Health

Overview

The complainant (Miss C) raised a number of concerns about the care and treatment provided to her by Greater Glasgow and Clyde NHS Board (the Board) following a labyrinthectomy on 22 August 2006.  Miss C also complained about the attitude of a doctor during an eye examination.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to provide Miss C with appropriate care and treatment in August 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that there had been unacceptable delays by Forth Valley NHS Board (the Board) in arranging follow up for her husband (Mr C) and a consequent failure to provide any treatment for him following his diagnosis of cancer.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)  did not arrange timely follow-up to Mr C (upheld); and
• (b)  did not provide Mr C with treatment following his diagnosis of cancer (not upheld).

Redress and recommendations

In light of the action taken by the Board the Ombudsman recommends that the Board make a written apology to Mrs C for the delays in arranging the follow-up appointment and requests that they send a copy of the finalised policy on Patient Access to this office.

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

Overview

The complainants (Mr and Mrs C), complaining on behalf of Mrs C's late mother (Mrs A), raised concerns regarding an alleged failure by Mrs A's General Practitioner (the GP) to take urgent and appropriate action to investigate and treat problems she was suffering from between May 2006 and July 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the GP failed to take urgent and appropriate action to investigate and treat problems Mrs A was suffering from between May 2006 and July 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about aspects of the care and treatment of his mother (Mrs A) by NHS Greater Glasgow and Clyde (the Board) from May 2005 until her death in October 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  records were not knowingly available to staff or of sufficient quality (upheld);
• (b)  action taken to prevent falls was inadequate (not upheld);
• (c)  there was a lack of planned therapy for Mrs A (upheld); and
• (d)  there were delays in providing adequate pain relief (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  reflect on the lessons that emerge from the record-keeping issues in this case, consider whether the documentation should be changed or if the issue is rather about staff induction/training and advise her of the outcome of this consideration;
• (ii)  complete the work on a Bed Alarm Policy and submit a copy to SPSO when this is issued;
• (iii)  arrange for staff to reflect on the importance of good communication and involvement of patients and relatives in decisions about care and treatment and advise her of the steps taken to achieve this; and
• (iv)  consider how to address the needs of longer term patients for mental stimulation to enhance their quality of life and advise her of the outcome of this consideration.

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

Overview

The complainant’s representative raised a complaint against Argyll and Clyde NHS Board (the Board), on behalf of the complainant (Mrs C), about the treatment she received at the Royal Alexandra Hospital in respect of a top-up epidural to allow for the surgical removal of the retained placenta after the birth of her son in August 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  clinical errors by the consultant anaesthetist (Dr E) put Mrs C’s health at risk during her labour (not upheld); and
• (b)  Dr E’s recollection of the facts differs from those of Mrs C, who believes that Dr E is being untruthful (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  consider whether it needs to review when clinical risk reviews of incidents such as these are carried out; and
• (ii)  ensures that clinical staff are reminded of their responsibility to maintain detailed records, in particular, in respect of anaesthetic procedures.

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

Overview

The complainant (Mrs C) raised concerns about the nursing care received by her late husband (Mr C) in Lorn and Islands District General Hospital (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr C’s medication for Parkinson’s disease was not correctly administered in relation to his PEG feeding (not upheld);
• (b)  Mr C’s PEG tube was not properly cleaned by nursing staff so as to avoid blockage (no finding);
• (c)  Mr C was not kept satisfactorily hydrated (not upheld);
• (d)  Mr C’s feet were not kept elevated when he was sitting in his chair and this resulted in the formation of blisters on his heels (upheld);
• (e)  Mr C was not given adequate physiotherapy in hospital (not upheld);
• (f)  Mr C was not given access to his own oral suction machine and oral suction was not performed sufficiently frequently by staff (no finding);
• (g)  Mr C’s torso and head were not kept elevated when he was in bed (upheld); and
• (h)  Mr C was wrongly assessed as fit for discharge as he died shortly later (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  take steps to ensure that relatives are given appropriate information where treatment given in hospital is different from at home;
• (ii)  apologise to Mrs C for their failure to appropriately manage Mr C’s pressure areas; and
• (iii)  remind relevant staff to be attentive to any physiotherapy advice given on positioning a patient.  Furthermore, the Board should apologise to Mrs C for their failure to return Mr C to an upright position after a positional change.

