Health

Overview

The complainant (Mrs C) raised a number of concerns about the care provided to her husband (Mr C) by Ambulance staff on 7 January 2005 during his discharge home from hospital.  Mr C was terminally ill with advanced cancer at this time.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the ambulance crew failed to take adequate care in carrying Mr C from the ambulance to his home (upheld);
• (b)  a crew member spoke aggressively to Mr C's family when they challenged the crew about how they were carrying Mr C (no finding); and
• (c)  there was an excessive and uncomfortable delay while waiting for a new crew to arrive (not upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i)  apologise in writing to Mrs C for the distress and anxiety caused by the failure to provide suitable equipment to staff and ensure that staff had been adequately trained in manual handling techniques for the equipment available; and
• (ii)  consider the recommendations from the Specialist Adviser and provide the Ombudsman's office with an action plan arising from consideration of the recommendations.

The Service have accepted the recommendations and will report back to the Ombudsman on progress towards achieving them.

Overview

Ms C complained about the care and treatment provided to her brother (Mr A) by the Royal Cornhill Hospital, Aberdeen (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are about:

• (a)  Mr A's loss of weight was not dealt with appropriately (upheld);
• (b)  the response to Mr A's falls was poor (upheld);
• (c)  poor communication between staff and relatives (not upheld); and
• (d)  poor hygiene (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  review how eating and drinking/weight problems are dealt with in the Hospital and take action to ensure that a plan is drawn up and implemented in each relevant case;
• (ii)  review care planning in the Hospital;
• (iii)  implement their new policy on patient falls if they have not already done so;
• (iv)  develop and implement a policy on the use of restraints at the Hospital in line with Mental Welfare Commission Guidelines; and
• (v)  take steps to ensure that the guidelines on pressure ulcer prevention are followed in the Hospital.

The Board have accepted the recommendations and are acting on them accordingly.

Overview

The complainant (Ms C) raised a number of concerns about surgery she underwent for removal of a breast tumour at the Western Infirmary, Glasgow, (the Hospital) and about the subsequent radiotherapy treatment at the Beatson Oncology Centre (the Centre).  She believed that both had been more extensive than she had been advised and that, as a result, she was at a greater risk of developing lymphoedema.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  on 24 March 2004 at the Hospital, during surgery to remove the tumour, all lymph nodes in Ms C's armpit were removed against her express wishes (partially upheld to the extent that consent was not correctly taken) ; and
• (b)  during subsequent radiotherapy treatment at the Centre, the total armpit area was irradiated (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)  when launching the new policy on consent, the Board arrange appropriate training for staff to ensure it is fully implemented and audit its implementation to confirm that it is being followed consistently; and
• (ii)  the Board ensure that all staff are aware of the need to provide full explanations when responding to complaints and that staff dealing with complaints contact all appropriate staff for comment when doing so.

