Health

Overview
The complainant (Mr C) was referred to an orthopaedic consultant (Consultant 1) at Ninewells Hospital for treatment to his knee and foot.  Before a date for surgery could be arranged, personal circumstances meant that Consultant 1 had to take an extended period of absence from work, at short notice.  Mr C complained that his surgery was unacceptably delayed, as Tayside NHS Board (the Board) did not make adequate arrangements to progress the treatment of Consultant 1’s patients during his absence.

Specific complaint and conclusion
The complaint which has been investigated is that Mr C was subjected to an unacceptably long wait for operations on his foot and knee (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board considers Mr C’s overall treatment plan, and the time taken up by administration, when reviewing their procedures in line with the Scottish Government’s revised waiting time targets.

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

Overview
The complainant (Mrs C) was concerned about the way in which a ward closure in Lynebank Hospital (the Hospital) was handled.  Her niece (Ms A) was resident on the ward.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the closure of a ward in which Ms A was resident was poorly handled (upheld); and
(b) the response to Mrs C's complaint about this matter was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that Fife NHS Board:
(i) apologise to Ms A and Mrs C's husband for the limited time available to prepare for and consult about the move between wards;
(ii) draw on the experience of this ward transfer to review the way in which such moves are planned in future; and
(iii) review the way in which such decisions are documented.

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

Overview
Mrs C complained that there had been a significant delay in diagnosing her late husband (Mr C)'s kidney condition and, further, that he had not been told he was suffering from kidney problems for some months.  Mr C had been treated as an emergency by Crosshouse Hospital in February 2005.  He attended his GP Practice (the Practice) over the following months before being admitted as an in-patient to Ayr Hospital on 19 January 2006 where, sadly, he died on 30 January 2006.  Mrs C said that Mr C had been diagnosed with a serious kidney condition while being treated as an out-patient in June 2005 but that this had never been communicated to him.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) there was a delay in diagnosing Mr C's kidney condition and his treatment for this was inadequate (not upheld); and
(b) information about Mr C's kidney condition was not appropriately communicated to him (not upheld).

Redress and recommendations
The Ombudsman has made no recommendations.

Overview
The complainant (Mr C) raised a number of concerns about the cleanliness of his room in the Royal Infirmary of Edinburgh (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that Mr C's room in the Hospital was not adequately cleaned during his stay (upheld to the extent that any evidence to back up Lothian NHS Board's (the Board) position had been mislaid and that the Board's response to Mr C was not adequately evidenced).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) remind the relevant cleaning contractor of the importance of good record keeping; and
(ii) ensure that they obtain all of the available evidence when investigating a complaint and verify any statements provided during the course of the investigation.

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

Overview
The complainant (Ms C) raised a number of complaints against Tayside NHS Board (the Board) about the care and treatment of her late brother (Mr A) in Ninewells Hospital (the Hospital).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Mr A was administered laxatives inappropriately and at the incorrect dose (not upheld);
(b) Mr A developed gastroenteritis which was not treated appropriately (not upheld);
(c) the Board failed to properly monitor Mr A's fluid levels and administer his intravenous drip on 25 and 26 April 2006 (upheld);
(d) the result of the post-mortem examination of Mr A's heart is at odds with his previous cardiac examinations at the Hospital (not upheld);
(e) the Board used insensitive language to describe the events leading to Mr A's death (not upheld);
(f) Mr A was inappropriately taken for an x-ray shortly before his death (not upheld); and
(g) nursing staff failed to appropriately monitor Mr A (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Ms C for their failure to properly monitor Mr A's fluid levels on 25 April 2006 and to properly administer his intravenous drip on 26 April 2006.

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

Overview
The complainant (Mrs C) claimed that staff within Tayside NHS Board (the Board), in particular, a Diabetic Specialist Nurse (Nurse 1), failed to provide adequate advice and support in relation to her husband (Mr C)'s condition.

Specific complaint and conclusion
The complaint which has been investigated is that there was a lack of information, and misleading information, about Type 1 diabetes provided to Mr and Mrs C at the time of, and following, Mr C's diagnosis (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise in writing to Mr and Mrs C for the deficiencies in record-keeping and the lack of clarity of communication; and
(ii) consider introducing a protocol for post-discharge care of patients with diabetes to reduce the potential for confusion as illustrated by this complaint, in particular, in instances where more than one Board is involved in patient care.