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

Overview

The complainant raised a number of concerns about the care and treatment of his late sister (Miss C) by Greater Glasgow and Clyde NHS Board (the Board).  In particular he complained that Miss C had an operation to fuse her ankle joint which left her in considerable pain when it would have been clinically more appropriate to have amputated the foot; and also that on her final admission on 25 July 2005 to hospital she had been inappropriately admitted to orthopaedics which delayed diagnosis of the septicaemia which caused her death on 6 August 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  doctors did not take the clinically appropriate step to remove Miss C's foot from the ankle (not upheld); and
• (b)  Miss C was inappropriately admitted to an orthopaedic ward rather than a medical ward (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their procedures for ensuring an overall treatment plan with ongoing input from all the relevant specialisms where a patient has a number of underlying medical problems.

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

Overview

The complainant (Mrs C) raised a number of concerns that her GP Practice (the Practice) withheld information from her when she requested copies of her medical records, initially by not supplying the full records, then by refusing to give written explanations of them and that they wrote misleading and inaccurate referral letters to specialists because they do not believe she had a heart attack.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a)  manipulated Mrs C’s medical care via misleading and inaccurate referral letters (not upheld); and
• (b)  withheld medical information from Mrs C (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained that the GP Practice (the Practice)'s late diagnosis of her mother (Mrs A)'s colon cancer could have been avoided by their greater consideration of her symptoms.  Mrs A died in hospital in June 2003, about a month after diagnosis, aged 76.

Specific complaints and conclusions

The complaint which has been investigated is that the Practice should have investigated more fully than they did (upheld).

Redress and recommendations

The Ombudsman recommends that the GPs in question:

• (i)  apologise in writing to Mrs C, acknowledging that further investigation should have been done in mid 2002; and
• (ii)  inform the Ombudsman what steps they have taken and/or are taking to learn from, and try to avoid a recurrence of, this serious case, for example, by discussing it at their general practitioner appraisals and discussing other relevant cases with the clinical governance lead of the appropriate Community Health Partnership.

The Ombudsman is pleased that the Practice have accepted the recommendations and are taking action on them.

Overview

The complainant (Mrs C) raised a concern that her late father's GP (GP 1) failed to provide reasonable care and treatment to her father (Mr A) in the two days immediately prior to his unexpected death in January 2006.

Specific complaint and conclusion

The complaint which has been investigated is that GP 1 failed to provide reasonable care and treatment to Mr A (not upheld)

Redress and recommendation

The Ombudsman has no recommendations to make.

Please note that this Report contained typographical errors in paragraph 4.  It should read:

4.     On 24 January 2006 the Practice received a call from one of Mr A's daughters (Mrs D) stating that Mr A was shaky and confused and requesting a home visit for him.  GP 1 visited later that day after evening surgery.  GP 1 made a working diagnosis of viral infection (she later noted that a flu virus was prevalent in the community at the time) and advised Mr A to increase his fluid intake and take paracetamol if needed.  GP 1 later called Mrs D and repeated this advice.  The following evening Mrs C called her father and was concerned when he dropped the telephone and she lost contact with him.  Mrs C and Mrs D drove to Mr A's house but could not gain access and called the paramedics who broke down the door.  Mr A was found in a state of collapse and was admitted to hospital by emergency ambulance at 22:30.  He was in acute renal failure and treated with antibiotics and IV fluids.  He suffered a cardiac arrest and died in the early hours of 26 January 2006.  The primary causes of death were listed as multiple organ failure, sepsis and urinary tract infection.

The SPSO has apologised to the complainant for these errors.