Health

Overview

The complainant (Mr C) felt that his GP practice (the Practice), did not take his illness seriously, that they were slow to carry out and follow-up tests and that the diagnosis of his cancer was subsequently delayed.

Specific complaint and conclusion

The complaint which has been investigated is that the diagnosis of Mr C's condition was unnecessarily delayed (not upheld).

Redress and recommendation

The Ombudsman recommends that the Practice review their procedures for recording and tracking the dispatch and receipt of blood tests.

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

Overview

The complainant (Mr C) raised concerns that, at a consultation with an orthopaedic consultant on 7 June 2005, an incorrect decision was taken to treat a knee injury with analgesia rather than surgery and that he had to have an operation carried out privately to resolve the matter.

Specific complaint and conclusion

The complaint which has been investigated is that, at an appointment with an orthopaedic consultant on 7 June 2005, the clinical decision to treat Mr C's knee injury by analgesia rather than surgery was inappropriate (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised concerns that a GP Practice (the Practice) had failed to diagnose her brother (Mr A) with deep vein thrombosis (DVT) or subsequent pulmonary embolism.

Specific complaint and conclusion

The complaint which has been investigated is that the Practice failed to diagnose Mr A with DVT or subsequent pulmonary embolism (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review the circumstances of this case and consider whether any lessons can be learned for the future management of young adults with chest symptoms;
• (ii) apologise to Mr A's family for the poor management of Mr A's pulmonary embolism; and
• (iii) review their clinical record-keeping practice.

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

Overview

The complainant (Ms C) raised a number of concerns about the dental treatment which she had received from her General Dental Practitioner (the Dentist) during the period 2005 to December 2006.

Specific complaints and conclusions

The complaints which have been investigated are that the Dentist:

• (a) failed to provide Ms C with an appropriate level of dental treatment (upheld); and
• (b) failed to keep accurate and contemporaneous records (upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) apologises to Ms C for the failings which have been identified in this report;
• (ii) arranges postgraduate training on root canal treatment and periodontal monitoring and screening;
• (iii) carries out a clinical audit on the justification, quality and use of radiographs in providing adequate information to make effective treatment planning decisions; and
• (iv) conducts a review of his record-keeping and treatment planning procedures.

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

Overview

The complainant (Mr C) raised a number of concerns about the nursing care which he received during his admission to Dr Gray's Hospital (the Hospital), the advice given to him about MRSA and the way his complaint was handled by Grampian NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C did not receive adequate emotional support during his admission to the Hospital (upheld);
• (b) nursing staff advised Mr C's wife to leave the ward due to things being too busy (upheld);
• (c) Mr C was not given clear information in relation to the Board's visitor policy and the risks of MRSA (not upheld);
• (d) Mr C's chemotherapy was carried out in a ward setting and he was required to answer personal questions within earshot of other patients (not upheld);
• (e) Mr C's concerns were ignored when he raised them with the specialist nurses (partially upheld to the extent that Mr C was not given feedback about the way in which his complaints were dealt with); and
• (f) the Board failed to adhere to the NHS complaints handling procedure when investigating Mr C's complaint (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that staff assess the emotional needs of patients, especially those with the diagnosis of a life threatening or limiting illness, and plan care appropriate to this assessment;
• (ii) apologise to Mr C for their failure to formally assess his need for emotional support;
• (iii) review their visiting policy and consider whether to include guidance on the application of discretion according to the circumstances;
• (iv) remind relevant staff to ensure that they respond fully to all elements of complaints;
• (v) remind staff: of their role in the complaints process; to take steps to identify complaints; and to feedback to patients any steps taken as a result of their complaint and any response to the complaint; and
• (vi) consider whether, in these sorts of circumstances, it may be appropriate to use conciliation or mediation as part of the complaints process.

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

Overview

The complainants (Mr C and Ms C) raised a number of concerns that Forth Valley NHS Board (the Board) did not properly diagnose potential complications with the twin babies Ms C was carrying, did not provide proper treatment to Ms C and the twin babies when those complications became critical and did not properly handle Mr C and Ms C's subsequent complaint.

