Health

Overview

The complainant, Mr C, broke his leg while playing rugby.  He complained about his treatment at Queen Margaret Hospital (the Hospital), where the Accident and Emergency doctor (the Doctor) diagnosed a soft tissue injury.  Mr C was also dissatisfied about how his complaint was handled.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's fracture was not diagnosed (upheld);
• (b) Mr C's indication of the location of the pain was ignored both by the Doctor and the bank radiographer (no finding);
• (c) different treatment would have been provided, had the fracture been diagnosed earlier (not upheld); and
• (d) Mr C's complaint was not handled adequately (upheld).

Redress and recommendations

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

• (i) share this report with the Doctor and the clinicians in the Accident and Emergency Department to allow them to reflect on it; and
• (ii) remind staff of the importance of obtaining information from all staff, including locum and bank staff, in relation to complaints; and
• (iii) remind staff to respond to complaints in a timely manner or to request an extension if they are unable to do so, in line with the NHS complaints procedure.

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

Overview

The complainant (Mrs C) raised a number of concerns about the level of nursing care which her late husband (Mr C) received at Borders General Hospital (the Hospital) during two admissions in 2006 and 2007.

Specific complaint and conclusions

The complaint which has been investigated is that, during two admissions to the Hospital in 2006 and 2007, staff failed to ensure that Mr C received an adequate level of nursing care (upheld).

Redress and recommendations

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

• (i) conduct an audit of the cleaning regime which is in use throughout the Hospital and advise her of the outcome;
• (ii) provide evidence of the systems in place to monitor and audit the nursing notes (which would include patient assessment and the care plan);
• (iii) remind staff of the importance to record incidents of injury to patients in the nursing records, in addition to completing incident reports;
• (iv) provide evidence that there are measures in place to monitor compliance with the Administration of Medicines Policy; and
• (v) share this report with the Senior Charge Nurse on the ward and consider, in light of the issues which have been raised, whether additional education and development is required.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment she received for a fractured arm at her community hospital (Hospital 1), following a fall on 24 October 2006.  Mrs C attended Hospital 1 from 24 October 2006 to 12 December 2006 but remained unhappy with the treatment she received and eventually referred herself to a major hospital (Hospital 2) for treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) further to Mrs C’s attendance at Hospital 1, from 25 October 2006, staff failed to arrange a follow-up x-ray (upheld); and
• (a) the management of Mrs C’s injury was inadequate (upheld).

Redress and recommendations

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

• (i) apologise to Mrs C for the failure to carry out a repeat x-ray; and
• (ii) develop a protocol for the management of patients who attend community hospitals with fractures, as suggested by the professional medical adviser.

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

Overview

The complainant (Mrs C) said that a neck injury prevented her from being able to lie in the conventional, fully recumbent, position in a dentist’s chair.  Her dentist (the Dentist) refused to treat her, as a back problem prevented him from working on patients that were not in the conventional position.  Mrs C had to find another dentist that would treat her in a more comfortable position.  Mrs C complained about the dental practice (the Practice)'s handling of her situation and the attitude of the Dentist and other staff at the Practice.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist unfairly refused to treat Mrs C (not upheld);
• (a) the Dentist failed to provide appropriate information to help Mrs C access the dental treatment that she required (no finding); and
• (b) the Practice’s complaint handling was poor (not upheld).

Redress and recommendations

The Ombudsman draws the Dentist’s attention to the General Dental Council Standards for Dental Professionals guidance, which suggests producing a public version of the Practice’s complaints procedure that can be prominently displayed and made easily available to patients.

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment provided to his wife (Mrs C) in the weeks leading up to her death in June 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Highland NHS Board (the Board) failed to:

• (a) obtain properly informed consent for an operation (upheld);
• (a) manage a 'Do Not Attempt Resuscitation' order properly (upheld); and
• (b) provide reasonable care and treatment to Mrs C from 2004 onwards (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake an audit of operative consent and reflect if further action is needed in light of the results of the audit; and
• (ii) undertake an audit of the use of 'Do Not Attempt Resuscitation' orders and reflect if further action is needed in light of the results of the audit.

