Health

Overview

A MSP (Ms C) raised a number of concerns about the referral process that her constituent (Mr A) had been through after he was diagnosed with cancer.  Specifically, she raised concerns that Mr A's GP Practice (the Practice) had failed to identify that Mr A had not been informed of his referral to Oncology and that Lanarkshire NHS Board (the Board) failed to properly administer Mr A's referral and follow-up when he failed to attend the appointment.  Mr A died during the course of this complaint and his wife (Mrs A) continued to pursue the complaint on his behalf.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       the Board failed to properly administer Mr A's referral to the Medical Oncology Unit and to follow-up when Mr A did not attend his appointment (upheld);
• (b)       the Board did not respond appropriately to Mr A's complaint about their failings (upheld); and
• (c)       the Practice failed to identify that Mr A was not aware of his referral to the Medical Oncology Unit (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Mr A's family for their failure to properly administer his referral; and
• (ii)       confirm to her that they have gained assurance that the new referral system functions properly.

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

Overview

The complainant, Mr C, alleged that between August and December 2005, his painful shoulder was not diagnosed or treated properly.

Specific complaint and conclusion

The complaint which has been investigated is that Mr C's painful shoulder was not diagnosed or treated properly (not upheld)

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the dental treatment she received prior to and following surgical extraction of teeth on 3 May 2005.  She also raised concerns that she had not given informed consent, there was a lack of communication from staff and poor complaints handling.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       the treatment which was provided prior to and following surgical extraction of teeth on 3 May 2005 was inadequate and it was inappropriate to extract an additional tooth (not upheld);
• (b)       staff failed to obtain informed consent from Mrs C (not upheld);
• (c)       communication from staff was poor (partially upheld); and
• (d)       there were delays and communication failures when handling the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board  remind staff of the timescales in the NHS Complaints Procedure Guidance and offer Mrs C an apology for the failings which have been identified.

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

Overview

The complainant (Mrs C) raised concerns about a delay by doctors at Monklands Hospital (the Hospital) in diagnosing that she had cancer of the cervix and that she should have been referred to the Colposcopy Clinic sooner.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay by doctors at the Hospital in diagnosing that Mrs C was suffering from cancer of the cervix (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        provide Mrs C with an apology for the failings which have been identified in this report; and
• (ii)       share this report with Gynaecologist 1 and his staff and encourage them to reflect on its findings.

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

Overview

Mrs C raised a number of serious concerns about the failure of staff at Ninewells Hospital (the to diagnose and treat her husband when he was admitted with heart failure.  Mr C died within 24 hours of being admitted to the Hospital.  Mrs C also raised a concern about a change in Mr C's medication shortly before his death.  A final complaint concerned the time taken by the Board to respond to Mrs C's complaint and the failure to fully address her concerns.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)       failure to diagnose and provide treatment for Mr C's heart failure (upheld);
• (b)       inappropriate change in medication (not upheld); and
• (c)       failure in complaint handling (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        undertake a review of the operation and knowledge of the two Chest Pain Protocols at the Hospital and consider the adoption of a single unified protocol;
• (ii)       review the events in this complaint at an MAU multi-disciplinary meeting to ensure lessons are learned from the failure to recognise the seriousness of Mr C's condition and to react promptly and appropriately to his deterioration;
• (iii)      apologise in writing to Mrs C for their failure to provide an adequate or timely response to her complaint; and
• (iv)      ensure that their complaints handling process both acknowledges any errors identified  and uses these to drive service improvement.

