Health

Overview

The complainant (Mrs C) raised a number of concerns about the nursing care her late mother, Mrs A, received at Ayr Hospital and Biggart Hospital between October 2004 and February 2005 regarding pressure sores (heel) her mother developed.  She also complained that staff failed to keep the family informed of Mrs A's condition.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the management of Mrs A's pressure sores was inadequate (upheld); and
• (b) staff communication with Mrs A's family was poor (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide evidence that the implementation of improvements in the prevention of pressure ulcers has resulted in an increase in standards. This should include: information relating to the monitoring of standards of pressure ulcer prevention; the role of the senior nursing and specialist nursing staff in the monitoring process; and details of the provision of training and support for staff in making decisions about choices of pressure-relieving equipment and appropriate dressing materials; and
• (ii) provide evidence to demonstrate that changes in communication strategies for carers had resulted in improved care.

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

Overview

The complainant (Mrs C) complained about the care and treatment her sister (Mrs A) received at Ninewells Hospital, Dundee (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in arranging an MRI scan following Mrs A's admission to the Hospital in November 2003 (upheld);
• (b) the delay caused Mrs A's condition to worsen and become irreparable leaving her in constant and severe pain (not upheld);
• (c) there was a failure by the Hospital's Pain Clinic to monitor or arrange appropriate follow-up in relation to the medication prescribed for Mrs A (not upheld); and
• (d) there was an unreasonable delay by Tayside NHS Board (the Board) in the handling of the complaint (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) issue Mrs A with a full formal apology for the failures identified in part (a) of the complaint. The apology is to be in accordance with the Ombudsman's guidance note on 'apology' which sets out what is meant by and what is required for a meaningful apology; and
• (ii) provide evidence to the Ombudsman of the steps taken to prevent a reoccurrence of the failures identified in paragraphs 21 to 23 of the report.

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

Overview

The complainant's (Mrs C) father (Mr A) died on 28 December 2004 following treatment in Gartnavel General Hospital (the Hospital).  She was concerned that there was an unreasonable delay in diagnosing his cancer and that he was not provided with adequate treatment on admission to the Hospital.  Mrs C also felt that there were unreasonable delays in the handling of her complaint by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in diagnosing Mr A's cancer (not upheld);
• (b) during MrA's admission to the Hospital in November and December 2004, he was not provided with adequate treatment; in particular, there was a delay before any attempt was made to arrange a stent and radiotherapy (upheld);
• (c) Mr A had an unnecessary second bronchoscopy (upheld); and
• (d) there were undue delays in the handling of the complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board, reflecting on this case:

• (i) review their guidelines to ensure that in cases similar to this one, staff understand the need for the appropriate multi-disciplinary team to meet at the earliest possible opportunity to discuss all options for investigation, treatment or non treatment. She also recommends that options are discussed in detail with patients and/or with their family in such circumstances;
• (ii) review the circumstances in which it may be appropriate to provide palliative treatment prior to firm diagnosis, and that they include their findings in revised clinical guidelines for staff. The Ombudsman asks that the Board inform her of the outcome of this review and the actions taken; and
• (iii) review their methods of obtaining information from internal sources with a view to ensuring that there are no resultant avoidable delays in responding to complaints.

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

Overview

Ms C raised a number of concerns on behalf of her mother (Mrs A) that she had not received proper or adequate treatment from Grampian NHS Board (the Board) whilst in Woodend Hospital (Hospital 1) for a knee operation.  She was transferred to Aberdeen Royal Infirmary (Hospital 2) on 11 December 2004.  

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a) the Board failed to provide proper or adequate nursing and medical care to Mrs A (upheld);
• (b) the Board failed to identify a small bowel obstruction (upheld); and
• (c) the Board failed to communicate effectively with Mrs A’'s family (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review medical and nursing documentation and advise the Ombudsman of the outcome of the review;
• (ii) introduce a system for the audit of clinical documentation, for example pulling five files on a monthly basis, and advise the Ombudsman of the proposed action; and
• (iii) consider if there are training needs for staff in relation to communication with patients and relatives/friends.

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

Overview

The complainant, Ms C, raised a number of concerns about what happened to her when she was admitted to Crosshouse Hospital (the Hospital) for diagnostic endoscopy.

Specific complaint and conclusion

The complaint which has been investigated is that the Hospital failed to explain Ms C's inappropriate admission adequately (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make; however, she asks that this office be provided with a copy of the guidelines when they are ratified.

Overview

The complainant (Mrs C) raised a number of concerns about the way her late mother, Mrs A, had been assessed and treated on three occasions at the Accident and Emergency Department (the Department) at Ninewells Hospital in March and April 2004.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A was inadequately assessed and had been inappropriately discharged from the Department on three occasions (upheld).

Redress and recommendations

The Ombudsman recommends that, as a matter of urgency, the Board undertake an audit of all of the Departmental nursing documentation including observation charts in use in the Department and conduct a review of the chest pain protocol and advise her of the outcome.

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

Overview

The complainant (Mrs C) raised a number of issues regarding her treatment and care following an ankle fracture.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) failure by the Consultant to align properly Mrs C’s broken ankle (upheld);
• (b) Mrs C’s concerns about the alignment had been dismissed by medical staff at the time (upheld); and
• (c) failure by medical staff to provide appropriate advice to Mrs C on managing her injury (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the case be discussed at the Consultant's next annual appraisal;
• (ii) the Board provide evidence that their records have been submitted to scrutiny, via audit, and address the problems identified in this report in record-keeping; and
• (iii) the Board introduce a protocol on providing advice to patients on managing plaster cast injuries.

Overview

Mrs C was concerned that her late husband, Mr C, was only diagnosed as suffering from non-Hodgkins Lymphoma shortly before his death.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay in the diagnosis of Mr C's non-Hodgkins Lymphoma (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant raised a concern that her mother (Mrs A) had been refused NHS Continuing Care Funding by Lothian NHS Board.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A was unreasonably refused NHS Continuing Care Funding (not upheld).

Redress and Recommendations

The Ombudsman has no recommendation to make.

Further Action

This and other complaints to the Ombudsman indicated an urgent need to review the guidance on NHS Continuing Care Funding which was issued more than 11 years ago.  This is not a matter which an individual Health Board is able to address so cannot be resolved within this report.  The Ombudsman has previously drawn this matter to the attention of the (then) Scottish Executive Health Department and has now been informed that a review of this policy is underway with the intention that it will report in January 2008.  In light of this action this office has formally suspended consideration of any further complaints raised with us on this matter pending the outcome of the review by the Scottish Government Department of Health and Wellbeing.

Overview

The complainant, Mr C, raised a number of concerns about the podiatry treatment he received while he was recovering from a stroke.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) staff at Liberton Hospital did not take his speech and mobility problems into account before giving him treatment and pain relief was not discussed with him, as a consequence of which he suffered extreme discomfort (upheld);
• (b) pain relief was not offered at the local podiatry clinic, where he was referred for further treatment (not upheld); and
• (c) reception staff were unhelpful (no finding).

Redress and recommendations

The Ombudsman recommends that for stroke patients like Mr C who are receiving podiatry treatment, the Board discuss, and record, the situation with regard to pain relief.  Furthermore, that they emphasise to reception staff the importance of good communication and, if information is required when attending for appointment (however that appointment is made), to be clear with patients about this.

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