Health

Overview
The complainant (Mr C) and his sister raised a number of concerns about the care and treatment provided to their sister (Ms A) by Mental Health Services within Ailsa Hospital (Hospital 1), Ayrshire and Arran NHS Board (the Board) in February 2006. Ms A sustained a major spinal injury as a result of a fall from a window after her discharge from Ayr Hospital (Hospital 2) on 14 February 2006. Ms A never recovered, her condition deteriorated and she died in January 2007. Following the submission of Mr C's complaint to the Ombudsman's office the Board undertook a further review of Mr C's concerns and at a meeting with Mr C a number of issues were explained and apologies given for the failings in communication with Ms A's family which had been identified. Mr C was satisfied with much of this but remain concerned about the treatment provided to his sister. These are the issues investigated in this report.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Ms A's treatment at Hospital 1 during January and February 2006 was ineffective and she was discharged inappropriately (not upheld); and
(b) Ms A was treated and discharged inappropriately from Hospital 2 following her attendances at the Accident and Emergency Department on 10 and 13 February 2006 (not upheld).

Redress and recommendations
Because of the action already taken by the Board to address failures in communication since the complaint was submitted to the Ombudsman's office, the Ombudsman has no recommendations to make.

Overview
The complainant (Mrs C) raised a number of concerns regarding the treatment that her father (Mr A) received from staff at Ninewells Hospital (the Hospital). She complained that, for a five day period following admission to the Hospital, her father was neglected by nursing staff, his condition left unmonitored and incorrect assumptions made regarding his mental state. Mrs C felt that inattention and poor record-keeping by staff of Tayside NHS Board (the Board) contributed to a deterioration in Mr A's condition, and to his death.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:
(a) incorrectly assumed that Mr A had dementia (not upheld);
(b) failed to treat Mr A appropriately for a five day period following his admission to the Hospital (upheld); and
(c) failed to appropriately monitor Mr A's fluid intake (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review their progress against the action plan and provide an updated version of the document;
(ii) provide details of the steps that they have taken to implement the Scottish Government's new Food, Fluid and Nutrition programme;
(iii) provide details of the steps that they have taken to achieve the Scottish Government's new Clinical Quality Indicators for Food, Fluid and Nutrition; and
(iv) formally apologise to Mrs C and her family for the distress and anxiety caused to them and Mr A during his stay at the Hospital.

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

Overview
The complainant (Mrs C) raised a number of concerns about the information provided to her about the extent of her late husband (Mr C)'s ill health and the operation of a Do Not Resuscitate (DNR) order. Mrs C was also concerned about the adequacy of steps taken to protect Mr C in hospital.

Specific complaints and conclusions
The complaints which have been investigated are that Fife NHS Board (the Board) failed to:
(a) communicate adequately with Mrs C and in particular failed to follow the procedure for instituting and implementing a DNR order (upheld); and
(b) keep Mr C safe using appropriate restraint (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review the DNR policy, the use, and value added by the use of, the resuscitation box in the Unitary Patient Record; followed by an ongoing audit (or similar improvement methodology) to ensure that there is clarity about when the policy applies and whether it is sustained in practice. The audit should measure the completion of the DNR form and associated documentation in the patient record;
(ii) review how Cardio Pulmonary Resuscitation status is communicated at ward level, to ensure nursing staff are aware of the importance of robust communication at handover and transfer. The national 'Leading Better Care' policy may be helpful here;
(iii) consider including DNR orders in both induction and Basic Life Support staff training. This is already done in some parts of NHS Scotland and is endorsed by the Scottish Palliative Care Society;
(iv) review the mechanisms in place to ensure that communication between patients, their relatives and carers and staff is recognised as an important part of the patient experience; and
(v) develop a specific policy for the WanderGuard bracelet to ensure that its use complies with the Adults with Incapacity (Scotland) Act 2000 to ensure patients are treated with dignity and respect.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their baby daughter (Baby C) and Forth Valley NHS Board (the Board)'s failure to diagnose meningitis and hydrocephalus when she was seen by clinicians at Stirling Royal Infirmary (Hospital 1) on
20 September 2007.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care and treatment to Baby C on 20 September 2007 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr and Mrs C for the failings identified in this report;
(ii) carry out a root cause analysis of the inadequate assessment on
20 September 2007. This should explore why the obvious concerns of the GP were not addressed by the junior paediatricians. It should also establish whether the staff grade doctor involved in the decisions was sufficiently trained and experienced to be in this position of responsibility. The Board should then give consideration to further training for the relevant staff in light of the results of their analysis of the case. They should also provide Mr and Mrs C with a full and detailed explanation of their findings and the steps that will be taken to prevent recurrence; and
(iii) note the specialist medical adviser's comments that a cranial ultrasound scan should have been performed on 20 September 2007 to exclude a build up of fluid in the brain.

