Health

Overview
The complainant (Ms C) claimed that the conduct of a rectal/intestinal examination at Falkirk and District Royal Infirmary (the Hospital) was inappropriate and also raised concerns about the subsequent handling of her complaint by Forth Valley NHS Board (the Board).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the conduct of a rectal/intestinal examination at the Hospital was inappropriate, in particular that lubricant was not used (not upheld); and
(b) the Board failed to deal with Ms C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Ms C in writing for their failure to conduct as thorough an investigation of her complaint as was required in this situation; and
(ii) reflect on how they obtain evidence from all parties involved in a complaint and ensure that key staff always provide statements, and that those statements deal with the specific issues raised by complainants.  The Board should send the Ombudsman the outcome of this reflection and a copy of any consequent amendments to guidance or procedure.

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

Overview
The complainant (Ms C) raised a number of concerns about her mother (Mrs A)'s care and treatment following her admission to Ninewells Hospital (the Hospital) on 3 October 2004.  Mrs A was elderly, frail and suffered from dementia.  Sadly, Mrs A died on 9 October 2004.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) drugs were administered to Mrs A inappropriately (not upheld);
(b) Mrs A was not provided with adequate nutrition (not upheld);
(c) nursing care provided to Mrs A was inappropriate (not upheld);
(d) Mrs A was not provided with appropriate medical care (not upheld); and
(e) communication with Mrs A's family was inadequate (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant, Ms C, raised a number of concerns about the care and treatment provided to her mother, Mrs A, by the Consultant in Clinical Oncology (the Consultant) at the Beatson Oncology Centre (the Centre).  Mrs A was subsequently admitted to Stobhill Hospital (the Hospital) then transferred to a hospice but, sadly, died the same night.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the treatment provided by the Consultant was not reasonable (not upheld);
(b) the Consultant failed to communicate reasonably with Mrs A and her family about her disease and treatment (not upheld); and
(c) the Centre failed to communicate reasonably with the Hospital following Mrs A's admission (not upheld).

Redress and recommendation
The Ombudsman has no recommendations to make.

Overview
The complainant (Mrs C) raised a number of serious concerns about the examination given to her son by the local GP out-of-hours service prior to his admission to hospital and subsequent death from meningococcal septicaemia.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the out-of-hours GP failed to carry out an appropriate examination and as a result failed to make a correct diagnosis (not upheld); and
(b) Ayrshire and Arran NHS Board failed to carry out an appropriate investigation into the circumstances surrounding the examination (not upheld).

Redress and recommendations
The Ombudsman has no recommendations to make.

Overview
The complainant, Ms C, complained that she was given conflicting information regarding the diagnosis of her condition and the need for her to have an operation.  Ms C made a further complaint about what happened when she attended the Accident and Emergency department (the Department).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) between December 2004 and June 2005, Ms C was given conflicting information regarding her diagnosis and treatment (upheld); and
(b) Ms C was not treated in a reasonable manner when she attended the Department on 4 June 2005 (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise to Ms C for the shortcomings identified in this report;
(ii) consider offering Ms C further clinical investigation, including imaging of the biliary tract, under the care of a consultant not previously involved with her care, that they liaise with the psychiatric team who provide support for Ms C;
(iii) share a copy of this report with Consultant 1; and
(iv) ensure that there are appropriate procedures for safe storage, filing and tracking of clinical notes in the Department, to ensure they are available for retrieval and reference in future.  She asks that the Board notify her of the action taken in this regard.

