Health

Overview

The complainant (Mr C) raised a number of concerns about the podiatry treatment which he had received from a podiatrist (the Podiatrist) of Western Isles NHS Board (the Board) on 7 December 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to provide Mr C with appropriate podiatry treatment (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the diagnosis of her husband (Mr C) and his treatment for small bowel obstruction.  Specifically, she raised concerns that Mr C's GP Practice (the Practice) had delayed referring him to hospital and that the treatment provided by Highland NHS Board (the Board) was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice failed to timeously diagnose Mr C with small bowel obstruction and to refer him to hospital for treatment (upheld); and
• (b) the Board failed to provide appropriate care and treatment for Mr C (not upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for their failure to review Mr C following her telephone call on 1 August 2006;
• (ii) review their protocol for telephone consultations to ensure that patients are seen by a doctor when necessary in order to exclude more serious diagnoses; and
• (iii) consider the management of severe abdominal pain over the telephone.

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

The Ombudsman has no recommendations in respect of the Board.

Overview

The complainant, Ms C, raised a number of concerns about the delay in obtaining an appointment at Neurosurgery Out-Patient Services at the Southern General Hospital (Hospital 1).  This was arranged by Highland NHS Board (the Board) as part of Ms C's ongoing treatment for back pain.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Orthopaedic Consultant Service contracted from NHS Greater Glasgow and Clyde failed to refer Ms C to the Neurosurgeon within Hospital 1 in September 2005 (upheld); and
• (b) the complaint response from the Board did not address the complaint that was raised (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review the current pilot in progress and let her know the outcome;
• (ii) consider introducing a system to ensure that a referral has been received by the receiving clinic;
• (iii) provide a local contact for a patient to be able to enquire about their referral;
• (iv) apologise to Ms C for the additional wait experienced as a result of the delay in treatment;
• (v) ensure they have a mechanism in place to follow up on any outstanding issues when an offer of a meeting, as part of local resolution in line with the NHS complaints procedure, has been made and declined;
• (vi) ensure, where appropriate, that they consider if there are any problems which may be faced by a complainant offered a meeting to discuss a complaint and the venue for the meeting is not local to the complainant; and
• (vii) apologise to Ms C for not providing a further response to her complaint.

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

Overview

The complainant, Ms C, was concerned that, a few weeks after discharge from the Raigmore Hospital (the Hospital) following treatment for an obstructed gallbladder, her father, Mr A, was diagnosed with advanced pancreatic cancer.  Sadly, Mr A died shortly after this diagnosis.  In her complaint to the Ombudsman, Ms C was concerned that clinical staff at the Hospital had failed to detect this cancer and, in particular, questioned the quality of an ultrasound examination and why this was regarded as conclusive of Mr A’s diagnosis despite contrary symptoms.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A’s ultrasound examination was not carried out with due care (not upheld); and
• (b) in arriving at his diagnosis, Mr A’s consultant did not take into account symptoms which conflicted with the ultrasound and, in particular, a CT scan should not have been cancelled (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) was concerned that she had not been offered appropriate treatment when she was seen by a doctor (Doctor 1) during an out-patient appointment at the Western General Hospital.

Specific complaint and conclusion

The complaint which has been investigated is that Doctor 1 failed to provide Mrs C with appropriate treatment (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainant (Mr C)’s brother (Mr A) collapsed suddenly on 1 January 2007 while at his mother’s home in Uig, Isle of Lewis.  Mr A was taken to hospital by ambulance.  Mr C raised a number of concerns:  that a GP working for Western Isles NHS Board (the Board) out-of-hours service did not attend, although the Scottish Ambulance Service (the Service) requested he do so; a First Responders Unit (FRU) was not correctly called; and information was released to the press, relating to this incident, inappropriately.  The Service accepted the problem with the FRU but Mr C remained concerned about the actions taken to remedy this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP working for the Board unreasonably did not attend (partially upheld, to the extent that there were clear issues with communication on the night of 1 January 2007);
• (b) a FRU was not correctly called and actions taken to remedy this were insufficient (not upheld); and
• (c) information was released to the press inappropriately (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review the equipment provided to out-of-hours GPs, in the light of the problems identified in this report;
• (ii) the Board and the Service meet to consider how best to respond to the communication failures identified and ensure that lines of responsibility and procedures are clearly in place where appropriate;
• (iii) the Service undertake a short review of emergency calls in FRU areas, to see if they can identify cases where FRUs could have been called but were not and consider if any lessons can be learned from this;
• (iv) the Service apologise to Mr C for the release of inaccurate information; and
• (v) the Board and the Service use this complaint as a case study with press staff, in order to encourage learning from the problems identified.

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

Overview

The complainant (Mr C) complained on behalf of his wife (Mrs C), concerning the care and treatment she received prior to being diagnosed as having ovarian cancer.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C's care and treatment were inadequate and, despite her history of breast cancer and an ovarian cyst, no follow-up appointment was made for her in November 2003 (upheld);
• (b) in Mrs C's circumstances, a hysterectomy should have been considered much earlier (not upheld); and
• (c) Mrs C's treatment was dictated by financial concerns (not upheld).

Redress and recommendations

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board) proffer a sincere apology to Mrs C for the failure to treat her properly.  Further, in view of the Consultant's comments about not doing anything differently, and given the Board's comments at paragraph 15, the Ombudsman requests that the Board provide her with a copy of the 2008 audit of Guideline 34.

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

Overview

The complainant (Ms C) raised concerns that her brother (Mr A) was unable to walk without aids after his discharge from Hairmyres Hospital (the Hospital) and that this had not been detected prior to his discharge.

Specific complaint and conclusion

The complaint which has been investigated is that Mr A’s mobility was not adequately assessed prior to his discharge from the Hospital (upheld).

Redress and recommendations

The Ombudsman recommends that Lanarkshire NHS Board (the Board) remind relevant staff of the need to take measures to prevent foot drop and to record all relevant information in patients’ clinical records.

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

Overview

The complainant (Mr C) raised concerns regarding his removal from his general practitioner (GP)'s list of patients.  Mr C was unhappy with the circumstances surrounding this removal and he felt that the correct procedures were not followed by his Medical Practice (the Practice).

Specific complaint and conclusion

The complaint which has been investigated is that the Practice did not follow the correct procedures in removing Mr C from their list of patients (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review their removal procedures in line with the guidance and regulations governing the removal of patients from practice lists. Revised procedures could incorporate suggested wording for warning and removal letters, ensuring that patients are quoted relevant timescales and advised of all options available to them; and
• (ii) apologise to Mr C for their failure to follow the correct procedure in removing him from their list.

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