Health

Overview

The complainant (Miss C) raised a number of concerns about the care and treatment that her late father (Mr A) had received before his death.

Specific complaint and conclusion

The complaint which has been investigated is that Grampian NHS Board (the Board) did not provide reasonable care and treatment to Mr A in relation to a referral from his GP for hoarseness (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that all clinical staff are aware that persistent hoarseness should be taken to be a symptom of cancer of the larynx unless proved otherwise;
• (ii) ensure that such cases are dealt with urgently;
• (iii) ensure that endoscopies undertaken to exclude cancer have the direct involvement of a senior trained practitioner;
• (iv) ensure that any junior staff involved in such procedures are adequately trained and supervised and that this is recorded;
• (v) review the way in which the laryngoscopy performed on Mr A in 2005 was carried out to establish if there are any lessons that can be learned and whether further guidelines in relation to such procedures are required;
• (vi)consider further investigation where a laryngoscopy shows no evidence of malignancy, but the patient continues to display laryngeal symptoms; and
• (vii) apologise to Miss C for the failings identified in 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 of his 86-year-old father (Mr A) at one of the hospitals of Forth Valley NHS Board (the Board), Stirling Royal Infirmary (the Hospital), between his admission, following a fall, and his death there, several months later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) aspects of the care and treatment fell below a reasonable standard (not upheld); and
• (b) the Board's handling of the complaint fell below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the psychiatric care and treatment of her late husband (Mr C) who suffered from bi-polar affective disorder.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's GP Practice failed to properly monitor his lithium levels (not upheld);
• (b) Forth Valley NHS Board (the Board) inappropriately discharged Mr C from psychiatric care (upheld);
• (c) the Board failed to provide Mr C with appropriate psychiatric care from October 2005 to October 2006 (not upheld); and
• (d) the Board failed to take Mrs C's input on Mr C's psychiatric condition and requirements (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) develop more effective and practical policies for dealing with a breakdown in doctor-patient relationships and for referring patients between services; and
• (ii) apologise to Mrs C for discharging Mr C without ensuring that necessary support mechanisms were in place.

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

The Ombudsman has no recommendations in respect of Mr C's GP Practice.

Overview

The complainant, Mrs C, raised several concerns about the care and treatment provided to her mother (Mrs A) at Stirling Royal Infirmary, following her admission on 29 May 2006. Mrs A did not respond to treatment and the decision was taken to pursue palliative treatment only. Sadly, Mrs A died on 7 June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was proposed, inappropriately, to send Mrs A to a ward where her family could not be guaranteed to have access to her at all times (upheld);
• (b) the bed managers initiated inappropriate conversation in Mrs A's room (upheld);
• (c) when Mrs A moved from a High Dependency bed, intravenous medication was stopped and no adequate alternative medication was arranged (upheld);
• (d) medical staff failed to review Mrs A's medication (upheld);
• (e) the response to Mrs C's complaint was inadequate and did not address her concerns (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Mrs C for the shortcomings identified in this report and specifically for the actions of the bed managers;
• (ii) review the operation of the Palliative Care Manual in relation to the bed management of terminally ill patients;
• (iii) ensure that this incident is discussed at the bed managers' annual appraisals;
• (iv) remind staff of the importance of documenting concerns raised by patients and their families in the patient's clinical records;
• (v) review their pain management documentation and recording;
• (vi) demonstrate how they will ensure that the two documents Living and Dying Well and Palliative and End of Life Care in Scotland can be implemented and that such change in practice can be reviewed by all hospital staff on a regular basis;
• (vii) conduct an audit in prescription chart recording over a six month period;
• (viii) ensure that night staff recognise when there is a need to contact on call staff to review medication for patients in pain; and
• (ix) ensure that information is obtained from the staff involved to allow complaints to be investigated appropriately and all issues raised in complaints are addressed.

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

Overview

The complainant (Mr C) complained about the transport arrangements for his wife (Mrs C) after her feeding tube blocked and she required hospital treatment to unblock it. He also complained about the care and treatment she received at Gilbert Bain Hospital, Shetland (Hospital 1).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a delay in the arrival of the ambulance and when it arrived it could not take Mrs C in a powered wheelchair (upheld to the extent that the ambulance could have been dispatched more quickly and the delay avoided had the crew been advised when the request for the ambulance arrived);
• (b) no arrangements were made to take Mrs C home after her attendance at Accident and Emergency at Hospital 1 (upheld);
• (c) Mrs C had no nutrition or fluids for 20 hours (upheld);
• (d) Mrs C was sent to the wrong address in a taxi (upheld); and
• (e) the initial travel arrangements made for Mrs C to attend a hospital outwith the Shetland NHS Board area were unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that the Scottish Ambulance Service:

• (i) apologise to Mr C for the failings identified in this paragraphs 5 to 12 of this report; and
• (ii) demonstrate that, through providing more tailored options for requesting physicians, the response and appropriateness of that response has improved.

The Ombudsman recommends that Shetland NHS Board:

• (iii) apologise to Mr C for the failings identified in paragraphs 18 to 29 of this report;
• (iv) send him a copy of the results of the audit of record keeping in the Accident and Emergency department and any action taken to improve practice; and
• (v) audit the Patient Travel Service to ensure that they are now requesting sufficient information to allow them to make appropriate arrangements for all patients in the Board area who require to travel.