Specific complaints and conclusions

The complaints which have been investigated are that the Board did not:

• (a) provide adequate clinical care to Ms C (not upheld); and
• (b) properly handle Mr C and Ms C's complaints (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider including the recording of the depth of the deepest pool of fluid in each amniotic sac as part of their routine record of ultrasound scans; and
• (ii) provide an apology to Mr C and Ms C for the comments during the meeting of 24 February 2006 which were insensitive in the circumstances.

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 and advice which she received in relation to her heart condition.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C was given conflicting interpretations of echocardiography examinations undertaken between 2002 and 2005 and that she was given erroneous advice about her condition (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C)'s advocacy worker raised a complaint on his behalf against the State Hospitals Board for Scotland (the Board) about the way they had investigated Mr C's complaint about the conduct of a student nurse.

Specific complaint and conclusion

The complaint which has been investigated is that the Board inadequately responded to Mr C's complaint about the conduct of a student nurse (upheld).

Redress and recommendations

The Ombudsman recommends that the Board remind staff that they should ensure that all aspects of a complaint are addressed when providing the response.

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

Overview

The complainant (Mrs C) raised a number of concerns regarding the care and treatment of her husband (Mr C) during admissions to Glasgow Royal Infirmary (Hospital 1) in October 2004 and March 2005.

Specific complaints and conclusions

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

• (a) failed to store medication appropriately and supervise drug-taking (upheld);
• (b) told Mrs C that failure to administer Warfarin was the cause of Mr C's stroke and Mrs C believed that the alleged failures relating to the storage of Mr C's drugs and supervision of his drug-taking between 4 and 6 October 2004 might have contributed to the stroke (partially upheld to the extent that there were failures in monitoring Mr C's INR during the admission);
• (c) inappropriately discharged Mr C too soon (not upheld);
• (d) failed to notice that Mr C was suffering from constipation while in hospital (upheld);
• (e) failed to provide any home help to Mrs C after her husband was discharged from hospital (no finding); and
• (f) failed to investigate Mrs C's complaint in a timely fashion or respond to all the points raised and adhere to NHS complaints guidelines and failed to clarify why the complaint was responded to from the complaints team at Stobhill Hospital (Hospital 2) rather than at Hospital 1 (partially upheld to the extent that the Board failed to respond to the complaint within the timescale required in NHS complaints guidelines and did not respond to all the points raised).

As the investigation progressed, I identified issues concerning Mr C's clinical records and his post-operative management.  I, therefore, informed the Board and Mrs C that the investigation would additionally consider the following points:

• (g) Mr C's discharge summary dated 26 October 2004  included details about another patient (upheld); and
• (h) the Board failed to carry out Mr C's post-operative management appropriately from 2 March 2005 onwards (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C and Mrs C for their failure to monitor Mr C's bowel movements and for any discomfort or pain he would have suffered as a result;
• (ii) write to Mrs C repeating the apologies they have provided to me regarding their failure to handle her complaint properly;
• (iii) put measures in place to ensure that meaningful medical records are made on a daily basis;
• (iv) put measures in place to ensure that when investigations are carried out they are recorded and the results documented and where there are abnormalities, entries in the medical records should acknowledge them and record medical staff's intentions regarding them;
• (v) monitor and audit the effectiveness of the measures taken as a result of recommendations (iii) and (iv);
• (vi) consider Adviser 2's comments about the management of anaemia and review their practice with advice from, for example, a physician in charge of elderly patients. This review should lead to an agreed policy being formulated, which should particularly be directed towards post-operative care; and
• (vii) regularly review patients' medications so that inappropriate treatments are noted and, if necessary, stopped.

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 he received from Western Isles NHS Board (Board 1) and Greater Glasgow and Clyde NHS Board (Board 2) following a sudden onset of severe leg pain in November 2005.  Mr C also complained about the handling of his complaints by both Boards.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Board 1 failed to provide timely or appropriate care and treatment to Mr C (not upheld);
• (b) Board 1 failed to promptly or adequately address Mr C's complaints (not upheld);
• (c) Board 2 failed to provide timely or appropriate care and treatment to Mr C (not upheld) and;
• (d) Board 2 failed to promptly or adequately address Mr C's complaints (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.