Health

Overview

The complainant (Miss C) raised a number of concerns about the care and treatment her mother (Mrs A) received in Stirling Royal Infirmary (the Hospital) between her admission on 7 May 2006 and her death on 28 May 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A's care and treatment while a patient in the Hospital in May 2006 was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that Forth Valley NHS Board (the Board):

• (i) apologise to Miss C for the failures identified in this report;
• (ii) remind all their doctors of the importance of appropriate recording of working and differential diagnosis; and
• (iii) ensure that two of the consultant surgeons (identified in this report as Consultant 1 and Consultant 2) reflect on these events at their next annual review.

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

Overview

The complainants, Mr and Mrs C, raised a number of concerns about a sequence of events which occurred when they attended the Medical Centre for an appointment with the Community Dentist (the Dentist), on 22 September 2006, for Mrs C to receive dental treatment.  Mr and Mrs C complained that the treatment Mrs C expected to receive on that day was refused.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist refused to treat Mrs C on 22 September 2006 as she could not lie completely flat on the dentist's chair (not upheld);
• (b) the Dentist told Mr C to go to a private dentist (no finding); and
• (c) Mrs C did not receive any information that there was a Senior Dental Officer for Special Care Dentistry consulting at the Medical Centre, until after she complained about the events of 22 September 2006 (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 that her uncle, Mr A, received in Vale of Leven Hospital (Hospital 1), between his admission on 23 January 2006 and his transfer to Gartnaval General Hospital (Hospital 2) on 8 February 2006.  Sadly, Mr A died on 8 March 2006.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A was given inconsistent advice (no finding);
• (b) Mr A's pain was not managed effectively between 28 January and 8February 2006 (upheld);
• (c) Mr A's pressure sore could have been avoided (upheld);
• (d) Mr A should have been referred to the vascular surgeons more quickly (upheld);
• (e) Mr A's room was not clean and this contributed to his illness (not upheld); and
• (f) Mr A was inappropriately referred to as a problem patient (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to ensure they respond in full to formal complaints;
• (ii) ensure that the clinical team responsible for Mr A's care in Hospital 1:
• (a)  review this report; consider what lessons can be learned from Mr A's experience and review how pain is managed effectively;
• (b)  are aware of the need for accurate records to be kept; and 
• (c)  utilise best practice statements on Pressure Ulcer Prevention and the Treatment and Management of Pressure Ulcers issued by NHS Quality Improvement Scotland (March 2005 and November 2005);
• (iii) audit the use of MRSA screening on Ward 14 and report back to her proof of review and change in practice;
• (iv) ensure that the clinical team consider the lessons to be learned as a result of the failings identified in this report and report back to her changes in practice put in place as a result; and
• (v) apologise to Ms C fully and formally for the failings identified in this report;

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 that her husband had received before his death in Bo'ness Hospital on 30 March 2006.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C was not allowed to visit her husband, because of an outbreak of the winter vomiting virus in his ward in the days leading up to his death in Bo'ness Hospital in March 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained about the treatment he received from his General Practitioner (GP) when he received a house call on 21 January 2005.  He complained that the GP took too long to arrive to visit him, and failed to examine him.  He also complained that the GP delayed referral to the ambulance service to have him transferred to hospital for admission.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the GP took three hours to respond to a request for a house call (not upheld);
• (b) the GP did not carry out a physical examination of Mr C (not upheld); and
• (c) Mr C understood the ambulance was going to be arranged as an urgent case (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns in respect of the treatment provided to his wife by a consultant surgeon (Consultant 1) prior to her death on 11 April 2005.  Additionally, he has stated that both he and his wife were not given a clear picture of her condition and the options for treatment available to her.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1 did not fully consider the surgical options, including seeking opinions of specialists where necessary (not upheld); and
• (b) the communication from Consultant 1 was unacceptable (upheld).

Redress and recommendations

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

• (i) apologise to Mr C for the failure to effectively communicate with both him and his wife;
• (ii) consider using the events of this complaint to inform practise in communicating with patients, particularly when a number of different specialists are involved in care. This consideration should include both communication with patients and family and the recording of such communication in the clinical records; and
• (iii) review their procedures to ensure that all responses provided by them, or on their behalf, to complainants are factually accurate.

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

Overview

The complainant (Mrs C) raised concerns that she had an eye operation at Ayr Hospital (the Hospital) which was performed by a consultant surgeon (the Consultant) on the wrong eye (her right eye) and she has been left blind because of this.  Mrs C also complained that correct procedures were not followed by the senior house doctor who obtained her consent for the operation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was subjected to an eye operation, performed by the Consultant, on the wrong eye (her right eye) (not upheld); and
• (b) Mrs C was asked to sign a consent form for the operation which she could not see and the contents of the form were not read out to her (no finding).

