Health

Overview
The complainant (Mr C) raised a number of concerns regarding the standard of cleanliness in Ward 17 of Ninewells Hospital (the Hospital). He complained that Tayside NHS Board (the Board) failed to maintain an adequate standard of cleanliness in the ward and that their systems for monitoring cleanliness were flawed. Mr C also complained that, when he visited the Hospital, patient records were left unattended in areas accessible by the public.

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

• (a) cleanliness standards at the Hospital were poor (no finding);
• (b) staff at the Hospital failed to adhere to the Board's hygiene policies (no finding);
• (c) the Board's procedures for monitoring cleanliness were ineffective (not upheld); and
• (d) the Board failed to securely store patient records (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) invite Mr C to a meeting at the Hospital to discuss his concerns about cleanliness and infection control; and
• (ii) instruct their Caldecott Guardian to review the procedures for transferring clinical records between the Orthopaedic Out-patient Clinic reception area and clinical staff to ensure the security of clinical records at all times.

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

Overview
The complainant (Mr C) raised his concerns that his optometrist (Optometrist 1) failed to provide reasonable care and treatment to him at his visit on 8 January 2008. Mr C considers that the prescription he was given was significantly different to that which should have been prescribed.

Specific complaint and conclusion
The complaint which has been investigated is that Optometrist 1 failed to provide reasonable care and treatment to Mr C at his visit of 8 January 2008 (upheld).

Redress and recommendations
The Ombudsman recommends that Optometrist 1:

• (i) provide patients with a warning (which should be recorded on their record cards) that a reduced power prescription may require some adjustment;
• (ii) review the way he communicates the possible implications of reducing a myopic prescription with a patient and records this communication in the clinical records; and
• (iii) review the way he operates his formal complaints procedure when providing NHS services to ensure that complaints are considered in line with the NHS complaints guidance. Optometrist 1 has viewed a draft of this report.

He has made clear that he does not accept the conclusion in the report but has accepted the recommendations and will act on them.

Overview
The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had not received reasonable care and treatment whilst under the care of Greater Glasgow and Clyde NHS Board (the Board) in early 2007. She was particularly concerned about the arrangements made for her husband to undergo a surgical procedure at another hospital and the administration of medicines to her husband. She also raised concerns about the action the Board took following her complaints about discussions between medical staff and Mr C's family.

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

• (a) the Board's requirement that Mr C attend Gartnavel Hospital at 09:00 on 11 January 2007 for a procedure that did not begin until 11:35 was unreasonable (no finding);
• (b) the Board's administration of steroids to Mr C during his admission in January 2007 was not reasonable (upheld); and
• (c) the Board did not take adequate action in response to Mrs C's complaints about discussions with Mr C's family on 12 January 2007 about his resuscitation (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C's family that the dosage of steroids was not increased following either the suspicion of sepsis or the incident of septic shock;
• (ii) take steps to ensure that medical staff are aware of the need to increase the dose of steroids following suspicion of sepsis or incidents of septic shock; and
• (iii) ensure that induction materials for medical staff clearly cover the specific requirements of the Board's resuscitation policy. This would serve to draw inductees' attention to the policy, and, specifically, its application in terms of provision of information to, and discussion with, patients, relatives and carers and provide evidence of this to the Ombudsman.

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

Overview
The complainants (Mr C and his partner Ms C) were unhappy about the care provided to Ms C during her pregnancy by Lanarkshire NHS Board (the Board). Sadly, Mr and Ms C's daughter (Baby A) was stillborn on 21 October 2007. Mr and Ms C considered a number of warning signs had been missed and, in particular, a scan at 36 weeks which showed the umbilical cord near Baby A's neck should have been followed up. They also complained about the postnatal care provided and that the response to their complaint was not adequate.

