Health

Overview

The complainant Mr C complained on behalf of his wife (Mrs C) about what happened when she attended the Accident and Emergency Department at Perth Royal Infirmary (Hospital 1).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was inappropriately referred to the out-of-hours service (not upheld);
• (b) Hospital 1 failed to diagnose Mrs C's condition (not upheld); and
• (c) Mrs C was treated rudely and uncaringly by the Emergency Nurse Practitioner (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review the completion of triage documentation in the Accident and Emergency Department of Hospital 1 to ensure the reasons for the triage assessment are documented.

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

Overview

The complainant (Ms C) complained about the response of her GP Practice to an infected rash on her legs.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment for a rash on Ms C's legs was inadequate and has led to tissue damage and difficulty in walking (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment of his sister, Miss A, during an admission to Ninewells Hospital (the Hospital) in the 13 days leading up to her death.  Mr C believed that had failures in Miss A's care and treatment not occurred, the outcome might have been different for her.

Specific complaints and conclusions

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

• (a) failed to make an urgent and correct diagnosis of Miss A's condition when she was admitted to hospital (not upheld);
• (b) failed to provide urgent and appropriate treatment to Miss A (upheld);
• (c) failed in their duty of care towards Miss A (upheld);
• (d) failed to treat Miss A without delay due to holidays and staff not being available and, in particular, delayed in arranging a second Computerised Tomography scan (CT scan) (upheld);
• (e) might have saved Miss A's life had they not failed to provide her with urgent and appropriate treatment (not upheld);
• (f) stigmatised Miss A in relation to her alleged alcohol abuse and this affected the nature and urgency of the treatment she received (not upheld);
• (g) failed to explain to Mr C how the figure of 70 units of alcohol a week was noted as Miss A's alcohol intake on admission (not upheld);
• (h) failed to explain to Mr C why Miss A was unconscious during the first few days of her admission (upheld); and
• (i) failed to have a single doctor in charge of Miss A's care, which made communication with Mr C very difficult (upheld).

Redress and recommendations

The Ombudsman recommends that the Board inform ward staff and relatives of the named consultant in charge of a patient's care either in the form suggested by the Adviser at paragraph 56 or similar.

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

I am also pleased that the Board, in response to my investigation, have repeated their apology to Mr C and his family for the failings in Miss A's care.  I am also satisfied that the recommendations the Board put in place when initially responding to the complaint (see paragraphs 13 to 14 above) adequately address the central failings highlighted in complaints (b), (c) and (d), as they will ensure appropriate medical management and review and better care planning.  It is unfortunate that, while the Board put appropriate recommendations in place in response to Mr C's complaint, they did not sufficiently acknowledge the nature and seriousness of the problems that occurred in this case when they wrote to Mr C.  This has led to an unusual situation whereby the Board did not fully explain and acknowledge problems that occurred when responding to the complainant's complaint, but nevertheless put in place recommendations that, as it happens, adequately address the issues and failings that have been highlighted in this report.  Consequently, while there have been serious failings in relation to Miss A's care and treatment, I have no recommendations regarding complaints (b), (c), and (d) because measures have already been taken by the Board that appropriately remedy the complaints.

Overview

Mrs C has complained that the admission assessment which took place in her home on 2 November 2004 was inappropriate, after which she was admitted to Rosslynlee Hospital (the Hospital) under section 24 of the Mental Health (Scotland) Act 1984 (the legislation at the time).  This investigation, therefore, focuses on the detailed assessment that is recorded as having taken place and the subsequent admission into hospital.  Mrs C was transferred to the Royal Infirmary of Edinburgh (RIE) after two days in the Hospital, as she was physically unwell and the assessment of symptoms and care she required could not be provided within the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was not properly assessed prior to admission to the Hospital in November2004 (not upheld); and
• (b) Mrs C was inappropriately admitted to the Hospital in November2004 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) was unhappy with the treatment her mother (Mrs A) had received at St John's Hospital (the Hospital) on 16 July 2005, that certain questions she had raised with Lothian NHS Board (the Board) during the complaints process had not been answered, that the staff at the Hospital failed to act in a professional manner and that, though the Board had admitted that the date of Mrs A's death was recorded incorrectly, they had not arranged for the death certificate to be corrected.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs A's care and treatment at the Hospital on 16 July 2005 was inadequate (not upheld);
• (b) staff at the Hospital did not act in a professional manner towards Mrs A or her family (not upheld); and
• (c) the response from the Board to Mrs C's complaints contained inaccuracies and did not address all the issues she raised (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) considered that his daughter (Ms A)'s GP Practice (the Practice), the Out of Hours Service and Accident & Emergency (A&E) at Victoria Hospital, Kirkcaldy, did not properly diagnose and treat her illness.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice did not properly diagnose and care for Ms A's illness (not upheld); and
• (b) the Out of Hours Service and A&E at Victoria Hospital, Kirkcaldy, did not properly diagnose and care for Ms A's illness (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review its threshold for considering whether or not a patient might have a subarachnoid haemorrhage, and whether or not early/urgent imaging would be beneficial; and
• (ii) consider recording patients' actual blood pressure when a check is made.

