Health

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.

Overview

The complainant (Mr C) raised a number of concerns about a lack of physiotherapy assessment, provision and follow-up as well as the quality of the in-patient care provided and the overall discharge planning by Tayside NHS Board (the Board) following his late mother (Mrs A)'s admission to Ninewells Hospital, Dundee on 17 February 2006.  Mr C was also dissatisfied with the Board's responses to his concerns which he considered to be deliberately confusing and contradictory.  Mr C considered that these many failures had hastened his mother's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly assess and provide appropriate care and treatment to Mrs A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on the failures identified by the advisers in the management of Mrs A as part of the on-going reviews already being undertaken by the Board;
• (ii) monitor compliance with the revised template for the discharge letter as part of the existing review of record-keeping; and
• (iii) review the Guidelines for (physiotherapy) Referrals and consider specifically how it impacts on those discharged to a nursing home (particularly in light of the advisers' comments that this appears to be discriminating against such patients).

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

Overview

The complainant (Mrs C) said that the death of her husband (Mr C) could have been avoided if staff of Tayside NHS Board (the Board) had done more to establish the extent of his condition.  Mrs C felt that the diagnostic process was unnecessarily delayed and that, had Mr C's liver cancer been diagnosed sooner, it may have been treatable.

Specific complaint and conclusion

The complaint which has been investigated is that the Board took unnecessarily long to diagnose and treat Mr C's condition (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board consider ways to minimise any delays to cases being discussed by the upper gastrointestinal multi-disciplinary team.

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

Overview

The complainant (Ms C) raised concerns with regard to a delay by East Lothian Council (the Council) in replacing windows in her home, in carrying out a repair to a damaged window lintel, and about the way her contact with the Council was recorded.

Specific complaints and conclusions

The complaints which have been investigated are that the Council:

• (a) unduly delayed in replacing the windows in Ms C's home (partially upheld);
• (b) unduly delayed in repairing a lintel above a window (upheld); and
• (c) failed to keep an accurate record of Ms C's contact with them (partially upheld).

Redress and recommendations

The Ombudsman recommended that the Council:

• (i) apologise to Ms C for the delays which occurred in installing the new windows and for implementing the repair to the lintel above the living room window; and
• (ii) make Ms C an appropriate payment in recognition of the costs she incurred in pursuing matters with them.

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

Overview

The complainants (Mrs C and Mrs D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at St Johns Hospital at Howden (the Hospital) between 19 December 2005 and 2 February 2006.

Specific complaints and conclusions

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

• (a) failed to provide adequate care and treatment to Mrs A (partially upheld); and
• (b) failed to properly plan for Mrs A's discharge (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that discussions take place within the clinical team on Ward 9 of the Hospital to agree the appropriate standard of practice with regards to the importance of a) thorough examination of a patient prior to discharge, with particular reference to patients with pre-existing medical problems and multiple medications, and b) recording of medical examination findings and the rational behind any changes to medications;
• (ii) consider the use of fully unified records, i.e. including therapy follow-up records with the joint medical/nursing records;
• (iii) consider regular (at least weekly) multi-disciplinary team meetings where discharge planning for complex cases, particularly for elderly patients, can be discussed, coordinated and recorded;
• (iv) consider that where family conflicts or carer anxieties are raised, case conference meetings are organised when the key disciplines and family and carers can meet to exchange information and plan discharges and that all family meetings are adequately recorded; and
• (v) consider whether current occupational therapist staffing levels in this area are sufficient to avoid the delays experienced by Mrs A.

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

Overview

The complainant, Ms C, raised a number of concerns that her late mother (Mrs A) had received inadequate medical post-operative care in her own home from her practice GP ( GP 1) and the District Nursing Service (the DNS), before Mrs A was re-admitted to a Dundee hospital (the Hospital) and subsequently died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 failed to re-refer Mrs A back to the Hospital when this was requested by a district nurse (no finding);
• (b) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to enter relevant details in case notes about Mrs A's condition (upheld); and
• (c) during the period when Mrs A was receiving post-operative care within her home, the district nurses failed to relay family concerns to the practice GPs (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) GP 1 reflects on Adviser 1 and Adviser 2's comments (see paragraphs 17 to 21) and considers discussing these at her next appraisal;
• (ii) the fundamental standards of documentation are considered by the practice and the Board and revisited across the DNS as an outcome of complaints (b) and (c); and
• (iii) although the services within the complaint (the Board, the practice and the DNS) have demonstrated a willingness to deal with complaints and identify solutions, from the information reviewed, there is no evidence to suggest that any of the work/actions identified have fully addressed the fundamental areas of holistic assessment and communication between teams, or been referenced to any professional standards or guidelines in relation to the assessment process, documentation, communication, wound care, care planning and patient held records. Accordingly the Ombudsman recommends that these areas are explored and that she is advised of the outcome.

The Board and the Practice have accepted the recommendations, some have already been implemented and others will be acted on accordingly.

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)  Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment Mr A received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)   Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment MrA received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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

Overview

The complainant, Mrs C, raised concerns that her late father (Mr A) had not received adequate and appropriate care and treatment from Fife NHS Board (the Board), that the Board had not adequately responded to her complaints and that the action plan generated as a result of her complaints was not adequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr A's medical treatment and care were inadequate and unsatisfactory in:
• (i)  the Urology Department of Queen Margaret Hospital, Dunfermline (upheld);
• (ii)  the Accident and Emergency Department of The Victoria Hospital, Kirkcaldy (not upheld);
• (iii)  Ward 14 of The Victoria Hospital, Kirkcaldy (not upheld); and
• (iv)   Ward 2 of Glenrothes Hospital (upheld);
• (b) the Board did not adequately respond to Mrs C's complaints (partially upheld); and
• (c) the action plan generated as a result of Mrs C's complaints was not adequate (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr A's family for the inadequate care and treatment MrA received at the Urology Department of Queen Margaret Hospital, Dunfermline and in Ward 2 of Glenrothes Hospital;
• (ii) review their procedures on the investigation of symptoms of cancer of the prostate;
• (iii) satisfy themselves that Specialist Urology Nurse and the Urologist have the appropriate competencies to carry out the care required by patients presenting with the symptoms of cancer of the prostate;
• (iv) put in place a firm timescale for when patients in all areas of Glenrothes Hospital will have access to a call bell system;
• (v) review their procedures for the communication of information between departments and wards and the procedures ward staff follow when assessing a patient's well-being on the ward;
• (vi) review their procedures and guidance for the recommendation of catheterisation, and emphasise these to staff in Ward 2 of Glenrothes Hospital;
• (vii) undertake a full audit of their record-keeping procedures, guidance and training, and strengthen these as necessary; and
• (viii) introduce guidance to all staff regarding how to respond to requests for statements on complaints, with specific reference to consulting medical or nursing notes when dealing with events which they were not personally party to.

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