Health

Overview

The complainant (Mrs C) raised a number of concerns that her husband (Mr C) had been wrongly diagnosed as having Bells Palsy by an NHS24 Nurse Adviser (the NHS24 Adviser) after he contacted NHS24 complaining of numbness in his face and index finger, slurred speech and a headache.  Mrs C also complained that Mr C had been informed of the diagnosis inappropriately by the NHS24 Adviser and that he should have arranged for an ambulance for Mr C and treated him as a medical emergency.  Instead, Mr C was advised by the NHS24 Adviser to attend the Primary Care Emergency Centre (PCEC) and an appointment made for him there.

Mr C drove to the PCEC himself and was seen by a GP (GP 1), who made a diagnosis of Transient Ischaemic Attack (TIA).  After this consultation, he was allowed home and advised to see his own GP if he did not begin to feel better.  Mr C then waited in the PCEC car park until Mrs C arrived.  He re-attended the PCEC where, after a 30 minute wait, he was seen by a second GP (GP 2).  Mr C was then admitted to hospital and found to have suffered a stroke.  Mrs C complained about the consultation with GP 1 and the care offered to Mr C by the PCEC and Lanarkshire NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was wrongly diagnosed and informed inappropriately of the diagnosis over the telephone by the NHS24 Adviser (upheld);
• (b) the NHS24 Adviser failed to treat Mr C as a medical emergency and should have arranged an ambulance, instead of sending Mr C to an out-of-hours GP practice (upheld);
• (c) GP 1 diagnosed Mr C wrongly and, therefore, treated him inappropriately (upheld);
• (d) GP 1 did not offer to admit Mr C to hospital (no finding);
• (e) GP 1 failed to record sufficient data about his consultation with Mr C (upheld);
• (f) GP 1 rushed his consultation with Mr C (not upheld) and;
• (g) Mr C waited an unreasonably long time on re-attending the PCEC (not upheld).

Redress and recommendations

The Ombudsman had no recommendations to make in relation to NHS24.

The Ombudsman recommends that the Board:

• (i) ensure that GP 1 shares this report with his appraiser at annual review and that he reflects on the comments made in this report regarding the diagnosis of a TIA;
• (ii) review GP 1’s record-keeping to ensure it meets the required standards of the regulatory bodies; and
• (iii) write to Mr C with an apology for the failures which have been 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 that her husband (Mr C) had been wrongly diagnosed as having Bells Palsy by an NHS24 Nurse Adviser (the NHS24 Adviser) after he contacted NHS24 complaining of numbness in his face and index finger, slurred speech and a headache.  Mrs C also complained that Mr C had been informed of the diagnosis inappropriately by the NHS24 Adviser and that he should have arranged for an ambulance for Mr C and treated him as a medical emergency.  Instead, Mr C was advised by the NHS24 Adviser to attend the Primary Care Emergency Centre (PCEC) and an appointment made for him there.

Mr C drove to the PCEC himself and was seen by a GP (GP 1), who made a diagnosis of Transient Ischaemic Attack (TIA).  After this consultation, he was allowed home and advised to see his own GP if he did not begin to feel better.  Mr C then waited in the PCEC car park until Mrs C arrived.  He re-attended the PCEC where, after a 30 minute wait, he was seen by a second GP (GP 2).  Mr C was then admitted to hospital and found to have suffered a stroke.  Mrs C complained about the consultation with GP 1 and the care offered to Mr C by the PCEC and Lanarkshire NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was wrongly diagnosed and informed inappropriately of the diagnosis over the telephone by the NHS24 Adviser (upheld);
• (b) the NHS24 Adviser failed to treat Mr C as a medical emergency and should have arranged an ambulance, instead of sending Mr C to an out-of-hours GP practice (upheld);
• (c) GP 1 diagnosed Mr C wrongly and, therefore, treated him inappropriately (upheld);
• (d) GP 1 did not offer to admit Mr C to hospital (no finding);
• (e) GP 1 failed to record sufficient data about his consultation with Mr C (upheld);
• (f) GP 1 rushed his consultation with Mr C (not upheld) and;
• (g) Mr C waited an unreasonably long time on re-attending the PCEC (not upheld).

