Health

Overview

The complainant (Mrs C) raised a number of concerns, alleging that the community dentist (Dentist 1) fitted a denture which had been incorrectly prepared.  Also, she was unhappy about the clinical decision which was taken to proceed with treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the community dentist (Dentist 1) proceeded with treatment using an incorrectly prepared denture (upheld); and
• (b) Mrs C subsequently disagreed with the decision taken, to continue with treatment without regard to the stressful circumstances which applied (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) identify and evaluate the measures which are now in place to prevent this occurring again;
• (ii) consider the use of a pre-extraction appointment to ensure full understanding of a treatment plan;
• (iii) draw up guidelines to consider management and consent when a patient is under particular stress;
• (iv) consider the development of a pro-forma to jointly support all clinicians' agreement that the denture made is correctly prepared; and
• (v) ensure that a full apology is made to Mrs C for the distress and discomfort caused as a result of the treatment option followed in this particular case.

The Board 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 of her 64-year-old husband (Mr C) on Ward 58, a high dependency unit in the Western General Hospital (the Hospital), Edinburgh.  He had been transferred there on 1 August 2006 after several weeks on other wards in the Hospital and had a cardiac arrest there on 5 August 2006.  Sadly, he died later that day in an intensive care unit of the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C’s care and treatment from 1 to 5 August 2006 on Ward 58 were below a reasonable standard (upheld); and
• (b) Lothian NHS Board (the Board)’s complaint handling time was not in accordance with the NHS Complaints Procedure (upheld).

Redress and recommendation

The Ombudsman recommends that the Board put in place rigorous measures to address each of the five shortcomings arising from the leaking central line.

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

Overview

The complainant, Mr C, complained about the lack of clinical follow-up for his ear, nose and throat complaint and that a Consultant Surgeon (the Consultant) did not refer him for a further clinical opinion.  He also complained that Greater Glasgow and Clyde NHS Board (the Board) took over three months to respond to his formal complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) no action was taken for seven months to identify the cause of the symptoms of Mr C’s condition (not upheld);
• (b) the Consultant did not refer Mr C to another specialist for an opinion (upheld); and
• (c) the NHS took over three months to respond to the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind the Consultant of the importance of clear communication with patients, to assist their understanding of any potential diagnosis or otherwise, when symptoms are still present;
• (ii) ensure that staff clearly record the outcome of a clinical decision regarding a second opinion; and
• (iii) review their internal procedure for investigating and resolving complaints and consider ways to improve their response times to complaints.

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

Overview

The complainants, Mr C and Ms A, raised a number of concerns that, following a routine laparoscopy investigation for an infertility problem at Stirling Royal Infirmary (the Hospital) on 9 August 2005, Ms A was admitted as an emergency patient to the Hospital on 12 August 2005 and received inadequate care and treatment.  Thereafter, Mr C and Ms A also complained that Forth Valley NHS Board (the Board) had not treated Mr C and Ms A either appropriately or fairly as patients of their Infertility Service (the Service).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Ms A received inadequate care and treatment from the Hospital (not upheld); and
• (b) the Board's infertility service made matters worse (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment provided to his mother, Mrs A at Monklands Hospital (the Hospital) and the Beatson Oncology Centre (the Centre).  The Hospital is managed by Lanarkshire NHS Board (Board 1).  The Centre is managed by Greater Glasgow and Clyde NHS Board (Board 2).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unacceptable delay in the Hospital making a correct diagnosis (upheld);
• (b) the Hospital's decision to operate on Mrs A was incorrect (upheld);
• (c) Mrs A's prognosis was not adequately explained to the family by either the Hospital or the Centre (partially upheld); and
• (d) Mr C's complaints about the conditions in the Hospital ward were not dealt with appropriately (upheld).

Redress and recommendations

The Ombudsman recommends that Board 1 apologise to Mr C for the delay in making the diagnosis and for making the incorrect decision to operate.

The Ombudsman recommends that both Boards apologise to Mr C for the fact that Mrs A's prognosis was not adequately explained to the family and review the way that a poor prognosis is explained to patients and their families.

The Ombudsman will send a copy of this report to SIGN for their consideration when Guideline 61 on post-menopausal bleeding is reviewed later this year.

Overview

The complainant (Mr C) raised a number of concerns about the treatment he received when he attended the Accident and Emergency Department at Stirling Royal Infirmary (the Hospital) on 24 June 2007, following a road traffic accident.

