Health

Overview

The complainant, Mr C, complained that treatment received by his late wife, Mrs C, was inadequate and that staff failed to diagnose that she was suffering from melanoma.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment Mrs C received from 2004 was inadequate and staff failed to diagnose that Mrs C was suffering from melanoma (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review their procedures, in line with the findings of this report, for the carrying out of biopsies on patients diagnosed with cancer and having a similar history to that of Mrs C;
• (ii) consider the findings of this report in relation to removing complaints from the NHS Complaints Procedure and consider subsequently reinstating them if dealing with future complaints resulting from similar circumstances; and
• (iii) write to Mr C with an apology for the distress caused by 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 the care and treatment she received while attending Inverclyde Royal Hospital (the Hospital) on 8 June 2006. She also complained that Greater Glasgow and Clyde NHS Board (the Board) failed to satisfactorily respond to her in good time, following the concerns she raised about the care and treatment she received from the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms C received inadequate care and treatment from the Hospital on 8 June 2006 (partially upheld to the extent that there were failings in obtaining consent and in communicating with her regarding the administering of the local anaesthetic (LA));
• (b) the Board's final response, dated 5 June 2007, did not address Ms C's complaint satisfactorily (upheld); and
• (c) the Complaints Department of the Board failed to respond to Ms C in good time, after she complained to them about the care and treatment she received at the Hospital she attended for recurring breast cancer surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Ms C for the way in which the decision to administer the LA was communicated to Ms C;
• (ii) remind staff of the correct procedures to be followed when obtaining consent prior to surgery taking place;
• (iii) apologise to Ms C for their unsatisfactory final response to her complaint; and
• (iv) apologise to Ms C for the delay in responding to her complaint.

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

Overview

The complainant (Ms C) raised concerns that she and her two children were inappropriately removed from their GP practice (the Practice)'s list because her partner (Mr B) was removed for abusive behaviour.

Specific complaint and conclusion

The complaint which has been investigated is that Ms C and her children were inappropriately removed from the Practice's list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ensure that their policy on the removal of patients from their list complies with the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 and is within the spirit of the guidance available;
• (ii) ensure they have followed the Regulations and considered and followed alternative courses of action before removing a patient from their list; and
• (iii) apologise to Ms C for inappropriately removing her and her children from their list.

Overview

The complainant (Mr C) raised a number of concerns about the treatment which his wife (Mrs C), who was suspected of having multiple sclerosis (MS), received from a consultant neurologist (Consultant 1) at Western Isles Hospital (the Hospital) between October 2006 and February 2007.  Mr C also complained about the behaviour of Consultant 1 and the Western Isles NHS Board (the Board)'s handling of the complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) between 18 October 2006 and 21 February 2007 Consultant 1 provided Mrs C with an inadequate level of treatment (not upheld);
• (b) Consultant 1 behaved inappropriately when he learned that Mrs C had made a complaint against him (upheld); and
• (c) the Board's handling of the complaint was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) Consultant 1 apologise to Mrs C for the comments he made about her in  his letter to the GP dated 22 August 2007; and that the Board:
• (ii) ensure that this report is shared with Consultant 1's appraiser and is discussed at Consultant 1's next annual appraisal;
•  (iii) carry out an audit to ensure that complaints are being dealt with in accordance with the timescales as stated in the NHS complaints procedure;
• (iv) remind staff who deal with complaints or are subject to complaints of their obligations to act in accordance with the guidance as stated in the NHS complaints procedure; and
• (v) apologise to Mr and Mrs C for the failings which have been identified in this report.

The Board have accepted recommendations (ii) to (v) and will act on them accordingly.  As at the date of issue of this report Consultant 1 has not accepted recommendation (i).

Overview

The complainant (Mr C) alleged that the prescription of Pramipexole medication was inappropriate in his care and treatment for Parkinson's disease. He also complained that there was a failure in the follow-up care provided for him in the early part of 2006.

 Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was inappropriately prescribed Pramipexole after his care transferred to the Southern General Hospital (the Hospital) in June 2005 (not upheld); and
• (b) there was a failure of appropriate support and monitoring of Mr C's condition during the early part of 2006 (partially upheld to the extent that it is possible alternative support services could have been considered as part of Mr C's care).

