Health

Overview
The complainants (Mr and Mrs C) raised a number of concerns that, during four attendances at Ninewells Hospital (Hospital 1) during July and August 2007, Tayside NHS Board (the Board) had not taken their concerns for the health of their infant daughter (Child C) seriously, that Child C had not been adequately examined and that her condition had not been investigated appropriately. They were also concerned that the Board's handling of their subsequent complaints was not adequate due to the time taken to respond to the complaints. They also felt the quality of the review the Board undertook was poor and the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the written evidence. Following Child C's final attendance, the Board sent a letter to Child C's GP. Mr and Mrs C complained that this letter contained inaccurate and unnecessary comments, and that sending it was inappropriate.

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

• (a) the Board did not appropriately examine, diagnose and treat Child C at four attendances in July and August 2007 (partially upheld to the extent that further investigations of Child C's condition should have been undertaken in August 2007 and she should have been admitted on 16 August 2007);
• (b) the Board did not respond appropriately to Mr and Mrs C's complaint of 24 August 2007 (partially upheld to the extent that the Board's conclusion that there had been a change in Child C's clinical condition, following her final attendance at Hospital 1, was not supported by the available written evidence); and
• (c) the Board's letter of 3 September 2007 to Child C's GP was inappropriate in the circumstances (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr and Mrs C that further investigations of Child C's condition were not undertaken and that she was not admitted on 16 August 2007;
• (ii) review the decision-making in this case with the appropriate Board staff at their next appraisals; and
• (iii) apologise to Mr and Mrs C that the conclusion that Child C's clinical condition had changed between 16 August 2007 and 17 August 2007 was not supported by the available written evidence.

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

Overview
The complainant (Mrs C) raised a number of concerns about the lack of psychology and other adolescent mental health services available to her daughter (Miss A) by Tayside NHS Board (the Board). In particular Mrs C was concerned that a failure to provide Miss A with appropriate services led to an escalation of Miss A's depression and subsequent eating disorder which ultimately contributed to her death by suicide in 2007. Mrs C also complained that her attempts to raise her concerns with the Board received a patchy and slow response that did not recognise the ongoing importance of the concerns she was raising.

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

• (a) provide Miss A with access to appropriate psychology services (upheld);
• (b) provide Miss A with access to appropriate eating disorder services (upheld); and
• (c) handle Mrs C's complaint in a timely and appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise in writing to Mrs C for all the failures identified in this report;
• (ii) review the current service provision of family therapy to adolescents with eating disorders; and
• (iii) consider the introduction of an Integrated Care Pathway designed around the NHS Quality Improvement Scotland and NICE guidelines on the management of anorexia.

Overview
The complainant (Ms C) raised a number of concerns about her treatment by Tayside NHS Board (the Board), following the delivery of her first child by emergency caesarean. Ms C said that she suffered major blood loss after her discharge from hospital and had to be re-admitted. Ms C explained that the Board tried various procedures to control her bleeding which proved unsuccessful and eventually carried out a hysterectomy. Ms C said she wanted to know why 'a healthy 24 year old woman goes into hospital to have her first baby and comes out unable to have any more children and nearly dies in the process'.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment Ms C received from the Board, following the delivery of her first child, was inappropriate (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board ensure that, in future, good contemporaneous notes are made following delivery by caesarean section.

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

Overview
The complainant (Mr C) raised concerns regarding the care and treatment received by his late mother (Mrs A) at the Royal Infirmary of Edinburgh (the Hospital). Mrs A underwent surgery on 27 June 2007 for the removal of a pelvic cyst and a hysterectomy and Mr C was unhappy with the level of information provided prior to the surgery; the appropriateness of the decision to operate; the handling of the surgical complications and the timing of Mrs A's discharge. The specific points of complaint are listed below.