Redress and recommendations

The Ombudsman recommends that Ayrshire and Arran NHS Board (the Board):

• (i) ensure that discussions with patients about treatment is recorded, particularly where a change to the planned operation is made. She also recommends that the Board ensure that the recognised complications arising from surgery are discussed with the patient and a record of the discussion made; and
• (ii) ensure that the Consultant makes certain that his procedure in obtaining consent from patients who are visually impaired is properly recorded in the clinical notes whenever it is followed.

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

Overview

The complainant, Ms C, an advocacy worker complaining on behalf of a woman (Mrs A), raised concerns regarding the care and treatment provided to Mrs A in respect of her bowel operation at the Royal Alexandra Hospital (the Hospital) on 24 February 2003.  Mrs A was unhappy with the lack of information provided to her, her family and her general practitioner (the GP), the timing of her discharge, the failure to timeously diagnose an abscess in her bowel and the failure to arrange a follow-up appointment.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was insufficient communication by the surgical team with regard to operative risks, the complications that arose and the information provided to the GP following discharge (upheld);
• (b) following the operation, Mrs A was discharged prematurely from the Hospital (upheld);
• (c) the clinicians involved failed to diagnose an abscess in Mrs A's bowel within a reasonable time-frame (upheld); and
• (d) a follow-up appointment was not arranged after Mrs A was discharged (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider the way that they currently record episodes of communication. As a minimum, they should remind staff of the importance of recording significant communication episodes between clinical staff and their patients and their carers. These records should include the time and date of such episodes, the parties present, matters discussed and the patient/carer's understanding of the same;
• (ii) consider introducing measures to ensure that any known complications of surgery which occur, and any resultant consequences, are recorded on the discharge sheet and sent to patients' GPs in a timely manner;
• (iii) inform the Ombudsman of any changes that they have made in response to the Scottish Executive Health Department's guidance 'A Good Practice Guide on Consent for Health Professionals in NHSScotland' (June 2006); and
• (iv) consider introducing measures to ensure that biopsy results following local trans-anal surgery are reviewed urgently and any full thickness perforation is specifically recorded in the case notes. When such perforations are recorded and the patient is still in hospital, the Board should take steps to ensure that the patient is not discharged until reviewed by a senior surgeon. When any such results are received after a patient has been discharged, these should be reported immediately to the patient's GP and an urgent review by the surgical team should be arranged.

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

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.

Overview

The complainant (Mr C) had a lump on his lower left leg removed in 1998 at Stonehouse Hospital (Hospital 1).  This was diagnosed at the time as a benign fibromatosis.  Some years later, Mr C became aware of a second lump close to the site of the first and he consulted his GP, on 12 July 2004.  Mr C was referred by his GP to Hairmyres Hospital (Hospital 2).[1]  The referral letter referred to the lump as a recurrence of a 'ganglion' which had been removed in 1998.  Following removal of the second lump in May 2005 at Hospital 2, Mr C was diagnosed as having a rare form of cancer and referred for further treatment to a specialist group at the Beatson Centre in Glasgow (the Centre).[2]  Mr C complained to the Ombudsman about the GP's diagnosis in the referral letter.  In the course of the Ombudsman's investigation, samples from the lump removed in 1998 were re-examined and also found to be cancerous.  Concerns were raised that this had not been diagnosed by Hospital 1 in 1998 and also about the treatment Mr C had received in 2004/2005 from Hospital 2 and in 2005 from the Centre.  As a result, the investigation was widened to include these aspects of his care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP unreasonably misdiagnosed a lump on Mr C's leg as a ganglion (not upheld);
• (b) the care and treatment provided by Hospital 1 and Hospital 2 was inadequate (not upheld); and
• (c) the care and treatment provided by the Centre was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice feed back to clinical staff the adviser's comments in connection with note keeping and referral letters;
• (ii) this report be shared with the clinical staff involved in Mr C's care and treatment by Lanarkshire NHS Board to consider whether the learning identified could be shared more widely; and
• (iii) Lanarkshire NHS Board consider whether the procedures in place are adequate to ensure that the outcomes of tests are appropriately communicated to GP Practices.

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

The Ombudsman has no recommendations in respect of Greater Glasgow and Clyde NHS Board. 

[1]Lanarkshire NHS Board are responsible for Hospital 1 and Hospital 2.

[2] Greater Glasgow and Clyde NHS Board are responsible for the Centre.