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

Overview

The complainants (Mr and Mrs C) raised concerns on behalf of their son (Mr A) about the decision by the Scottish Ambulance Service (the Service) not to send an ambulance for their son and the way the Service handled their complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Service's decision not to send an ambulance jeopardised Mr A's safety (upheld); and
• (a) the Service mishandled the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i) acknowledges to Mr and Mrs C that the wrong decision had been made and apologises for the distress the decision had caused;
• (ii) writes to her outlining the steps it has taken to implement the new guidance so that the assurances can be given to the Ombudsman that the relevant Service personnel, local authorities and organisers of private hire events are clear on the Service’s role; and
• (iii) apologises to Mr and Mrs C for its handling of the complaint.

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

Overview

The complainant (Mr C) raised concerns about the treatment that he received for his urological condition and the fact that he was not appropriately referred for surgery.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Fife NHS Board (the Board) failed to refer Mr C for surgery (upheld);
• (a) the Board did not provide timely follow-up after Mr C's supra-pubic catheterisation (not upheld); and
• (b) unnecessary investigations were carried out prior to Mr C's referral to another hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for failing to list him for surgery; and
• (ii) take steps to ensure that patients are followed up when required.

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

Overview

The complainant (Mr C)'s GP referred him to a Consultant Urological Surgeon at the Southern General Hospital (the Hospital).  After tests, however, Mr C was referred on to a clinic for the treatment of sexual and reproductive health problems (the Clinic).  Mr C's complaints concern his treatment at the Hospital and the confusion surrounding his referral to the Clinic.

Specific complaints and conclusions

The complaints which have been investigated are that Mr C's treatment:

• (a) at the Hospital was unreasonable (partially upheld); and
• (b) at the Clinic was unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) apologise to Mr C for the shortcomings identified in this report;
• (ii) offer Mr C an appointment to have a full assessment with the new consultant at the Hospital;
• (iii) audit the Clinic's system of dealing with referrals to ensure it is now working properly and advise her of the outcome; and
• (iv) offer Mr C an appointment to begin therapy with a named counsellor and a further follow-up appointment with the Clinic Consultant.

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

Overview

The complainant (Mrs C) raised a number of concerns relating to her husband (Mr C)'s admission to Ninewells Hospital, Dundee (the Hospital), his treatment during his stay and the way in which her complaint was handled by Tayside NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's belongings were never recorded on his admission to the Hospital (upheld);
• (a) no response was made to Mr C's cardiac monitor sounding an alarm at various points during his stay in the ward and it was entirely ignored during the night (no finding);
• (b) Mr C was given contradictory information about how he could get his cardiac monitor reset (no finding);
• (c) Mr C's pressing of the call button was not answered for one hour (no finding);
• (d) staff on duty in the ward were not appropriately qualified (not upheld); and
• (e) there were inadequacies in the handling of Mrs C's complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to comply with the 'Patients' Funds and Property Procedure' when admitting patients to the ward;
• (ii) ensure that all staff, especially bank nurses, are reminded of the importance of accurate record-keeping; and
• (iii) take action to remind appropriate staff of the need to comply with the relevant procedures, in relation to investigating and responding to complaints within the required timescales.

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

Overview
The complainant (Miss C) raised a number of concerns about the care and treatment received by her mother (Mrs A) in Stobhill Hospital (the Hospital) prior to her death on 11 July 2007.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) despite having suffered Transient Ischaemic Attacks (TIA), Mrs A was discharged without having had a scan to determine the exact cause of her symptoms; in particular, she should not have been discharged after her second TIA (not upheld);
(b) Mrs A was prescribed aspirin, which Miss C said was unsafe (not upheld); and
(c) there was a delay in the Greater Glasgow and Clyde NHS Board (the Board) informing the family that Mrs A had contracted MRSA (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) stress to nursing staff the importance of comprehensive note taking;
(ii) formally apologise to Miss C for the delay in advising that Mrs A had contracted MRSA; and
(iii) emphasise to staff the importance of good communication in keeping family members advised of a patient's changing condition and of recording such conversations in the appropriate clinical notes.

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