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

Overview

The complainant (Mr C) raised two specific complaints regarding a Clinician (Clinician 1)'s diagnosis of his condition and the quality of the records taken by Clinician 1 during a consultation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Clinician 1's diagnosis did not take into account all of the complainant's conditions and symptoms (upheld); and
• (b) the notes taken at a consultation were inaccurate and of poor quality (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about the treatment and care his mother (Mrs A) received at the Royal Alexandra Hospital, Paisley (Hospital 1) in October 2004.  Mr C also complained about delay by Argyll and Clyde NHS Board, now Greater Glasgow and Clyde NHS Board (the Board), in dealing with his complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs A was left alone without adequate clothing and bedding in a cold room (upheld);
• (b) Mrs A's family were not told about the circumstances which led to Mrs A gashing her legs until after they had enquired about them (upheld);
• (c) Mrs A's medical records did not accompany her when she was transferred from Hospital 1 to Hospital 2 and that there was subsequent delay thereafter in forwarding the records (upheld); and
• (d) there was a delay by the Board in dealing with Mr C's complaint (partially upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board issue Mr C and his family with a full formal apology for the failures identified in complaints (a) and (b) of this Report;
• (ii) the Board should audit their care planning document in one year and share the findings with the Ombudsman's office;
• (iii) when a hospital patient is being transferred internally or externally, a 'tick list' of what needs to go with that patient should be completed before the patient leaves the ward;
• (iv) when a hospital patient is being transferred externally, staff transporting the patient should also check that all the items contained on the 'tick list' accompany the patient;
• (v) the 'tick list' should then be immediately checked by the receiving ward or hospital when the patient arrives there;
• (vi) the Board issue Mr C with a formal apology for the errors contained in their letter of 21 January 2005, as identified in paragraph 41 of this report; and
• (vii) the apology in recommendations (i) and (vi) 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 (Ms C) raised a complaint that the South Glasgow University Hospital NHS Trust (the Trust) [now Greater Glasgow and Clyde NHS Board] had failed to provide her with an appropriate level of care during her stay in the Southern General Hospital (the Hospital) in Glasgow.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       Ms C was not supported to the bathroom and had to lie on a bed pad and urinate and defecate in bed (upheld);
• (b)       The above resulted in a deterioration in her skin condition (not upheld); and
• (c)       the Convenor failed to take appropriate professional advice on the nursing and clinical aspects of Ms C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Ms C for failing to take sufficient account of her needs when considering her care provision; and
• (ii)       ensure that it now has appropriate training in place to ensure staff are aware of the potential issues which may arise when treating patients who have communication difficulties.

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

Overview

The complainant (Mr C) raised concerns that Tayside NHS Board had refused to reimburse him for the costs of a private operation which he had arranged due to the time he would have had to wait for the operation to be funded by the NHS.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay by staff in placing Mr C's name on the waiting list for surgery (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained about the Greater Glasgow and Clyde NHS Board (the Board)'s delay in dealing with her complaint concerning the circumstances pertaining when she required to view her son's body in the Royal Alexandra Hospital (the Hospital)'s mortuary.

Specific complaint and conclusion

The complaint which has been investigated is that the Board delayed in dealing with Mrs C's complaint concerning the circumstances pertaining when she required to view her son's body in the Hospital's mortuary (upheld).

Redress and recommendations

The Ombudsman recommends that the Board re-emphasise to staff the importance of following the stated complaints procedure and that, in the event of investigations over-running target dates, the complainant must be contacted on day 20 and fully advised.  Further, that complainants' agreement to an extension should be sought and after 40 days, where they do not agree, complainants should be advised of their right to raise the matter with the Ombudsman.

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 which her son (Mr A) received from the GP Practice (the Practice) and that doctors failed to diagnose that he was suffering from pneumonia which resulted in an emergency hospital admission.

Specific complaint and conclusion

The complaint which has been investigated is that doctors at the Practice provided Mr A with inadequate treatment and failed to diagnose that he was suffering from pneumonia (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Practice shares this report with the GPs concerned to reflect on the lessons learned in relation to the importance of chest examination in diagnosing chest disease and the difficulties of assessment of patients with communication difficulties.  The Ombudsman further recommends that GP 2 shares the case with his/her appraiser at annual appraisal if this has not already been done.

The Practice have accepted the recommendations and will act on them accordingly

Overview

The complainant (Mrs C) raised a concern about the treatment which her son (Mr A) received from a GP (the GP) from NHS Lothian Unscheduled Care Service (LUCS) on 25 April 2006.  Mrs C said the GP failed to diagnose that Mr A was suffering from pneumonia which resulted in an emergency hospital admission on 26 April 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the GP provided Mr A with inadequate treatment and failed to diagnose that he was suffering from pneumonia (upheld).

Redress and recommendations

The Ombudsman recommends that the Board share this report with the GP to reflect on the lessons learned in relation to the importance of chest examination in diagnosing chest disease and the difficulties of assessment of patients with communication difficulties and share the case with his appraiser at annual appraisal if he has not already done so.

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