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

• (a) the consent process was not properly carried out and there was insufficient communication with regard to operative risks (partially upheld to the extent that the doctor obtaining consent did not have the appropriate level of seniority and experience);
• (b) the surgical decision-making process was inappropriate (upheld);
• (c) the surgical complications were not dealt with appropriately (upheld); and
• (d) Mrs A was discharged prematurely from the Hospital (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review their procedures to ensure that the process of obtaining patient consent is carried out by a clinician with an appropriate level of seniority and experience, ideally the doctor who will be carrying out the surgery;
• (ii) review their procedures to ensure that there is consultant involvement in decisions to proceed to surgery and in decisions regarding the type of surgery to be carried out;
• (iii) reflect on the delay in identifying Mrs A's intra-abdominal bleed and implement an action to prevent similar future failures;
• (iv) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective; and
• (v) apologise to Mr C for the failings identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns that her mother (Mrs A) had not been reasonably cared for or treated by medical staff at St John's Hospital (the Hospital) or her GP practice (the Practice) in the months before her death, and that the responses to Mrs C's enquiries and complaints by Lothian NHS Board (the Board) and the Practice had not been appropriate and had been unnecessarily distressing to her.

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

• (a) the Board did not provide reasonable care and treatment to Mrs A between May 2007 and February 2008 (partially upheld to the extent that the investigation, diagnosis, care and treatment of Mrs A from November 2007 to February 2008 was not reasonable);
• (b) the actions taken by the Board in response to Mrs C's complaints about the care and treatment of Mrs A were not reasonable (upheld);
• (c) Mrs A did not receive adequate care and treatment from the Practice between November 2007 and February 2008 (partially upheld to the extent that the Practice did not reasonably address or follow-up the symptoms that Mrs A displayed which can be linked to cancer, that the Practice's prescription of pills rather than other forms of treatment to Mrs A was not reasonable, that the Practice did not reasonably take into account changes in Mrs A's condition and that the level of information recorded in Mrs A's notes was not comprehensive); and
• (d) the Practice's responses to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing (partially upheld to the extent that, although the Practice appropriately responded to some of Mrs C's enquiries and complaints, some of the Practice's responses, or lack of responses, to Mrs C's enquiries and complaints were inappropriate and unnecessarily distressing).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A's family that the chest x-ray of 26 November 2007 was mis-reported and that this led to a delay in the diagnosis of Mrs A's cancer;
• (ii) remind medical staff that letters to GPs should be dictated immediately after consultations with patients;
• (iii) encourage the practice of discussing patients with atypical clinical features at multi-disciplinary meetings;
• (iv) take steps to assure themselves of the quality of their chest x-ray reporting service;
• (v) apologise to Mrs C that the investigation of her complaints did not uncover the mis-reporting of the chest x-ray of 26 November 2007; and
• (vi) ensure that investigations of similar complaints in the future consider the possibility that x-rays, scans, test results or similar may have been mis-reported.

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs A's family for those aspects of her care and treatment that were not reasonable;
• (ii) produce a plan for reviewing their adherence to national guidelines. This plan should be minuted and form part of the Practice's clinical governance meetings. The minutes should be inspected by the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these issues;
• (iii) ensure that national guidelines are readily available to all practitioners;
• (iv) undertake a review of clinical record-keeping using the Royal College of General Practitioners (Scotland) template on section 3D (2) of the Revalidation Toolkit. The review should be discussed with the Board's clinical governance lead to ensure that the Practice have identified areas for improvement and taken action to address these areas;
• (v) apologise to Mrs C that their responses to her enquiries and complaints were inappropriate and unnecessarily distressing; and
• (vi) review their complaints handling procedure to ensure that complainants are given direct answers to reasonable direct questions, that individual circumstances, distress and stated preferences are reasonably taken into account when suggesting meetings with correspondents and complainants, that it is made clear to correspondents how to set in motion the Practice's complaints procedure and that avoidable errors are reasonably eliminated, taking into account the individual circumstances of a complaint.

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

Overview
The Ombudsman received a complaint from an advice worker (Mrs C) on behalf of a member of the public (Mrs A). Mrs A's daughter, Child A, had a narrowing of the main artery from her heart which needed surgical repair. Mrs A complained that the surgery had left Child A paralysed. She also complained about what she considered was poor communication from Greater Glasgow and Clyde NHS Board.

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

• (a) alleged clinical failure during surgery to repair a coarctation of the aorta (not upheld); and
• (b) poor communication from the Board both before and after surgery (not upheld).

Redress and recommendation
The Ombudsman has no recommendation to make.

Overview
The complainant (Miss C) complained about her general practitioner practice (the Practice), saying that they had removed her, her mother (Mrs C) and her father (Mr C) from their list of patients.

Specific complaint and conclusion
The complaint which has been investigated is that the Practice wrongly removed Miss C, Mrs C and Mr C from their patient list (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant (Ms C) complained about the care and treatment her client (Ms A) received while she was a patient at Crosshouse Hospital (Hospital 2).

