Health

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment of her late husband (Mr C) and the handling of his complaint about that care and treatment by Lothian NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was prematurely discharged from the Royal Infirmary of Edinburgh (Hospital 1) on 16 September 2005 (upheld);
• (b) the Board failed to provide Mr C with appropriate and timely care and treatment between 27 September 2005 and 6 October 2005 (upheld); and
• (c) the Board failed to make an adequate response to Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) inform her of progress towards achieving the objectives set out in paragraph 16 of this Report; and
• (ii) make a written apology to Mrs C for the failure to maintain proper records and the additional distress this has caused to Mr C's family in pursuing this matter.

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

Overview

The complainant (Ms C) raised a number of concerns about her mother (Mrs A)'s care and treatment at Aberdeen Royal Infirmary (the Hospital).  In particular, she wondered whether Mrs A's cancer could have been diagnosed a few months earlier and whether this would have affected the sad outcome for her mother, who died, aged 60, in October 2005, the day after being temporarily discharged whilst waiting for the result of a biopsy.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A's care and treatment at the Hospital from July 2005 to October 2005 were inappropriate (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Miss C) raised a number of concerns about her late uncle (Mr A)'s care at Ninewells Hospital (the Hospital), to which he was admitted on 20 December 2005 and where he died on 25 December 2005, aged 62.

Specific complaint and conclusion

The complaint which has been investigated is that Mr A's care in December 2005 fell below a reasonable standard (upheld).

Redress and recommendations

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

• (i) put in place a policy, protocol or guidance in relation to infective exacerbations of chronic lung disease;
• (ii) advise urgent contact from clinical staff to carers in particularly grave situations and, more generally, encourage proactive communication from clinical staff to patients and their carers;
• (iii) provide evidence of the systems in place to monitor and audit nursing records; and
• (iv) provide evidence of the main improvements which they have made in the standard of care as part of their 'safer patient' initiatives.

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

Overview

The complainant (Ms C) raised concerns about her care and treatment by a consultant (Consultant 1), information that was included in a letter and subsequent effect on her medical care as a result.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1's medical treatment of Ms C was inadequate (not upheld);
• (b) Consultant 1 wrote a letter to Ms C's GP containing information Ms C had advised was incorrect (upheld); and
• (c) Consultant 1's comments had a negative influence on other medical practitioners involved with Ms C's case (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) considered that his GP Practice (the Practice) failed to diagnose and treat his illness and he was unhappy that the Practice decided to no longer provide medical treatment to him, his brother and his father.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) the alleged failure to diagnose and treat Mr C's illness (not upheld); and
• (b) that the decision by the Practice to remove Mr C and his family from their list was wrongly taken (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise in writing to Mr C, his brother and his father for the failure to follow the appropriate procedures when taking the decision to remove them from the Practice list; and
• (ii) review how it takes such decisions in light of The National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004, and ensure that Practice policy and actions are compliant with this Statutory Instrument.

The Practice have accepted the recommendations and will act on them accordingly.  The Ombudsman asks that the Practice notify her when the recommendations have been implemented.

Overview

The complainant, Mr C, complained about various aspects of the treatment of his brother, Mr A, prior to Mr A's death in the Southern General Hospital, Glasgow (the Hospital).  In particular, Mr C complained that Mr A's general practitioner (the GP) failed to diagnose Mr A's brain tumour, and that the care and treatment Mr A received in the Southern General Hospital, Glasgow (the Hospital) was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that there was:

• (a) inadequate treatment by the GP (not upheld); and
• (b) inadequate treatment by the Hospital (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the care and treatment given to his late father (Mr A) during a consultation with a GP (GP 1) at a medical practice (the Practice) on 5 April 2005, as Mr A died approximately one hour after the consultation.

Specific complaint and conclusion

The complaint which has been investigated is that GP 1 should have recognised that Mr A was suffering from coronary heart disease, realised the severity of his medical condition and taken appropriate action (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a complaint regarding the length of time he had been advised he would have to wait to see a Neurologist within the former Argyll and Clyde NHS Board (the Board), after his General Practitioner (GP 1) had requested a routine referral on his behalf when he presented with a clinical picture of a six to eight month history of a constant ache in his arm.

Specific complaint and conclusion

The complaint which has been investigated is that the waiting time for a Neurology out-patient appointment was too long (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board should ensure GPs and potential referrers are reminded how to find up to date local waiting times for out-patient services they are referring to within the Board so that, as referrers, they may prioritise their patients accordingly. She asks that the Board advise her of the measures that are put in place, or have been introduced, to facilitate this; and
• (ii) as one of several factors, some formal consideration should be given to the age of the patient being referred to a lengthy waiting list, where a list is unavoidably long. She asks that the Board tell her what they have implemented.

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 she had received for a bowel condition.

Specific complaints and conclusions

The complaints which have been investigated are that there was failure:

• (a) by medical staff to manage adequately Mrs C's care, reach a diagnosis quickly and provide appropriate treatment (not upheld);
• (b) to keep Mrs C in a special unit for a reasonable time following her operation (not upheld);
• (c) by nursing staff to provide adequate post-operative nursing care (upheld);
• (d) to provide a clean room (not upheld); and
• (e) to discharge Mrs C from hospital within a reasonable time (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) stress to clinicians the importance of ensuring, as far as possible, that patients are made aware of the reasons for clinical decisions made in relation to their care, particularly when being transferred between medical teams;
• (ii) provide evidence of the use of their Manual Handling Policy on all wards so that staff are aware of patients' handling needs and the recording of these needs and provide further evidence that staff receive the appropriate training in handling techniques;
• (iii) put in place procedures to prevent a recurrence of the delay in replacing broken handsets and, in the interim, ensure alternatives are available;
• (iv) provide evidence of the strategies in place to implement effective patient discharge planning; and
• (v) provide evidence of recent audit of nursing discharge planning on the surgical wards.

The Board have accepted the recommendations and have acted upon them accordingly.

Overview

The complainant (Ms C) was a patient at Dykebar Hospital (the Hospital), Paisley, in August/September 2003.  She raised a number of issues concerning the conduct and behaviour of Mr and Mrs D (two of the Hospital's staff) towards her and the manner in which the former Argyll and Clyde NHS Board, (the Board) dealt with her complaint.

Specific complaint and conclusion

The complaint which has been investigated is the handling of Ms C's complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that they have in place a system for handling complaints that can demonstrate to a complainant that their complaint has been fairly, impartially and thoroughly investigated;
• (ii) ensure that, in particular, they have in place a system for handling complaints in circumstances where serious allegations are made by a patient about a member of staff;
• (iii) ensure that they and their employees understand their responsibilities in relation to protecting staff and patients, particularly in mental health settings;
• (iv) ensure that current arrangements for separating the complaints process from the disciplinary process meet the requirements of the current NHS complaints guidance; and
• (v) issue Ms C with a full formal apology for the failures identified in this report. The apology should be in accordance with the Ombudsman's guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

The Board have accepted the recommendations.