Health

Overview

The complainant (Mr C) considered that his daughter (Ms A)'s GP Practice (the Practice), the Out of Hours Service and Accident & Emergency (A&E) at Victoria Hospital, Kirkcaldy, did not properly diagnose and treat her illness.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice did not properly diagnose and care for Ms A's illness (not upheld); and
• (b) the Out of Hours Service and A&E at Victoria Hospital, Kirkcaldy, did not properly diagnose and care for Ms A's illness (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review its threshold for considering whether or not a patient might have a subarachnoid haemorrhage, and whether or not early/urgent imaging would be beneficial; and
• (ii) consider recording patients' actual blood pressure when a check is made.

The Ombudsman recommends that (Fife NHS Board) the Board:

• (iii) apologise to Mr C for the failure of medical staff to reach a differential diagnosis of subarachnoid haemorrhage on 22and 23 July 2005;
• (iv) review its locally agreed indications and process for admission, observation and investigation of patients presenting with acute headache in A&E, including ensuring that the teaching and guidance given to A&E junior doctors is based on current research; and
• (v) ensure that Out of Hours records are in line with relevant record-keeping standards, for example as laid down by the General Medical Council.

The Practice have accepted the recommendations.  The Board have also accepted the recommendations, and in some respects have already taken action and made procedural changes to address them.

Overview

The complainant (Mrs C) raised a number of concerns regarding the treatment she received at Crosshouse Hospital, Kilmarnock (Hospital 1).  She complained of the delay in diagnosing her uterine fibroids and subsequent Benign Intracranial Hypertension (BIH), as well as raising concerns regarding the side effects resulting from her treatment, and the lack of prior information relating to these.  Mrs C also raised issues regarding her pain management upon admission to Hospital 1 and also the delay in issuing her discharge letter to her General Practitioner (GP).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C's uterine fibroids were not diagnosed within a reasonable timescale (not upheld);
• (b) the Prostap therapy caused severe side effects which were not explained in advance (not upheld);
• (c) upon admission to Hospital 1, adequate pain relief was not initially provided (not upheld);
• (d) upon discharge from Hospital 1, there was a delay in issuing the discharge letter to Mrs C's GP (not upheld); and
• (e) when the lumbar puncture was carried out at Hospital 1, the Cerebrospinal Fluid opening pressure was not taken and this led to a delay in diagnosing Mrs C's BIH (not upheld).

Redress and recommendations

The Ombudsman has no formal recommendations to make but does suggest that the Board considers making the manufacturer's patient information leaflet available to patients prior to the commencement of Prostap therapy.

Overview

The complainant (Mrs C) raised a number of concerns about the care her late brother (Mr A) received in the days before he died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs C was not kept properly informed about Mr A's condition (upheld);
• (b) Mr A's condition was not adequately monitored on the night he died (not upheld);
• (c) the way Mr A's death was communicated to the family was inappropriate (not upheld);
• (d) a member of the nursing staff was rude to the family (upheld); and
• (e) some of Mr A's personal belongings were lost during his stay in hospital (not upheld).

Redress and recommendations

The Ombudsman recommends that the Greater Glasgow and Clyde NHS Board (the Board):

• (i) apologise to Mrs C for shortcomings in communications about Mr A's condition;
• (ii) take further action to ensure that a proactive approach is taken to establishing good communication with relatives;
• (iii) use this complaint as a case study to illustrate the importance of good communication with relatives, especially when the hospital are aware that the patient is unlikely to survive; and
• (iv) apologise to Mrs C formally for the conduct of a member of nursing staff and also give consideration to providing to staff dealing with patients and their families a more focussed reinforcement of the importance of good customer care through, for example, appropriate training.

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

Overview

The complainant (Mr C) raised a complaint about a delay in a referral for a urodynamics study at the Department of Urology (the Department) in the Southern General Hospital (the Hospital).  Mr C had not received an appointment after he had cancelled three previous opportunities to attend the Department.  Mr C complained that he had been told his name had been taken off the waiting list at his request.  Additionally, Mr C was unhappy that the complaint response from the Chief Executive of the then South Glasgow University Hospitals Division, wrongly referred to his original out-patient referral as having come from his General Practitioner (GP), rather than the Gastrointestinal Clinic at the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had an excessive wait for an appointment at the Department (upheld);
• (b) Greater Glasgow and Clyde NHS Board (the Board) had wrongly stated that Mr C's GP had referred him to the Department (upheld); and
• (c) Mr C was removed from the waiting list although he had not asked for this (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board apologise to Mr C for their error in saying the referral was from Mr C's GP;
• (ii) staff members are reminded of the importance of keeping accurate and contemporaneous records to verify their understanding of all patient information; and
• (iii) the Department staff are reminded of the value of alerting patients' GPs to the changes in the clinical care of patients on their practice list.

