Health

Overview

The complainant, Mr C, raised concerns that, following the withdrawal of part of his medication by the manufacturer, clinical staff failed to adequately assess his condition and provide him with suitable alternative medication or check his blood pressure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff failed to adequately assess Mr C following the withdrawal of his medication (not upheld);
• (b)  a staff grade doctor (the Staff Grade Doctor) inappropriately refused to check Mr C's blood pressure (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant Mr C was concerned about the care and treatment provided to his late wife (Mrs C).  He said that a delay in the initial diagnosis of her cancer meant she had to attend the hospital daily for injections for suspected deep vein thrombosis.  He also said that he was unhappy about the care and treatment Mrs C had received following her admission to Inverclyde Royal Hospital (the Hospital) and felt that the communication both to Mrs C, her family and between the Hospital staff had been inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a delay in the initial diagnosis of Mrs C's condition (upheld);
• (b)  the treatment given to Mrs C was inappropriate (partially upheld); and
• (c)  there were significant failures of communication, concerning her treatment and care, both to Mrs C and her family and between the Hospital staff (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mr C and his family for the delay in diagnosis and share this report with the clinical staff responsible for Mrs C's care;
• (ii)  review their pain assessment and management procedures and ensure that these include a full explanation of the role and involvement of specialist or palliative care teams in the care of patients with non-surgical pain;
• (iii)  apologise to Mr C and his family for not fully explaining Mrs C's pain management regime and for any unnecessary pain that Mrs C suffered as a result of this;
• (iv)  review their policies and procedures to ensure that there is suitable monitoring of nutritional care and management;
• (v)  provide evidence that standards of communication have improved and, in particular, that there are policies and procedures in place to ensure that patients who are terminally ill and their families are fully supported and treated with appropriate dignity;
• (vi)  emphasise to staff responsible for responding to complaints the importance of doing so in a non-defensive and open manner; and
• (vii)  apologise to Mr C and his family for all the failures identified in record keeping and communication; for failing to provide adequate support to them and Mrs C during her final illness; for the confusion about the circumstances surrounding Mrs C's death; and for failing to respond with appropriate care and sensitivity to the concerns raised by Miss C on their behalf.

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 mother (Mrs A) received at the Southern General Hospital, Glasgow in November and December 2005.  Her concerns included that Mrs A should have been treated in a High Dependency Unit; nursing staff failed to maintain Mrs A's oral and personal hygiene; staff failed to react when Mrs A's condition deteriorated; and poor communication.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mrs A received inadequate clinical treatment (not upheld);
• (b)  staff failed to provide Mrs A with basic nursing care (not upheld); and
• (c)  staff failed to communicate adequately with Mrs A's relatives (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns about clinical treatment and delays in appointments and results.

Specific complaints and conclusions

The complaints which have been investigated are that Greater Glasgow and Clyde NHS Board (the Board) failed to:

• (a)  perform the correct biopsy in the first instance (upheld);
• (b)  arrange timely follow-up (upheld); and
• (c)  report biopsy results in a timely manner (upheld).

Redress and recommendations

The Ombudsman recommends that the Board make a written apology to Ms C for all the identified failures.

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

Overview

The complainant (Mrs C) complained that administrative and complaint handling errors by Greater Glasgow and Clyde NHS Board (the Board) had resulted in an unreasonable delay in her referral for treatment from the NHS and that consequently she felt it necessary to obtain the treatment privately.  Mrs C sought reimbursement of the costs directly incurred by her in having her surgery performed outwith the NHS.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly administer Mrs C's referral for non-cosmetic plastic surgery (upheld).

Redress and recommendation

The Ombudsman recommends that the Board reimburse Mrs C's invoiced treatment costs.

The Board have accepted the recommendation and have acted on it accordingly.

Overview

The complainant Mrs C raised a number of concerns about the treatment her daughter (Miss C) received from a GP (the GP) at her medical practice during 2005 and that the GP failed to diagnose that she was suffering from pneumonia.

Specific complaint and conclusion

The complaint which has been investigated is that during consultations in 2005 the GP failed to diagnose that Miss C was suffering from pneumonia (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make but asks that the GP reflect on the comments relating to the recording of relevant information at consultations.

