Health

Overview

The complainant (Mr C) complained about the transport arrangements for his wife (Mrs C) after her feeding tube blocked and she required hospital treatment to unblock it. He also complained about the care and treatment she received at Gilbert Bain Hospital, Shetland (Hospital 1).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a delay in the arrival of the ambulance and when it arrived it could not take Mrs C in a powered wheelchair (upheld to the extent that the ambulance could have been dispatched more quickly and the delay avoided had the crew been advised when the request for the ambulance arrived);
• (b) no arrangements were made to take Mrs C home after her attendance at Accident and Emergency at Hospital 1 (upheld);
• (c) Mrs C had no nutrition or fluids for 20 hours (upheld);
• (d) Mrs C was sent to the wrong address in a taxi (upheld); and
• (e) the initial travel arrangements made for Mrs C to attend a hospital outwith the Shetland NHS Board area were unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that the Scottish Ambulance Service:

• (i) apologise to Mr C for the failings identified in this paragraphs 5 to 12 of this report; and
• (ii) demonstrate that, through providing more tailored options for requesting physicians, the response and appropriateness of that response has improved.

The Ombudsman recommends that Shetland NHS Board:

• (iii) apologise to Mr C for the failings identified in paragraphs 18 to 29 of this report;
• (iv) send him a copy of the results of the audit of record keeping in the Accident and Emergency department and any action taken to improve practice; and
• (v) audit the Patient Travel Service to ensure that they are now requesting sufficient information to allow them to make appropriate arrangements for all patients in the Board area who require to travel.

Both the Scottish Ambulance Service and Shetland NHS Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which his wife (Mrs C) received leading up to and following a planned left nephrectomy (kidney removal) for transplant, which took place on 22 June 2007. The nephrectomy operation was started but was not completed because the clinicians involved deemed Mrs C's donor kidney was unsuitable for transplantation. Mr C had concerns that the clinicians should have been aware prior to the planned nephrectomy that the kidney was not suitable and this would have prevented Mrs C from having to undergo the operation. Mr C also had concerns about the treatment which Mrs C received following the operation and the way Greater Glasgow and Clyde NHS Board (the Board) handled his complaints.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the process used by the Transplant Team to identify Mrs C's suitability for the nephrectomy prior to the operation was inadequate (not upheld);
• (b) the decision to abort the nephrectomy on 22 June 2007 was unreasonable (not upheld);
• (c) Mrs C’s post-operation management was inadequate (upheld);
• and (d) the Board's handling of the complaint was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the clinicians reflect on the Adviser's comments about the level of clinical information which has been entered in the clinical records;
• (ii) the Board apologise to Mrs C for the failings identified in her post-operation management;
• (iii) the Board review their discharge arrangements for surgery of this type and take steps to ensure there is appropriate post-surgery discharge planning in each case; and
• (iv) the Board remind staff of their obligations to manage complaints in line with the NHS complaints procedure and take action to ensure that information about the NHS complaints procedure which is held locally in hospitals and clinics is up to date.

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

Overview

The complainant, Mrs C, raised a number of concerns about her husband (Mr C)'s consultations with various GPs from his GP Practice (the Practice) and from the Greater Glasgow and Clyde NHS Board's GP Out of Hours Service (the Service) prior to his admission to hospital where, sadly, he died of heart problems.

Specific complaints and conclusions

The complaints which have been investigated are that;

• (a) Mr C's heart problems were not diagnosed by GP 1 and GP 2 from the Practice at consultations on 20 October, 28 October and 11 November 2005 (not upheld);
• (b) Mr C's heart problems were not diagnosed by GP 3 and GP 4 from the Service at consultations on 30 November and 1 December 2005 (not upheld);
• (c) the Practice did not deal with Mrs C's complaint properly (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice;

• (i) apologise to Mrs C for failing to deal with her complaint properly; and
• (ii) reflect on their complaints policy, review their complaints protocol and discuss how to respond to complaints from non-patients.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board.

Overview

The complainant (Mr C) raised concerns about the fact that his grandmother (Mrs A) was not provided with NHS funded continuing care by Lanarkshire NHS Board (the Board). Mr C also raised concerns that the Scottish Government's policy on NHS funded continuing care was unclear and did not appear to allow for somebody living in the community to be assessed under the policy.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to appropriately assess Mrs A for NHS funded continuing care (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, in the Vale of Leven Hospital (Hospital 1) between 26 August 2004 and 6 September 2004. Mrs A was subsequently admitted to Gartnavel General Hospital (Hospital 2) on 10 September 2004 but, sadly, died on 19 September 2004.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a renal ultrasound scan was not performed on admission to Hospital 1 and when one was done at Hospital 2 the results were not acted upon (upheld);
• (b) communication with Consultant 2 at Hospital 2 was inadequate (upheld);
• (c) Mrs A was inappropriately noted as having 'no medical issues' when allowed home on weekend pass (upheld);
• (d) Mrs A was discharged from Hospital 1 without appropriate action (upheld); and
• (e) the discharge letter was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) this case be discussed urgently with Consultant 1 and formally recorded at her next annual appraisal;
• (ii) the clinical team responsible for Mrs A's care in Hospital 1 consider and act on the lessons to be learned as a result of the failings identified in this report;
• (iii) Greater Glasgow and Clyde NHS Board (the Board) remind staff of the need for accurate records to be kept;
• (iv) the Board share with the Ombudsman a copy of the regular audit of communications which is presented to the NHS Board's Clinical Governance Committee; and
• (v) the Board apologise fully and formally to Ms C for the failings identified in this report.