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

Overview

The complainant Mr C raised a number of concerns about the care and treatment provided by two General Practitioners (GP 1 and GP 2) to his mother (Mrs A) prior to her death.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       GP 1 and GP 2 failed to respond appropriately to Mrs A's symptoms (upheld);
• (b)       GP 1 failed to refer Mrs A to the pain clinic quickly enough (not upheld); and
• (c)       GP 1's letter referring Mrs A to the pain clinic was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)        both GP 1 and GP 2 raise this case at their annual appraisal with a view to incorporating further training on recognising the progress of cancer into their continuing professional development;
• (ii)       GP 1 raises this case at her annual appraisal to ensure that she fully understands which information should appropriately be included in referral letters.; and
• (iii)      the Practice apologise to Mr C for the shortcomings identified in this report.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the delay in diagnosing his sister's stroke and admitting her to hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) NHS 24 failed to make a correct diagnosis despite evidence to indicate that Mrs D had suffered a stroke (not upheld);
• (b) NHS 24 failed to give this case a high priority (not upheld);
• (c) NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance (not upheld);
• (d) the GP failed to stay with the patient whilst waiting for the ambulance (upheld);
• (e) the GP failed to give the case a high priority (upheld);
• (f) the GP failed to provide a referral note to the hospital (not upheld); and
• (g) the ambulance took an unreasonable time to attend (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on what lessons can be learned from this case;
• (ii) consider how to communicate these lessons to Practitioners; and
• (iii) advise her of their conclusions.

The Ombudsman recommends that the Service:

• (iv) issue a further apology to Mr C and his nephew Mr D in respect of the additional delays in responding to the call from the GP;
• (v) issue an apology for the incorrect information detailed in their earlier response to the complaint; and
• (vi) consider reviewing their procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the delay in diagnosing his sister's stroke and admitting her to hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       NHS 24 failed to make a correct diagnosis despite evidence to indicate that Mrs D had suffered a stroke (not upheld);
• (b)       NHS 24 failed to give this case a high priority (not upheld);
• (c)       NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance (not upheld);
• (d)       the GP failed to stay with the patient whilst waiting for the ambulance (upheld);
• (e)       the GP failed to give the case a high priority (upheld);
• (f)        the GP failed to provide a referral note to the hospital (not upheld); and
• (g)       the ambulance took an unreasonable time to attend (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        reflect on what lessons can be learned from this case;
• (ii)       consider how to communicate these lessons to Practitioners; and
• (iii)      advise her of their conclusions.

The Ombudsman recommends that the Service:

• (iv)      issue a further apology to Mr C and his nephew Mr D in respect of the additional delays in responding to the call from the GP;
• (v)       issue an apology for the incorrect information detailed in their earlier response to the complaint; and
• (vi)      consider reviewing their procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

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

Overview

The complainant (Mr C) raised a number of concerns regarding the delay in diagnosing his sister's stroke and admitting her to hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) NHS 24 failed to make a correct diagnosis despite evidence to indicate that Mrs D had suffered a stroke (not upheld);
• (b) NHS 24 failed to give this case a high priority (not upheld);
• (c) NHS 24 incorrectly called for an out-of-hours GP rather than an ambulance (not upheld);
• (d) the GP failed to stay with the patient whilst waiting for the ambulance (upheld);
• (e) the GP failed to give the case a high priority (upheld);
• (f) the GP failed to provide a referral note to the hospital (not upheld); and
• (g) the ambulance took an unreasonable time to attend (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) reflect on what lessons can be learned from this case;
• (ii) consider how to communicate these lessons to Practitioners; and
• (iii) advise her of their conclusions.

The Ombudsman recommends that the Service:

• (iv) issue a further apology to Mr C and his nephew Mr D in respect of the additional delays in responding to the call from the GP;
• (v) issue an apology for the incorrect information detailed in their earlier response to the complaint; and
• (vi) consider reviewing their procedures for adhering to timescales for attendance at incidents, particularly with a view to ensuring that the correct information is provided to callers.

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

Overview

Ms C complained about the care and treatment provided to her mother, Mrs A, in Ninewells Hospital (the hospital).  Mrs A was admitted to the hospital to have a dialysis tube inserted but following the procedure a complication arose and Mrs A died.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)       that the incorrect procedure was used (not upheld); and
• (b)       failure to diagnose a complication (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Ms C for the distress caused to her and the rest of Mrs A's family by failure to diagnose the complication; and
• (ii)       ensure that staff on wards which receive patients who have undergone tunnelled line insertion are aware of the possibility of this known complication and can recognise the symptoms of perforation of a major blood vessel.

The Board have accepted the recommendations and have acted on them.