Health

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.

Overview

Ms C called NHS 24 when her mother (Mrs A)'s condition deteriorated.  She was concerned that she did not receive accurate information on the night of the call about the time it might take for a GP to attend.  She was also unhappy that she had been informed only one GP was on duty overnight to cover the large, rural area where Mrs A lived.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the communication about GP attendance time was inadequate (upheld); and
• (b) GP out-of-hours cover for the Borders NHS Board (the Board) area was inadequate (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board review their procedures for keeping patients who are referred from NHS24 informed about likely GP attendance, when the GP is not in the hub when the referral is received;
• (ii) NHS24 and the Board both apologise to Mrs A's family for not appropriately communicating to Ms C the difficulties in arranging GP attendance and the likely time this would take; and
• (iii) NHS24 share with her the results of their audit of home visits that are made within one hour.

The Board and NHS24 have accepted the recommendations and will act on them accordingly.

* Ms C's complaint was fully supported by her sister and they brought the complaint to the Ombudsman's office together.  For clarity, I refer only to Ms C in this report.

Overview

Mr C complained about the treatment he received when he was a patient in Glasgow Royal Infirmary.  In particular, he said that his condition was misdiagnosed and, therefore, he did not receive appropriate, timely treatment.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr  C's condition was misdiagnosed, in that he had pleurisy rather than pneumonia; had he had a CT scan at the outset, his diagnosis would have been quite clear (not upheld);
• (b) as a consequence of Mr C's condition being incorrectly diagnosed, he did not receive appropriate, timely treatment and an antibiotic was incorrectly administered (partially upheld); and
• (c) staff failed to listen to him and an x‑ray was taken covertly (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board emphasise to staff that extreme care should be taken when drugs are being administered and recorded.

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

Overview

Mr C raised a number of concerns regarding the arrangements put in place for the management of his care and behaviour in a hospital where he was receiving treatment.

Specific complaints and conclusions

Mr C complained that those arrangements were inadequate, unfair and deprived him of his right to dignity and privacy. Mr C also had concerns regarding the Board's relationship with the media, which he claimed caused him and his family unnecessary distress.  I did not uphold those complaints, but I did uphold the complaint that the Board's application of their complaints procedure unfairly prevented Mr C from receiving responses to his complaints.

Redress and recommendations

I made a number of recommendations to the Board in connection with Mr C’s complaints.

Overview

The complainant (Ms C) complained about the standard of treatment she received from a dental practitioner which, she felt, had led to further problems with her dental health.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a root was perforated during treatment, but this was not identified (not upheld); and
• (b) the fitting of a crown was done poorly, leading to periodontal damage (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

The dentist who was involved in this complaint was working in a practice in Lothian NHS Board area at the time of this complaint and thereafter moved to the area covered by Greater Glasgow and Clyde NHS Board

Overview

The complainant Mr C complained on behalf of his wife (Mrs C) about what happened when she attended the Accident and Emergency Department at Perth Royal Infirmary (Hospital 1).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was inappropriately referred to the out-of-hours service (not upheld);
• (b) Hospital 1 failed to diagnose Mrs C's condition (not upheld); and
• (c) Mrs C was treated rudely and uncaringly by the Emergency Nurse Practitioner (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review the completion of triage documentation in the Accident and Emergency Department of Hospital 1 to ensure the reasons for the triage assessment are documented.

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

Overview

The complainant (Ms C) complained about the response of her GP Practice to an infected rash on her legs.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment for a rash on Ms C's legs was inadequate and has led to tissue damage and difficulty in walking (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment of his sister, Miss A, during an admission to Ninewells Hospital (the Hospital) in the 13 days leading up to her death.  Mr C believed that had failures in Miss A's care and treatment not occurred, the outcome might have been different for her.

Specific complaints and conclusions

The complaints which have been investigated are that Tayside NHS Board (the Board):

• (a) failed to make an urgent and correct diagnosis of Miss A's condition when she was admitted to hospital (not upheld);
• (b) failed to provide urgent and appropriate treatment to Miss A (upheld);
• (c) failed in their duty of care towards Miss A (upheld);
• (d) failed to treat Miss A without delay due to holidays and staff not being available and, in particular, delayed in arranging a second Computerised Tomography scan (CT scan) (upheld);
• (e) might have saved Miss A's life had they not failed to provide her with urgent and appropriate treatment (not upheld);
• (f) stigmatised Miss A in relation to her alleged alcohol abuse and this affected the nature and urgency of the treatment she received (not upheld);
• (g) failed to explain to Mr C how the figure of 70 units of alcohol a week was noted as Miss A's alcohol intake on admission (not upheld);
• (h) failed to explain to Mr C why Miss A was unconscious during the first few days of her admission (upheld); and
• (i) failed to have a single doctor in charge of Miss A's care, which made communication with Mr C very difficult (upheld).

Redress and recommendations

The Ombudsman recommends that the Board inform ward staff and relatives of the named consultant in charge of a patient's care either in the form suggested by the Adviser at paragraph 56 or similar.

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

I am also pleased that the Board, in response to my investigation, have repeated their apology to Mr C and his family for the failings in Miss A's care.  I am also satisfied that the recommendations the Board put in place when initially responding to the complaint (see paragraphs 13 to 14 above) adequately address the central failings highlighted in complaints (b), (c) and (d), as they will ensure appropriate medical management and review and better care planning.  It is unfortunate that, while the Board put appropriate recommendations in place in response to Mr C's complaint, they did not sufficiently acknowledge the nature and seriousness of the problems that occurred in this case when they wrote to Mr C.  This has led to an unusual situation whereby the Board did not fully explain and acknowledge problems that occurred when responding to the complainant's complaint, but nevertheless put in place recommendations that, as it happens, adequately address the issues and failings that have been highlighted in this report.  Consequently, while there have been serious failings in relation to Miss A's care and treatment, I have no recommendations regarding complaints (b), (c), and (d) because measures have already been taken by the Board that appropriately remedy the complaints.

Overview

Mrs C has complained that the admission assessment which took place in her home on 2 November 2004 was inappropriate, after which she was admitted to Rosslynlee Hospital (the Hospital) under section 24 of the Mental Health (Scotland) Act 1984 (the legislation at the time).  This investigation, therefore, focuses on the detailed assessment that is recorded as having taken place and the subsequent admission into hospital.  Mrs C was transferred to the Royal Infirmary of Edinburgh (RIE) after two days in the Hospital, as she was physically unwell and the assessment of symptoms and care she required could not be provided within the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was not properly assessed prior to admission to the Hospital in November2004 (not upheld); and
• (b) Mrs C was inappropriately admitted to the Hospital in November2004 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) was unhappy with the treatment her mother (Mrs A) had received at St John's Hospital (the Hospital) on 16 July 2005, that certain questions she had raised with Lothian NHS Board (the Board) during the complaints process had not been answered, that the staff at the Hospital failed to act in a professional manner and that, though the Board had admitted that the date of Mrs A's death was recorded incorrectly, they had not arranged for the death certificate to be corrected.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs A's care and treatment at the Hospital on 16 July 2005 was inadequate (not upheld);
• (b) staff at the Hospital did not act in a professional manner towards Mrs A or her family (not upheld); and
• (c) the response from the Board to Mrs C's complaints contained inaccuracies and did not address all the issues she raised (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.