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

Overview

The complainant (Mrs C) raised a number of concerns about the quality and quantity of information provided to her late daughter (Miss C) following her diagnosis of epilepsy in April 2006. Mrs C considered that Miss C was denied an opportunity to fully understand the consequences of not taking her prescribed medication on a regular basis and that this may in turn have contributed to Miss C's premature death.

Specific complaint and conclusion

The complaint which has been investigated is that Fife NHS Board (the Board) failed to provide Miss C with adequate information thereby denying her appropriate care and management between April 2006 and her death in October 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide written information to patients following diagnosis on a proactive basis and in line with that recommended in SIGN 70;
• (ii) advise her when the epilepsy nurse-specialist is in post; and
• (iii) apologise to Mrs C that written information about Miss C's condition and changes in her drug regime were not made available to Miss C and that there is no evidence of an individualised decision being made not to tell Miss C about Sudden Unexpected Death in Epilepsy.

The Board have accepted and acted on recommendations (i) and (ii). Recommendation (iii) has not been accepted (see paragraph 48).

The Ombudsman will ask the Scottish Intercollegiate Guidance Network (SIGN) to consider the findings of this report as part of their on-going consideration of the review of the guidelines on Epilepsy in Adults (SIGN 70). Further, in light of the difference in views recognised in paragraph 48, the Ombudsman will ask that the Directorate of Health and Wellbeing consider the need for more research into patient views on information giving and into the possible risk factors for SUDEP and the use of this research to inform ethical guidance.

Overview

The complainant (Mrs C) raised a number of concerns about the services relating to travel provided to her daughter by her GP practice (the Practice).

Specific complaint and conclusion

The complaint which has been investigated is that the Practice failed to provide services relating to travel in accordance with the relevant regulations from February 2008 to date (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ceases immediately its policy for charging for all travel advice;
• (ii) as far as possible, refunds patients it has charged wrongly; and
• (iii) amends its policy in light of the regulations.

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 provided to her daughter (Ms A) who had mental health problems. Ms A's treatment was provided by Clinical Psychologists and was then transferred to a Community Psychiatric Nurse.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms A's treatment from the Clinical Psychologists was withdrawn inappropriately (not upheld); and
• (b) explanations provided to Mrs C and Ms A were inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Mrs C and Ms A for the failures identified in this report;
• (ii) remind staff that clinical decisions should be documented and of the importance of doing this; and
• (iii) remind staff that adequate explanations of clinical decisions need to be provided to patients.

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

Overview

The complainant (Mr C) raised a number of concerns about the response he received from Greater Glasgow Health Board (the Board) following an investigation by the Mental Welfare Commission for Scotland into the care and treatment which his late son (Mr A) received at Gartnavel Hospital, Glasgow (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the level of medical supervision for the senior house officer who decided on Mr A's mental health state and supervision status during the period 15 March 2001 to 21 March 2001 was inadequate (upheld);
• (b) the Board's response that a care plan was agreed by all staff was incorrect (upheld);
• (c) the charge nurse failed to act on an instruction in Mr A's medical notes that he was not allowed to leave the ward unless accompanied by members of staff (upheld); and
• (d) the Board have not accepted responsibility for failing in its duty of care or offered an appropriate apology (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) give consideration to amending the risk assessment tool to include issues such as impulsivity or when the patient's state of mind is unknown; and
• (ii) offer Mr and Mrs C a full apology for the failings in care which have been identified in this report.  The Ombudsman draws the Board's attention to the SPSO guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

Overview

The complainant (Mrs C) raised concerns about her husband's care and treatment at Dunoon General Hospital (Hospital 1) on 14 June 2006. She complained that medical staff did not consider a diagnosis of acute meningitis when they were considering her husband's diagnosis, and that his transfer to Inverclyde Royal Hospital (Hospital 2) was delayed. Following the decision to transfer her husband (Mr C), he became very unwell and, sadly, he died in Hospital 1 on 14 June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that: (a) an alternative diagnosis of acute meningitis was not considered when a diagnosis of stroke was given to the family on Wednesday 14 June 2006 (not upheld); and (b) there was a delay by Hospital 1 in arranging Mr C's transfer to Hospital 2 on 14 June 2006 (not upheld).

Redress and recommendations

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

• (i) ensure that the local redesign process currently being undertaken between the Board and the Scottish Ambulance Service covers the need for medical staff to have access to the most up-to-date details of inter-hospital transfer times and with all the relevant transportation matters clearly established at the time (of arranging the transfer); and
• (ii) review their acute unit transfers policy to take account of changing patterns of acute stroke management.

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