Health

Overview

The complainant (Miss C) was concerned that the cause of her abdominal pain was not diagnosed despite several admissions to Victoria Infirmary (the Hospital) and that not all necessary investigations had been carried out.  Miss C also raised issues regarding Greater Glasgow and Clyde NHS Board (the Board)'s communication with her and her mother and regarding the accuracy of the Board's response to her complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to diagnose the cause of Miss C's abdominal pain and to carry out all necessary investigations (not upheld);
• (b) the Board failed to communicate properly with Miss C and her mother during an admission between 22 February 2007 and 5 March 2007 (partially upheld to the extent that Miss C's return to the ward on 5 March 2007 was not adequately managed); and
• (c) the letter responding to Miss C's complaint contained inaccuracies (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) did not consider that Lothian NHS Board (the Board) had taken seriously, or learnt from, the death of his 46-year-old son (Mr A).

Specific complaint and conclusion

The complaint which has been investigated is that the Board's response to Mr A's death was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for: the failure to provide convincing evidence of a thorough investigation, with lessons learnt; the impression at various times that no action would be taken in response to his son's death; the poor quality of some of the complaint responses; and the delay in giving him a definitive response to a complaint meeting and letter of early 2005; and
• (ii) ensure that, where appropriate, this investigation drives further service improvement in future complaints.

Overview

The complainant (Ms C) raised a number of concerns regarding her medical care and treatment during investigations of painful sensations in her throat.  Ms C specifically complained about the length of time it had taken for her to be referred for an endoscopy; the actions of the gastroenterology department when she attended for pH studies and oesophageal motility studies and the length of time it had taken for a Consultant (the Consultant) to notify her of the results of a Fine Needle Aspiration Cytology (FNAC) examination.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in referring Ms C for an endoscopy (not upheld);
• (b) the gastroenterology department unreasonably continued with a procedure despite the changes that had occurred in Ms C's condition since the referral had been made (not upheld); and
• (c) the Consultant unreasonably delayed notifying Ms C of the results of a FNAC examination (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) was concerned that her mother (Mrs A) received inadequate care and treatment after being admitted to Royal Victoria Hospital (the Hospital) between 17 July 2006 and 20 October 2006.  She also raised concerns about the cleanliness of the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Lothian NHS Board (the Board) failed to appropriately monitor and audit the cleanliness of the Hospital (partially upheld to the extent that there were failures in cleaning and monitoring);
• (b) nursing staff failed to take action when they were advised of concerns by Mrs A's family and were often unavailable, in several instances because they were at management meetings (no finding);
• (c) a nurse acted inappropriately by trying to remove Mrs A's ring without a local anaesthetic (upheld); and
• (d) as a result of the poor care Mrs A received, her health and general condition deteriorated during her stay at the Hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) bring the findings of this report to the attention of all staff involved in cleaning, supervising and monitoring cleaning, to remind them of the importance of cleaning all required areas, recording cleaning appropriately and carefully checking cleaning and monitoring documentation so that the omissions highlighted in this report are not repeated in future;
• (ii) ensure that the induction of new staff includes appropriate and adequate training on the completion of cleaning records;
• (iii) apologise to Mrs A and her family for attempting to remove her ring without local anaesthetic and for the distress this caused; and
• (iv) put measures in place to ensure that, where the condition of a finger is clearly such that removal of a ring will be painful, removal should be carried out with the use of a local anaesthetic.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment her late son, Mr A, received at Aberdeen Royal Infirmary for a heart condition.  In particular Mrs C complained that, although doctors first realised there was a problem with Mr A's heart in December 2004, no active cardiac treatment was commenced until May 2006.

Specific complaint and conclusion

The complaint which has been investigated is that, between December 2004 and May 2006, Mr A received inadequate treatment from staff in relation to his heart problems (upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for the failure to perform a left sided catheterisation of Mr A's heart in February 2005.

