Health

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment provided to his late mother (Mrs A) at the Queen Margaret Hospital, Dunfermline (the Hospital) between 26 March 2006 and her death there on 21 May 2006.

Specific complaints and conclusions

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

• (a) failed to provide appropriate care and treatment to Mrs A (not upheld);
• (b) failed to ensure adequate communication with Mrs A and her family about Mrs A's condition and treatment (not upheld); and
• (c) failed to adequately respond to Mr C's complaints (not upheld).

Redress and recommendations

The Ombudsman recommends that Fife NHS Board use the events of this case, in particular the differing perceptions of staff and family about these events, in staff training to consider how communication in these circumstances might be improved for the future.

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

Overview

The complainant (Mrs C) raised a number of concerns about the care given to her mother (Mrs A) at Perth Royal Infirmary (the Hospital) following her admission for a suspected oesophageal stent blockage on 9 August 2005.

Specific complains and conclusions

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

• (a) prescribed morphine unnecessarily (no finding);
• (b) failed to provide appropriate nursing care (partially upheld);
• (c) failed to maintain accurate records (upheld); and
• (d) failed to provide an adequate complaint response (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) emphasise to nursing staff in the relevant ward the importance of recording in the clinical records any change in the condition of the skin or injury and of ensuring that the commensurate care plan is also formulated and recorded;
• (ii) apologise to Mrs C for the confusion and distress caused by the apparently contradictory nature of some of the responses to her complaints;
• (iii) review the operation of the admission assessment and adopt a consistent process for recording alterations within the assessment;
• (iv) use the events of this complaint in a multi-disciplinary team meeting to illustrate the impact of poor complaint handling and record-keeping on the patient/carer experience; and
• (v) ask that those responsible for providing complaint responses ensure that, where possible, evidence, comment or information is obtained from and checked against, original sources.

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

Overview

The complainant (Mr C) is 16 and was born with a progressive spinal deformity, for which he was reviewed in Glasgow between the ages of five months and 13 years.  When he was 13, the service was transferred to Edinburgh.  At review there, five months later, Mr C was told that an operation some years previously could have prevented his current, permanent, deformity.  Mr C complained, therefore, about not having had such an operation in Glasgow.

Specific complaints and conclusions

The complaint which has been investigated is that it was unreasonable not to have performed an operation at an early age (not upheld).

The investigation has involved consideration of a number of issues to do with clinical practice and arrangements for the provision of health services which, although not all specifically raised in Mr C's complaint, are relevant to any assessment of how his healthcare needs have been addressed.  Paragraph 1 of the main report outlines these issues.

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns about the diagnosis and treatment given to her father (Mr A) on his admission to Aberdeen Royal Infirmary as an emergency by his General Practitioner.  In particular, she feels that had medical staff correctly diagnosed Mr A's condition, they could potentially have saved his life.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) medical staff failed to diagnose an aortic abdominal aneurysm or carry out an appropriate scan to allow them to discount this condition (no finding); and
• (b) Grampian NHS Board failed to investigate Ms C's complaint in a timely manner (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainants (Mr and Mrs C) raised concerns regarding dental treatment received by their daughter (Miss A) at a General Dental Practice (the Practice).  They consider this treatment to have caused one of Miss A's teeth to become non-vital (see Annex 2) and they believe that they should have been warned of this risk in advance.  They were also dissatisfied with the alignment of Miss A's teeth following the treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) after dental correction with braces, Miss A had a non-vital front upper tooth which may require expensive treatment in the future (not upheld);
• (b) the risk of the tooth becoming non-vital should have been pointed out to Mr and Mrs C prior to treatment commencing (not upheld); and
• (c) following treatment, the centre lines of the top and bottom teeth did not match (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained that he had received inadequate care and treatment during and after a tooth extraction at Dundee Dental Hospital (the Hospital) on 15 March 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had a tooth removed at the Hospital which resulted in nerve damage, leaving him in constant and severe pain (not upheld); and
• (b) the tooth was removed in a rough manner by an unsupervised dental student (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their protocol, whether it is best practice that an x-ray should be taken to help identify any potential problems or infections, following the re-presenting of a post-extraction patient.

