Health

Overview

The complainant (Mrs C) felt that the death of her husband (Mr  C) could have been avoided had staff of Greater Glasgow and Clyde NHS Board (the Board) been more proactive in diagnosing his condition.  She complained that Mr C's assigned consultant (Consultant 1) should have been more directly involved in his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was not seen by Consultant 1, the consultant that he was referred to at Glasgow Royal Infirmary (not upheld);
• (b) the diagnostic process was unnecessarily delayed (upheld); and
• (c) ward staff did not deal with Mr C respectfully (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider asking the clinical team to review the circumstances of this case to see if there are any lessons to be learned regarding communication with patients and relatives;
• (ii) apologise to Mrs C and her family for the additional distress and suffering caused by the delays to Mr C's diagnosis; and
• (iii) revise their procedures to include written notice to the referring consultant of all failed scan results.

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

Overview

The complainant, Mrs C, raised a number of concerns about the care and treatment provided to her late mother, Mrs A, while she had been a patient at Ayr Hospital (Hospital 1).  She said she felt Mrs A had been wrongly given Diazepam and that the nursing care was inadequate.  She believed that the care had led to a significant deterioration in Mrs A's condition.

Specific complaint and conclusion

The complaints which have been investigated are that:

• (a) the nursing care provided to Mrs A was inadequate (not upheld);
• (b) Mrs A did not receive appropriate treatment and was wrongly prescribed Diazepam (upheld);
• (c) Mrs A's family was not given sufficient time to consider a proposed move of hospital (not upheld);
• (d) Mrs A's transfer to another hospital was carried out inappropriately (no finding); and
• (e) a conversation about Mrs A's treatment was inappropriately held in a public place (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failures in record-keeping, which have made it difficult for the Ombudsman's advisers to fully evaluate Mrs A's care, and for the error in their letter to Mrs C of 5 December 2006 concerning the use of Diazepam in Mrs A's care;
• (ii) provide clinical staff involved in Mrs A's care and the Board's relevant clinical director with a copy of this report; and
• (iii) provide evidence of the systems in place to monitor and audit medical and nursing records.

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mrs C) complained that both her mother (Mrs A)'s GP Practice (the Practice) and Templar Day Hospital (Hospital 1) failed to examine Mrs A thoroughly enough to correctly diagnose her broken hip.  She felt that Mrs A suffered unnecessary pain and limited mobility due to incomplete examinations and assumptions being made by staff of both bodies.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice misdiagnosed Mrs A's broken hip as arthritis (not upheld);
• (b) the Practice failed to follow correct procedures to consider any problems other than arthritis (not upheld); and
• (c) Hospital 1 staff failed to diagnose Mrs A's broken hip prior to, or during, months of physiotherapy (upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board (the Board) review Hospital 1's admissions procedures to ensure that all patients receive a full diagnostic assessment prior to the commencement of treatment.

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

Overview

The complainant (Mr C) raised a number of concerns about a lack of physiotherapy assessment, provision and follow-up as well as the quality of the in-patient care provided and the overall discharge planning by Tayside NHS Board (the Board) following his late mother (Mrs A)'s admission to Ninewells Hospital, Dundee on 17 February 2006.  Mr C was also dissatisfied with the Board's responses to his concerns which he considered to be deliberately confusing and contradictory.  Mr C considered that these many failures had hastened his mother's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly assess and provide appropriate care and treatment to Mrs A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on the failures identified by the advisers in the management of Mrs A as part of the on-going reviews already being undertaken by the Board;
• (ii) monitor compliance with the revised template for the discharge letter as part of the existing review of record-keeping; and
• (iii) review the Guidelines for (physiotherapy) Referrals and consider specifically how it impacts on those discharged to a nursing home (particularly in light of the advisers' comments that this appears to be discriminating against such patients).

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

Overview

The complainant (Mrs C) said that the death of her husband (Mr C) could have been avoided if staff of Tayside NHS Board (the Board) had done more to establish the extent of his condition.  Mrs C felt that the diagnostic process was unnecessarily delayed and that, had Mr C's liver cancer been diagnosed sooner, it may have been treatable.

Specific complaint and conclusion

The complaint which has been investigated is that the Board took unnecessarily long to diagnose and treat Mr C's condition (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board consider ways to minimise any delays to cases being discussed by the upper gastrointestinal multi-disciplinary team.

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

Overview

The complainant (Ms C) raised concerns with regard to a delay by East Lothian Council (the Council) in replacing windows in her home, in carrying out a repair to a damaged window lintel, and about the way her contact with the Council was recorded.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) unduly delayed in replacing the windows in Ms C's home (partially upheld);
• (b) unduly delayed in repairing a lintel above a window (upheld); and
• (c) failed to keep an accurate record of Ms C's contact with them (partially upheld).

Redress and recommendations

The Ombudsman recommended that the Council:

• (i) apologise to Ms C for the delays which occurred in installing the new windows and for implementing the repair to the lintel above the living room window; and
• (ii) make Ms C an appropriate payment in recognition of the costs she incurred in pursuing matters with them.

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

Overview

The complainants (Mrs C and Mrs D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at St Johns Hospital at Howden (the Hospital) between 19 December 2005 and 2 February 2006.

Specific complaints and conclusions

The complaints which have been investigated are that Lothian NHS Board (the Board):

• (a) failed to provide adequate care and treatment to Mrs A (partially upheld); and
• (b) failed to properly plan for Mrs A's discharge (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that discussions take place within the clinical team on Ward 9 of the Hospital to agree the appropriate standard of practice with regards to the importance of a) thorough examination of a patient prior to discharge, with particular reference to patients with pre-existing medical problems and multiple medications, and b) recording of medical examination findings and the rational behind any changes to medications;
• (ii) consider the use of fully unified records, i.e. including therapy follow-up records with the joint medical/nursing records;
• (iii) consider regular (at least weekly) multi-disciplinary team meetings where discharge planning for complex cases, particularly for elderly patients, can be discussed, coordinated and recorded;
• (iv) consider that where family conflicts or carer anxieties are raised, case conference meetings are organised when the key disciplines and family and carers can meet to exchange information and plan discharges and that all family meetings are adequately recorded; and
• (v) consider whether current occupational therapist staffing levels in this area are sufficient to avoid the delays experienced by Mrs A.

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