Health

Overview

An Advocacy Worker (Ms C) complained on behalf of the family of an elderly woman (Mrs A) who had been a patient at Glasgow Royal Infirmary (the Hospital).  She raised a number of concerns about the nursing care provided, communication with the family and procedures for discharge.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a lack of communication with the family, in particular in relation to whether or not Mrs A had a stroke while in hospital (partially upheld);
• (b)  the standard of nursing care provided by some nursing staff was poor (not upheld);
• (c)  there was no effective planning of Mrs A's discharge from hospital (upheld); and
• (d)  pancreatitis was given as the secondary cause of death even though the family's understanding was that this condition had been successfully treated (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  highlight to staff the need to manage the expectations of the families of patients and to be aware of the need to communicate in non-technical language and provide clear explanations;
• (ii)  undertake an audit of the new care plan documentation and share the results of that audit with her;
• (iii)  apologise to Mrs A's family for their failure to carry out their own discharge policy effectively and the inconvenience, distress and concern that this caused; and
• (iv)  audit their discharge policy to ensure that it is now being fully implemented.

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

Overview

The complaint concerns the care and treatment of the complainant (Mr C)'s late wife (Mrs C) by a doctor (Doctor 1) from an out-of-hours General Practitioner Service (the Service) in December 2002.

Specific complaint and conclusion

The complaint which has been investigated is that Doctor 1 failed to provide Mrs C with adequate care and treatment during a home consultation on 31 December 2002 (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)  Doctor 1 issue Mr C and his family with a full formal apology for the failures identified in this Report; and
• (ii)  the apology should be in accordance with the Ombudsman's guidance note on 'apology' (which sets out what is meant and what is required for a meaningful apology).

Doctor 1 has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C), through his Advocacy Worker (Tthe Advocacy Worker), raised a concern about the circumstances which led to him discharging himself from hospital.

Specific complaint and conclusion

The complaint which has been investigated is that staff failed to take into account Mr C's mental health problems and as a result he discharged himself from hospital (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) was concerned that his 86-year old late uncle (Mr A)'s chances of survival were compromised by the GP's late referral to hospital and by Uist & Barra Hospital (the Hospital)'s care and treatment.  His uncle died during his time in the Hospital.

Specific complaints and conclusions

The complaints which have been investigated concern:

• (a)      the timing of the hospital referral (no finding); and
• (b)      the Hospital's care and treatment (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the treatment her late father (Mr A) received at the Royal Alexandra Hospital, Paisley (the Hospital) from 2 July 2005 to 11 July 2005.  This included whether it was appropriate for staff to prescribe oral rather than intravenous antibiotics and whether account was taken of Mr A's pre-existing medical condition prior to the hospital admission.

Specific complaint and conclusion

The complaint which has been investigated is that Mr A was provided with inadequate treatment and staff failed to take into account his pre-existing medical condition (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Board consider the development of Board-wide bereavement guidance and inform her of the outcome of the audit of nursing records.

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 late husband (Mr C) received at the Royal Alexandra Hospital, Paisley (Hospital 1) from 1 August 2005 to 15 October 2005.  She had concerns about his clinical treatment; lack of communication between medical and surgical staff and the family and inadequate complaints handling.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)      Mr C' s clinical treatment was inadequate (not upheld);
• (b)      medical staff failed to communicate between specialities and with the family (partially upheld); and
• (c)      there was inadequate complaints handling (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       remind staff of the importance of communication with family members;
• (ii)      conduct an audit to ensure that responses to complaints are within NHS Complaints Procedure Guidelines; and
• (iii)      conduct an investigation into the circumstances which led to a letter being issued to Mr C nearly three months after his death enquiring whether he wished to remain on the waiting list for orthopaedic surgery and offer a sincere apology to Mrs C for the distress which was caused.  On this point she would also draw to the Board's attention to recommendation (ii) of report 200502722 published in September 2006.