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

Overview
The complainant Mr C , was unhappy with the care provided to his late mother, Mrs A. Mrs A had been admitted to the Victoria Infirmary (the Hospital) following a fall. Shortly after her admission, the Hospital identified an outbreak of the winter vomiting virus in the ward to which Mrs A had been admitted (Ward A). While there, Mrs A was diagnosed with an infection and her condition deteriorated. Sadly, Mrs A died a few days after moving from Ward A to Ward B. Mr C said he was concerned about the care and treatment provided to Mrs A and that he and his family had been distressed by the way Mrs A had been cared for after it became clear she was unlikely to recover. He said Mrs A had been moved into an open ward (Ward B) and the curtains around her bed left open. Mr C also raised complaints about matters relating to the closure of Ward A and stated that the Hospital had failed to ensure the public was aware there was an outbreak of infection. He also said he had been concerned about the general level of hygiene in and around Ward A.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the care and treatment provided to Mrs A was inadequate (upheld);
(b) there was insufficient care taken by staff handling an outbreak of infection in Ward A (upheld);
(c) the level of hygiene in and around the ward was inadequate (no finding);
(d) there were significant failures in communication about the effect on Mrs A of the infection and the serious nature of Mrs A's condition (upheld);
(e) there was a failure to ensure Mrs A's dignity (upheld); and
(f) the Board did not respond appropriately to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) use a root cause analysis or similar tool to examine the reasons for the clinical failures identified in treating Mrs A’s diarrhoea and managing her fluid intake;
(ii) provide clear evidence over the next 12 months that the new policy on professional standards of record-keeping is having significant improvements on the quality of documentation;
(iii) provide the Ombudsman with evidence that the initiatives underway on infection control should prevent a recurrence of the failings identified in this report;
(iv) use this complaint as part of their own ongoing programmes to improve cleanliness and, in particular, consider how hygiene standards can be tracked and monitored and how visitors and patients can be encouraged to feel they can approach staff about any concerns they have;
(v) share with the Ombudsman the results of patient and staff surveys on communication over the next 12 months and the audit of communication following report 200600345 and any action taken as a result;
(vi) keep the Ombudsman informed of the progress of implementation of the Liverpool Care Pathway over the next 12 months;
(vii) provide evidence of the actions being taken to ensure individual patient dignity until the Hospital is closed;
(viii) ensure that guidance to complaint handling staff emphasises the need for full disclosure of relevant information; and
(ix) make a full, detailed apology to Mr C and his family for the failings identified in this report.

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, which she had received from Greater Glasgow and Clyde NHS Board (the Board) during the period April 2003 to October 2005.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care following Ms C's operation on 18 April 2003 (upheld).

Redress and recommendation
The Ombudsman has no recommendations to make on these issues because he is satisfied that the Board have made changes that address the concerns raised in this report.

