Health

Overview

The complainant (Mr C) raised a number of concerns regarding the treatment he received at the Royal Infirmary of Edinburgh (the Hospital) for an injury to his knee.  Mr C also claimed that the consultant treating him (Consultant 1) at the Hospital failed to fully consider all the potential causes for Mr C's problems with his knee.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1's assessment of Mr C's symptoms was inadequate and did not go into sufficient detail (not upheld); and
• (b) Consultant 1's diagnosis was not reasonable and he failed to consider the possibility that Mr C was suffering from Chronic Regional Pain Syndrome (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mrs C, visited the medical practice (the Practice) with her three year old grandson (Child A), who was unwell, and was seen by the doctor (the GP).  After examining Child A, the GP diagnosed that he had tonsillitis.  The GP then asked Mrs C to have Child A's parents contact him as he wished to address the issue of 'targeted kicks' from the child towards the GP during the consultation.  Mrs C was unhappy with the GP's attitude and complained to the Practice Manager.  She remained unhappy with the response to her complaint, which was sent by the GP, and asked the Ombudsman to investigate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was unreasonable for the GP to complain about being kicked by ChildA (upheld); and
• (b) the handling of, and response to, Mrs C's complaint by the Practice was unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the GP should make a full formal written apology to Mrs C for the distress caused to her following the consultation;
• (ii) the GP should consult with the Director of General Practice Postgraduate Education (or his Deputy) to discuss, identify and participate in training and developmental initiatives designed to improve his consultation and communication skills;
• (iii) the Practice should revise their 'Practice Complaints Procedure' to ensure that patients are made aware that they may request that their complaint is investigated and responded to by someone other than the person complained about. This review should also include the development of a process to investigate and address each part of a complaint made before a response is issued; and
• (iv) the Practice should communicate the updated Complaints Procedure in a revised 'Practice Information' leaflet.

Overview

The complainant, Mr C, raised a number of concerns about his General Practitioner (GP 1) following a consultation in August 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 behaved unprofessionally towards Mr C during the consultation (upheld);
• (b) GP 1 unfairly removed Mr C from the medical practice (the Practice)'s patient list (upheld); and
• (c) GP 1's response to a complaint from Mr C's daughter was unsatisfactory (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) GP 1 should make a full formal written apology to Mr C for failing to deal with him in a professional manner and for the distress caused to Mr C and his family in pursuing this matter;
• (ii) GP 1 should consult with the Director of General Practice Postgraduate Education (or his deputy) to discuss, identify and participate in training and developmental initiatives designed to improve his consultation and communication skills;
• (iii) GP 1 should make a full formal written apology to Mr C for removing him unfairly from the Practice patient list;
• (iv) the Practice should reflect on this case and reconsider their policy for removing patients. This revised policy should be open to the patient population and advertised in a revised 'Practice Information' leaflet;
• (v) the Practice should revise their 'Practice Complaints Procedure' to ensure that patients are made aware that they can ask for their complaint, and the response, to be handled by someone other than the person complained about; and
• (vi) the Practice should communicate the revised complaints procedure in a revised 'Practice Information' leaflet.

Overview

The complainant (Mrs C) raised concerns that the Medical Practice (the Practice) inadequately monitored her husband (Mr C)'s blood clotting therapy, which led to him requiring frequent hospital admissions.

Specific complaint and conclusions

The complaint which has been investigated is that, between January 2005 and June 2007, the Practice inadequately monitored and failed to take appropriate action in relation to Mr C's blood clotting therapy (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the treatment which he received at the Ear Nose and Throat Department at Stirling Royal Infirmary (the Hospital) regarding nasal problems which he had suffered for many years.

Specific complaint and conclusions

The complaint which has been investigated is that, during the period 2003 to 2005, Mr C received inadequate treatment from staff at the Hospital regarding his nasal problems (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns that his father (Mr A) had received inadequate treatment while he was a patient at Ninewells Hospital (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that there was:

• (a) inadequate treatment for Mr A's pressure sores (upheld);
• (b) inadequate monitoring of Mr A's pressure sores (upheld); and
• (c) an inappropriate decision to continue with a course of treatment for Mr A's pressure sores (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) provide evidence of a robust standard for records and record-keeping and provide evidence of measures that are in place to audit this area of practice;
• (ii) provide evidence that there is a programme of formalised education and training of the staff on Ward 11 with reference to the transfer of patients which includes the importance of effective communication and proactive nursing in relation to this process;
• (iii) provide assurances that they have a robust policy in place regarding inter-ward transfers;
• (iv) devise a quality assurance system whereby all patients suffering from pressure sores have care plans which are sufficiently detailed and also highlight the monitoring arrangements for the patient;
• (v) apologise to Mr A for the failings which have been identified; and
• (vi) reiterate to all relevant staff at the Hospital the importance of clearly recording the factors which lead to a decision regarding continuing or changing treatment.

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

Overview

The complainants (Mr C and Mr D) raised a number of concerns about the care and treatment of their late mother (Mrs A) at Stirling Royal Infirmary (the Hospital) between 7 March and 21 March 2006.

Specific complaints and conclusions

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

• (a) failed to provide appropriate care and treatment to Mrs A (upheld); and
• (b) failed to adequately investigate Mr C's original complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) inform her of the progress of the recommendations in their Internal Review;
• (ii) apologise to Mrs A's family for the failures identified in this report and their Internal Review and the additional distress caused by the failure of their original investigation to identify and address these failures; and
• (iii) build more robust senior and independent review into the local resolution stage of the NHS Complaints Process to ensure complaints are addressed more comprehensively and review of complaints is built in to Clinical Governance to ensure lessons can be learned form complaints.

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

Overview

The complainant (Mr C) raised some concerns that he was treated inappropriately by a consultant (Clinician 1) during a consultation.  Mr C also suggested that Clinician 1's suggested treatment was inappropriate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the conduct of Clinician 1 during the consultation was inappropriate (not upheld); and
• (b) the treatment suggested by Clinician 1 was inappropriate (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for Clinician 1's failure to clarify the significance of lifestyle rather than sexuality when taking a history from Mr C during the consultation; and
• (ii) ensure Mr C's medical records are amended, where possible, to remove the term 'homosexuality' where it refers to a medical condition, including the GP records, as this is inappropriate.

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

Overview

The complainant (Mrs C) raised a number of concerns that her mother (Miss A) had not been appropriately treated by her GP practice (the Practice) and also that her own complaint to the Practice had not been properly responded to.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a) did not give Miss A appropriate care between January and June 2006 (not upheld); and
• (b) did not respond appropriately to Mrs C's complaint of 4 July 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

Mrs C was concerned that her mother, Mrs A, had developed a pressure sore while in Ninewells Hospital (Hospital 1) and this prevented her from accessing stroke rehabilitation services.

Specific complaint and conclusion

The complaint which has been investigated is that the care and treatment received by Mrs A from Hospital 1 was inadequate and reduced her ability to access rehabilitation services (partially upheld to the extent that the Board did not fully respond to concerns raised by Mrs C).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for failing to respond clearly to her concerns about the effect on Mrs A of the problems in the care she had received; and
• (ii) use this case as a learning tool for staff to demonstrate the importance of good documentation and the effect that failing to complete documentation can have on patient care.

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