Health

Overview
The complainant (Ms C) raised a number of concerns that a GP from her mother (Mrs A)'s GP Practice (the Practice) and a consultant psychiatrist working for Fife NHS Board (the Board) prescribed anti-depressants and anti-psychotics to her mother without adequate assessment and had failed to report concerns about potential unprofessional conduct of a nurse to the appropriate organisation.

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

• (a) the Practice unreasonably prescribed anti-depressants to Mrs A based on information from a third party (not upheld);
• (b) the Practice unreasonably changed a routine psychiatric referral to an urgent referral based on information from a third party (not upheld);
• (c) the Practice failed to refer the actions of another health professional, which they knew had given rise to professional concern, to the appropriate authority (upheld);
• (d) the Board unreasonably prescribed medication to Mrs A based on information from a third party (not upheld); and
• (e) the Board failed to refer the actions of a health professional, which had given rise to professional concern, to the appropriate authority (upheld).

Redress and recommendations
There are no recommendations in respect of the Practice.

The Ombudsman recommends that the Board take steps to remind all clinical staff, including Primary Care staff and Family Health Service providers in the Board area, of their professional duty to act when they have a concern about the fitness to practise of a health professional.

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

Overview
The complainant (Mr C) complained on behalf of himself and his family that Lothian NHS Board (the Board) failed to provide reasonable care and treatment to his wife (Mrs C) from 28 September 2007 to 15 January 2008. Mrs C was admitted to the Royal Infirmary of Edinburgh (Hospital 1) following a fall in September 2007. Mrs C suffered a fracture of her left ankle and a plaster cast was applied to her left leg. Mrs C subsequently had an above knee amputation of her left leg. Mr C did not consider this treatment was reasonable given Mrs C's other medical conditions. Mr C further complained that Mrs C contracted a Methicillin-resistant staphylococcus aureus (MRSA) infection while in Hospital 1 and about the overall standard of nursing care that Mrs C received. During the course of my investigation, I also included, as part of the investigation, the standard of record-keeping in respect of Mrs C's medical records.

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

• (a) the plaster cast that was applied to Mrs C's left leg was not appropriate treatment given Mrs C's other medical conditions (not upheld);
• (b) Mrs C contracted a MRSA infection whilst a patient in Hospital 1 (not upheld);
• (c) the standard of nursing care which Mrs C received was inadequate (not upheld); and
• (d) the standard of record-keeping in respect of Mrs C's medical notes was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) undertake a review of the policy for reviewing plaster casts and in particular referral to senior medical staff;
• (ii) encourage the doctor concerned to reflect on the case at their next appraisal;
• (iii) apologise to Mrs C and her family for the failing to review Mrs C's plaster cast which has been identified in head of complaint (a) of this report;
• (iv) provide the Ombudsman with copies of the next Scottish Patient Safety Programme audit documentation in relation to all patient records within the orthopaedics department of Hospital 1; and
• (v) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in head of complaint (d) of this report.

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

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment he received during three Accident and Emergency admissions at Campbeltown Hospital (Hospital 1) on 24 and 26 August 2008.

Specific complaint and conclusion
The complaint which has been investigated is that Highland NHS Board (the Board) failed to provide Mr C with adequate care and treatment at Hospital 1 on 24 and 26 August 2008 (upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Mr C in writing for the failing identified in this report and their failure to provide him with adequate care and treatment on 24 and 26 August 2008.

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 by Western Isles NHS Board (the Board) to her and her daughter (Baby C) before, during and after labour over 29 and 30 April 2007.

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

• (a) did not provide adequate care to Mrs C before and during labour (upheld);
• (b) did not provide adequate care to Mrs C after delivery (not upheld); and
• (c) did not provide adequate care to Baby C after delivery (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to provide adequate care to her before and during labour;
• (ii) reviews the guidelines for the use of electronic fetal monitoring to ensure that they are appropriate; and
• (iii) ensures that clinical staff take note of the findings of this report and make any necessary adjustments to clinical practice accordingly.

