Health

Overview

The complainants (Mr and Mrs C) raised a number of concerns that their relative, Mrs A (Mrs C's sister, Mr C's sister-in-law), had suffered as a result of a break in the skin of her left heel not being adequately monitored and treated.  They also raised concerns regarding a potential communication breakdown between two hospitals when Mrs A was transferred from one hospital to the other.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       staff failed to inform Mrs A that she was suffering from a potential pressure sore on her left heel (upheld);
• (b)       staff at Western Infirmary, Glasgow (Hospital 1) failed to treat the potential pressure sore (no finding);
• (c)       Hospital 1 failed to advise Drumchapel Hospital (Hospital 2) about the potential pressure sore at the time of transfer (not upheld); and
• (d)       Hospital 2 failed to diagnose and treat the sore for approximately ten days after Mrs A's admission (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board reiterate to the staff involved the importance of making clear notes after assessments.

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

Overview

The complainant (Mrs C) raised concerns about a delay by a GP (the GP) at the Medical Practice in referring her husband (Mr C) to hospital for a urology opinion and as a result this delayed treatment for a prostate tumour.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay by the GP in referring Mr C for a urology opinion (upheld).

Redress and recommendation

The Ombudsman recommends that the GP shares this report with his appraiser and reflects on the actions which had been taken.

The GP has accepted the recommendation and will act on it accordingly

Overview

The complainant (Mrs C) raised a number of concerns about the nursing care afforded to her late father (Mr A) during an admission at the Royal Alexandra Hospital, Paisley (the Hospital) from February 2004 to January 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr A's fluid intake was inadequately monitored and there was a delay in commencing IV fluids (upheld); and
• (b)  there was poor communication between nursing staff and relatives (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board apologise to Mrs C for the failure to chart fluid intake adequately and to consider commencing IV fluids earlier.

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

Overview

The complainant (Mr C) raised a number of concerns that doctors at the GP Practice (the Practice) failed to take action when his brother (Mr A) reported headaches following his discharge from hospital in April 2005.  Sadly Mr A sadly died on 9 July 2005 after suffering an aneurysm (dilation of an artery, vein or the heart).

Specific complaint and conclusion

The complaint which has been investigated is that the treatment provided by the Practice following Mr A’s discharge from hospital was inadequate (not upheld). 

Redress and recommendations

The Ombudsman recommends that the Practice take note of the Adviser’s comments in regard to record-keeping.

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

Overview

The complainant, Mr C raised a number of concerns associated with the removal of two facial lesions.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr C was not told that the procedure undertaken on 8 July 2005 involved a large scale biopsy (not upheld);
• (b)  Mr C was told that a basal cell carcinoma (BCC) was being removed from his lip whereas his notes refer to it being a squamous cell carcinoma (SCC) (not upheld);
• (c)  the procedure to Mr C's lip was undertaken without proper investigation, which involved increased risk (not upheld);
• (d)  there was belated acknowledgement that the words lip and lid had been transposed, and an insincere apology was offered (partially upheld);
• (e)  Mr C had not been seen by a dermatologist or skin cancer specialist (not upheld);
• (f)  the Board failed to admit errors or variations to Mr C's medical notes (not upheld);
• (g)  the surgeon involved failed to communicate with Mr C properly (not upheld);
• (h)  there were delays associated with Mr C's appointment times (not upheld); and
• (i)  there were delays in responding to Mr C's complaint (not upheld).

Redress and recommendation

The Ombudsman recommends that;

• (i)  in addition to discussing with the patient any surgical procedure, its possible outcomes and common complications, the Board should consider whether written information, reiterating information given, would enhance informed consent for the patient;
• (ii)  a further apology is made to Mr C, to acknowledge the Board's initial failure to apologise to him in a timely manner; and
• (iii)  the Board look to reducing the timescales between the dates of dictation, typing and issue of correspondence.

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

Overview

The complainant (Mrs C) raised concerns that her daughter (Baby C) had developed an infection in her leg after receiving her immunisations on 9 February 2006.  However, doctors at the practice (the Practice) told her on 20 February 2006 and 21  February 2006 that it was not an infection.  Mrs C took her daughter back to the Practice on 24 February 2006 and it was then that Baby C was referred to hospital for treatment to the infected wound.

Specific complaint and conclusion

The complaint which has been investigated iswas that there was a delay in diagnosing that Baby C had a leg infection and that as a result a hospital referral was required (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the care which her diabetic husband (Mr C) had received when he attended the Western Isles Hospital (Hospital 1) with serious foot ischaemia.  Mrs C complained about a consultant’s (Consultant 1) behaviour, the delay in referring Mr C to the Consultant Vascular Surgeon (Consultant 2) and that unsuitable medication was prescribed to her husband.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Consultant 1's behaviour was inappropriate when he explained the results of his examination to Mr and Mrs C (no finding);
• (b)  Consultant 1 delayed writing to Consultant 2 after seeing Mr C (not upheld);
• (c)  Consultant 1 did not reflect the urgency of Mr C's condition in his referral to Consultant 2 (upheld); and
• (d)  Consultant 1 prescribed Voltarol to Mr C and this is not suitable for diabetics (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  review its procedures for urgent referrals; and
• (ii)  apologise to Mr and Mrs C for their failure to adequately convey the urgency of Mr C's condition in their letter of referral.

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 husband (Mr C) received at Crosshouse Hospital, Kilmarnock in February 2005.  In particular she was concerned that there was a delay by staff in reaching a diagnosis and that medication which was administered was not written in the medical records.  Mrs C also complained about the way her complaint was handled.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a delay in reaching a diagnosis (not upheld);
• (b)  staff failed to record when medication was administered to Mr C (not upheld); and
• (c)  there was inadequate complaints handling (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  bring to the attention of staff the comments made by Adviser 1 in regard to the failure to recognise the decrease in Mr C's kidney function from 17 February 2005 and the monitoring of his Gentamicin levels;
• (ii)  conduct an audit of the nursing records for Ward 3A to ascertain if they are in accordance with the standards as set out by the Nursing and Midwifery Council; and
• (iii)  conduct a review of their complaints procedure to ensure that staff are acting in accordance with the National Guidance.

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

Overview

The complainant Mr C raised a number of concerns regarding his dental treatment and the preparation and fitment of a dental bridge and a temporary denture.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the Dental Practice failed to provide Mr C with an appropriate bridge (not upheld);
• (b)  the dentist incorrectly drilled into the root of Mr C's tooth at an angle, leading to the tooth requiring extraction (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The aggrieved (Mr A) raised a number of concerns, through his Member of the Scottish Parliament (Mr C), about the treatment received by his wife (Mrs A) prior to and during an admission to Raigmore Hospital (the Hospital) in 2000.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the hospital admission was caused by the staff's failure to ensure that Mrs A received vitamin B12 injections (not upheld); and
• (b)  staff incorrectly stated there were traces of benzodiazepines in Mrs A's urine samples and this led to Mr A being interviewed by the police (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.