Health

Overview

The complainant (Mrs C) was concerned that she had not been offered appropriate treatment when she was seen by a doctor (Doctor 1) during an out-patient appointment at the Western General Hospital.

Specific complaint and conclusion

The complaint which has been investigated is that Doctor 1 failed to provide Mrs C with appropriate treatment (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainant (Mr C) complained on behalf of his wife (Mrs C), concerning the care and treatment she received prior to being diagnosed as having ovarian cancer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C's care and treatment were inadequate and, despite her history of breast cancer and an ovarian cyst, no follow-up appointment was made for her in November 2003 (upheld);
• (b) in Mrs C's circumstances, a hysterectomy should have been considered much earlier (not upheld); and
• (c) Mrs C's treatment was dictated by financial concerns (not upheld).

Redress and recommendations

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board) proffer a sincere apology to Mrs C for the failure to treat her properly.  Further, in view of the Consultant's comments about not doing anything differently, and given the Board's comments at paragraph 15, the Ombudsman requests that the Board provide her with a copy of the 2008 audit of Guideline 34.

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

Overview

The complainant (Ms C) raised concerns that her brother (Mr A) was unable to walk without aids after his discharge from Hairmyres Hospital (the Hospital) and that this had not been detected prior to his discharge.

Specific complaint and conclusion

The complaint which has been investigated is that Mr A’s mobility was not adequately assessed prior to his discharge from the Hospital (upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board) remind relevant staff of the need to take measures to prevent foot drop and to record all relevant information in patients’ clinical records.

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

Overview

The complainant (Mr C) raised concerns regarding his removal from his general practitioner (GP)'s list of patients.  Mr C was unhappy with the circumstances surrounding this removal and he felt that the correct procedures were not followed by his Medical Practice (the Practice).

Specific complaint and conclusion

The complaint which has been investigated is that the Practice did not follow the correct procedures in removing Mr C from their list of patients (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review their removal procedures in line with the guidance and regulations governing the removal of patients from practice lists. Revised procedures could incorporate suggested wording for warning and removal letters, ensuring that patients are quoted relevant timescales and advised of all options available to them; and
• (ii) apologise to Mr C for their failure to follow the correct procedure in removing him from their list.

The Practice 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 her mother (Mrs A) received in Stirling Royal Infirmary (the Hospital) between her admission on 7 May 2006 and her death on 28 May 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A's care and treatment while a patient in the Hospital in May 2006 was inadequate (upheld).

Redress and recommendations

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

• (i) apologise to Miss C for the failures identified in this report;
• (ii) remind all their doctors of the importance of appropriate recording of working and differential diagnosis; and
• (iii) ensure that two of the consultant surgeons (identified in this report as Consultant 1 and Consultant 2) reflect on these events at their next annual review.

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

Overview

The complainants, Mr and Mrs C, raised a number of concerns about a sequence of events which occurred when they attended the Medical Centre for an appointment with the Community Dentist (the Dentist), on 22 September 2006, for Mrs C to receive dental treatment.  Mr and Mrs C complained that the treatment Mrs C expected to receive on that day was refused.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist refused to treat Mrs C on 22 September 2006 as she could not lie completely flat on the dentist's chair (not upheld);
• (b) the Dentist told Mr C to go to a private dentist (no finding); and
• (c) Mrs C did not receive any information that there was a Senior Dental Officer for Special Care Dentistry consulting at the Medical Centre, until after she complained about the events of 22 September 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment that her uncle, Mr A, received in Vale of Leven Hospital (Hospital 1), between his admission on 23 January 2006 and his transfer to Gartnaval General Hospital (Hospital 2) on 8 February 2006.  Sadly, Mr A died on 8 March 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A was given inconsistent advice (no finding);
• (b) Mr A's pain was not managed effectively between 28 January and 8February 2006 (upheld);
• (c) Mr A's pressure sore could have been avoided (upheld);
• (d) Mr A should have been referred to the vascular surgeons more quickly (upheld);
• (e) Mr A's room was not clean and this contributed to his illness (not upheld); and
• (f) Mr A was inappropriately referred to as a problem patient (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to ensure they respond in full to formal complaints;
• (ii) ensure that the clinical team responsible for Mr A's care in Hospital 1:
• (a)  review this report; consider what lessons can be learned from Mr A's experience and review how pain is managed effectively;
• (b)  are aware of the need for accurate records to be kept; and 
• (c)  utilise best practice statements on Pressure Ulcer Prevention and the Treatment and Management of Pressure Ulcers issued by NHS Quality Improvement Scotland (March 2005 and November 2005);
• (iii) audit the use of MRSA screening on Ward 14 and report back to her proof of review and change in practice;
• (iv) ensure that the clinical team consider the lessons to be learned as a result of the failings identified in this report and report back to her changes in practice put in place as a result; and
• (v) apologise to Ms C fully and formally 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 care and treatment that her husband had received before his death in Bo'ness Hospital on 30 March 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C was not allowed to visit her husband, because of an outbreak of the winter vomiting virus in his ward in the days leading up to his death in Bo'ness Hospital in March 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.