Health

Overview

The complainant (Ms C) suffered shoulder pain following a fall at home on 3 January 2006.  She attended Accident and Emergency (A&E) at Ninewells Hospital.  Examination of her shoulder revealed no new injuries and she was allowed to return home on the basis that a pre-existing frozen shoulder was the root cause.  Ms C said that she continued to experience a great deal of pain despite ongoing treatment for her frozen shoulder.  An x-ray in May 2006 showed that she had fractured her humerus.  Ms C complained that an x-ray should have been taken during her A&E attendance on 3 January 2006.  She felt that failure to take an x-ray prolonged her pain and delayed the operation that she required to repair her humerus.

Specific complaints and conclusions

The complaints which have been investigated are that Tayside NHS Board:

• (a) failed to properly diagnose and treat Ms C's painful shoulder (not upheld); and
• (b) failed to provide emergency treatment to Ms C upon her arrival at A&E (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that her late father (Mr A) had not received adequate treatment from Ayrshire and Arran NHS Board (the Board) after being admitted to Ayr Hospital on 11 November 2005.  Mr A was transferred to Ayrshire Central Hospital (Hospital 2) on 20 December 2005, but died there on 27 December 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A was catheterised without his consent (upheld);
• (b) a consultant decided not to artificially hydrate Mr A (upheld);
• (c) the Board inappropriately transferred Mr A to Hospital 2 (upheld); and
• (d) the Board failed to communicate effectively with Mr A's family (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to record that verbal consent to insert the catheter had been obtained from Mr A and the failure to adhere to the General Medical Council's guidance regarding the decision not to artificially hydrate Mr A;
• (ii) review the guidelines for catheterisation in order that they make explicit reference to recording that verbal consent has been obtained;
• (iii) take steps to ensure that staff adhere to the General Medical Council's guidance when they consider withholding or withdrawing life-prolonging treatments, by involving the patient (or those close to the patient where the patient's wishes cannot be determined) in the decision making. Details of the decision taken should be clearly recorded in the medical records; and

• (iv) review Mr A's case in order to establish if there are any lessons that can be learned regarding the transfer of patients to other hospitals.

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

Overview

The complainant (Mrs C) was concerned that the podiatry treatment she received at a podiatry clinic (the Clinic) was inappropriate.  Mrs C complained that her bunion had been cut into against her wishes and that the same scalpel had been used to treat two different parts of her foot.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a podiatrist (the Podiatrist) cut into Mrs C's bunion against her wishes (not upheld); and
• (b) the scalpel used to cut into Mrs C's bunion was the same as that which had been used to cut into her toenail (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mrs C, complained of a lack of local care provision for her son, Mr A, from June 2004 to March 2007.  Mr A is severely autistic, has learning difficulties and also suffers from epilepsy.  Specifically, Mrs C complained that Mr A was seen by his Consultant (Consultant 1) in June 2004 but that there was no direct access to care offered by Forth Valley NHS Board (the Board) following this review and the departure of Consultant 1 in May 2005.  Mrs C also complained that the medication prescribed for her son by Consultant 1 was inappropriate in that, if fully implemented, it would have placed Mr A at risk.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a lack of care provision for Mr A from June 2004 to March 2007; (upheld); and
• (b) medication prescribed for Mr A by Consultant 1 in June 2004 was inappropriate in that, if fully implemented, it would have placed Mr A at risk (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board offer Mrs C a full and sincere apology for the shortcomings identified in this report.

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

Overview

The complainant (Ms C) was referred to a consultant orthopaedic surgeon (Consultant 1) at the Southern General Hospital in Glasgow for a diagnosis of the knee pain she had been suffering for some time.  Because the pain continued, she then saw a private consultant who recommended treatment which proved successful.

Specific complaint and conclusion

The complaint which has been investigated is that Consultant 1 incorrectly diagnosed Ms C's knee condition, leading to damage which could have been prevented if a correct diagnosis had been made earlier (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns regarding the treatment he received at the Royal Infirmary of Edinburgh (the Hospital) for an injury to his knee.  Mr C also claimed that the consultant treating him (Consultant 1) at the Hospital failed to fully consider all the potential causes for Mr C's problems with his knee.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1's assessment of Mr C's symptoms was inadequate and did not go into sufficient detail (not upheld); and
• (b) Consultant 1's diagnosis was not reasonable and he failed to consider the possibility that Mr C was suffering from Chronic Regional Pain Syndrome (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mrs C, visited the medical practice (the Practice) with her three year old grandson (Child A), who was unwell, and was seen by the doctor (the GP).  After examining Child A, the GP diagnosed that he had tonsillitis.  The GP then asked Mrs C to have Child A's parents contact him as he wished to address the issue of 'targeted kicks' from the child towards the GP during the consultation.  Mrs C was unhappy with the GP's attitude and complained to the Practice Manager.  She remained unhappy with the response to her complaint, which was sent by the GP, and asked the Ombudsman to investigate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was unreasonable for the GP to complain about being kicked by ChildA (upheld); and
• (b) the handling of, and response to, Mrs C's complaint by the Practice was unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the GP should make a full formal written apology to Mrs C for the distress caused to her following the consultation;
• (ii) the GP should consult with the Director of General Practice Postgraduate Education (or his Deputy) to discuss, identify and participate in training and developmental initiatives designed to improve his consultation and communication skills;
• (iii) the Practice should revise their 'Practice Complaints Procedure' to ensure that patients are made aware that they may request that their complaint is investigated and responded to by someone other than the person complained about. This review should also include the development of a process to investigate and address each part of a complaint made before a response is issued; and
• (iv) the Practice should communicate the updated Complaints Procedure in a revised 'Practice Information' leaflet.

Overview

The complainant, Mr C, raised a number of concerns about his General Practitioner (GP 1) following a consultation in August 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 behaved unprofessionally towards Mr C during the consultation (upheld);
• (b) GP 1 unfairly removed Mr C from the medical practice (the Practice)'s patient list (upheld); and
• (c) GP 1's response to a complaint from Mr C's daughter was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) GP 1 should make a full formal written apology to Mr C for failing to deal with him in a professional manner and for the distress caused to Mr C and his family in pursuing this matter;
• (ii) GP 1 should consult with the Director of General Practice Postgraduate Education (or his deputy) to discuss, identify and participate in training and developmental initiatives designed to improve his consultation and communication skills;
• (iii) GP 1 should make a full formal written apology to Mr C for removing him unfairly from the Practice patient list;
• (iv) the Practice should reflect on this case and reconsider their policy for removing patients. This revised policy should be open to the patient population and advertised in a revised 'Practice Information' leaflet;
• (v) the Practice should revise their 'Practice Complaints Procedure' to ensure that patients are made aware that they can ask for their complaint, and the response, to be handled by someone other than the person complained about; and
• (vi) the Practice should communicate the revised complaints procedure in a revised 'Practice Information' leaflet.

Overview

The complainant (Mrs C) raised concerns that the Medical Practice (the Practice) inadequately monitored her husband (Mr C)'s blood clotting therapy, which led to him requiring frequent hospital admissions.

Specific complaint and conclusions

The complaint which has been investigated is that, between January 2005 and June 2007, the Practice inadequately monitored and failed to take appropriate action in relation to Mr C's blood clotting therapy (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the treatment which he received at the Ear Nose and Throat Department at Stirling Royal Infirmary (the Hospital) regarding nasal problems which he had suffered for many years.

Specific complaint and conclusions

The complaint which has been investigated is that, during the period 2003 to 2005, Mr C received inadequate treatment from staff at the Hospital regarding his nasal problems (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.