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

Overview
The complainant (Mrs C) complained that Greater Glasgow and Clyde NHS Board (the Board) did not correctly diagnose her misplaced vertebra when she attended the Western Infirmary with back pain and 'neurological symptoms'. She was further concerned that the Board did not offer treatment once her condition was diagnosed. Mrs C was also disappointed by the Board's handling of her complaint.

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

• (a) the Board failed to correctly diagnose the severity of Mrs C's spinal problems (not upheld);
• (b) the Board failed to treat Mrs C's spinal symptoms (not upheld); and
• (c) the Board's complaint handling was poor (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider reviewing Mrs C's case with a view to identifying any aspects of the communication between consultants and her GP that could be improved; and
• (ii) consider how NHS Scotland's publication: Can I help you? Learning from comments complaints and suggestions should be taken into account when making decisions on complaint time limits.

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

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment his late mother (Mrs A) received while a patient in Ward 8 (the Ward) of the Royal Victoria Hospital, Edinburgh (the Hospital). Mrs A died, aged 82-years-old, on 7 May 2007 in the Hospital. The complaint is brought by Mr C on behalf of himself, his sister (Mrs D) and other family members. Mr C and his family were also unhappy with the way in which Lothian NHS Board (the Board) dealt with their complaint.

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

• (a) Mr C and his family were given conflicting reasons by nursing staff for Mrs A's move to a two bedded room in the Ward (upheld);
• (b) the language used by nursing staff about Mrs A was inappropriate (upheld);
• (c) the attitude of a staff nurse on the Ward was unacceptable (no finding);
• (d) the attitude of nursing staff towards mobilising Mrs A was reprimanding in manner and unreasonable (not upheld);
• (e) the temperature in the Ward was high and uncomfortable (upheld);
• (f) the conditions in the two bedded room contributed to the speed of Mrs A's decline in the final days of her life (not upheld); and
• (g) the Board failed to handle the complaint from Mr C and his family appropriately (partially upheld).
   

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

• (i) issue Mr C, Mrs D and their family with a formal written apology for the failings identified in heads of complaint (a), (b), (e) and (g) of this report; and
• (ii) audit and update the Action Plan in one year and share the findings with the Ombudsman's office.

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

Overview
The complainant (Ms C), who is an advice caseworker, raised a number of concerns on behalf of her client (Ms A), about the treatment which Ms A had received at the Department of Urogynaecology at the Southern General Hospital, Glasgow (the Department). Ms A had undergone surgery in 2007 and since then has suffered with incontinence, urinary infections, loss of lower body sensation, vaginal discharge and severe pain.

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

• (a) proper informed consent was not obtained prior to surgery (upheld);
• (b) the clinical treatment which was provided was inadequate (not upheld); and
• (c) following surgery, staff failed to take prompt action to establish the cause of Ms A's concerns (upheld).
   

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) review their consent process, to ensure that patients have enough time to digest the information provided by staff and in information leaflets and that sufficient space is available on the consent forms to list what has been discussed;
• (ii) share this report with the staff involved and ask them to reflect on the advisers' comments about considering alternative procedures prior to surgery; and
• (iii) apologise to Ms A for the failings which have been identified in this report.

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

Overview
The complainant (Ms C), who was aged 33, was admitted to the Southern General Hospital in the area of Greater Glasgow and Clyde NHS Board (the Board) in September 2007 and October 2007 with possible cauda equina syndrome (CES). She complained that the decision not to operate near the start of the first admission seriously compromised her condition and that, despite ongoing symptoms and inability to manage her daily life, her discharge home did not include adequate follow-up support.

Specific complaint and conclusion
The complaint which has been investigated is that surgery should have been done near the start of the first hospital admission, there was inadequate communication with Ms C about the nature and outcome of her condition and the after-discharge support was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Ms C for not having operated earlier;
• (ii) reflect on this report's conclusions and take appropriate action in respect of each;
• (iii) satisfy themselves that the consultant in question has an appropriate understanding of CES; and
• (iv) update the Ombudsman's office on the main audit findings and main plans regarding after-discharge support.