Both the Scottish Ambulance Service and Shetland NHS Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which his wife (Mrs C) received leading up to and following a planned left nephrectomy (kidney removal) for transplant, which took place on 22 June 2007. The nephrectomy operation was started but was not completed because the clinicians involved deemed Mrs C's donor kidney was unsuitable for transplantation. Mr C had concerns that the clinicians should have been aware prior to the planned nephrectomy that the kidney was not suitable and this would have prevented Mrs C from having to undergo the operation. Mr C also had concerns about the treatment which Mrs C received following the operation and the way Greater Glasgow and Clyde NHS Board (the Board) handled his complaints.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the process used by the Transplant Team to identify Mrs C's suitability for the nephrectomy prior to the operation was inadequate (not upheld);
• (b) the decision to abort the nephrectomy on 22 June 2007 was unreasonable (not upheld);
• (c) Mrs C’s post-operation management was inadequate (upheld);
• and (d) the Board's handling of the complaint was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the clinicians reflect on the Adviser's comments about the level of clinical information which has been entered in the clinical records;
• (ii) the Board apologise to Mrs C for the failings identified in her post-operation management;
• (iii) the Board review their discharge arrangements for surgery of this type and take steps to ensure there is appropriate post-surgery discharge planning in each case; and
• (iv) the Board remind staff of their obligations to manage complaints in line with the NHS complaints procedure and take action to ensure that information about the NHS complaints procedure which is held locally in hospitals and clinics is up to date.

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

Overview

The complainant, Mrs C, raised a number of concerns about her husband (Mr C)'s consultations with various GPs from his GP Practice (the Practice) and from the Greater Glasgow and Clyde NHS Board's GP Out of Hours Service (the Service) prior to his admission to hospital where, sadly, he died of heart problems.

Specific complaints and conclusions

The complaints which have been investigated are that;

• (a) Mr C's heart problems were not diagnosed by GP 1 and GP 2 from the Practice at consultations on 20 October, 28 October and 11 November 2005 (not upheld);
• (b) Mr C's heart problems were not diagnosed by GP 3 and GP 4 from the Service at consultations on 30 November and 1 December 2005 (not upheld);
• (c) the Practice did not deal with Mrs C's complaint properly (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice;

• (i) apologise to Mrs C for failing to deal with her complaint properly; and
• (ii) reflect on their complaints policy, review their complaints protocol and discuss how to respond to complaints from non-patients.

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

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

Overview

The complainant (Mr C) raised concerns about the fact that his grandmother (Mrs A) was not provided with NHS funded continuing care by Lanarkshire NHS Board (the Board). Mr C also raised concerns that the Scottish Government's policy on NHS funded continuing care was unclear and did not appear to allow for somebody living in the community to be assessed under the policy.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to appropriately assess Mrs A for NHS funded continuing care (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, in the Vale of Leven Hospital (Hospital 1) between 26 August 2004 and 6 September 2004. Mrs A was subsequently admitted to Gartnavel General Hospital (Hospital 2) on 10 September 2004 but, sadly, died on 19 September 2004.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a renal ultrasound scan was not performed on admission to Hospital 1 and when one was done at Hospital 2 the results were not acted upon (upheld);
• (b) communication with Consultant 2 at Hospital 2 was inadequate (upheld);
• (c) Mrs A was inappropriately noted as having 'no medical issues' when allowed home on weekend pass (upheld);
• (d) Mrs A was discharged from Hospital 1 without appropriate action (upheld); and
• (e) the discharge letter was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) this case be discussed urgently with Consultant 1 and formally recorded at her next annual appraisal;
• (ii) the clinical team responsible for Mrs A's care in Hospital 1 consider and act on the lessons to be learned as a result of the failings identified in this report;
• (iii) Greater Glasgow and Clyde NHS Board (the Board) remind staff of the need for accurate records to be kept;
• (iv) the Board share with the Ombudsman a copy of the regular audit of communications which is presented to the NHS Board's Clinical Governance Committee; and
• (v) the Board apologise fully and formally to Ms C for the failings 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 about the quality and quantity of information provided to her late daughter (Miss C) following her diagnosis of epilepsy in April 2006. Mrs C considered that Miss C was denied an opportunity to fully understand the consequences of not taking her prescribed medication on a regular basis and that this may in turn have contributed to Miss C's premature death.

Specific complaint and conclusion

The complaint which has been investigated is that Fife NHS Board (the Board) failed to provide Miss C with adequate information thereby denying her appropriate care and management between April 2006 and her death in October 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide written information to patients following diagnosis on a proactive basis and in line with that recommended in SIGN 70;
• (ii) advise her when the epilepsy nurse-specialist is in post; and
• (iii) apologise to Mrs C that written information about Miss C's condition and changes in her drug regime were not made available to Miss C and that there is no evidence of an individualised decision being made not to tell Miss C about Sudden Unexpected Death in Epilepsy.

The Board have accepted and acted on recommendations (i) and (ii). Recommendation (iii) has not been accepted (see paragraph 48).

The Ombudsman will ask the Scottish Intercollegiate Guidance Network (SIGN) to consider the findings of this report as part of their on-going consideration of the review of the guidelines on Epilepsy in Adults (SIGN 70). Further, in light of the difference in views recognised in paragraph 48, the Ombudsman will ask that the Directorate of Health and Wellbeing consider the need for more research into patient views on information giving and into the possible risk factors for SUDEP and the use of this research to inform ethical guidance.