Health

Overview

The complainant (Mrs C) raised a number of concerns that she had not consented to the operation as performed and had not consented to a spinal anaesthetic.  Mrs C also complained that there was a lack of follow-up.

Specific complaints and conclusions

The complaints which have been investigated are that Tayside NHS Board (the Board):

• (a) failed to obtain informed consent for spinal anaesthesia (upheld);
• (b) performed an operation which was different to the planned haemorrhoidectomy without appropriate explanation of the new procedure (upheld); and
• (c) failed to provide the necessary follow-up care and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to ensure she adequately understood and consented to the anaesthetic options; and
• (ii) use the events of this case and in particular Mrs C's experience, as part of induction and training programmes about the consent process.

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

Overview

The complainant (Mrs C) raised concerns about the delays in being assessed when she attended the Reproductive Health Department of the Royal Infirmary of Edinburgh (the Department) on 28 May 2005.

Specific complaints and conclusions

The complaints which have been investigated are that there was a delay by staff in:

• (a) examining Mrs C on arrival at the Department (not upheld); and
• (b) checking for Mrs C's baby's fetal heart rate (not upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board, as a matter of urgency, develop and implement:

• (i) a written triage protocol for patients who attend the Department; and
• (ii) a document which records the contents of telephone conversations between patients and the Department and is retained in their clinical records.

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

Overview

The complainant (Mrs C) felt that the death of her husband (Mr  C) could have been avoided had staff of Greater Glasgow and Clyde NHS Board (the Board) been more proactive in diagnosing his condition.  She complained that Mr C's assigned consultant (Consultant 1) should have been more directly involved in his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was not seen by Consultant 1, the consultant that he was referred to at Glasgow Royal Infirmary (not upheld);
• (b) the diagnostic process was unnecessarily delayed (upheld); and
• (c) ward staff did not deal with Mr C respectfully (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider asking the clinical team to review the circumstances of this case to see if there are any lessons to be learned regarding communication with patients and relatives;
• (ii) apologise to Mrs C and her family for the additional distress and suffering caused by the delays to Mr C's diagnosis; and
• (iii) revise their procedures to include written notice to the referring consultant of all failed scan results.

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 provided to her late mother, Mrs A, while she had been a patient at Ayr Hospital (Hospital 1).  She said she felt Mrs A had been wrongly given Diazepam and that the nursing care was inadequate.  She believed that the care had led to a significant deterioration in Mrs A's condition.

Specific complaint and conclusion

The complaints which have been investigated are that:

• (a) the nursing care provided to Mrs A was inadequate (not upheld);
• (b) Mrs A did not receive appropriate treatment and was wrongly prescribed Diazepam (upheld);
• (c) Mrs A's family was not given sufficient time to consider a proposed move of hospital (not upheld);
• (d) Mrs A's transfer to another hospital was carried out inappropriately (no finding); and
• (e) a conversation about Mrs A's treatment was inappropriately held in a public place (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failures in record-keeping, which have made it difficult for the Ombudsman's advisers to fully evaluate Mrs A's care, and for the error in their letter to Mrs C of 5 December 2006 concerning the use of Diazepam in Mrs A's care;
• (ii) provide clinical staff involved in Mrs A's care and the Board's relevant clinical director with a copy of this report; and
• (iii) provide evidence of the systems in place to monitor and audit medical and nursing records.

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mr C) raised a number of concerns about a lack of physiotherapy assessment, provision and follow-up as well as the quality of the in-patient care provided and the overall discharge planning by Tayside NHS Board (the Board) following his late mother (Mrs A)'s admission to Ninewells Hospital, Dundee on 17 February 2006.  Mr C was also dissatisfied with the Board's responses to his concerns which he considered to be deliberately confusing and contradictory.  Mr C considered that these many failures had hastened his mother's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly assess and provide appropriate care and treatment to Mrs A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on the failures identified by the advisers in the management of Mrs A as part of the on-going reviews already being undertaken by the Board;
• (ii) monitor compliance with the revised template for the discharge letter as part of the existing review of record-keeping; and
• (iii) review the Guidelines for (physiotherapy) Referrals and consider specifically how it impacts on those discharged to a nursing home (particularly in light of the advisers' comments that this appears to be discriminating against such patients).

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

Overview

The complainant (Mrs C) said that the death of her husband (Mr C) could have been avoided if staff of Tayside NHS Board (the Board) had done more to establish the extent of his condition.  Mrs C felt that the diagnostic process was unnecessarily delayed and that, had Mr C's liver cancer been diagnosed sooner, it may have been treatable.

Specific complaint and conclusion

The complaint which has been investigated is that the Board took unnecessarily long to diagnose and treat Mr C's condition (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board consider ways to minimise any delays to cases being discussed by the upper gastrointestinal multi-disciplinary team.

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