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

• (a) when Ms A was admitted as an emergency to Hospital 2 on 17 December 2007, there was a delay in performing surgery to remove a dermoid ovarian cyst (upheld);
• (b) there was a failure to inform Ms A of the removal of her right ovary and tube until 20 December 2007 - the day after her surgery (upheld);
• (c) there was a failure to take into account Ms A's description of the pain she was suffering while she was an out-patient (not upheld); and
• (d) when Ms A was a patient in Ward 6 of Hospital 2 she was sometimes forgotten about (not upheld).
   

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

• (i) apologise to Ms A for the delay in undertaking her surgery and take steps to ensure that such delays do not recur;
• (ii) inform the Ombudsman of the measures being undertaken to address the issues raised; and
• (iii) take steps to ensure delays in communicating the results of surgery to patients do not recur.

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

Overview
The complainant (Mr C) had part of a lung removed following a diagnosis of cancer at Crosshouse Hospital (Hospital 1). He was subsequently found not to have cancer and Mr C complained that the treatment had been unnecessary. Mr C also said that staff at Hospital 1 had delayed in communicating the change in diagnosis to him and had not answered his questions fully. In addition, Mr C complained that there had been a delay in putting him back on the kidney transplant waiting list and that the response to his complaints by Ayrshire and Arran NHS Board (the Board) had been inadequate.

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

• (a) there had been an error in the diagnosis of cancer, which led to an unnecessary operation (upheld);
• (b) there were problems with the communication to Mr C about the new diagnosis and the response to his questions about this (upheld);
• (c) there had been an unreasonable delay in ensuring Mr C was put back on the kidney transplant list (upheld); and
• (d) the responses to Mr C's complaints were inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake a short, focussed audit of lung fine needle aspirations (FNA)s carried out by the department;
• (ii) review, as a matter of urgency, the clinical use of such FNAs by Hospital 1;
• (iii) emphasise to clinical staff involved the importance of taking and documenting a full clinical history; this matter should be confirmed with Consultant 1 as part of his annual appraisal;
• (iv) emphasise to staff involved the importance of timely and open communication;
• (v) alert staff to the need to ensure appropriate communication with patients and file management, in an effort to prevent the situation recurring, where a patient could be concerned about information placed in his/her file which has not been discussed with him/her;
• (vi) undertake a full review of the operation of their complaints process and the relationship of this to clinical governance, as a matter of urgency;
• (vii) establish why an incident review was not considered and this matter not re considered by the lung cancer multi-disciplinary team and take appropriate steps to ensure that their own policies and procedures are followed by clinical and complaints handling staff; and (viii) make a full apology 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 (Miss C), supporting her mother (Mrs A), raised a number of significant concerns about the care and treatment her father (Mr A) received at Ninewells Hospital, Dundee in the days leading up to his death, from cancer, in June 2008. Miss C was particularly concerned that Tayside NHS Board (the Board) had delivered sub-standard care to her father in a number of important respects such as assistance with feeding, hygiene, cleanliness, management of symptoms and pain as well as failing to accord him dignity and respect. Miss C also complained that hospital staff failed to communicate adequately with Mr A's family about his palliative care or to properly manage Mr A's transfer to a hospice. Miss C was also unhappy with the handling of her complaint.

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

• (a) failed to treat Mr A with all appropriate medical, nursing and personal care and dignity (upheld);
• (b) failed to communicate adequately with Mr A or his family (upheld); and
• (c) failed to deal with Mrs A's complaint in a timely or appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A and Miss C for the failings identified in this report;
• (ii) review their administrative policy for the documentation of the administration of controlled drugs; documentation of patient symptom control; and support to foundation level doctors in the management of terminal patients;
• (iii) review their policy for the insertion of chest drains to include the reporting of chest x-rays following drain insertion and the management and investigation of pain following drain insertion; and
• (iv) review their approach to the documentation of complications of procedures such as chest drains including; i) decisions relating to best management of the complications; and ii) information given to the injured party or their relatives.

The Ombudsman also asks that the Board keep him appraised of progress towards achieving the goals of the Action Plan.

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

Please note this report refers to an Annex 4 (at paragraph 16).  The report does not contain an Annex 4 and we apologise for including the reference.