Health

Overview 

The complainant (Mrs C) had concerns about some aspects of communication at the Western Infirmary, Glasgow (the Hospital), and about their decision to transfer her 84-year-old husband (Mr C) to a hospital near his home in England.  When Mr C was being transferred by ambulance from the WesternHospital Infirmary to the English hospital, his condition worsened, and she complained that the ambulance crew continued the journey, instead of stopping at another hospital on the way.  He died in the English hospital a few days later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) communication with the family and care at the GlHasgow hospital wereere inadequate (not upheld);
• (b) the ambulance crew's decision to continue the journey was inappropriate (not upheld but recommendations made for the Health Board and for the Scottish Ambulance Service);
• (c) the ambulance crew's record- keeping lacked detail (upheld);
• (d) the Glasgow hHospital should have operated (not upheld); and
• (e) the Glasgow hHospital should not have allowed the ambulance journey (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Health Board ensure that, where appropriate, 'Do Not Attempt Resuscitation' orders (DNARs) are communicated clearly, in writing, for ambulance crews and receiving hospitals;
• (ii) the Scottish Ambulance Service ensure that, where appropriate, ambulance crews obtain formal written DNAR information from referring hospitals; and
• (iii) the Scottish Ambulance Service ensure that record- keeping by ambulance crews during journeys is adequate.

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

Overview 

The complainant (Mrs C) had concerns about some aspects of communication at the Western Infirmary, Glasgow (the Hospital), and about their decision to transfer her 84-year-old husband (Mr C) to a hospital near his home in England.  When Mr C was being transferred by ambulance from the WesternHospital Infirmary to the English hospital, his condition worsened, and she complained that the ambulance crew continued the journey, instead of stopping at another hospital on the way.  He died in the English hospital a few days later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) communication with the family and care at the GlHasgow hospital wereere inadequate (not upheld);
• (b) the ambulance crew's decision to continue the journey was inappropriate (not upheld but recommendations made for the Health Board and for the Scottish Ambulance Service);
• (c) the ambulance crew's record- keeping lacked detail (upheld);
• (d) the Glasgow hHospital should have operated (not upheld); and
• (e) the Glasgow hHospital should not have allowed the ambulance journey (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Health Board ensure that, where appropriate, 'Do Not Attempt Resuscitation' orders (DNARs) are communicated clearly, in writing, for ambulance crews and receiving hospitals;
• (ii) the Scottish Ambulance Service ensure that, where appropriate, ambulance crews obtain formal written DNAR information from referring hospitals; and
• (iii) the Scottish Ambulance Service ensure that record- keeping by ambulance crews during journeys is adequate.

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

Overview

The complainant (Mr C) had an AVF (arteriovenous fistula) in his spine.  When the Consultant Neuroradiologist clotted the blood vessels, some glue (embolic fluid) escaped into the central draining vein of the spinal cord which became blocked.  Mr C complained that his symptoms were worse after the procedure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C was given insufficient information to allow him to make an informed choice of treatment; (upheld) and
• (b) the procedure was not adequately explained and he was not appropriately warned about possible complications (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review their current protocols for consent and recording of consent in line with 'A Good Practice Guide on Consent for Health Professionals in NHS Scotland' issued by the Scottish Executive on 16 June 2006 especially for neurosurgical and radiological interventions;
• (ii) include details of procedures, alternatives and possible complications in leaflets and that they are given to patients as soon as the diagnosis is made;
• (iii) develop standard letters to be used until the leaflets are available;
• (iv) ensure that the fact that the relevant leaflet has been given to the patient is recorded in the patient's notes;
• (v) include information about embolisation and the possibility of complication occurring in the appropriate leaflet;
• (vi) ensure that Handbooks for Doctors and protocols on consent include detail on when, where and how to obtain informed consent; and
• (vii) apologise to Mr C for the failings in giving him information.

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

Overview

The complainant (Mr C) raised a number of concerns about the treatment his late mother, (Mrs A) received at the Victoria Infirmary, Glasgow in February 2006.  These included communication failures between staff and the relatives; inadequate care and treatment; and difficulties in reporting lost property.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff failed to ensure that Mrs A's nutritional intake was monitored and did not obtain a complete medical history (not upheld);
• (b)  staff failed to communicate adequately with Mrs A's family (upheld); and
• (c)  the procedure for reporting lost property was not adequately followed (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  ensure that this report is shared with the staff involved so that they are reminded of the importance of communication with relatives;
• (ii)  consider whether the procedure on change over of shifts for passing information to relatives about patients who have recently died is adequate; and
• (iii)  conducts a review of the availability of claim forms at ward level in the hospital and send Mr C a claim form and consider a request for reimbursement of Mrs A's glasses should he wish to pursue the matter.

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

Overview

The complainant Mr C raised a number of concerns about the treatment his wife (Mrs C) received at the Vale of Leven Hospital (the Hospital) during two admissions in September 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the treatment which Mrs C received was inadequate(not upheld);
• (b)  there was a delay in carrying out a CT scan (not upheld); and
• (c)  there was poor communication concerning the need to inform the Procurator Fiscal of Mrs C's death (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised concerns about the nursing care which her daughter (Miss C) received at Monklands Hospital (the Hospital) on 12  October  2005 and 13 October 2005 following an admission for a minor operation.  Miss  C is an insulin dependent diabetic and requires to eat meals on a regular basis.  Mrs C felt the staff failed to monitor Miss C's diabetic condition.

Specific complaint and conclusion

The complaint which has been investigated is that between 12  October  2005 and 13  October  2005 nursing staff failed to adequately monitor Miss C's diabetic condition (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about the treatment provided by his General Dental Practitioner (the Dentist) in regard to the provision of a set of upper and lower dentures.

Specific complaint and conclusion

The complaint which has been investigated is that the treatment which the Dentist provided to Mr C concerning upper and lower denture plates was inadequate (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the hernia surgery which he had and about his post-operative nursing care.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr C was asked by nursing staff to walk too early after his first operation (not upheld);
• (b)  Mr C was asked by nursing staff to walk unaided despite the fact that he complained of numbness in his leg (upheld); and
• (c)  Mr C’s operations were not carried out with a reasonable degree of skill (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Mr C for the distress caused to him with regard to complaint (b).  She also suggests that relevant staff are reminded of the importance of adequate documentation of the pre-operative consent process.

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 that her late father (Mr A) received at Ailsa Hospital, Ayr.  She complained that staff handled her father roughly; inappropriate oxygen therapy was provided; and staff failed to monitor Mr A's fluid intake.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff handled Mr A roughly (not upheld);
• (b)  Mr A received inappropriate oxygen therapy (partially upheld); and
• (c)  there was inadequate monitoring of Mr A's fluid intake (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board share this report with Doctor 1 and encourage him to reflect on its findings.

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

Overview

The complainant (Mr C) raised a number of concerns about the GP Practice (the Practice)'s treatment of him as a separated parent in respect of his son (Mr A)'s prescriptions for his ongoing serious medical condition.

Specific complaint and conclusion

The complaint which has been investigated is that the Practice's prescribing and their treatment of Mr C were inappropriate (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.