Health

Overview

The complainant, Mr C , was concerned that his late father (Mr A) had suffered serious pressure sores while in the Southern General Hospital (Hospital 1) following an operation on both his knees. Mr C felt that the decision to operate had not been taken appropriately and that the care provided while Mr A was in Hospital 1 was inadequate. Mr C was also unhappy about the way the Board had responded to concerns raised by him and his family.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the decision to operate was not appropriate, in that further tests should have been taken prior to the operation (upheld);
• (b) the post-operative care provided to Mr A was inadequate (upheld);
• (c) communication with Mr A and his family, concerning Mr A's care and treatment, was not adequate (upheld); and
• (d) the Board did not respond appropriately to the complaint raised by Mr C (partially upheld, to the extent that there was a delay in responding with no reasonable explanation given for this).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar tool to examine the reason why the pressure ulcers developed and why there was no proactive treatment once this occurred;
• (ii) provide the policy/guidance for the assessment and treatment of pressure ulcers, with particular reference to the referral to the specialist teams in tissue viability, pain and nutrition; undertake an audit to review the processes; and provide an action plan to address any shortcomings;
• (iii) undertake an audit of documentation to include nursing assessment, pain assessment and nursing care of Wards A and B;
• (iv) provide evidence of the education and training programme provided to nursing staff in relation to the assessment and care of pressure ulcers;
• (v) undertake an external peer review of the nursing care in Ward A, to include an examination of the clinical leadership and management, patient experience and quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the Scottish Government initiatives outlined in Leading Better Care;
• (vi) provide details of the action plan created as a result of the above recommendations and provide updates where relevant. Action plans should be specific, measurable, achievable, realistic and timely (SMART) and include robust quality indicators such as the Clinical Quality Indicator for Pressure Ulcer Prevention;
• (vii) as a priority, review the documentation provided to patients and provide the Ombudsman with the results of this;
• (viii) provide details of the audit made in response to report 200600345 and any action taken as a result;
• (ix) if not covered by that audit, undertake a specific audit of communication within Hospital 1, to include communication with families, and between staff;
• (x) reinforce to clinical staff the importance of responding to requests from complaint handling staff timeously; and
• (xi) make a full 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) complained about some aspects of care and treatment and communication with the family in respect of her mother, aged 80, who had been admitted to Aberdeen Royal Infirmary (the Hospital), a hospital in the area of Grampian NHS Board (the Board) in October 2007. She had been badly injured in a road traffic accident and, most sadly, never properly recovered full consciousness, dying in the Hospital about a fortnight later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) some aspects of the care and treatment were inadequate (upheld); and
• (b) communication with the family was inadequate (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise direct to Ms C for the shortcomings identified in this report;
• (ii) reflect on the medical lessons to be learnt from this case and consider appropriate action;
• (iii) ensure that, in future, they are able to evidence patients fluid levels, by retaining, for example, a record of daily fluid totals for a year after the event, in case needed;
• (iv) consider how to improve the record-keeping, including notes of discussions with patients and families, of medical staff in the ward in question, and take action accordingly;
• (v) consider any need for a wider audit of medical record-keeping; and
• (vi) reflect on the criticisms about complaint handling and consider appropriate action.

Overview

The complainant raised a number of concerns about the care and treatment of an 80-year-old woman (Mrs A), on behalf of Mrs A's son. Mrs A was admitted to the Royal Alexandra Hospital (the Hospital), in the area of Greater Glasgow and Clyde NHS Board (the Board), in September 2006 with stomach pain and constipation. The complainant said the admission should have been made several days earlier and that the inadequate treatment received in the Hospital might have contributed to Mrs A's death later that month in the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) out-of-hours doctors should have admitted Mrs A to the Hospital earlier (not upheld);
• (b) Mrs A's care and treatment in the Hospital were inadequate (upheld); and
• (c) the Board lost some of Mrs A's medical records (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that all appropriate healthcare professionals in the Board's hospitals are made aware of the appropriate management of constipation in older people; and
• (ii) reflect on the lessons learnt from this complaint and take appropriate action to help avoid a recurrence.

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

Overview

The complainant (Mrs C)'s 19-year-old son had a dental operation at St John's Hospital (the Hospital) in the area of Lothian NHS Board (the Board). His learning disability meant he did not have the mental capacity to make his own decisions about treatment or consent, nor to understand much of what was happening to him at the Hospital. Mrs C complained that she did not have the chance to withhold her consent to all the work being done at one session because she considered that the large volume of work should have been spread across more than one surgical session. She said that she had not been told before the operation of the possibility of so much work. She added that the amount of work done at the one session had caused her son such distress that, amongst other things, he had been chewing his lip, which she said had become an open, infected, sore.

Specific complaint and conclusion

The complaint which has been investigated is that informed consent to the operation was not properly sought (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to seek informed consent;
• (ii) satisfy themselves that relevant administrators and healthcare professionals at the Board have an appropriate knowledge and understanding of the Adults with Incapacity (Scotland) Act 2000, its Code of Practice and other relevant guidance;
• (iii) share lessons learnt from this case across their hospitals and disciplines;
• (iv) use the events of this case as part of their induction and other training programmes about consent and about communication with carers etc who have a legal say in decisions about the medical treatment of an adult with incapacity;
• (v) ensure that the Board's Consent Policy, in relation to obtaining consent in writing, is followed;
• (vi) advise clinicians across the Board's hospitals that recording only key points of consent discussions will not be sufficient in some cases; and
• (vii) consider revising their consent form in respect of adults with incapacity.

Overview

The complainant, Mr C, raised a number of concerns regarding his care and treatment during his admission to Aberdeen Royal Infirmary (Hospital 1) for cardiopulmonary bypass surgery.  At the time, the High Dependency Unit and the Cardiothoracic Ward where Mr C was treated were housed in temporary accommodation, which Mr C considered to be unsuitable.  Mr C required further treatment at another hospital, where it was discovered that he had contracted MRSA.  Mr C also complained about how his complaint was handled by the Grampian NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the facilities at Hospital 1 were unsuitable and did not meet minimum standards (not upheld);
• (b) Mr C was not tested for MRSA before discharge and there were no facilities for quickly diagnosing MRSA and isolating MRSA positive patients (not upheld);
• (c) there was a lack of cleanliness, no control over the numbers of visitors and handwashing advice was ignored (not upheld); and
• (d) Mr C's complaints were not handled appropriately (upheld).

Redress and recommendation

The Ombudsman recommends that the Board remind staff dealing with complaints of the need to have regard to the NHS complaints procedure timescales.

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 provided to her by Accident and Emergency (A and E) staff which resulted in her being misdiagnosed and discharged only to be readmitted hours later suffering from bacterial meningitis and septicaemia.

Specific complaints and conclusions

The complaints which have been investigated are that following her admission to A and E on the morning of 11 January 2008 Grampian NHS Board failed to:

• (a) properly monitor and record Mrs C's condition (upheld);
• (b) supervise the actions of junior staff (upheld); and
• (c) provide Mrs C with appropriate transport at discharge (not upheld).

Redress and recommendations

The Ombudsman recommends that Grampian NHS Board:

• (i) undertake an audit (or provide evidence of a recent audit) of the quality of clinical documentation in A and E, with particular reference to discharge documentation;
• (ii) review their practice in relation to patient call buzzers being removed and consider how patients can summon assistance from staff when required;
• (iii) use events of this case to remind frontline staff of the importance of early diagnosis of meningitis and use in teaching for new junior doctors and nursing staff; and
• (iv) stress the importance of documenting consultation outcomes and requests for senior review to all grades of staff in the A and E department.

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

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.