Health

Overview

The complainant (Mr C) complained about the treatment he received from his General Practitioner (GP) when he received a house call on 21 January 2005.  He complained that the GP took too long to arrive to visit him, and failed to examine him.  He also complained that the GP delayed referral to the ambulance service to have him transferred to hospital for admission.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the GP took three hours to respond to a request for a house call (not upheld);
• (b) the GP did not carry out a physical examination of Mr C (not upheld); and
• (c) Mr C understood the ambulance was going to be arranged as an urgent case (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns in respect of the treatment provided to his wife by a consultant surgeon (Consultant 1) prior to her death on 11 April 2005.  Additionally, he has stated that both he and his wife were not given a clear picture of her condition and the options for treatment available to her.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1 did not fully consider the surgical options, including seeking opinions of specialists where necessary (not upheld); and
• (b) the communication from Consultant 1 was unacceptable (upheld).

Redress and recommendations

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

• (i) apologise to Mr C for the failure to effectively communicate with both him and his wife;
• (ii) consider using the events of this complaint to inform practise in communicating with patients, particularly when a number of different specialists are involved in care. This consideration should include both communication with patients and family and the recording of such communication in the clinical records; and
• (iii) review their procedures to ensure that all responses provided by them, or on their behalf, to complainants are factually accurate.

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

Overview

The complainant (Mrs C) raised concerns that she had an eye operation at Ayr Hospital (the Hospital) which was performed by a consultant surgeon (the Consultant) on the wrong eye (her right eye) and she has been left blind because of this.  Mrs C also complained that correct procedures were not followed by the senior house doctor who obtained her consent for the operation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was subjected to an eye operation, performed by the Consultant, on the wrong eye (her right eye) (not upheld); and
• (b) Mrs C was asked to sign a consent form for the operation which she could not see and the contents of the form were not read out to her (no finding).

Redress and recommendations

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

• (i) ensure that discussions with patients about treatment is recorded, particularly where a change to the planned operation is made. She also recommends that the Board ensure that the recognised complications arising from surgery are discussed with the patient and a record of the discussion made; and
• (ii) ensure that the Consultant makes certain that his procedure in obtaining consent from patients who are visually impaired is properly recorded in the clinical notes whenever it is followed.

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

Overview

The complainant, Ms C, an advocacy worker complaining on behalf of a woman (Mrs A), raised concerns regarding the care and treatment provided to Mrs A in respect of her bowel operation at the Royal Alexandra Hospital (the Hospital) on 24 February 2003.  Mrs A was unhappy with the lack of information provided to her, her family and her general practitioner (the GP), the timing of her discharge, the failure to timeously diagnose an abscess in her bowel and the failure to arrange a follow-up appointment.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was insufficient communication by the surgical team with regard to operative risks, the complications that arose and the information provided to the GP following discharge (upheld);
• (b) following the operation, Mrs A was discharged prematurely from the Hospital (upheld);
• (c) the clinicians involved failed to diagnose an abscess in Mrs A's bowel within a reasonable time-frame (upheld); and
• (d) a follow-up appointment was not arranged after Mrs A was discharged (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider the way that they currently record episodes of communication. As a minimum, they should remind staff of the importance of recording significant communication episodes between clinical staff and their patients and their carers. These records should include the time and date of such episodes, the parties present, matters discussed and the patient/carer's understanding of the same;
• (ii) consider introducing measures to ensure that any known complications of surgery which occur, and any resultant consequences, are recorded on the discharge sheet and sent to patients' GPs in a timely manner;
• (iii) inform the Ombudsman of any changes that they have made in response to the Scottish Executive Health Department's guidance 'A Good Practice Guide on Consent for Health Professionals in NHSScotland' (June 2006); and
• (iv) consider introducing measures to ensure that biopsy results following local trans-anal surgery are reviewed urgently and any full thickness perforation is specifically recorded in the case notes. When such perforations are recorded and the patient is still in hospital, the Board should take steps to ensure that the patient is not discharged until reviewed by a senior surgeon. When any such results are received after a patient has been discharged, these should be reported immediately to the patient's GP and an urgent review by the surgical team should be arranged.

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

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.

Overview

The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had been wrongly diagnosed as having Bells Palsy by an NHS24 Nurse Adviser (the NHS24 Adviser) after he contacted NHS24 complaining of numbness in his face and index finger, slurred speech and a headache.  Mrs C also complained that Mr C had been informed of the diagnosis inappropriately by the NHS24 Adviser and that he should have arranged for an ambulance for Mr C and treated him as a medical emergency.  Instead, Mr C was advised by the NHS24 Adviser to attend the Primary Care Emergency Centre (PCEC) and an appointment made for him there.