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

Overview
Mr C was admitted to the Western General Hospital, Edinburgh, after suffering a brain haemorrhage.  On the following day, during the Consultant Neuroradiologist's attempt to clot the blood vessels, the catheter ruptured and glue escaped which caused Mr C to have a stroke.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the cause of the rupture was that the syringe containing the glue was pushed too hard, causing too much pressure on the catheter (not upheld);
(b) the risk of the catheter breaking and the risk associated with the use of that particular catheter were not disclosed to Mr C (partially upheld);
(c) Mr C was not informed of alternative treatments available to him (upheld);
(d) Mr C was not allowed a cooling off period to make a decision about treatment (upheld);
(e) Mr C's consent to the procedure was inadequately documented (upheld);
(f) the incident was not properly recorded or investigated (not upheld);
(g) the explanation of what had happened given to Mr C and his wife was inadequate (no finding); and
(h) Lothian NHS Board (the Board) whitewashed the incident (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) provide her with details of the outcome of their review of their current consent policy, taking into account 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive  on 16 June 2006, especially for neurosurgical and radiological interventions;
(ii) advise her of the outcome of their review of their Incident/Near Miss Reporting and Investigation procedure;
(iii) take steps to ensure that where explanations are given in situations such as this they are properly recorded; and
(iv) apologise to Mr C for the shortcomings identified in this report.

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

Overview

The complainant, Mrs C, complained on behalf of her husband, Mr C, about the nursing care he received while he was a patient in Raigmore Hospital.

Specific complaint and conclusion

The complaint which has been investigated is that while Mr C was in Raigmore Hospital he failed to receive appropriate nursing care in that proper hygiene (in relation to his skin) was not given and sustained (upheld).

Redress and recommendations

The Ombudsman recommends that the Board write to Mr and Mrs C apologising for the condition of Mr C's skin on his discharge from hospital.  Further, she suggests that where the risk of skin ulcers has been identified, as in Mr C's case, an appropriate care plan be formulated and followed.  Thereafter, on discharge, a record be made in the notes confirming whether or not the situation has been resolved.

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

Overview

The complainant (Mr C) raised concerns about the treatment he received at Monklands Hospital (the Hospital), which resulted in the removal of his right kidney.  Mr C had been told by staff that it was suspected a lump on his right kidney was cancerous and that removal of the kidney was required.  Following the operation, Mr C was advised by staff that the removed kidney was non-cancerous.  Mr C had concerns that staff took the decision to remove the kidney without taking a biopsy of the lump and the manner in which he was informed of the pathology of the removed kidney.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) staff acted unreasonably in removing Mr C's kidney before a definitive diagnosis had been made on the suspected cancerous lump (not upheld); and
• (b) the manner in which Mr C was informed of the result of the pathology report of his removed kidney was insensitive (upheld).

Redress and recommendations

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

• (i) reflect on the Adviser's comments in relation to the way in which the consent was documented and consider whether they need to make any changes to procedure; and
• (ii) make Mr C a further full and meaningful apology.

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

Overview

The complainant, Mr C, complained that, despite the fact that Forth Valley NHS Board (the Board) felt unable to treat him, they did not refer him elsewhere.  In the circumstances, he felt that he had to pay for his eye operation.  He believed that he should be refunded the costs involved.

Specific complaint and conclusion

The complaint which has been investigated is that, although the Board felt unable to treat Mr C, they did not refer him elsewhere (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board write to Mr C expressing their sincere regret that an opportunity to consider all the options in relation to his future treatment was lost.

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

Overview

The complainant (Mrs C) cancelled her planned hysterectomy at Borders General Hospital (the Hospital).  She complained that poor administration by staff of Borders NHS Board (the Board) led to the temporary loss of her clinical records, leaving her with doubts as to the competence of the staff that were caring for her.  Mrs C also had a number of concerns over the treatment that she was offered and did not feel that sufficient consideration was given to her family's medical history or her reaction to certain medications.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) administration and staff communication at the Hospital were poor (upheld);
• (b) staff at the Hospital provided conflicting information about Mrs C's iron levels (not upheld);
• (c) staff at the Hospital did not acknowledge the severity of Mrs C's gluten intolerance (not upheld); and
• (d) staff at the Hospital inappropriately recommended a hysterectomy as the best treatment for Mrs C's condition (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their record tracking procedures and ensures that all staff are reminded of their responsibilities as far as updating the tracking system whenever records are forwarded to another party.

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