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

• (iii) apologise to Mr C for the failure of medical staff to reach a differential diagnosis of subarachnoid haemorrhage on 22and 23 July 2005;
• (iv) review its locally agreed indications and process for admission, observation and investigation of patients presenting with acute headache in A&E, including ensuring that the teaching and guidance given to A&E junior doctors is based on current research; and
• (v) ensure that Out of Hours records are in line with relevant record-keeping standards, for example as laid down by the General Medical Council.

The Practice have accepted the recommendations.  The Board have also accepted the recommendations, and in some respects have already taken action and made procedural changes to address them.

Overview

The complainant (Mrs C) raised a number of concerns regarding the treatment she received at Crosshouse Hospital, Kilmarnock (Hospital 1).  She complained of the delay in diagnosing her uterine fibroids and subsequent Benign Intracranial Hypertension (BIH), as well as raising concerns regarding the side effects resulting from her treatment, and the lack of prior information relating to these.  Mrs C also raised issues regarding her pain management upon admission to Hospital 1 and also the delay in issuing her discharge letter to her General Practitioner (GP).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C's uterine fibroids were not diagnosed within a reasonable timescale (not upheld);
• (b) the Prostap therapy caused severe side effects which were not explained in advance (not upheld);
• (c) upon admission to Hospital 1, adequate pain relief was not initially provided (not upheld);
• (d) upon discharge from Hospital 1, there was a delay in issuing the discharge letter to Mrs C's GP (not upheld); and
• (e) when the lumbar puncture was carried out at Hospital 1, the Cerebrospinal Fluid opening pressure was not taken and this led to a delay in diagnosing Mrs C's BIH (not upheld).

Redress and recommendations

The Ombudsman has no formal recommendations to make but does suggest that the Board considers making the manufacturer's patient information leaflet available to patients prior to the commencement of Prostap therapy.

Overview

The complainant (Mrs C) raised a number of concerns about the care her late brother (Mr A) received in the days before he died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was not kept properly informed about Mr A's condition (upheld);
• (b) Mr A's condition was not adequately monitored on the night he died (not upheld);
• (c) the way Mr A's death was communicated to the family was inappropriate (not upheld);
• (d) a member of the nursing staff was rude to the family (upheld); and
• (e) some of Mr A's personal belongings were lost during his stay in hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Greater Glasgow and Clyde NHS Board (the Board):

• (i) apologise to Mrs C for shortcomings in communications about Mr A's condition;
• (ii) take further action to ensure that a proactive approach is taken to establishing good communication with relatives;
• (iii) use this complaint as a case study to illustrate the importance of good communication with relatives, especially when the hospital are aware that the patient is unlikely to survive; and
• (iv) apologise to Mrs C formally for the conduct of a member of nursing staff and also give consideration to providing to staff dealing with patients and their families a more focussed reinforcement of the importance of good customer care through, for example, appropriate training.

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

Overview

The complainant (Mr C) raised a complaint about a delay in a referral for a urodynamics study at the Department of Urology (the Department) in the Southern General Hospital (the Hospital).  Mr C had not received an appointment after he had cancelled three previous opportunities to attend the Department.  Mr C complained that he had been told his name had been taken off the waiting list at his request.  Additionally, Mr C was unhappy that the complaint response from the Chief Executive of the then South Glasgow University Hospitals Division, wrongly referred to his original out-patient referral as having come from his General Practitioner (GP), rather than the Gastrointestinal Clinic at the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had an excessive wait for an appointment at the Department (upheld);
• (b) Greater Glasgow and Clyde NHS Board (the Board) had wrongly stated that Mr C's GP had referred him to the Department (upheld); and
• (c) Mr C was removed from the waiting list although he had not asked for this (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board apologise to Mr C for their error in saying the referral was from Mr C's GP;
• (ii) staff members are reminded of the importance of keeping accurate and contemporaneous records to verify their understanding of all patient information; and
• (iii) the Department staff are reminded of the value of alerting patients' GPs to the changes in the clinical care of patients on their practice list.

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

Overview

The complainant (Mrs C) complained to the Ombudsman about the care and treatment received by her husband (Mr C) from Lothian NHS Board (the Board)'s Unscheduled Care Service.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP (GP 2) should have arranged Mr C's admission to hospital (upheld);
• (b) a GP (GP 3) was unhelpful and provided Mrs C with inadequate information (upheld); and
• (c) there was undue delay by the Board in dealing with Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) enables GP2 to reflect on the importance of assessing hydration status in future case management;
• (ii) ensures that GP3 gives full details of any arrangements he has made or intends to make, on behalf of a patient, to the patient or the person acting for the patient;
• (iii) consider whether there would be benefit in reminding all GPs working for the Unscheduled Care Service that clear comprehensive communication with callers is essential; and
• (iv) ensures that complainants are kept up-to-date with progress and expected timescales in accordance with the NHS complaints procedure.