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

• (a) the care and treatment provided to Ms C during her pregnancy was inadequate (upheld);
• (b) there were failings to ensure appropriate support was provided following the death of Baby A (upheld); and
• (c) the response to Mr and Ms C's complaint was not adequate (partially upheld, to the extent that full information was not provided at the time of Mr and Ms C's complaint).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) reassess the training provided to midwives on cardiotocographs, given the failure to recognise, record or follow up the deceleration correctly;
• (ii) review the use and purpose of the Board's telephone call records, given the failure to complete any record on 18 October 2007 and the presence on file of a badly completed record;
• (iii) apologise to Mr and Ms C for failing to recognise, record and respond appropriately to the deceleration;
• (iv) review their standard care pathway for bereaved parents, in light of the concerns raised in this report and the best practice examples elsewhere in NHS Scotland, and ensure that parents are given timely advice about counselling;
• (v) review the supervision arrangements for their ante-natal clinics taking into account the advice received in paragraph 17 and inform the Ombudsman of action taken as a result of this review;
• (vi) apologise to Mr and Ms C for failing to communicate with their GP, in line with their procedures, and for the time taken to provide them with information about counselling; and (vii) when responding to complaints, take into account the need to provide as full information as possible, particularly where interviews have been held with staff.

Overview

The complainant (Mrs C) was unhappy with the care provided to her late father (Mr A) by Greater Glasgow and Clyde NHS Board (the Board). Mr A was admitted to the Western Infirmary (Hospital 1) on 5 January 2008, as he had been diagnosed with bladder and prostate cancer and his condition was deteriorating. On the following day, it was recorded that he had two pressure sores and that his heel was red and soft. Mr A was transferred to ward 3A in Gartnavel General Hospital (Hospital 2) on 7 January 2008. He was then transferred to the Beatson West of Scotland Cancer Centre (Hospital 3) on 15 January 2008 and discharged on 24 January 2008. During this time, he contracted Noro virus (more commonly known as winter vomiting virus). On 28 January 2008, he was readmitted to Hospital 1 and was transferred to Hospital 2 on the following day. He was discharged again on 5 February 2008. He was then readmitted to Hospital 1 on 9 February 2008, but was transferred to Hospital 2 on the following day. Tests completed showed that Mr A had contracted MRSA and Clostridium difficile. Mr A was referred to the palliative care team on 20 February 2008. Sadly, he died later that day.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to effectively manage Mr A's pressure sores (upheld);
• (b) Mr A contracted MRSA and other infections because the infection control measures were inadequate (not upheld);
• (c) there was a delay in referring Mr A to the palliative care team (upheld); and
• (d) there was a lack of continuity in the nursing care provided to Mr A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar improvement tool to examine the reason why Mr A received inadequate treatment for his pressure ulcers;
• (ii) ensure that the policies in place reflect current national best practice standards for pressure ulcer assessment, prevention and treatment and that robust systems are in place to review, monitor and report adherence;
• (iii) confirm that the learning from report 200702913, published by the Ombudsman in June 2009, is being transferred across the Board region;
• (iv) ensure that there are steps in place to verify that staff are able to diagnose patients who might benefit from palliative care and then make timely referrals to palliative care teams;
• (v) take immediate steps to implement the Liverpool Care Pathway or similar end of life care planning system;
• (vi) continue to review and monitor the nursing care in Ward 3A in Hospital 2. This should include an examination of the clinical leadership and management; the patient experience; and the quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the implementation of the Scottish Government policy for Senior Charge Nurses - Leading Better Care;
• (vii) ask the Director of Nursing to verify that appropriate education and development is in place to ensure that nursing staff throughout the Board are aware of and adhere to national standards in relation to pressure ulcers, control of infection and end of life care;
• (viii) ensure that systems are in place to review and monitor standards of all aspects of nursing documentation in line with professional standards;
• (ix) ensure that patient transfer policies exist and are used in the best interests of patients, ensuring that communication and continuity of care is paramount; and
• (x) make a full and detailed apology to Mrs 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 provided by Tayside NHS Board (the Board) to his father (Mr A) in the months before his death in October 2007. Mr C also complained about delays in diagnoses and treatment of Mr A and the handling of his complaint about these matters.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) delayed in diagnosing Mr A (upheld);
• (b) failed to provide timely treatment following diagnosis (not upheld);
• (c) did not provide adequate care to Mr A in the respiratory ward (the Ward) of Ninewells Hospital, Dundee (upheld); and
• (d) failed to handle Mr C's complaint appropriately (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ask the consultant responsible for Mr A's care in the Ward to apologise to Mr C for any contribution he may have made to the misunderstanding with Mr A about visiting him on 28 September 2007;
• (ii) apologise to Mr C for the failure to provide adequate care to Mr A as identified in this report; and
• (iii) review the current arrangements for selecting patients for consultant out of hours review, including processes for communication and handover between doctors.

