Health

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.

Overview

The complainant (Mr C) raised concerns that, at a consultation with an orthopaedic consultant on 7 June 2005, an incorrect decision was taken to treat a knee injury with analgesia rather than surgery and that he had to have an operation carried out privately to resolve the matter.

Specific complaint and conclusion

The complaint which has been investigated is that, at an appointment with an orthopaedic consultant on 7 June 2005, the clinical decision to treat Mr C's knee injury by analgesia rather than surgery was inappropriate (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised concerns that a GP Practice (the Practice) had failed to diagnose her brother (Mr A) with deep vein thrombosis (DVT) or subsequent pulmonary embolism.

Specific complaint and conclusion

The complaint which has been investigated is that the Practice failed to diagnose Mr A with DVT or subsequent pulmonary embolism (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review the circumstances of this case and consider whether any lessons can be learned for the future management of young adults with chest symptoms;
• (ii) apologise to Mr A's family for the poor management of Mr A's pulmonary embolism; and
• (iii) review their clinical record-keeping practice.

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

Overview

The complainant (Ms C) raised a number of concerns about the dental treatment which she had received from her General Dental Practitioner (the Dentist) during the period 2005 to December 2006.

Specific complaints and conclusions

The complaints which have been investigated are that the Dentist:

• (a) failed to provide Ms C with an appropriate level of dental treatment (upheld); and
• (b) failed to keep accurate and contemporaneous records (upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) apologises to Ms C for the failings which have been identified in this report;
• (ii) arranges postgraduate training on root canal treatment and periodontal monitoring and screening;
• (iii) carries out a clinical audit on the justification, quality and use of radiographs in providing adequate information to make effective treatment planning decisions; and
• (iv) conducts a review of his record-keeping and treatment planning procedures.

The Dentist has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C) raised a number of concerns about the nursing care which he received during his admission to Dr Gray's Hospital (the Hospital), the advice given to him about MRSA and the way his complaint was handled by Grampian NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C did not receive adequate emotional support during his admission to the Hospital (upheld);
• (b) nursing staff advised Mr C's wife to leave the ward due to things being too busy (upheld);
• (c) Mr C was not given clear information in relation to the Board's visitor policy and the risks of MRSA (not upheld);
• (d) Mr C's chemotherapy was carried out in a ward setting and he was required to answer personal questions within earshot of other patients (not upheld);
• (e) Mr C's concerns were ignored when he raised them with the specialist nurses (partially upheld to the extent that Mr C was not given feedback about the way in which his complaints were dealt with); and
• (f) the Board failed to adhere to the NHS complaints handling procedure when investigating Mr C's complaint (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that staff assess the emotional needs of patients, especially those with the diagnosis of a life threatening or limiting illness, and plan care appropriate to this assessment;
• (ii) apologise to Mr C for their failure to formally assess his need for emotional support;
• (iii) review their visiting policy and consider whether to include guidance on the application of discretion according to the circumstances;
• (iv) remind relevant staff to ensure that they respond fully to all elements of complaints;
• (v) remind staff: of their role in the complaints process; to take steps to identify complaints; and to feedback to patients any steps taken as a result of their complaint and any response to the complaint; and
• (vi) consider whether, in these sorts of circumstances, it may be appropriate to use conciliation or mediation as part of the complaints process.

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