Health

Overview

The complainant (Mr C) raised a number of concerns that his father (Mr A) had received inadequate treatment while he was a patient at Ninewells Hospital (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that there was:

• (a) inadequate treatment for Mr A's pressure sores (upheld);
• (b) inadequate monitoring of Mr A's pressure sores (upheld); and
• (c) an inappropriate decision to continue with a course of treatment for Mr A's pressure sores (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide evidence of a robust standard for records and record-keeping and provide evidence of measures that are in place to audit this area of practice;
• (ii) provide evidence that there is a programme of formalised education and training of the staff on Ward 11 with reference to the transfer of patients which includes the importance of effective communication and proactive nursing in relation to this process;
• (iii) provide assurances that they have a robust policy in place regarding inter-ward transfers;
• (iv) devise a quality assurance system whereby all patients suffering from pressure sores have care plans which are sufficiently detailed and also highlight the monitoring arrangements for the patient;
• (v) apologise to Mr A for the failings which have been identified; and
• (vi) reiterate to all relevant staff at the Hospital the importance of clearly recording the factors which lead to a decision regarding continuing or changing treatment.

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

Overview

The complainants (Mr C and Mr D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at Stirling Royal Infirmary (the Hospital) between 7 March and 21 March 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Forth Valley NHS Board (the Board):

• (a) failed to provide appropriate care and treatment to Mrs A (upheld); and
• (b) failed to adequately investigate Mr C's original complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) inform her of the progress of the recommendations in their Internal Review;
• (ii) apologise to Mrs A's family for the failures identified in this report and their Internal Review and the additional distress caused by the failure of their original investigation to identify and address these failures; and
• (iii) build more robust senior and independent review into the local resolution stage of the NHS Complaints Process to ensure complaints are addressed more comprehensively and review of complaints is built in to Clinical Governance to ensure lessons can be learned form complaints.

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

Overview

The complainant (Mr C) raised some concerns that he was treated inappropriately by a consultant (Clinician 1) during a consultation.  Mr C also suggested that Clinician 1's suggested treatment was inappropriate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the conduct of Clinician 1 during the consultation was inappropriate (not upheld); and
• (b) the treatment suggested by Clinician 1 was inappropriate (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for Clinician 1's failure to clarify the significance of lifestyle rather than sexuality when taking a history from Mr C during the consultation; and
• (ii) ensure Mr C's medical records are amended, where possible, to remove the term 'homosexuality' where it refers to a medical condition, including the GP records, as this is inappropriate.

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

Overview

The complainant (Mrs C) raised a number of concerns that her mother (Miss A) had not been appropriately treated by her GP practice (the Practice) and also that her own complaint to the Practice had not been properly responded to.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a) did not give Miss A appropriate care between January and June 2006 (not upheld); and
• (b) did not respond appropriately to Mrs C's complaint of 4 July 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

Mrs C was concerned that her mother, Mrs A, had developed a pressure sore while in Ninewells Hospital (Hospital 1) and this prevented her from accessing stroke rehabilitation services.

Specific complaint and conclusion

The complaint which has been investigated is that the care and treatment received by Mrs A from Hospital 1 was inadequate and reduced her ability to access rehabilitation services (partially upheld to the extent that the Board did not fully respond to concerns raised by Mrs C).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for failing to respond clearly to her concerns about the effect on Mrs A of the problems in the care she had received; and
• (ii) use this case as a learning tool for staff to demonstrate the importance of good documentation and the effect that failing to complete documentation can have on patient care.

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 provided to his late mother (Mrs A) at the Queen Margaret Hospital, Dunfermline (the Hospital) between 26 March 2006 and her death there on 21 May 2006.

Specific complaints and conclusions

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

• (a) failed to provide appropriate care and treatment to Mrs A (not upheld);
• (b) failed to ensure adequate communication with Mrs A and her family about Mrs A's condition and treatment (not upheld); and
• (c) failed to adequately respond to Mr C's complaints (not upheld).

Redress and recommendations

The Ombudsman recommends that Fife NHS Board use the events of this case, in particular the differing perceptions of staff and family about these events, in staff training to consider how communication in these circumstances might be improved for the future.

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 given to her mother (Mrs A) at Perth Royal Infirmary (the Hospital) following her admission for a suspected oesophageal stent blockage on 9 August 2005.

Specific complains and conclusions

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

• (a) prescribed morphine unnecessarily (no finding);
• (b) failed to provide appropriate nursing care (partially upheld);
• (c) failed to maintain accurate records (upheld); and
• (d) failed to provide an adequate complaint response (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) emphasise to nursing staff in the relevant ward the importance of recording in the clinical records any change in the condition of the skin or injury and of ensuring that the commensurate care plan is also formulated and recorded;
• (ii) apologise to Mrs C for the confusion and distress caused by the apparently contradictory nature of some of the responses to her complaints;
• (iii) review the operation of the admission assessment and adopt a consistent process for recording alterations within the assessment;
• (iv) use the events of this complaint in a multi-disciplinary team meeting to illustrate the impact of poor complaint handling and record-keeping on the patient/carer experience; and
• (v) ask that those responsible for providing complaint responses ensure that, where possible, evidence, comment or information is obtained from and checked against, original sources.

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

Overview

The complainant (Mr C) is 16 and was born with a progressive spinal deformity, for which he was reviewed in Glasgow between the ages of five months and 13 years.  When he was 13, the service was transferred to Edinburgh.  At review there, five months later, Mr C was told that an operation some years previously could have prevented his current, permanent, deformity.  Mr C complained, therefore, about not having had such an operation in Glasgow.

Specific complaints and conclusions

The complaint which has been investigated is that it was unreasonable not to have performed an operation at an early age (not upheld).

The investigation has involved consideration of a number of issues to do with clinical practice and arrangements for the provision of health services which, although not all specifically raised in Mr C's complaint, are relevant to any assessment of how his healthcare needs have been addressed.  Paragraph 1 of the main report outlines these issues.

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns about the diagnosis and treatment given to her father (Mr A) on his admission to Aberdeen Royal Infirmary as an emergency by his General Practitioner.  In particular, she feels that had medical staff correctly diagnosed Mr A's condition, they could potentially have saved his life.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) medical staff failed to diagnose an aortic abdominal aneurysm or carry out an appropriate scan to allow them to discount this condition (no finding); and
• (b) Grampian NHS Board failed to investigate Ms C's complaint in a timely manner (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainants (Mr and Mrs C) raised concerns regarding dental treatment received by their daughter (Miss A) at a General Dental Practice (the Practice).  They consider this treatment to have caused one of Miss A's teeth to become non-vital (see Annex 2) and they believe that they should have been warned of this risk in advance.  They were also dissatisfied with the alignment of Miss A's teeth following the treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) after dental correction with braces, Miss A had a non-vital front upper tooth which may require expensive treatment in the future (not upheld);
• (b) the risk of the tooth becoming non-vital should have been pointed out to Mr and Mrs C prior to treatment commencing (not upheld); and
• (c) following treatment, the centre lines of the top and bottom teeth did not match (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.