Redress and recommendations

The Ombudsman had no recommendations to make in relation to NHS24.

The Ombudsman recommends that the Board:

• (i) ensure that GP 1 shares this report with his appraiser at annual review and that he reflects on the comments made in this report regarding the diagnosis of a TIA;
• (ii) review GP 1’s record-keeping to ensure it meets the required standards of the regulatory bodies; and
• (iii) write to Mr C with an apology for the failures which have been identified in this report.

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 when she attended her GP Practice (the Practice) and about what happened when she subsequently made a complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the treatment provided to Ms C when she attended the Practice on 2 August 2004 was inappropriate (not upheld);
• (b) Ms C's removal from the Practice list was unfair (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Practice apologise to Ms C for the shortcomings identified in this report;
• (ii) the Practice undertake training on complaint handling and the guidance and Regulations governing the removal of patients from the Practice list and, following this training, the GPs and the Practice Manager meet to discuss and draw up a Practice protocol for complaint handling and, specifically, for removal of patients from their list, a copy of which to be sent to the Board's Medical Director for approval and to the Ombudsman for her information; and
• (iii) GP 1 discusses the issue of how he dealt with this complaint at his next annual appraisal as part of his continuing professional development.

The Practice and GP 1 have accepted the recommendations and will act on them accordingly.

Overview

The complainants (Mr and Mrs C) are tenants of Fife Housing Association Ltd (the Association).  They raised a number of concerns regarding the Association's actions in respect to an extension built by their neighbour (Mrs N) in 2004.

Specific complaints and conclusions

The complaints which have been investigated are that the Association:

• (a) failed at the outset to discuss with Mr and Mrs C the implications of the application for planning consent made by Mrs N (not upheld);
• (b) failed to take appropriate action when Mr and Mrs C reported to them that the extension encroached into Mr and Mrs C's tenancy (partially upheld);
• (c) changed their view, to Mr and Mrs C's detriment, to allow access to Mrs N's builder to carry out underpinning work which could and should have been done from Mrs N's own property (not upheld);
• (d) failed to ensure that undertakings they gave to Mr and Mrs C to permit access to Mrs N's builder were adhered to (not upheld ); and
• (e) failed to take up with Fife Council as building authority, Mr and Mrs C's continuing concerns about the safety of an extension wall (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that she had not consented to the operation as performed and had not consented to a spinal anaesthetic.  Mrs C also complained that there was a lack of follow-up.

Specific complaints and conclusions

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

• (a) failed to obtain informed consent for spinal anaesthesia (upheld);
• (b) performed an operation which was different to the planned haemorrhoidectomy without appropriate explanation of the new procedure (upheld); and
• (c) failed to provide the necessary follow-up care and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to ensure she adequately understood and consented to the anaesthetic options; and
• (ii) use the events of this case and in particular Mrs C's experience, as part of induction and training programmes about the consent process.

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

Overview

The complainant (Mrs C) raised concerns about the delays in being assessed when she attended the Reproductive Health Department of the Royal Infirmary of Edinburgh (the Department) on 28 May 2005.

Specific complaints and conclusions

The complaints which have been investigated are that there was a delay by staff in:

• (a) examining Mrs C on arrival at the Department (not upheld); and
• (b) checking for Mrs C's baby's fetal heart rate (not upheld).

Redress and recommendations

The Ombudsman recommends that Lothian NHS Board, as a matter of urgency, develop and implement:

• (i) a written triage protocol for patients who attend the Department; and
• (ii) a document which records the contents of telephone conversations between patients and the Department and is retained in their clinical records.

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

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.