Health

Overview

The complainant (Ms C) raised a number of concerns about the care and treatment given to her late father (Mr A) at the Western Infirmary, Glasgow (the Hospital) from the day he was admitted on 10 August 2005, up to his death in the Hospital on 13 August 2005.  Ms C also complained that the Hospital's communication with her during this period was poor and that her subsequent complaint to Greater Glasgow and Clyde NHS Board (the Board) was dealt with inadequately.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the late Mr A received inadequate care and poor treatment when he was a patient in the Hospital between 10 August 2005 and 13 August 2005 (not upheld);
• (b) the Hospital's communication with Ms C was poor from 10 August 2005 to 13 August 2005 when Mr A was alive (upheld);
• (c) no medical records were available for 12 August 2005 (upheld);
• (d) the Board's reply to Ms C's complaint was unsatisfactory; she did not receive it in good time and they delayed in providing Ms C with a copy of Mr A's medical records or giving reasons why these were not sent (upheld); and
• (e) nurses failed to attend a meeting between Ms C and Hospital staff on 27March 2006 (upheld).

Redress and recommendations

The Ombudsman recommends that the Board

• (i) advise her on the steps they have taken to avoid breakdowns in communication recurring;
• (ii) advise her on the steps they have taken to avoid medical notes being unavailable;
• (iii) emphasise to staff the need to adhere to the terms of the NHS guidance for dealing with complaints and ensure that their records are updated when a patient dies; and
• (iv) apologise to Ms C and explain the reason why the clinical nurse manager did not attend the meeting on 27 March 2006.

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

Overview

The complainant (Mr C) considered that his partner (Ms A) did not receive professional care and treatment from hospital staff, and that former Argyll and Clyde NHS Board Area (the Board) failed to deal with his complaint appropriately.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) inadequate treatment by staff at Inverclyde Royal Hospital (the Hospital) prior to and after Ms A's day surgery on 25 May 2005 (upheld); and
• (b) the Board's failure to adequately address Mr C's complaint in their response to him (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) with reference to the SPSO Guidance Note on Apology, apologise to Ms A and Mr C for the distress and pain caused by the poor preparation for the procedure carried out on 25 May 2005, as well as the uncertainty over the stent before that time which led to Ms A having to be x-rayed unnecessarily; and
• (ii) ask staff at the Hosptial's Day Surgery Unit to review their practice for Endoscopy procedure preparation, and benchmark that practice against other similar units within the Board area. This would form part of the work already in progress to review pre-assessment practice for day surgery throughout the Board area.

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

Overview

The complainant (Mrs C) raised a number of concerns about the treatment her late husband (Mr C) received from his General Practitioner (GP 2) and at Ninewells Hospital, Dundee (the Hospital).  Mrs C complained this led to an unreasonable delay in diagnosing that Mr C was suffering from colon cancer, which later spread to his liver.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was delay by GP 2 in referring Mr C to the Hospital in January 2004 (not upheld);
• (b) there was delay by the Hospital in diagnosing Mr C’s cancer (upheld); and
• (c) there was delay by the Hospital in obtaining the results of a CT scan (upheld).

Redress and recommendations

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

• (i) issue Mrs C with a full formal apology for the failures identified in part (b) of the complaint and for the distress that this caused. 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);
• (ii) review their procedures for the reporting of CT scan results, particularly where more than one hospital is involved, to ensure that delay in reporting such results, such as occurred with Mr C, does not recur; and
• (iii) issue Mrs C with a full formal apology for the failures identified in part (c) of the complaint and for the distress and anxiety that this caused. 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 and will act on them accordingly.

Overview

The complainant (Mrs C) raised a number of concerns about the manner in which Lothian NHS Board (the Board) had responded to complaints raised originally by her mother (Mrs A) and continued by Mrs C after Mrs A's death.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to deal with Mrs A and Mrs C's complaints in a timely and appropriate manner (upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for their failure to deal with the complaints raised by Mrs A or Mrs C in a timely or appropriate manner.

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

Overview

The complainant (Mr C) was concerned that he had to wait two years for an operation to remove a benign acoustic neuroma (a tumour which develops on the eighth cranial/hearing nerve), which he felt was an unacceptable amount of time.  He was also concerned that no follow-up or review had been conducted within those two years.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had to wait two years for an operation to remove a benign acoustic neuroma (upheld); and
• (b) Mr C was seen only once by a consultant, in October 2005, and received no follow-up or review of his condition after that (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for their failure to arrange his surgery in a reasonable timescale and for the anxiety and distress this will have caused; and
• (ii) apologise to Mr C for their failure to arrange a review of his condition and for the anxiety and distress this will have caused.

