Health

Overview

The complainant (Mr C) complained that he had received inadequate care and treatment during and after a tooth extraction at Dundee Dental Hospital (the Hospital) on 15 March 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had a tooth removed at the Hospital which resulted in nerve damage, leaving him in constant and severe pain (not upheld); and
• (b) the tooth was removed in a rough manner by an unsupervised dental student (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their protocol, whether it is best practice that an x-ray should be taken to help identify any potential problems or infections, following the re-presenting of a post-extraction patient.

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

Overview

The complainant (Mrs C) raised concerns that her husband (Mr C), who suffered from a degenerative neurological disease (the disease), had been given inappropriate advice by a nurse working with patients with the disease.  She also complained that her complaint to Grampian NHS Board (the Board) had not been adequately investigated.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) inappropriate advice was given to Mr C about possible treatment available to him for the disease (no finding);
• (b) there was inadequate communication between members of the clinical team involved in Mr C's care (upheld); and
• (c) the Board did not appropriately investigate Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider establishing a protocol for clinicians re-entering a patient's care after a period without contact;
• (ii) consider how communication can be improved in circumstances where a team of several clinicians is involved in a patient's care and when a general practice team are the only professionals involved for significant periods; and
• (iii) take steps to ensure that staff involved in the investigation or consideration of complaints are appropriately informed of the details of the complaint and that any decisions reached are properly reasoned and take into account all of the circumstances of the complaint.

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

Overview

The complainant (Ms C) raised a number of concerns regarding the care and treatment provided to her by her dentist (the Dentist).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist failed to properly examine Ms C's teeth and overlooked the need for a filling (upheld);
• (b) the Dentist failed to make an accurate impression of Ms C's teeth (not upheld);
• (c) the Dentist failed to properly fit a Maryland Bridge (not upheld);
• (d) there was a delay of two months mid treatment leading to the decay of Ms C's teeth (not upheld);
• (e) a denture had been fitted improperly which induced Ms C's gag reflex and resulted in the loss of four adjacent teeth (not upheld);
• (f) appointment times were insufficient to allow for dental work of a reasonable standard (not upheld);
• (g) the Dentist improperly refitted a crown (not upheld); and
• (h) the Dentist failed to take into account the radiotherapy and chemotherapy treatment Ms C had had previously which had affected her teeth (not upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) carries out a Clinical Audit of his own x-ray procedures to ensure that any problems with the current system can be identified and removed; and
• (ii) carries out a similar audit in respect of his record-keeping to ensure compliance with General Dental Council Standards.

The Dentist has 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 father (Mr A) during the final months of his life while he was a patient of Ayrshire and Arran NHS Board (the Board).  She was particularly concerned with the administration of drugs to her father and the palliative care he received.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board's administration of Amisulpride to Mr A was not appropriate (not upheld); and
• (b) the Board did not provide adequate palliative care to Mr A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Mr A's family for the inadequacy of the palliative care afforded to Mr A to the extent that the use of syringe drivers would have been a more appropriate method of pain management than fentanyl patches.

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

Overview

The complainant (Miss C), an advocacy worker, complained on behalf of a man (Mr A) regarding the treatment received by his late wife (Mrs A) at her GP Practice (the Practice).  Mr A complained about the Practice's failure to promptly diagnose Mrs A's secondary cancer and he considered that the overall treatment provided to her was inappropriate.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a) failed to diagnose and properly treat Mrs A's illness (not upheld);
• (b) provided inaccurate information about waiting times for an ultrasound scan (upheld);
• (c) inaccurately completed an out-patient appointment form (not upheld);
• (d) delayed arranging blood tests and only did so upon Mrs A's request (no finding);
• (e) delayed admitting Mrs A to hospital (not upheld);
• (f) failed to respond to Mrs A and her family sympathetically and empathetically (not upheld);
• (g) caused distress by asking Mrs A why she needed a medical certificate (no finding); and
• (h) dealt inefficiently with a request for a repeat prescription (not upheld).

