Health

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment of her husband (Mr C) at a number of hospitals in Greater Glasgow between June 2004 and his death from mesothelioma in September 2004.  Mrs C complained that Mr C was not given information about his prognosis and delays occurred which prevented his being given any useful treatment.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr C with timely and appropriate care and treatment between June and September 2004 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for communication failures;
• (ii)  consider using the events of this complaint to inform practise in communicating with patients affected by cancer; particularly when a number of different specialists are involved in care; and
• (iii)  gives consideration to improving written recording of discussions with patients and their elatives especially in situations where there are a number of clinicians involved in delivering care.

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

Overview

The complainants, a firm of solicitors (the Solicitors) raised a concern on behalf of their clients, the family of Mr A, that Mr A had not been properly assessed by  Fife NHS Board (the Board) and consequently was not receiving funding for NHS Continuing Care.  The family were also concerned that they had not been able to appeal against the decision not to fund Mr A's care.

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a)  properly assess Mr A for his continuing health needs and to provide details of the criteria used in deciding to discharge Mr A from in-patient care (not upheld); and
• (b)  consider an appeal against the decision to refuse funding (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  make a formal, evidenced record of decisions to discharge and that this record is provided to the patient and/or family in a timely manner; and
• (ii)  ensure that when a decision to discharge is reached such a decision is made known to the patient and/or family at the time the decision is taken and that where objections are presented the process for appealing against such a decision is clearly and fully explained.

Further Action

This and other complaints to the Ombudsman indicate an urgent need to review the guidance on NHS Funded Continuing Care which was issued more than 11 years ago.  This is not a matter which an individual Health Board is able to address so cannot be resolved within this report.  The Ombudsman will instead draw this matter to the attention of the Scottish Executive Health Department.

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 his late wife, Mrs C, received in hospital where she received surgery and subsequently died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the full risks of surgery were never explained to Mrs C or Mr C (upheld);
• (b)  the Hospital failed to explain why Mrs C's drips were removed on 24 August 2004 (upheld);
• (c)  the Hospital failed to investigate adequately the cause of Mrs C's confusion and agitation displayed the week before her deterioration (not upheld); and
• (d)  the Hospital did not let Mr C know at the first opportunity that his wife was going into final decline and, as a result, he was denied the chance to spend valuable time with her before her death (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board audit their practice in obtaining informed patient consent and implement any necessary change.

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

Overview

The complainant (Ms C) raised a complaint that she visited her General Medical Practice's Well Woman Clinic and a smear test was carried out without a reasonable degree of care.

Specific complaint and conclusion

The complaint which has been investigated is that a smear test was performed without a reasonable degree of care (not upheld).

Recommendations

The Ombudsman has made no recommendations.

Overview

The complainant (Ms C) raised a number of concerns in respect of her attendance at the Breast Screening Service for tests and subsequent correspondence relating to her results.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a lack of information at the screening appointment (not upheld);
• (b)  the discharge letter was unclear (upheld);
• (c)  the Breast Screening Service failed to fully address Ms C's concerns (upheld); and
• (d)  the Breast Screening Service failed to issue a letter notifying Ms C that she was clear of breast cancer (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  consider reviewing the wording of the discharge letter; and
• (ii)  review procedures to ensure that telephone calls to the Breast Care Service are responded to appropriately.

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

Overview

The complainant (Mr C) complained about the care and treatment provided to his wife (Mrs C) by both Grampian NHS Board and Highland NHS Board.  Mr C said that there was an unreasonable delay in diagnosing Mrs C's condition.  This led to a delay in her treatment and Mrs C died.

Specific complaint and conclusion

The complaint which has been investigated is that there was an unreasonable delay in diagnosing Mrs C's condition (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained about the care and treatment provided to his wife (Mrs C) by both Grampian NHS Board and Highland NHS Board.  Mr C said that there was an unreasonable delay in diagnosing Mrs C's condition.  This led to a delay in her treatment and Mrs C died.

Specific complaint and conclusion

The complaint which has been investigated is that there was an unreasonable delay in diagnosing Mrs C's condition (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns that her ante-natal care had not been properly managed by NHS Greater Glasgow and Clyde NHS Board (the Board) and that in particular they had failed to provide adequate monitoring for potential gestational diabetes.  Ms C considered that but for this failure her daughter's stillbirth might have been prevented.

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a)  perform adequate urinalysis throughout Ms C's pregnancy (upheld);
• (b)  properly inform Ms C of an appointment (partially upheld);
• (c)  ensure Ms C's maternity records were available as needed (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board advise her of the outcome of their review of the guidance and protocol for management of gestational diabetes.

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

Overview

The complainants, a firm of solicitors (the Solicitors) raised a concern on behalf of their client, Mrs C, that her late husband, Mr C, had not been properly assessed by Fife NHS Board (the Board) and consequently had ceased to receive funding for NHS Continuing Care (Continuing Care).  Mrs C was also concerned that during her appeal against the decision not to fund Mr C's care she had been subjected to undue pressure from the Board.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)  failed to properly assess Mr C's ongoing eligibility for Continuing Care (partially upheld); and
• (b)  exerted undue pressure on Mrs C by supporting the local authority in making an application to the Sheriff Court to be appointed Mr C's welfare guardian (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  make a formal, evidenced record of decisions to discharge and that this record is provided to the patient and/or family in a timely manner;
• (ii)  ensure that when a decision to discharge is reached such a decision is made known to the patient and/or family at the time the decision is taken and that where objections are presented the process for appealing against such a decision is clearly and fully explained;
• (iii)  act on the recommendation of the Fife report  to produce written information on ongoing eligibility for patients assessed as eligible for NHS funded Continuing Care.  The Board should ensure that there is a single approach to such funding and that this is commonly understood by all relevant staff; and
• (iv)  make a written apology to Mrs C that the lack of clarity among staff about eligibility for Continuing Care led to miscommunication to Mrs C of Mr C's status and caused unnecessary distress.

Further Action

This and other complaints to the Ombudsman indicate an urgent need to review the guidance on NHS Funded Continuing Care which was issued more than 11 years ago.  This is not a matter which an individual Health Board is able to address so cannot be resolved within this report.  The Ombudsman will instead draw this matter to the attention of the Scottish Executive Health Department.

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

Overview

Mr C complained about the care and treatment he had received for back pain and an eye problem at a Hospital (the Hospital) in Lanarkshire NHS Board (the Board) area.  He said that treatment he had subsequently received in Turkey and Glasgow showed that this had been inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       treatment received for back pain at the Hospital was inadequate (not upheld); and
• (b)       treatment received for an eye problem at the Hospital was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review the Hospital's appointment systems to ensure that changes of address are correctly recorded on all relevant databases.

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