Board) did not re-test Mr C for Huntington's disease (HD) when new, more accurate, testing was introduced in 1993. Mr C had previously been diagnosed as a likely sufferer of the condition, but received a negative result when re-tested in October 2007. Mr and Mrs C said that their belief that the condition would affect Mr C, and potentially their daughters, caused a great deal of anxiety and led them to make certain life choices. They complained that, had re-testing been provided routinely upon the introduction of more accurate tests in 1993, much of the stress placed on the family would have been avoided and different decisions made about their daughters' future.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not act reasonably in failing to re-test Mr C for HD following the introduction of more accurate tests (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind clinicians of the importance of open discussions of available new genetic tests with affected patients in order to enable them to make informed choices; and
• (ii) remind clinicians of the importance of recording such discussions, including relevant information given to patients.

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

Overview
The complainant (Mr C), a caseworker at a Citizens Advice Bureau, raised a complaint on behalf of Mr A about the care and treatment of his late wife (Mrs A) by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to identify that Mrs A had a broken femur, following falls at Stobhill Hospital (the Hospital) in December 2008 and despite concerns about her mobility being raised by her family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) remind staff of the need to carry out and record medical assessments in line with policy;
• (ii) provide him with the results of the audit referred to in paragraph 10; and
• (iii) consider implementing the Adviser's suggestions in paragraph 18.

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

Overview
The complainant (Mr C) raised a number of concerns regarding the treatment his late father (Mr A) received during his admission to Ninewells Hospital (the Hospital). Mr C feels that Tayside NHS Board (the Board) failed to assess Mr A's creatine kinase (CK) level early enough and that the treatment he received for high potassium levels fell short of what could be reasonably expected. Mr C believes that the Board's failure to treat Mr A appropriately resulted in his premature death.

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

• (a) there was a delay in testing CK level (upheld); and
• (b) the Board failed to treat Mr A's elevated potassium levels appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures patients with new and significant muscular weakness, as was found in this case, who are taking statins, should have their CK level checked on admission;
• (ii) the Board issue an apology to the family of Mr A and accept that there was a failure to provide urgent medical treatment;
• (iii) the Board evaluate existing policy in relation to the usage of 12 lead electrocardiograms when determining cardiac risks and provide Mr C and the Ombudsman with the evidence and outcome of this review; and
• (iv) the Board apologise to the complainant and review the way this complaint was handled to see if there are any lessons to be learned for the future handling of complaints.

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