Overview
The complainant (Mr C) raised concerns about the care and treatment which his late wife (Mrs C), who had severe Multiple Sclerosis, received from Greater Glasgow and Clyde NHS Board (the Board) during her time in hospital for treatment of her painful right hip. Mr C complained that, whilst in hospital, the Board failed to feed his wife, who required to be fed via a percutaneous endoscopic gastrostomy tube, in a sufficiently upright position, which caused food to pass into her lungs. Mr C said he believed that the Board failed to notice that his wife had then developed a chest infection and provide necessary treatment and that this had resulted in her death.

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

• (a) the Board did not feed Mrs C in a sufficiently upright position (not upheld); and
• (b) the Board failed to notice that Mrs C had developed a chest infection and treat it in time (partially upheld).
   

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for failing to notice that Mrs C had developed a chest infection on 16 February 2007 and provide appropriate treatment at that time and for failing to produce a care pathway for Mrs C when the course of her treatment changed;
• (ii) feed back the adviser 's views on what he considers would have been the appropriate course of treatment for Mrs C on 16 February 2007, to the staff involved in cases of this type and in Mrs C's care, in particular;
• (iii) provide training to staff to ensure that, in all appropriate cases, where the direction of a patient's treatment changes, a new care pathway is devised - this could be by introducing a multi-disciplinary record or audit of documentation;
• (iv) ensure the staff involved in Mrs C's care are made aware of the need to record accurate information on patient mobility in their records;
• (v) review their current policy on the use of special mattresses and beds, incorporating the NHS QIS standards and flowchart; and
• (vi) provide feedback to the staff involved in Mrs C's care on the importance of seeking guidance from a more senior member of the medical team on appropriate treatment and/or to ask technical staff for assistance, in cases where the accuracy of medical equipment, such as a pulse oximeter, is in question.

Overview
The Ombudsman received a complaint from a member of the public (Mrs C). Mrs C complained that her husband (Mr C) had not received the appropriate treatment further to a telephone call to the out-of-hours emergency medical services provided jointly between the NHS 24 and Greater Glasgow and Clyde NHS Board (the Board), during which time it is stated by the family they had been unable to get the service to accept their description of Mr C's illness. He had been out early in the evening and returned home complaining of a headache. Initially, Mr C had been advised to take medication available in the house, rest and let NHS 24 know if there was no improvement. He was admitted to the Southern General Hospital the following morning and died eight days later of subarachnoid haemorrhage. Mrs C complained that there was a delay of 12 hours without treatment for her husband.

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

• (a) NHS 24 failed to provide proper care and treatment to Mr C (upheld); and
• (b) the Board failed to provide proper care and treatment to Mr C (upheld).
   

Redress and recommendations
The Ombudsman recommends that:

• (i) NHS 24 provide an apology to Mrs C and her family for the delay in transferring the necessary clinical details to the correct out-of-hours service;
• (ii) NHS 24 conduct an evaluation into a review of the improvements introduced by NHS 24 as a result of this complaint;
• (iii) NHS 24 ensure call handlers' basic training is developed enough to ensure staff are able to determine how to manage information they are given when a call is made from a service user, and the mechanism to transfer vital clinical information between services is reviewed to avoid mistakes in transmission arising;
• (iv) NHS 24 ensure the algorithms are fit for purpose in so far as they are able to capture the appropriate detailed information to assist the nurses to make the appropriate decisions;
• (v) the Board provide an apology to Mrs C and her family for the delay in picking up on the clinical symptoms described by Mr C and his family;
• (vi) the Board undertake a further review of the triage doctor's clinical practice in order to ensure their understanding of the signs and symptoms of a subarachnoid haemorrhage; and
• (vii) the Board ensure the triage doctor reflects on the lessons of the case, shares it with his appraiser during his next appraisal and is aware of the possibilities of rare diagnoses such as subarachnoid haemorrhage for future work.

NHS 24 and the Board have accepted the recommendations and will act on them accordingly.