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

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her late husband (Mr C) by Ayrshire and Arran Health Board (the Board) in the months immediately prior to his death in June 2005 and in particular an alleged failure to properly diagnose and treat his cardiomyopathy in a timely manner which led to his dying before arrangements could be made for a heart transplant.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)      failed to provide Mr C with timely or adequate medical treatment (partially upheld); and
• (b)      failed to provide Mr C with timely or adequate nursing treatment (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       give consideration to more urgent treatment being prescribed through the hospital pharmacy to prevent the administrative delays associated with prescribing through general practice and;
• (ii)      audit and review the existing procedures for monitoring possible cannula site infections and staff awareness of these procedures.

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

Overview

The complainant (Miss C) raised a number of concerns about the nursing care which her grandmother (Mrs A) received in Wishaw General Hospital (the Hospital), the nursing staff's management of her grandmother's diabetes, the communication between nursing staff and the Hospital Emergency Care Team (HECT), the communication between nursing staff and the family, the fact that information was missing from her grandmother's medical records and the fact that the wrong cause of death was recorded on her grandmother's death certificate.

The Board carried out an investigation into Mrs A's care and devised an action plan to remedy most of their failings, for which I commend them.  I have, however, upheld all of Miss C's complaints principally because the Board did not apologise to Mrs A's family for any of their failings.  An appropriate apology is an important part of remedying a failing and I am disappointed that the Board did not apologise despite recognising that aspects of Mrs A's care had been inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  nursing staff's communication with Miss C and her family about Mrs A's health was inadequate (upheld to the extent that no apology was given);
• (b)  erroneous information was given to Miss C and her family about the cause of Mrs A's death and, additionally, that the wrong cause of death was recorded on Mrs A's death certificate (upheld);
• (c)  nursing care and conduct were inadequate (upheld to the extent that no apology was given);
• (d)  nursing staff failed to adequately manage Mrs A's diabetes (upheld to the extent that no apology was given);
• (e)  nursing staff's communication with the HECT did not convey the urgency of Mrs A's situation (upheld); and
• (f)  information was missing from medical records (upheld).

 Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       issue an apology to Mrs A's family for staff's failure to adequately explain Mrs A's medical condition to them;
• (ii)      apologise to Mrs A's family for the distress and inconvenience caused by the fact that they recorded the wrong cause of death on Mrs A's death certificate;
• (iii)      take steps to ensure that the correct cause of death is recorded on a patient's death certificate;
• (iv)      issue an apology to Mrs A's family for the poor standard of nursing care received by Mrs A in the Hospital;
• (v)      apologise to Mrs A's family for their failure to adequately manage Mrs A's diabetes;
• (vi)      apologise to Mrs A's family for nursing staff's failure to convey the urgency of Mrs A's condition to HECT;
• (vii)     issue an apology to Mrs A's family for their failure to record all of the necessary information in Mrs A's medical records;
• (viii)    remind relevant staff of the importance of recording important patient data accurately; and
• (ix)      consider how best to improve communication between healthcare professionals, especially via the telephone.

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

Overview

The complainant raised a number of concerns about the care and treatment that her mother received in Vale of Leven hospital (Hospital 1) prior to her death.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  medical and nursing staff were not able to tell Mrs C what was wrong with her mother and did not seem to recognise that her condition was deteriorating rapidly (partially upheld);
• (b)  it was inappropriate to prescribe five antibiotics (not upheld);
• (c)  it was inappropriate to use a catheter when her mother had a urine infection (not upheld); and
• (d)  it was inappropriate to perform a CT scan because her mother was too ill, and that no account was taken of the fact that her mother was claustrophobic culminating in her having a panic attack (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board emphasise to staff the importance of communicating with relatives and of keeping an appropriate note of what was said.

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

Overview

The complainant (Ms C) raised concerns about the number of times her mother (Mrs A) had been moved while a patient at the Vale of Leven Hospital (the Hospital).  Some of Mrs A's personal belongings had been mislaid and Ms C wondered whether staff had taken into account that the moves would affect Mrs A's psychological and physical care.

Specific complaint and conclusion

The complaint which has been investigated is that staff failed to take into account the detrimental effect the multiple moves had on Mrs A and failed to take steps to ensure that all her personal belongings were moved with her (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.