Redress and recommendation

The Ombudsman recommends that the Practice considers putting procedures in place to regularly check prevailing waiting times for relevant out-patient services/clinics and does not continue to rely on historic data which may no longer be accurate.

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

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment which he had received from Greater Glasgow and Clyde NHS Board (the Board) since 1996 for his erectile dysfunction.  Mr C was particularly concerned that he had been asking for a penile implant operation for a number of years and only in 2005 had the Board agreed to consider him for the procedure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was unreasonable for the Board to have taken nine years to agree to Mr C's request to be considered for a penile implant operation (partially upheld);
• (b) the Board failed to correctly perform a Nesbit's operation, to correct the bend in Mr C's penis, which resulted in the bend moving from the base to half way up Mr C's penis (no finding);
• (c) Mr C did not have his follow-up appointment three months after his operation, as planned, and had to contact the hospital to ask for the appointment to be arranged (partially upheld);
• (d) the Board failed to provide Mr C with appropriate care and treatment for his erectile dysfunction (not upheld); and
• (e) the Board failed in their handling of Mr C's case from the point at which he was advised that he would be considered for the penile implant operation, ie July 2005, onwards, including that Mr C was later advised by the Board that the operation was not available within the NHS in Glasgow (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the delay in providing his penile implant operation, for adding his name to the waiting list prematurely and not advising him of the conditions and restrictions which applied and for the delay in his follow-up appointment for the Nesbit's operation;
• (ii) take steps to ensure that, early, well documented psychiatric reports are produced in future cases of this type when requested or required; and
• (iii) take appropriate steps to ensure that, in future cases of this type, patients' names are not added to waiting lists prematurely and that they are advised of any conditions or restrictions which apply.

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

Overview

The complainants, Mr and Mrs C, complained about the care and treatment provided by two GPs (referred to in this report as GP 1 and GP 2) to their son, Mr A, who died on 12 September 2004, aged 15.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 and GP 2 failed to investigate Mr A's symptoms and should have done so, even while waiting for referral elsewhere (upheld);
• (b) GP 1 and GP 2 failed to progress a diagnosis of Mr A's condition (upheld);
• (c) GP 1 failed to note the symptom of breathlessness in the records (no finding); and
• (d) GP 1 did not take Mr A's pulse (upheld).

Redress and Recommendations

The Ombudsman recommends that:

• (i) GP 1 and GP 2 apologise to Mr and Mrs C for the shortcomings identified in the report; and
• (ii) GP 1 raises complaints (a), (b) and (d) and GP 2 raises complaints (a) and (b) as issues at their annual appraisal and take them into account in their Continuing Professional Development.

GP1 and GP 2 have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mrs C) said that her GP Practice (the Practice) inappropriately removed her and her husband (Mr C) from their list.

Specific complaint and conclusion

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

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ensure that the relevant regulations and guidance are adhered to before they ask for a patient to be removed from their list; and
• (ii) apologise to Mr and Mrs C for not adhering to the relevant regulations and guidance before asking for them to be removed from their list.

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

Overview

The complainant (Ms C) visited the Royal Infirmary of Edinburgh (the Hospital)'s Accident and Emergency department suffering from chest and arm pain.  She was examined and sent home, being told that an existing stomach complaint was the most likely cause of her symptoms.  Two days later she suffered a myocardial infarction.  Ms C feels that the tests carried out by Lothian NHS Board (the Board) were insufficiently thorough and that her concerns regarding her family medical history of heart problems were not taken seriously.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to diagnose Ms C's condition (not upheld); and
• (b) staff in the Gastrointestinal Department of the Hospital were dismissive of Ms C's concerns during the diagnostic process (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) felt that his GP practice (the Practice), did not take his illness seriously, that they were slow to carry out and follow-up tests and that the diagnosis of his cancer was subsequently delayed.

Specific complaint and conclusion

The complaint which has been investigated is that the diagnosis of Mr C's condition was unnecessarily delayed (not upheld).

Redress and recommendation

The Ombudsman recommends that the Practice review their procedures for recording and tracking the dispatch and receipt of blood tests.

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