Health

Overview

The complainant, Mr C, complained about various aspects of the treatment of his brother, Mr A, prior to Mr A's death in the Southern General Hospital, Glasgow (the Hospital).  In particular, Mr C complained that Mr A's general practitioner (the GP) failed to diagnose Mr A's brain tumour, and that the care and treatment Mr A received in the Southern General Hospital, Glasgow (the Hospital) was inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that there was:

• (a) inadequate treatment by the GP (not upheld); and
• (b) inadequate treatment by the Hospital (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised concerns about the care and treatment given to his late father (Mr A) during a consultation with a GP (GP 1) at a medical practice (the Practice) on 5 April 2005, as Mr A died approximately one hour after the consultation.

Specific complaint and conclusion

The complaint which has been investigated is that GP 1 should have recognised that Mr A was suffering from coronary heart disease, realised the severity of his medical condition and taken appropriate action (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a complaint regarding the length of time he had been advised he would have to wait to see a Neurologist within the former Argyll and Clyde NHS Board (the Board), after his General Practitioner (GP 1) had requested a routine referral on his behalf when he presented with a clinical picture of a six to eight month history of a constant ache in his arm.

Specific complaint and conclusion

The complaint which has been investigated is that the waiting time for a Neurology out-patient appointment was too long (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board should ensure GPs and potential referrers are reminded how to find up to date local waiting times for out-patient services they are referring to within the Board so that, as referrers, they may prioritise their patients accordingly. She asks that the Board advise her of the measures that are put in place, or have been introduced, to facilitate this; and
• (ii) as one of several factors, some formal consideration should be given to the age of the patient being referred to a lengthy waiting list, where a list is unavoidably long. She asks that the Board tell her what they have implemented.

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 she had received for a bowel condition.

Specific complaints and conclusions

The complaints which have been investigated are that there was failure:

• (a) by medical staff to manage adequately Mrs C's care, reach a diagnosis quickly and provide appropriate treatment (not upheld);
• (b) to keep Mrs C in a special unit for a reasonable time following her operation (not upheld);
• (c) by nursing staff to provide adequate post-operative nursing care (upheld);
• (d) to provide a clean room (not upheld); and
• (e) to discharge Mrs C from hospital within a reasonable time (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) stress to clinicians the importance of ensuring, as far as possible, that patients are made aware of the reasons for clinical decisions made in relation to their care, particularly when being transferred between medical teams;
• (ii) provide evidence of the use of their Manual Handling Policy on all wards so that staff are aware of patients' handling needs and the recording of these needs and provide further evidence that staff receive the appropriate training in handling techniques;
• (iii) put in place procedures to prevent a recurrence of the delay in replacing broken handsets and, in the interim, ensure alternatives are available;
• (iv) provide evidence of the strategies in place to implement effective patient discharge planning; and
• (v) provide evidence of recent audit of nursing discharge planning on the surgical wards.

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

Overview

The complainant (Ms C) was a patient at Dykebar Hospital (the Hospital), Paisley, in August/September 2003.  She raised a number of issues concerning the conduct and behaviour of Mr and Mrs D (two of the Hospital's staff) towards her and the manner in which the former Argyll and Clyde NHS Board, (the Board) dealt with her complaint.

Specific complaint and conclusion

The complaint which has been investigated is the handling of Ms C's complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that they have in place a system for handling complaints that can demonstrate to a complainant that their complaint has been fairly, impartially and thoroughly investigated;
• (ii) ensure that, in particular, they have in place a system for handling complaints in circumstances where serious allegations are made by a patient about a member of staff;
• (iii) ensure that they and their employees understand their responsibilities in relation to protecting staff and patients, particularly in mental health settings;
• (iv) ensure that current arrangements for separating the complaints process from the disciplinary process meet the requirements of the current NHS complaints guidance; and
• (v) issue Ms C with a full formal apology for the failures identified in this report. 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).

The Board have accepted the recommendations.

Overview

The complainant (Miss C) raised a number of concerns about the care and treatment provided to her by Greater Glasgow and Clyde NHS Board (the Board) following a labyrinthectomy on 22 August 2006.  Miss C also complained about the attitude of a doctor during an eye examination.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to provide Miss C with appropriate care and treatment in August 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns that there had been unacceptable delays by Forth Valley NHS Board (the Board) in arranging follow up for her husband (Mr C) and a consequent failure to provide any treatment for him following his diagnosis of cancer.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)  did not arrange timely follow-up to Mr C (upheld); and
• (b)  did not provide Mr C with treatment following his diagnosis of cancer (not upheld).

Redress and recommendations

In light of the action taken by the Board the Ombudsman recommends that the Board make a written apology to Mrs C for the delays in arranging the follow-up appointment and requests that they send a copy of the finalised policy on Patient Access to this office.

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

Overview

The complainants (Mr and Mrs C), complaining on behalf of Mrs C's late mother (Mrs A), raised concerns regarding an alleged failure by Mrs A's General Practitioner (the GP) to take urgent and appropriate action to investigate and treat problems she was suffering from between May 2006 and July 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the GP failed to take urgent and appropriate action to investigate and treat problems Mrs A was suffering from between May 2006 and July 2006 (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about aspects of the care and treatment of his mother (Mrs A) by NHS Greater Glasgow and Clyde (the Board) from May 2005 until her death in October 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  records were not knowingly available to staff or of sufficient quality (upheld);
• (b)  action taken to prevent falls was inadequate (not upheld);
• (c)  there was a lack of planned therapy for Mrs A (upheld); and
• (d)  there were delays in providing adequate pain relief (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  reflect on the lessons that emerge from the record-keeping issues in this case, consider whether the documentation should be changed or if the issue is rather about staff induction/training and advise her of the outcome of this consideration;
• (ii)  complete the work on a Bed Alarm Policy and submit a copy to SPSO when this is issued;
• (iii)  arrange for staff to reflect on the importance of good communication and involvement of patients and relatives in decisions about care and treatment and advise her of the steps taken to achieve this; and
• (iv)  consider how to address the needs of longer term patients for mental stimulation to enhance their quality of life and advise her of the outcome of this consideration.

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

Overview

The complainant’s representative raised a complaint against Argyll and Clyde NHS Board (the Board), on behalf of the complainant (Mrs C), about the treatment she received at the Royal Alexandra Hospital in respect of a top-up epidural to allow for the surgical removal of the retained placenta after the birth of her son in August 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  clinical errors by the consultant anaesthetist (Dr E) put Mrs C’s health at risk during her labour (not upheld); and
• (b)  Dr E’s recollection of the facts differs from those of Mrs C, who believes that Dr E is being untruthful (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  consider whether it needs to review when clinical risk reviews of incidents such as these are carried out; and
• (ii)  ensures that clinical staff are reminded of their responsibility to maintain detailed records, in particular, in respect of anaesthetic procedures.

The Board have accepted the recommendations and will act on them accordingly.  The Ombudsman asks that the Board notify her when the recommendations have been implemented.