Overview

The complainant (Mrs C) raised a number of concerns about the care of her father (Mr A).  She complained about aspects of Mr A's nursing care and also the amount of medication which he was given.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  management of Mr A's catheter was poor (upheld);
• (b)  nursing staff did not adequately monitor Mr A (not upheld);
• (c)  contradictory reasons were given for the bruising on Mr A's forehead (not upheld); and
• (d)  the quantity of drugs given to Mr A was excessive (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Mr A's family for their failure to adequately manage Mr A's catheter and for the distress which this caused to Mr A and his family.

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

Overview

The complainants raised a number of concerns relating to the cremation of their baby (Baby C) and the subsequent handling and investigation of their complaint by Forth Valley NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)  denied the complainants the opportunity to attend Baby C's cremation (upheld);
• (b)  failed to provide adequate evidence that Baby C was cremated entire (upheld);
• (c)  failed to carry out a thorough investigation of the complaint (upheld); and
• (d)  treated the complainants with disregard for their emotional state (partially upheld).

Redress and recommendations

The Ombudsman notes that the Board and Mr and Mrs C have entered into discussion regarding appropriate alternative redress and I am satisfied with this approach.  Given the sensitivity and nature of this case, I have decided that the final redress arrangements should remain private to both parties.

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment which he received following his private, triple heart bypass operation at Aberdeen Royal Infirmary in June 2003.  He also complained about the way in which his complaint about these events had been handled by Grampian NHS Board (the Board).  The bulk of Mr C's complaint was not within the jurisdiction of the Ombudsman's office, as it related to the contract for the private treatment, and it was, therefore, only possible to look at the aspect of the complaint relating to complaint handling.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the Board failed to deal with Mr C's request to receive minutes of meetings with medical staff at which his complaint was discussed in accordance with procedure (partially upheld); and
• (b)  the Board failed to deal with Mr C's request that his concerns be discussed with the surgeons and medical staff involved in accordance with procedure (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for failing to deal with his requests to be provided with minutes of the meetings with medical staff in which his complaint was discussed, and his subsequent complaints, in accordance with procedure;
• (ii)  take steps to ensure that, in future, the Board completes any internal enquiries required to respond to issues raised by complainants;
• (iii)  take steps to ensure that, in future, any potential Data Protection Act requests are identified as such and dealt with in accordance with procedure;
• (iv)  apologise to Mr C for failing to deal with his request to have his concerns discussed with the surgeons and medical staff involved in accordance with procedure; and
• (v)  take steps to ensure that, in future, all points of complaint are addressed in response letters issued by the Board.

The Board have accepted the recommendations and provided information to show that (i) and (ii) have been implemented.  The Board have indicated that they will now act on the remaining recommendations.

Overview

Ms C complained about the care and treatment provided to her father, Mr A, in the Royal Dundee Liff Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  it was incorrectly stated in Mr A's clinical records that he had been discharged from the Royal Victoria Hospital because he was unmanageable (upheld);
• (b)  there was a delay in diagnosing a sub-dural haemorrhage (upheld);
• (c)  Mr A's stick was taken from him inappropriately and no further mobility assessment was done (not upheld);
• (d)  Mr A was over-sedated (not upheld);
• (e)  there was a failure to diagnose a pseudo-obstruction (upheld);
• (f)  a restraint was used unnecessarily (not upheld);
• (g)  a restraint was used inappropriately (upheld); and
• (h)  there was an unexplained delay in transferring Mr A to Ninewells Hospital (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)  the Board remind staff of the need to ensure that entries in clinical records are appropriate;
• (ii)  the Board remind staff of the need for clinical records to be updated each time a patient is seen by a doctor;
• (iii)  the Senior House Officers (SHOs) involved in Mr A's care raise the issue of record-keeping at their next appraisals;
• (iv)  the SHOs involved in Mr A's care raise the issue of failure to diagnose the return of pseudo-obstruction at their next appraisals;
• (v)  the Board develop and implement a policy on the use of restraints at the Hospital in line with Mental Welfare Commission guidelines;
• (vi)  the Board include patient and family communication as an item to be appraised in the regular appraisals on trainee doctors carried out by Educational Supervisors (Consultants) and, for nursing staff, that the Board demonstrate that communication has a high priority in the supervision of trainee nurses and is included in the programme for any review of nursing standards; and
• (vii)  the Board apologise to Ms C for the failures identified in this report.

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