Health

Overview

The complainant (Ms C) raised concerns with regard to a delay by East Lothian Council (the Council) in replacing windows in her home, in carrying out a repair to a damaged window lintel, and about the way her contact with the Council was recorded.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) unduly delayed in replacing the windows in Ms C's home (partially upheld);
• (b) unduly delayed in repairing a lintel above a window (upheld); and
• (c) failed to keep an accurate record of Ms C's contact with them (partially upheld).

Redress and recommendations

The Ombudsman recommended that the Council:

• (i) apologise to Ms C for the delays which occurred in installing the new windows and for implementing the repair to the lintel above the living room window; and
• (ii) make Ms C an appropriate payment in recognition of the costs she incurred in pursuing matters with them.

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

Overview

The complainants (Mrs C and Mrs D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at St Johns Hospital at Howden (the Hospital) between 19 December 2005 and 2 February 2006.

Specific complaints and conclusions

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

• (a) failed to provide adequate care and treatment to Mrs A (partially upheld); and
• (b) failed to properly plan for Mrs A's discharge (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that discussions take place within the clinical team on Ward 9 of the Hospital to agree the appropriate standard of practice with regards to the importance of a) thorough examination of a patient prior to discharge, with particular reference to patients with pre-existing medical problems and multiple medications, and b) recording of medical examination findings and the rational behind any changes to medications;
• (ii) consider the use of fully unified records, i.e. including therapy follow-up records with the joint medical/nursing records;
• (iii) consider regular (at least weekly) multi-disciplinary team meetings where discharge planning for complex cases, particularly for elderly patients, can be discussed, coordinated and recorded;
• (iv) consider that where family conflicts or carer anxieties are raised, case conference meetings are organised when the key disciplines and family and carers can meet to exchange information and plan discharges and that all family meetings are adequately recorded; and
• (v) consider whether current occupational therapist staffing levels in this area are sufficient to avoid the delays experienced by Mrs A.

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

Overview

The complainant, Ms C, raised a number of concerns that her late mother (Mrs A) had received inadequate medical post-operative care in her own home from her practice GP ( GP 1) and the District Nursing Service (the DNS), before Mrs A was re-admitted to a Dundee hospital (the Hospital) and subsequently died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 failed to re-refer Mrs A back to the Hospital when this was requested by a district nurse (no finding);
• (b) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to enter relevant details in case notes about Mrs A's condition (upheld); and
• (c) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to relay family concerns to the practice GPs (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) GP 1 reflects on Adviser 1 and Adviser 2's comments (see paragraphs 17 to 21) and considers discussing these at her next appraisal;
• (ii) the fundamental standards of documentation are considered by the practice and the Board and revisited across the DNS as an outcome of complaints (b) and (c); and
• (iii) although the services within the complaint (the Board, the practice and the DNS) have demonstrated a willingness to deal with complaints and identify solutions, from the information reviewed, there is no evidence to suggest that any of the work/actions identified have fully addressed the fundamental areas of holistic assessment and communication between teams, or been referenced to any professional standards or guidelines in relation to the assessment process, documentation, communication, wound care, care planning and patient held records. Accordingly the Ombudsman recommends that these areas are explored and that she is advised of the outcome.

The Board and the Practice have accepted the recommendations, some have already been implemented and others will be acted on accordingly.

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)  Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment Mr A received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)   Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment MrA received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)   Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment MrA received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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

Overview

The complainant (Ms C) raised a number of concerns about the care and treatment given to her late father (Mr A) at the Western Infirmary, Glasgow (the Hospital) from the day he was admitted on 10 August 2005, up to his death in the Hospital on 13 August 2005.  Ms C also complained that the Hospital's communication with her during this period was poor and that her subsequent complaint to Greater Glasgow and Clyde NHS Board (the Board) was dealt with inadequately.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the late Mr A received inadequate care and poor treatment when he was a patient in the Hospital between 10 August 2005 and 13 August 2005 (not upheld);
• (b) the Hospital's communication with Ms C was poor from 10 August 2005 to 13 August 2005 when Mr A was alive (upheld);
• (c) no medical records were available for 12 August 2005 (upheld);
• (d) the Board's reply to Ms C's complaint was unsatisfactory; she did not receive it in good time and they delayed in providing Ms C with a copy of Mr A's medical records or giving reasons why these were not sent (upheld); and
• (e) nurses failed to attend a meeting between Ms C and Hospital staff on 27March 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board

• (i) advise her on the steps they have taken to avoid breakdowns in communication recurring;
• (ii) advise her on the steps they have taken to avoid medical notes being unavailable;
• (iii) emphasise to staff the need to adhere to the terms of the NHS guidance for dealing with complaints and ensure that their records are updated when a patient dies; and
• (iv) apologise to Ms C and explain the reason why the clinical nurse manager did not attend the meeting on 27 March 2006.

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

Overview

The complainant (Mr C) considered that his partner (Ms A) did not receive professional care and treatment from hospital staff, and that former Argyll and Clyde NHS Board Area (the Board) failed to deal with his complaint appropriately.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) inadequate treatment by staff at Inverclyde Royal Hospital (the Hospital) prior to and after Ms A's day surgery on 25 May 2005 (upheld); and
• (b) the Board's failure to adequately address Mr C's complaint in their response to him (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) with reference to the SPSO Guidance Note on Apology, apologise to Ms A and Mr C for the distress and pain caused by the poor preparation for the procedure carried out on 25 May 2005, as well as the uncertainty over the stent before that time which led to Ms A having to be x-rayed unnecessarily; and
• (ii) ask staff at the Hosptial's Day Surgery Unit to review their practice for Endoscopy procedure preparation, and benchmark that practice against other similar units within the Board area. This would form part of the work already in progress to review pre-assessment practice for day surgery throughout the Board area.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment her late husband (Mr C) received from his General Practitioner (GP 2) and at Ninewells Hospital, Dundee (the Hospital).  Mrs C complained this led to an unreasonable delay in diagnosing that Mr C was suffering from colon cancer, which later spread to his liver.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was delay by GP 2 in referring Mr C to the Hospital in January 2004 (not upheld);
• (b) there was delay by the Hospital in diagnosing Mr C’s cancer (upheld); and
• (c) there was delay by the Hospital in obtaining the results of a CT scan (upheld).

Redress and recommendations

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

• (i) issue Mrs C with a full formal apology for the failures identified in part (b) of the complaint and for the distress that this caused. The apology should be in accordance with the Ombudsman's guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology);
• (ii) review their procedures for the reporting of CT scan results, particularly where more than one hospital is involved, to ensure that delay in reporting such results, such as occurred with Mr C, does not recur; and
• (iii) issue Mrs C with a full formal apology for the failures identified in part (c) of the complaint and for the distress and anxiety that this caused. The apology should be in accordance with the Ombudsman's guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

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

Overview

The complainant (Mrs C) raised a number of concerns about the manner in which Lothian NHS Board (the Board) had responded to complaints raised originally by her mother (Mrs A) and continued by Mrs C after Mrs A's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to deal with Mrs A and Mrs C's complaints in a timely and appropriate manner (upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for their failure to deal with the complaints raised by Mrs A or Mrs C in a timely or appropriate manner.

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