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

Overview

The complainant (Mrs C) raised concerns that her husband (Mr C), who suffered from a degenerative neurological disease (the disease), had been given inappropriate advice by a nurse working with patients with the disease.  She also complained that her complaint to Grampian NHS Board (the Board) had not been adequately investigated.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) inappropriate advice was given to Mr C about possible treatment available to him for the disease (no finding);
• (b) there was inadequate communication between members of the clinical team involved in Mr C's care (upheld); and
• (c) the Board did not appropriately investigate Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider establishing a protocol for clinicians re-entering a patient's care after a period without contact;
• (ii) consider how communication can be improved in circumstances where a team of several clinicians is involved in a patient's care and when a general practice team are the only professionals involved for significant periods; and
• (iii) take steps to ensure that staff involved in the investigation or consideration of complaints are appropriately informed of the details of the complaint and that any decisions reached are properly reasoned and take into account all of the circumstances of the complaint.

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

Overview

The complainant (Ms C) raised a number of concerns regarding the care and treatment provided to her by her dentist (the Dentist).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist failed to properly examine Ms C's teeth and overlooked the need for a filling (upheld);
• (b) the Dentist failed to make an accurate impression of Ms C's teeth (not upheld);
• (c) the Dentist failed to properly fit a Maryland Bridge (not upheld);
• (d) there was a delay of two months mid treatment leading to the decay of Ms C's teeth (not upheld);
• (e) a denture had been fitted improperly which induced Ms C's gag reflex and resulted in the loss of four adjacent teeth (not upheld);
• (f) appointment times were insufficient to allow for dental work of a reasonable standard (not upheld);
• (g) the Dentist improperly refitted a crown (not upheld); and
• (h) the Dentist failed to take into account the radiotherapy and chemotherapy treatment Ms C had had previously which had affected her teeth (not upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) carries out a Clinical Audit of his own x-ray procedures to ensure that any problems with the current system can be identified and removed; and
• (ii) carries out a similar audit in respect of his record-keeping to ensure compliance with General Dental Council Standards.

The Dentist has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment of her father (Mr A) during the final months of his life while he was a patient of Ayrshire and Arran NHS Board (the Board).  She was particularly concerned with the administration of drugs to her father and the palliative care he received.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board's administration of Amisulpride to Mr A was not appropriate (not upheld); and
• (b) the Board did not provide adequate palliative care to Mr A (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Mr A's family for the inadequacy of the palliative care afforded to Mr A to the extent that the use of syringe drivers would have been a more appropriate method of pain management than fentanyl patches.

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

Overview

The complainant (Miss C), an advocacy worker, complained on behalf of a man (Mr A) regarding the treatment received by his late wife (Mrs A) at her GP Practice (the Practice).  Mr A complained about the Practice's failure to promptly diagnose Mrs A's secondary cancer and he considered that the overall treatment provided to her was inappropriate.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a) failed to diagnose and properly treat Mrs A's illness (not upheld);
• (b) provided inaccurate information about waiting times for an ultrasound scan (upheld);
• (c) inaccurately completed an out-patient appointment form (not upheld);
• (d) delayed arranging blood tests and only did so upon Mrs A's request (no finding);
• (e) delayed admitting Mrs A to hospital (not upheld);
• (f) failed to respond to Mrs A and her family sympathetically and empathetically (not upheld);
• (g) caused distress by asking Mrs A why she needed a medical certificate (no finding); and
• (h) dealt inefficiently with a request for a repeat prescription (not upheld).

Redress and recommendation

The Ombudsman recommends that the Practice considers putting procedures in place to regularly check prevailing waiting times for relevant out-patient services/clinics and does not continue to rely on historic data which may no longer be accurate.

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