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

Overview

The complainant (Mrs C) complained to the Ombudsman about the care and treatment received by her husband (Mr C) from Lothian NHS Board (the Board)'s Unscheduled Care Service.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) a GP (GP 2) should have arranged Mr C's admission to hospital (upheld);
• (b) a GP (GP 3) was unhelpful and provided Mrs C with inadequate information (upheld); and
• (c) there was undue delay by the Board in dealing with Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) enables GP2 to reflect on the importance of assessing hydration status in future case management;
• (ii) ensures that GP3 gives full details of any arrangements he has made or intends to make, on behalf of a patient, to the patient or the person acting for the patient;
• (iii) consider whether there would be benefit in reminding all GPs working for the Unscheduled Care Service that clear comprehensive communication with callers is essential; and
• (iv) ensures that complainants are kept up-to-date with progress and expected timescales in accordance with the NHS complaints procedure.

Overview

The complainant (Mrs C) raised concerns about the fact that she was unfairly deregistered from a dental practice (the Practice) when she arrived late for an appointment.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C was unfairly deregistered from the Practice when she arrived late for an appointment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) apologise to Mrs C for deregistering her without warning;
• (ii) review the operation of their no-tolerance policy in light of the National Health Service (General Dental Services) Scotland Regulations 1996; and
• (iii) make any policies clear in the information which they give to new patients.

The Practice 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 from her General Practitioner (the GP) during 2006.  These included issues such as a failure by the GP to action treatment for Mrs A's reported concerns of nausea and weight loss and a failure to diagnose that she was suffering from fluid on her lungs.  In addition, Mr C complained that the GP failed to call an ambulance when Mrs A took ill at the Practice on 29 September 2006.  Mrs A was taken to hospital later the same day by ambulance from her home but sadly did not recover from a coma and died two weeks later.

Specific complaints and conclusions

The complaints which have been investigated are that the GP:

• (a) failed to provide treatment for Mrs A's reported concerns of nausea and weight loss and failed to diagnose that she was suffering from fluid on her lungs (not upheld); and
• (b) failed to call an ambulance when Mrs A took ill at the Practice on 29 September 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Miss C) raised concerns that she received an inadequate medical examination at the Accident and Emergency Department of the Royal Infirmary of Edinburgh on 21 December 2005 when she presented with a foot injury.

Specific complaint and conclusion

The complaint which has been investigated is that the medical examination which Miss C received at the Accident and Emergency Department of the Royal Infirmary of Edinburgh on 21 December 2005 was inadequate (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised concerns about a consultation with her GP on 9 February 2006, in that the GP failed to examine her properly or prescribe appropriate medication for a skin condition.

Specific complaint and conclusion

The complaint which has been investigated is that at a consultation on 9 February 2006, the GP failed to examine Ms C properly or prescribe appropriate medication (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained about the care her late husband (Mr C) received in Ayrshire Central Hospital (the Hospital).  In particular, she was concerned about the rapid deterioration in Mr C's condition during his stay.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the care Mr C received was unsatisfactory (upheld);
• (b) communication from senior medical staff was inadequate (not upheld); and
• (c) the follow-up to Mrs C's complaint was poorly handled (upheld).

Redress and recommendations

The Ombudsman recommends that Ayrshire and Arran NHS Board:

• (i) undertake training in the recognition of acute physical illness in patients on mental health wards using a well-recognised scoring system such as MEWS (medical early warning score);
• (ii) apologise to Mrs C for the failings in the care of Mr C identified in this report;
• (iii) apologise to Mrs C for failing to provide an explanation for the deterioration in Mr C's physical health during his stay in the Hospital; and
• (iv) take steps to ensure that the findings of critical incident reviews are fully incorporated in their responses to complainants.

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