Overview
The complainant (Miss C) raised a number of concerns regarding the treatment her late mother (Mrs A) received at Wishaw General Hospital (the Hospital). Miss C was unhappy with the level of nursing care which Mrs A received, specifically in relation to a fall she suffered in the early hours of the morning following her admission. Miss C also raised concerns regarding numerous cancellations of the proposed surgery to address damage suffered to Mrs A's femur during her fall.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the standard of nursing care provided was inadequate (upheld); and
(b) the decisions to cancel surgery were unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board (the Board):
(i) undertake an urgent investigation into the nursing staff's failure to follow the correct procedure when administering a controlled substance;
(ii) implement an action to address the failure to assess Mrs A's pain, using the Modified Early Warning System tool;
(iii) implement a formal bed move policy which restricts any avoidable movement of vulnerable patients;
(iv) clarify their policy on nursing confused patients, providing a copy of a relevant risk assessment for patients' mental capacity, along with an appropriate nursing action plan, to be adopted following a diagnosis of confusion;
(v) remind staff of the importance of frequent vital observations, particularly after incidents where patients have sustained head injuries;
(vi) remind staff of the importance of fully completing all significant documentation, paying particular attention to the omissions identified in this report;
(vii) apologise to Miss C for the failings which have been identified in this report; and
(viii) ensure that a proper multi-disciplinary approach to patient care is in place and seen to be effective.

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

Overview

The complainant (Mrs C) raised a number of concerns about the dental treatment she received from her dentist (the Dentist) on 25 January 2008, which led to her attending her local hospital in great pain and with a swollen face. Mrs C's care was then taken over by a consultant oral and maxillofacial surgeon who told her that the numbness in her face could take up to six weeks to heal or it could be permanent.

Specific complaint and conclusion

The complaint which has been investigated is that, on 25 January 2008, the Dentist provided Mrs C with an inadequate level of treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) apologises to Mrs C for the failings identified in this report; and
• (ii) reflects on the Adviser's comments in regard to the standard of radiographs, working length calculation and record-keeping.

The Dentist has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which he had received from clinicians for a finger injury following an assault on 10 June 2007. Mr C said that a consultant orthopaedic surgeon had failed to amputate a sufficient amount of the damaged finger and that this had hampered his ability to continue with his employment as an electrician. In addition, Mr C complained that another consultant orthopaedic surgeon had agreed to further amputate the finger if alternative therapy did not work but then subsequently denied that he had promised this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the clinicians failed to obtain informed consent prior to surgery (upheld);
• (b) the decision not to provide the level of amputation requested by Mr C was unreasonable (not upheld); and
• (c) the overall treatment provided by the clinicians was inadequate (not upheld).

Redress and recommendations

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

• (i) apologise to Mr C for not obtaining informed consent; and
• (ii) consider whether procedures require to be amended, so that the surgeon is available at the pre-assessment clinic to discuss the level of amputation which is planned and to take consent.

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

Overview

The complainant (Mr C) complained on behalf of his stepmother (Mrs A) about the assessment made of her condition on 15 October 2007, which led to Ayrshire and Arran NHS Board's (the Board) decision that she was not entitled to NHS Continuing Care, despite having qualified for a previous period in England. Mr C also complained that the benefits of moving to be closer to him as her only surviving relative were discounted by the Board and he also complained about how the Board handled the matter. Sadly, Mrs A died on 26 January 2008.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the assessment on 15 October 2007 was inadequate (not upheld);
• (b) the Board discounted the benefit of Mrs A's move to be closer to her family (not upheld); and
• (c) the Board failed to explain properly the decision not to award continuing care funding (upheld).

Redress and recommendations

The Ombudsman recommends that the Board;

• (i) apologise to Mr C for failing to explain the decision properly;
• (ii) undertake a retrospective assessment of Mrs A's eligibility for NHS Continuing Care from the point of her transfer to Scotland;
• (iii) consider whether they now have a preferred or standardised format for decisions relating to and documentation of assessments for NHS Continuing Care;
• (iv) consider what procedures they have in place to assess cross border transfers where there is no request or need for NHS Continuing Care;
• (v) consider what procedures they now have in place to ensure that all care home residents are routinely assessed at the point of entry and thereafter, with regard to their eligibility for NHS Continuing Care;
• (vi) consider under what circumstances they will consider retrospective requests for NHS Continuing Care; and
• (vii) review the instructions they give to their staff on the handling of assessments relating to extraordinary issues such as cross border patient movement.

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