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

Overview
Mrs C complained that there had been a significant delay in diagnosing her late husband (Mr C)'s kidney condition and, further, that he had not been told he was suffering from kidney problems for some months.  Mr C had been treated as an emergency by Crosshouse Hospital in February 2005.  He was then investigated over several months as an out-patient at a urology clinic and admitted as an in-patient to Ayr Hospital (Hospital 2) on 19 January 2006 and, sadly, died there on 30 January 2006.  Mrs C had concerns about the treatment provided to Mr C during this period of admission.  She said she believed that his medication was withdrawn prior to this death and that, during the weekend prior to his death, a nursing care plan was not followed.  Mrs C said that during this period of admission Mr C was not treated with appropriate dignity and respect and, in particular, he had died unobserved and been found by a cleaner on 30 January 2006.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) there was a delay in diagnosing Mr C's kidney condition and his treatment for this was inadequate (upheld);
(b) information about Mr C's kidney condition was not appropriately communicated to him (upheld);
(c) medication was withdrawn inappropriately during the last few days of Mr C's life (not upheld);
(d) nursing care was inadequate and, in particular, the care plan not adhered to over the last few days of Mr C's life (upheld); and
(e) Mr C was not treated with appropriate dignity and respect while in Hospital 2 (no finding).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mrs C for the delays identified in diagnosing Mr C's condition and, as a result, failing to inform him that he was suffering from severe impairment of kidney function following the ultrasound taken in June 2005;
(ii) ensure that the clinical team involved in Mr C's care consider the lessons to be learned as a result of the failings identified in this report;
(iii) review a random sample of the results of ultrasounds taken, to ensure that they are being followed up appropriately;
(iv) review their procedures for arranging urgent IVPs, to ensure that the delay identified in this case is prevented in the future where possible;
(v) undertake a short, focussed audit of letters issued by the Urological Unit to GPs and provide evidence of the results and any action flowing from this;
(vi) the Consultant should share this case with his appraiser at annual appraisal if this has not already been done;
(vii) use this complaint as a case study with complaints handling staff, to demonstrate the importance of answering clearly the concerns raised with appropriate information;
(viii) apologise to Mrs C for the failure to provide an acceptable standard of nursing care to Mr C during the weekend of 28 to 30 January 2006;
(ix) undertake a selective audit of nursing records for this ward for weekends and provide her with a copy of the results;
(x) apologise to Mrs C for the failures in record keeping; and
(xi) ask the Consultant to reflect on how his approach may be perceived.

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment of her late mother (Mrs A) during an admission to Monklands Hospital (the Hospital) between 5 April 2005 and 26 June 2005.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Lanarkshire NHS Board (the Board) inappropriately refused to admit Mrs A to the Hospital on 4 April 2005 (not upheld);
(b) two doctors were rude to Mrs A when they saw her in Accident and Emergency on 5 April 2005 (not upheld);
(c) the Board failed to supervise Mrs A when going to the toilet and did not do enough to prevent her from falling over (upheld);
(d) the Board failed to ensure that Mrs A was eating and failed to consider nasal tube feeding (not upheld);
(e) the Board failed to supervise Mrs A's drug-taking, failed to correctly record drug-taking and failed to ensure that the right medication was given to the right patient (partially upheld to the extent that the Board failed to supervise Mrs A's drug-taking and failed to ensure that the right medicine was given to the right person);
(f) the Board failed to introduce a care package for Mrs A despite promises to do so and refused to allow Mrs C to take Mrs A home in the last few days  of her life (not upheld);
(g) the Board failed to diagnose and treat an infection that Mrs A contracted while in the Hospital, which led to additional discomfort and pain and which Mrs A's family believe contributed to her death (not upheld);
(h) the Board failed to record sepsis as a cause of death on the death certificate (not upheld);
(i) the Board failed to carry out a post-mortem even though Mrs A had died sooner than expected (not upheld);
(j) the Board did not provide sufficient nursing care to Mrs A and did not help bring Mrs A's temperature down or remove her teeth and only checked up on her occasionally (upheld);
(k) the Board's nursing staff were unable to fit a syringe driver because a nurse was on her break (not upheld);
(l) a physiotherapist said that she could not help Mrs A because she was not co-operating, which was inappropriate (not upheld);
(m) nursing staff did not inform Mrs C or her brother that Mrs A was dying when they re-entered the room Mrs A was in (not upheld);
(n) no attempt at resuscitation was made and the family were not asked if they wanted it  (not upheld);
(o) an empty syringe driver contributed to Mrs A's death (not upheld);
(p) Mrs A had to wait a long time on both occasions when a doctor was called on 26 June 2005 (not upheld); and
(q) the clinical records were inadequate, because they contained no observations for 25 June 2005 and no fluid charts (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) emphasise to staff the importance of adjusting care plans in line with risk assessments, especially in relation to supervision needs, and ensure that staff fully understand the importance of, and the procedure for, incident reporting;
(ii) ensure that measures are put in place to monitor compliance with the Medicines Code of Practice;
(iii) reflect on this complaint and consider whether guidance or training is needed to ensure that patients' families feel appropriately supported when they decide to take an active role in caring for a relative; and
(iv) put measures in place to ensure that, where appropriate, fluid charts are filled out for patients and observations are recorded.