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

Overview

The complainant, Mrs C, who suffered from an anal fissure, was concerned that her general practitioner (the GP) waited too long before referring her to hospital and that the GP prescribed Proctosedyl (a cream which is used to reduce pain, inflammation and swelling in rectal lesions) for too long.

Specific complaints and conclusions

The complaints which have been investigated are that the GP:

• (a) waited too long before referring Mrs C to hospital (not upheld); and
• (b) prescribed Proctosedyl for too long (upheld).

Redress and recommendation

The Ombudsman recommends that the GP:

• (i) reacquaint herself with the use of topical steroids; and
• (ii) apologise to Mrs C for prescribing Proctosedyl for too long.

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

Overview

The complainant (Miss C) was concerned that the cause of her abdominal pain was not diagnosed despite several admissions to Victoria Infirmary (the Hospital) and that not all necessary investigations had been carried out.  Miss C also raised issues regarding Greater Glasgow and Clyde NHS Board (the Board)'s communication with her and her mother and regarding the accuracy of the Board's response to her complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to diagnose the cause of Miss C's abdominal pain and to carry out all necessary investigations (not upheld);
• (b) the Board failed to communicate properly with Miss C and her mother during an admission between 22 February 2007 and 5 March 2007 (partially upheld to the extent that Miss C's return to the ward on 5 March 2007 was not adequately managed); and
• (c) the letter responding to Miss C's complaint contained inaccuracies (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) did not consider that Lothian NHS Board (the Board) had taken seriously, or learnt from, the death of his 46-year-old son (Mr A).

Specific complaint and conclusion

The complaint which has been investigated is that the Board's response to Mr A's death was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for: the failure to provide convincing evidence of a thorough investigation, with lessons learnt; the impression at various times that no action would be taken in response to his son's death; the poor quality of some of the complaint responses; and the delay in giving him a definitive response to a complaint meeting and letter of early 2005; and
• (ii) ensure that, where appropriate, this investigation drives further service improvement in future complaints.

Overview

The complainant (Ms C) raised a number of concerns regarding her medical care and treatment during investigations of painful sensations in her throat.  Ms C specifically complained about the length of time it had taken for her to be referred for an endoscopy; the actions of the gastroenterology department when she attended for pH studies and oesophageal motility studies and the length of time it had taken for a Consultant (the Consultant) to notify her of the results of a Fine Needle Aspiration Cytology (FNAC) examination.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in referring Ms C for an endoscopy (not upheld);
• (b) the gastroenterology department unreasonably continued with a procedure despite the changes that had occurred in Ms C's condition since the referral had been made (not upheld); and
• (c) the Consultant unreasonably delayed notifying Ms C of the results of a FNAC examination (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) was concerned that her mother (Mrs A) received inadequate care and treatment after being admitted to Royal Victoria Hospital (the Hospital) between 17 July 2006 and 20 October 2006.  She also raised concerns about the cleanliness of the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Lothian NHS Board (the Board) failed to appropriately monitor and audit the cleanliness of the Hospital (partially upheld to the extent that there were failures in cleaning and monitoring);
• (b) nursing staff failed to take action when they were advised of concerns by Mrs A's family and were often unavailable, in several instances because they were at management meetings (no finding);
• (c) a nurse acted inappropriately by trying to remove Mrs A's ring without a local anaesthetic (upheld); and
• (d) as a result of the poor care Mrs A received, her health and general condition deteriorated during her stay at the Hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) bring the findings of this report to the attention of all staff involved in cleaning, supervising and monitoring cleaning, to remind them of the importance of cleaning all required areas, recording cleaning appropriately and carefully checking cleaning and monitoring documentation so that the omissions highlighted in this report are not repeated in future;
• (ii) ensure that the induction of new staff includes appropriate and adequate training on the completion of cleaning records;
• (iii) apologise to Mrs A and her family for attempting to remove her ring without local anaesthetic and for the distress this caused; and
• (iv) put measures in place to ensure that, where the condition of a finger is clearly such that removal of a ring will be painful, removal should be carried out with the use of a local anaesthetic.

The Board have accepted the Ombudsman's recommendations and will act on the accordingly.