Specific complaint and conclusions

The complaint which has been investigated is that Mr C received inadequate treatment when he attended the Accident and Emergency Department at the Hospital on two occasions on 24 June 2007, following a road traffic accident (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board:

• (i) apologise to Mr C for the failings identified in this report;
• (ii) share this report with the Senior House Officer so that she can reflect on her actions; and
• (iii) consider using the circumstances of this complaint in an anonymised form as a learning tool for junior staff working in Accident and Emergency.

The Board 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 which her late mother, Mrs A, received at the Royal Infirmary of Edinburgh (the Hospital) in August 2007.  Mrs C complained that there were delays in carrying out a CT scan and for Mrs A to be seen by a dietician.  She also complained that there were communication problems with the staff.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a delay in carrying out a CT scan following Mrs A’s admission to the Hospital (upheld);
• (b) it was inappropriate for staff to assume Mrs A was suffering from bowel cancer and this compromised her treatment plan (not upheld);
• (c) there was a delay in Mrs A being seen by a dietician and to ensure she received an adequate level of nutrition (upheld); and
• (d) the level of communication with Mrs A’s family was inadequate (upheld).

Redress and recommendations

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

• (i) give consideration to whether communication links between clinical and radiology staff require review in view of the findings in this report;
• (ii) conduct a review of the current procedures for requesting a CT scan at the weekend, to ensure that patient care is not compromised, should the status of the request be downgraded;
• (iii) conduct an audit of the clinical and nursing records in the ward, to ensure that they are completed in accordance with the guidance issued by the regulatory bodies such as the General Medical Council and the Nursing and Midwifery Council;
• (iv) reflect on Adviser 1’s comments about the lack of urgency in the clinical investigation and consider whether the degree of patient orientation or clinical leadership at ward level is appropriate;
• (v) review their policies for nutritional assessments and dietetic referrals and consider whether nursing staff would benefit from the implementation of a robust education programme related to meeting the nutritional needs of older people in hospital, with clear links to Food, Fluid and Nutritional Care Standards (NHS Quality Improvement, Scotland NHS Scotland September 2003);
• (vi) should provide evidence of clinical benchmarking of ‘Communication’, which is clearly linked to Standard 8 Clinical standards for older people in acute care (Clinical Standards Board for Scotland October 2002), to ensure that this aspect of practice is audited and there is demonstrable evidence of improvement in this aspect of care delivery; and
• (vii) issue Mrs C an apology for the failings which have been identified in this report.

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

Overview

The complainants raised a number of concerns about the care of their late mother (Mrs A) while she was a patient at Stobhill Hospital, Glasgow and Glasgow Royal Infirmary between January and August 2007.  In particular, they raised concerns about unnecessarily prolonged admission due to acquired infections, quality of food, lack of mental and social therapy, management of hearing aids, communication with family members and information about MRSA.

Specific complaints and conclusions

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide appropriate care to Mrs A between 14 January 2007 and her death on 31 August 2007 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) give consideration to the introduction of recorded, validated mental tests on admission for older people (whether the patient is considered confused or not) by way of a base-line assessment to assist in future diagnosis;
• (ii) review policy for handling of hearing aids and assistance available particularly in light of Mrs A’s experience;
• (iii) advise her of the action plan resulting from the November 2007 audit of Ward 45, Ward 46, and Ward 47 at Stobhill Hospital, Glasgow, and
• (iv) advise her of the action plan resulting from the Rehabilitation and Assessment Directorate review of the ‘patient day’.

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

Overview

The complainant (Miss C) raised a number of concerns about the medical and nursing care and treatment of her 74-year-old mother (Mrs A) at Ninewells Hospital in the few months up to her death in a hospice in August 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A’s care from May to August 2006 was below a reasonable standard (partially upheld - only in respect of record-keeping).

Redress and recommendations

The Ombudsman recommends that Tayside NHS Board (the Board) provide the Ombudsman’s office with evidence of appropriate monitoring of the guidelines about long-term feeding lines for diabetic patients.

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

Overview

The complainants (Mr B and Mrs C) raised a number of concerns about the care and treatment of their late mother (Mrs A) during her final admission through Accident and Emergency at Inverclyde Royal Infirmary in February 2006.  They were also concerned about the manner in which their complaints had been dealt with by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) failed to provide appropriate care to Mrs A on 14 and 15 February 2006 (upheld); and
• (b) failed to respond promptly and appropriately to Mr B and Mrs C's complaints (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise in writing to Mr B and Mrs C for the failure to provide appropriate care to Mrs A and her family on the 14 and 15 February 2006 and the failure to respond to their complaints in a timely and effective manner.

The Ombudsman recognises that a number of other changes introduced by the Board and NHS Scotland avoid the need for further recommendation, although she notes with concern the time taken to introduce some of the changes and the negative impact several structural reorganisations had on this complaint.

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