Health

Overview
Mr C was admitted to the Western General Hospital, Edinburgh, after suffering a brain haemorrhage.  On the following day, during the Consultant Neuroradiologist's attempt to clot the blood vessels, the catheter ruptured and glue escaped which caused Mr C to have a stroke.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the cause of the rupture was that the syringe containing the glue was pushed too hard, causing too much pressure on the catheter (not upheld);
(b) the risk of the catheter breaking and the risk associated with the use of that particular catheter were not disclosed to Mr C (partially upheld);
(c) Mr C was not informed of alternative treatments available to him (upheld);
(d) Mr C was not allowed a cooling off period to make a decision about treatment (upheld);
(e) Mr C's consent to the procedure was inadequately documented (upheld);
(f) the incident was not properly recorded or investigated (not upheld);
(g) the explanation of what had happened given to Mr C and his wife was inadequate (no finding); and
(h) Lothian NHS Board (the Board) whitewashed the incident (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) provide her with details of the outcome of their review of their current consent policy, taking into account 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive  on 16 June 2006, especially for neurosurgical and radiological interventions;
(ii) advise her of the outcome of their review of their Incident/Near Miss Reporting and Investigation procedure;
(iii) take steps to ensure that where explanations are given in situations such as this they are properly recorded; and
(iv) apologise to Mr C for the shortcomings identified in this report.

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

Overview

The complainant, Mrs C, complained on behalf of her husband, Mr C, about the nursing care he received while he was a patient in Raigmore Hospital.

Specific complaint and conclusion

The complaint which has been investigated is that while Mr C was in Raigmore Hospital he failed to receive appropriate nursing care in that proper hygiene (in relation to his skin) was not given and sustained (upheld).

Redress and recommendations

The Ombudsman recommends that the Board write to Mr and Mrs C apologising for the condition of Mr C's skin on his discharge from hospital.  Further, she suggests that where the risk of skin ulcers has been identified, as in Mr C's case, an appropriate care plan be formulated and followed.  Thereafter, on discharge, a record be made in the notes confirming whether or not the situation has been resolved.

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

Overview

The complainant (Mr C) raised concerns about the treatment he received at Monklands Hospital (the Hospital), which resulted in the removal of his right kidney.  Mr C had been told by staff that it was suspected a lump on his right kidney was cancerous and that removal of the kidney was required.  Following the operation, Mr C was advised by staff that the removed kidney was non-cancerous.  Mr C had concerns that staff took the decision to remove the kidney without taking a biopsy of the lump and the manner in which he was informed of the pathology of the removed kidney.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) staff acted unreasonably in removing Mr C's kidney before a definitive diagnosis had been made on the suspected cancerous lump (not upheld); and
• (b) the manner in which Mr C was informed of the result of the pathology report of his removed kidney was insensitive (upheld).

Redress and recommendations

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

• (i) reflect on the Adviser's comments in relation to the way in which the consent was documented and consider whether they need to make any changes to procedure; and
• (ii) make Mr C a further full and meaningful apology.

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

Overview

The complainant, Mr C, complained that, despite the fact that Forth Valley NHS Board (the Board) felt unable to treat him, they did not refer him elsewhere.  In the circumstances, he felt that he had to pay for his eye operation.  He believed that he should be refunded the costs involved.

Specific complaint and conclusion

The complaint which has been investigated is that, although the Board felt unable to treat Mr C, they did not refer him elsewhere (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board write to Mr C expressing their sincere regret that an opportunity to consider all the options in relation to his future treatment was lost.

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

Overview

The complainant (Mrs C) cancelled her planned hysterectomy at Borders General Hospital (the Hospital).  She complained that poor administration by staff of Borders NHS Board (the Board) led to the temporary loss of her clinical records, leaving her with doubts as to the competence of the staff that were caring for her.  Mrs C also had a number of concerns over the treatment that she was offered and did not feel that sufficient consideration was given to her family's medical history or her reaction to certain medications.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) administration and staff communication at the Hospital were poor (upheld);
• (b) staff at the Hospital provided conflicting information about Mrs C's iron levels (not upheld);
• (c) staff at the Hospital did not acknowledge the severity of Mrs C's gluten intolerance (not upheld); and
• (d) staff at the Hospital inappropriately recommended a hysterectomy as the best treatment for Mrs C's condition (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their record tracking procedures and ensures that all staff are reminded of their responsibilities as far as updating the tracking system whenever records are forwarded to another party.

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

Overview

The complainant (Mr C) raised a number of concerns about the podiatry treatment which he had received from a podiatrist (the Podiatrist) of Western Isles NHS Board (the Board) on 7 December 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to provide Mr C with appropriate podiatry treatment (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the diagnosis of her husband (Mr C) and his treatment for small bowel obstruction.  Specifically, she raised concerns that Mr C's GP Practice (the Practice) had delayed referring him to hospital and that the treatment provided by Highland NHS Board (the Board) was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice failed to timeously diagnose Mr C with small bowel obstruction and to refer him to hospital for treatment (upheld); and
• (b) the Board failed to provide appropriate care and treatment for Mr C (not upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for their failure to review Mr C following her telephone call on 1 August 2006;
• (ii) review their protocol for telephone consultations to ensure that patients are seen by a doctor when necessary in order to exclude more serious diagnoses; and
• (iii) consider the management of severe abdominal pain over the telephone.

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

The Ombudsman has no recommendations in respect of the Board.

Overview

The complainant, Ms C, raised a number of concerns about the delay in obtaining an appointment at Neurosurgery Out-Patient Services at the Southern General Hospital (Hospital 1).  This was arranged by Highland NHS Board (the Board) as part of Ms C's ongoing treatment for back pain.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Orthopaedic Consultant Service contracted from NHS Greater Glasgow and Clyde failed to refer Ms C to the Neurosurgeon within Hospital 1 in September 2005 (upheld); and
• (b) the complaint response from the Board did not address the complaint that was raised (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review the current pilot in progress and let her know the outcome;
• (ii) consider introducing a system to ensure that a referral has been received by the receiving clinic;
• (iii) provide a local contact for a patient to be able to enquire about their referral;
• (iv) apologise to Ms C for the additional wait experienced as a result of the delay in treatment;
• (v) ensure they have a mechanism in place to follow up on any outstanding issues when an offer of a meeting, as part of local resolution in line with the NHS complaints procedure, has been made and declined;
• (vi) ensure, where appropriate, that they consider if there are any problems which may be faced by a complainant offered a meeting to discuss a complaint and the venue for the meeting is not local to the complainant; and
• (vii) apologise to Ms C for not providing a further response to her complaint.

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

Overview

The complainant, Ms C, was concerned that, a few weeks after discharge from the Raigmore Hospital (the Hospital) following treatment for an obstructed gallbladder, her father, Mr A, was diagnosed with advanced pancreatic cancer.  Sadly, Mr A died shortly after this diagnosis.  In her complaint to the Ombudsman, Ms C was concerned that clinical staff at the Hospital had failed to detect this cancer and, in particular, questioned the quality of an ultrasound examination and why this was regarded as conclusive of Mr A’s diagnosis despite contrary symptoms.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A’s ultrasound examination was not carried out with due care (not upheld); and
• (b) in arriving at his diagnosis, Mr A’s consultant did not take into account symptoms which conflicted with the ultrasound and, in particular, a CT scan should not have been cancelled (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

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.