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

Overview

The complainant (Ms C) suffered shoulder pain following a fall at home on 3 January 2006.  She attended Accident and Emergency (A&E) at Ninewells Hospital.  Examination of her shoulder revealed no new injuries and she was allowed to return home on the basis that a pre-existing frozen shoulder was the root cause.  Ms C said that she continued to experience a great deal of pain despite ongoing treatment for her frozen shoulder.  An x-ray in May 2006 showed that she had fractured her humerus.  Ms C complained that an x-ray should have been taken during her A&E attendance on 3 January 2006.  She felt that failure to take an x-ray prolonged her pain and delayed the operation that she required to repair her humerus.

Specific complaints and conclusions

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

• (a) failed to properly diagnose and treat Ms C's painful shoulder (not upheld); and
• (b) failed to provide emergency treatment to Ms C upon her arrival at A&E (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that her late father (Mr A) had not received adequate treatment from Ayrshire and Arran NHS Board (the Board) after being admitted to Ayr Hospital on 11 November 2005.  Mr A was transferred to Ayrshire Central Hospital (Hospital 2) on 20 December 2005, but died there on 27 December 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A was catheterised without his consent (upheld);
• (b) a consultant decided not to artificially hydrate Mr A (upheld);
• (c) the Board inappropriately transferred Mr A to Hospital 2 (upheld); and
• (d) the Board failed to communicate effectively with Mr A's family (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the failure to record that verbal consent to insert the catheter had been obtained from Mr A and the failure to adhere to the General Medical Council's guidance regarding the decision not to artificially hydrate Mr A;
• (ii) review the guidelines for catheterisation in order that they make explicit reference to recording that verbal consent has been obtained;
• (iii) take steps to ensure that staff adhere to the General Medical Council's guidance when they consider withholding or withdrawing life-prolonging treatments, by involving the patient (or those close to the patient where the patient's wishes cannot be determined) in the decision making. Details of the decision taken should be clearly recorded in the medical records; and

• (iv) review Mr A's case in order to establish if there are any lessons that can be learned regarding the transfer of patients to other hospitals.

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

Overview

The complainant (Mrs C) was concerned that the podiatry treatment she received at a podiatry clinic (the Clinic) was inappropriate.  Mrs C complained that her bunion had been cut into against her wishes and that the same scalpel had been used to treat two different parts of her foot.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a podiatrist (the Podiatrist) cut into Mrs C's bunion against her wishes (not upheld); and
• (b) the scalpel used to cut into Mrs C's bunion was the same as that which had been used to cut into her toenail (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mrs C, complained of a lack of local care provision for her son, Mr A, from June 2004 to March 2007.  Mr A is severely autistic, has learning difficulties and also suffers from epilepsy.  Specifically, Mrs C complained that Mr A was seen by his Consultant (Consultant 1) in June 2004 but that there was no direct access to care offered by Forth Valley NHS Board (the Board) following this review and the departure of Consultant 1 in May 2005.  Mrs C also complained that the medication prescribed for her son by Consultant 1 was inappropriate in that, if fully implemented, it would have placed Mr A at risk.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was a lack of care provision for Mr A from June 2004 to March 2007; (upheld); and
• (b) medication prescribed for Mr A by Consultant 1 in June 2004 was inappropriate in that, if fully implemented, it would have placed Mr A at risk (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board offer Mrs C a full and sincere apology for the shortcomings identified in this report.

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

Overview

The complainant (Ms C) was referred to a consultant orthopaedic surgeon (Consultant 1) at the Southern General Hospital in Glasgow for a diagnosis of the knee pain she had been suffering for some time.  Because the pain continued, she then saw a private consultant who recommended treatment which proved successful.

Specific complaint and conclusion

The complaint which has been investigated is that Consultant 1 incorrectly diagnosed Ms C's knee condition, leading to damage which could have been prevented if a correct diagnosis had been made earlier (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.