Mr C drove to the PCEC himself and was seen by a GP (GP 1), who made a diagnosis of Transient Ischaemic Attack (TIA).  After this consultation, he was allowed home and advised to see his own GP if he did not begin to feel better.  Mr C then waited in the PCEC car park until Mrs C arrived.  He re-attended the PCEC where, after a 30 minute wait, he was seen by a second GP (GP 2).  Mr C was then admitted to hospital and found to have suffered a stroke.  Mrs C complained about the consultation with GP 1 and the care offered to Mr C by the PCEC and Lanarkshire NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was wrongly diagnosed and informed inappropriately of the diagnosis over the telephone by the NHS24 Adviser (upheld);
• (b) the NHS24 Adviser failed to treat Mr C as a medical emergency and should have arranged an ambulance, instead of sending Mr C to an out-of-hours GP practice (upheld);
• (c) GP 1 diagnosed Mr C wrongly and, therefore, treated him inappropriately (upheld);
• (d) GP 1 did not offer to admit Mr C to hospital (no finding);
• (e) GP 1 failed to record sufficient data about his consultation with Mr C (upheld);
• (f) GP 1 rushed his consultation with Mr C (not upheld) and;
• (g) Mr C waited an unreasonably long time on re-attending the PCEC (not upheld).

Redress and recommendations

The Ombudsman had no recommendations to make in relation to NHS24.

The Ombudsman recommends that the Board:

• (i) ensure that GP 1 shares this report with his appraiser at annual review and that he reflects on the comments made in this report regarding the diagnosis of a TIA;
• (ii) review GP 1’s record-keeping to ensure it meets the required standards of the regulatory bodies; and
• (iii) write to Mr C with an apology for the failures which have been 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 that her husband (Mr C) had been wrongly diagnosed as having Bells Palsy by an NHS24 Nurse Adviser (the NHS24 Adviser) after he contacted NHS24 complaining of numbness in his face and index finger, slurred speech and a headache.  Mrs C also complained that Mr C had been informed of the diagnosis inappropriately by the NHS24 Adviser and that he should have arranged for an ambulance for Mr C and treated him as a medical emergency.  Instead, Mr C was advised by the NHS24 Adviser to attend the Primary Care Emergency Centre (PCEC) and an appointment made for him there.

Mr C drove to the PCEC himself and was seen by a GP (GP 1), who made a diagnosis of Transient Ischaemic Attack (TIA).  After this consultation, he was allowed home and advised to see his own GP if he did not begin to feel better.  Mr C then waited in the PCEC car park until Mrs C arrived.  He re-attended the PCEC where, after a 30 minute wait, he was seen by a second GP (GP 2).  Mr C was then admitted to hospital and found to have suffered a stroke.  Mrs C complained about the consultation with GP 1 and the care offered to Mr C by the PCEC and Lanarkshire NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was wrongly diagnosed and informed inappropriately of the diagnosis over the telephone by the NHS24 Adviser (upheld);
• (b) the NHS24 Adviser failed to treat Mr C as a medical emergency and should have arranged an ambulance, instead of sending Mr C to an out-of-hours GP practice (upheld);
• (c) GP 1 diagnosed Mr C wrongly and, therefore, treated him inappropriately (upheld);
• (d) GP 1 did not offer to admit Mr C to hospital (no finding);
• (e) GP 1 failed to record sufficient data about his consultation with Mr C (upheld);
• (f) GP 1 rushed his consultation with Mr C (not upheld) and;
• (g) Mr C waited an unreasonably long time on re-attending the PCEC (not upheld).

Redress and recommendations

The Ombudsman had no recommendations to make in relation to NHS24.

The Ombudsman recommends that the Board:

• (i) ensure that GP 1 shares this report with his appraiser at annual review and that he reflects on the comments made in this report regarding the diagnosis of a TIA;
• (ii) review GP 1’s record-keeping to ensure it meets the required standards of the regulatory bodies; and
• (iii) write to Mr C with an apology for the failures which have been identified in this report.

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

Overview

The complainant, Ms C, raised a number of concerns about what happened when she attended her GP Practice (the Practice) and about what happened when she subsequently made a complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the treatment provided to Ms C when she attended the Practice on 2 August 2004 was inappropriate (not upheld);
• (b) Ms C's removal from the Practice list was unfair (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice apologise to Ms C for the shortcomings identified in this report;
• (ii) the Practice undertake training on complaint handling and the guidance and Regulations governing the removal of patients from the Practice list and, following this training, the GPs and the Practice Manager meet to discuss and draw up a Practice protocol for complaint handling and, specifically, for removal of patients from their list, a copy of which to be sent to the Board's Medical Director for approval and to the Ombudsman for her information; and
• (iii) GP 1 discusses the issue of how he dealt with this complaint at his next annual appraisal as part of his continuing professional development.

The Practice and GP 1 have accepted the recommendations and will act on them accordingly.

Overview

The complainants (Mr and Mrs C) are tenants of Fife Housing Association Ltd (the Association).  They raised a number of concerns regarding the Association's actions in respect to an extension built by their neighbour (Mrs N) in 2004.

Specific complaints and conclusions

The complaints which have been investigated are that the Association:

• (a) failed at the outset to discuss with Mr and Mrs C the implications of the application for planning consent made by Mrs N (not upheld);
• (b) failed to take appropriate action when Mr and Mrs C reported to them that the extension encroached into Mr and Mrs C's tenancy (partially upheld);
• (c) changed their view, to Mr and Mrs C's detriment, to allow access to Mrs N's builder to carry out underpinning work which could and should have been done from Mrs N's own property (not upheld);
• (d) failed to ensure that undertakings they gave to Mr and Mrs C to permit access to Mrs N's builder were adhered to (not upheld ); and
• (e) failed to take up with Fife Council as building authority, Mr and Mrs C's continuing concerns about the safety of an extension wall (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.