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

Overview

Mr C has complained about the care and treatment provided to his late mother (Mrs A) prior to and during her last hospital stay in a hospital (the Hospital) within the Shetland NHS Board (the Board) area. Mr C's mother was admitted to the Hospital on 8 March 2005 and discharged to her care home in the afternoon of 9 March 2005. Mrs A died later in the evening of 9 March 2005. Mr C has also complained that Mrs A should have remained in hospital longer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the reasons for medication, prescribed for Mrs A's suspected clinical condition at the time, were unclear (partially upheld, to the extent that the reason why medication was prescribed in the community for Mrs A's suspected condition was clear and appropriate but the reasons for the prescribing decisions made following admission to the Hospital were not clear and appropriate);
• (b) medical and nursing staff failed to assess and record the treatment and care requirements adequately throughout this particular episode of care (partially upheld, in relation to the actions of the Hospital);
• (c) Mrs A was not provided with an acceptable level of fluids during her stay in the Hospital (upheld); and
• (d) Mrs A should have remained in the Hospital longer (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) share this report with the staff involved in Mrs A's care, so they can reflect on the findings relevant to the prescription of medication when Mrs A was admitted to the Hospital and identify clear and explicit indications for the use of prescribed and administered medication;
• (ii) ensure thorough assessment, recording and treatment is undertaken for the ongoing care of a patient when health remains compromised and discharge is being considered;
• (iii) ensure nursing staff are appropriately trained to record baseline observations and understand the reasons for recording them;
• (iv) ensure a fluid intake and output record is kept for an unwell patient, where feeding and drinking assistance is required; and explanations are recorded when there is a delay in supporting the early, prompt intake of fluids;
• (v) remind staff of the importance of encouraging fluid intake, when a patient is unable to attend to that aspect of care independently;
• (vi) ensure full consideration is given to any potential discharge plan, when observations continue to indicate a level of patient distress or compromise;
• (vii) ensure appropriate family members are given an opportunity to contribute to the discharge planning process of an unwell relative; and
• (viii) provide Mr C with a full formal apology for the failures in care identified in this report.

Overview

The aggrieved (Mrs A) raised a concern that her husband (Mr A)'s prostate cancer was not detected in 2003/2004 when he attended a number of hospital appointments. Mrs A considered both that the cancer could have been detected at that earlier stage and that it should have been detected then.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr A with all appropriate care and treatment in 2003/2004 and as a consequence missed an opportunity to secure an earlier diagnosis of prostate cancer (upheld).

Redress and recommendation

The Ombudsman recommends that the Board review the Urology Department protocol for the assessment and management of men with new lower urinary tract symptoms bearing this case in mind.

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

Overview

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

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice delayed in examining Mr A after his family contacted them stating that he had chest pain on 28 June 2007 (upheld); and
• (b) the action taken to 'flag' Mr A's notes that he had special requirements was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for the delays in examining Mr A on 28 June 2007;
• (ii) organise a review of their triage systems and ensure that the revised procedures are communicated effectively to staff;
• (iii) apologise to Mrs C for the failure to effectively flag Mr A's notes; and
• (iv) consider how they can effectively flag the electronic records of a patient with significant health problems.

The Practice 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 of her mother (Mrs A). Mrs A was resident in a care home and two Doctors (Doctor 1 and Doctor 2) from Ayrshire and Arran NHS Board (the Board) had visited her in the final hours of her life.

Specific complaint and conclusion
The complaint which has been investigated is that the Board's care and treatment of Mrs A in the final hours of her life was not reasonable (partially upheld to the extent that some aspects of Mrs A's care and treatment were not reasonable).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) encourage Doctor 1 to reflect on the case at their next appraisal, with particular reference to: assessment of unfamiliar patients as part of the Ayrshire Doctors On Call team; the factors to be considered in reaching a decision on the admission to hospital of frail elderly patients; the discussion and recording of admission criteria with carers and relatives; and the dosage of antibiotics in relation to Scottish Intercollegiate Guidance Network guidance; and
(ii) encourage Doctor 2 to reflect on the case at their next appraisal, with particular reference to: the discussion and recording of terminal diagnoses with carers and relatives; andthe use of symptomatic measures in terminal care.

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