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

Overview
The complainant (Mr C) raised a number of concerns that his wife (Mrs C) was misdiagnosed during two admissions at Hairmyres Hospital (the Hospital) in 2004, that she was afforded poor clinical and nutritional care at the Hospital during admissions in 2004 and 2005, that record-keeping and communication between staff in relation to Mrs C's care was poor and that Lanarkshire NHS Board (the Board) did not take appropriate action as a result of Mrs C's experiences and Mr C's subsequent complaints.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Mrs C was misdiagnosed during two admissions at the Hospital (not upheld);
(b) Mrs C was afforded poor clinical and nursing care at the Hospital (partially upheld to the extent that Mrs C should have been advised on 6 October 2004 that it was unlikely that the promised visit by the surgical team would be able to be made);
(c) Mrs C was not given appropriate nutritional care at the Hospital (not upheld);
(d) the Hospital's record-keeping in relation to Mrs C was poor (not upheld);
(e) communication between the Hospital's staff in relation to Mrs C was poor (partially upheld to the extent that the prioritisation of Mrs C's endoscopy was not adequate following the observations made during her second admission); and
(f) the Board did not take appropriate action as a result of Mrs C's experience and Mr C's subsequent complaints (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Mr C that Mrs C was not advised timeously that it was unlikely that the visit by the surgical team would be able to be made;
(ii) remind staff of the importance of keeping patients informed in these circumstances;
(iii) apologise to Mr C for the insufficient urgency attached to the request for Mrs C's endoscopy; and
(iv) audit their referral process to satisfy themselves that the urgency of a referral is clear at all times.

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

Overview
The complainant (Mrs C) had concerns about the way the Scottish Ambulance Service (the Service) responded to enquiries and complaints she made about their response to a request to take her husband, Mr C, to hospital in September 2004.  Specifically, Mrs C complained about the Service's request that a disclosure of information form be completed in response to a letter from her Member of Parliament (MP), that the Service failed to make arrangements for a meeting with Mrs C that they advised had been made, that the Service unreasonably expected Mrs C to make arrangements for a meeting, that the Corporate Affairs Manager of the Service inaccurately represented the contents of a letter from the Head of Service (Accident and Emergency – South West) (Head of Service 1) and that the Head of Service (Accident and Emergency – West Central) (Head of Service 2) was unreasonably unable to answer Mrs C's questions during a meeting.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the Service incorrectly requested a disclosure of information form to be completed in response to a letter from Mrs C's MP (not upheld);
(b) the Service failed to make arrangements for a meeting with Mrs C that they advised had been made (upheld);
(c) the Service unreasonably expected Mrs C to make arrangements for a meeting (no finding);
(d) the Corporate Affairs Manager of the Service inaccurately represented the contents of Head of Service 1's letter of 9 November 2004 (not upheld); and
(e) Head of Service 2 was unreasonably unable to answer Mrs C's questions during a meeting (no finding).

Redress and recommendations
The Ombudsman recommends that the Service reminds all staff of the importance of ensuring the factual accuracy of communications.

The Service have accepted the Ombudsman's recommendation and will act on it accordingly.