 Redress and recommendations

The Ombudsman recommends that the Board:

•  (i) ensure that clear agreements, in writing if possible, are made between patients, clinicians and where appropriate, family members, about the plan of care and a patient's responsibility regarding the information expected from them during treatment; and
• (ii) remind clinical colleagues of the potential referral opportunities which may be available to augment aspects of patient care and to discuss these with colleagues and patients as appropriate.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the clinical treatment that his father (Mr A) received whilst under the care of Greater Glasgow and Clyde NHS Board (the Board).  He believed that staff at Glasgow’s Victoria Infirmary failed to give due consideration to Mr A’s previous medical history and that, had they done so, his death in December 2006 could have been avoided.  Mr C also complained that the medication prescribed for another of Mr A’s conditions was unsuitable and that it potentially contributed to his deterioration.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board inappropriately treated Mr A with Methotrexate (not upheld);
• (b) the Board failed to take adequate note of Mr A’s past medical history when treating him (upheld);
• (c) the Board failed to proactively seek information relating to Mr A’s past medical history (upheld);
• (d) the Board inappropriately reduced Mr A’s steroid dosages before the full extent of his illness was known (upheld); and
• (e) Mr A’s death certificate did not accurately reflect the cause of death (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) formally apologise to Mr C and his family;
• (ii) remind all staff of the importance of sourcing and reviewing historical clinical records;
• (iii) review their record-keeping practices and introduce procedures to ensure the prompt identification, sourcing and provision of historical clinical records;
• (iv) considers ways to promptly source specific records relating to relevant information raised by patients and their families; and
• (v) ask the clinical team to review the circumstances of this case to see if there are any lessons that can be learned regarding the diagnosis and treatment of organising pneumonia.

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

Overview

The complainant (Mr C) raised concerns about Tayside NHS Board (the Board) on behalf of his wife (Mrs C) about the fact that her contact details were not updated in her medical records and that this resulted in mail being sent to the wrong address.  He also raised concerns that the Board failed to respond to his complaint until he contacted them to follow this up.

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a) update their records of Mrs C's address and GP practice despite being notified of these on several occasions (upheld); and
• (b) efficiently respond to Mr C's complaint (not upheld).

Redress and recommendations

The Board have already taken steps to remedy the failings identified and the Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the treatment she received at Wishaw General Hospital after she was diagnosed with cancer in 2006.

Specific complaint and conclusion

The complaint which has been investigated is that a consultant inappropriately told Mrs C that, '[T]here is no doubt at all that all the cancer has been removed and currently you are cured', in a letter dated 16 March 2006.  Mrs C subsequently had a recurrence of the cancer (upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board) apologise to Mrs C for inappropriately telling her that, '[T]here is no doubt at all that all the cancer has been removed and currently you are cured'.

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

Overview

The complainant (Mr C) was diagnosed as having multiple sclerosis (MS) in an Edinburgh Hospital in September 1973.  The consultant who made the diagnosis decided not to tell Mr C of his condition.  Mr C found out that he had MS in May 2005 after referral to a neurologist but only discovered his earlier diagnosis in September 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's GP practice failed to inform him of a longstanding diagnosis of MS (not upheld); and
• (b) Mr C's MS was not identified or taken into account when he was receiving treatment from Fife NHS Board (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) attended the Royal Infirmary of Edinburgh (Hospital 1) for spinal surgery.  Complications of surgery left him with nerve damage and restricted mobility.  Mr C complained that staff of Lothian NHS Board (the Board) carried out his surgical procedure incorrectly and that hygiene standards and staff attitudes were poor during his stay at Hospital 1.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to perform Mr C's spinal surgery correctly (upheld);
• (b) hygiene standards at Hospital 1 were poor (upheld); and
• (c) the Board's staff acted unprofessionally when dealing with Mr C (no finding)

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) introduce a policy of carrying out appropriate diagnostic scans prior to any exploratory surgery;
• (ii) formally apologise to Mr C; and
• (iii) remind all ward staff of the procedure to be followed in the event of a linen shortage.

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