Health

Overview

The complainant (Mrs C) raised concerns about the nursing care received by her late husband (Mr C) in Lorn and Islands District General Hospital (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mr C’s medication for Parkinson’s disease was not correctly administered in relation to his PEG feeding (not upheld);
• (b)  Mr C’s PEG tube was not properly cleaned by nursing staff so as to avoid blockage (no finding);
• (c)  Mr C was not kept satisfactorily hydrated (not upheld);
• (d)  Mr C’s feet were not kept elevated when he was sitting in his chair and this resulted in the formation of blisters on his heels (upheld);
• (e)  Mr C was not given adequate physiotherapy in hospital (not upheld);
• (f)  Mr C was not given access to his own oral suction machine and oral suction was not performed sufficiently frequently by staff (no finding);
• (g)  Mr C’s torso and head were not kept elevated when he was in bed (upheld); and
• (h)  Mr C was wrongly assessed as fit for discharge as he died shortly later (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  take steps to ensure that relatives are given appropriate information where treatment given in hospital is different from at home;
• (ii)  apologise to Mrs C for their failure to appropriately manage Mr C’s pressure areas; and
• (iii)  remind relevant staff to be attentive to any physiotherapy advice given on positioning a patient.  Furthermore, the Board should apologise to Mrs C for their failure to return Mr C to an upright position after a positional change.

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 of his late sister (Miss C) by Greater Glasgow and Clyde NHS Board (the Board).  In particular he complained that Miss C had an operation to fuse her ankle joint which left her in considerable pain when it would have been clinically more appropriate to have amputated the foot; and also that on her final admission on 25 July 2005 to hospital she had been inappropriately admitted to orthopaedics which delayed diagnosis of the septicaemia which caused her death on 6 August 2005.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  doctors did not take the clinically appropriate step to remove Miss C's foot from the ankle (not upheld); and
• (b)  Miss C was inappropriately admitted to an orthopaedic ward rather than a medical ward (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their procedures for ensuring an overall treatment plan with ongoing input from all the relevant specialisms where a patient has a number of underlying medical problems.

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

Overview

The complainant (Mrs C) raised a number of concerns that her GP Practice (the Practice) withheld information from her when she requested copies of her medical records, initially by not supplying the full records, then by refusing to give written explanations of them and that they wrote misleading and inaccurate referral letters to specialists because they do not believe she had a heart attack.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a)  manipulated Mrs C’s medical care via misleading and inaccurate referral letters (not upheld); and
• (b)  withheld medical information from Mrs C (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained that the GP Practice (the Practice)'s late diagnosis of her mother (Mrs A)'s colon cancer could have been avoided by their greater consideration of her symptoms.  Mrs A died in hospital in June 2003, about a month after diagnosis, aged 76.

Specific complaints and conclusions

The complaint which has been investigated is that the Practice should have investigated more fully than they did (upheld).

Redress and recommendations

The Ombudsman recommends that the GPs in question:

• (i)  apologise in writing to Mrs C, acknowledging that further investigation should have been done in mid 2002; and
• (ii)  inform the Ombudsman what steps they have taken and/or are taking to learn from, and try to avoid a recurrence of, this serious case, for example, by discussing it at their general practitioner appraisals and discussing other relevant cases with the clinical governance lead of the appropriate Community Health Partnership.

The Ombudsman is pleased that the Practice have accepted the recommendations and are taking action on them.

Overview

The complainant (Mrs C) raised a concern that her late father's GP (GP 1) failed to provide reasonable care and treatment to her father (Mr A) in the two days immediately prior to his unexpected death in January 2006.

Specific complaint and conclusion

The complaint which has been investigated is that GP 1 failed to provide reasonable care and treatment to Mr A (not upheld)

Redress and recommendation

The Ombudsman has no recommendations to make.

Please note that this Report contained typographical errors in paragraph 4.  It should read:

4.     On 24 January 2006 the Practice received a call from one of Mr A's daughters (Mrs D) stating that Mr A was shaky and confused and requesting a home visit for him.  GP 1 visited later that day after evening surgery.  GP 1 made a working diagnosis of viral infection (she later noted that a flu virus was prevalent in the community at the time) and advised Mr A to increase his fluid intake and take paracetamol if needed.  GP 1 later called Mrs D and repeated this advice.  The following evening Mrs C called her father and was concerned when he dropped the telephone and she lost contact with him.  Mrs C and Mrs D drove to Mr A's house but could not gain access and called the paramedics who broke down the door.  Mr A was found in a state of collapse and was admitted to hospital by emergency ambulance at 22:30.  He was in acute renal failure and treated with antibiotics and IV fluids.  He suffered a cardiac arrest and died in the early hours of 26 January 2006.  The primary causes of death were listed as multiple organ failure, sepsis and urinary tract infection.

The SPSO has apologised to the complainant for these errors.

Overview

The complainant, Mr C, raised concerns that, following the withdrawal of part of his medication by the manufacturer, clinical staff failed to adequately assess his condition and provide him with suitable alternative medication or check his blood pressure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  staff failed to adequately assess Mr C following the withdrawal of his medication (not upheld);
• (b)  a staff grade doctor (the Staff Grade Doctor) inappropriately refused to check Mr C's blood pressure (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant Mr C was concerned about the care and treatment provided to his late wife (Mrs C).  He said that a delay in the initial diagnosis of her cancer meant she had to attend the hospital daily for injections for suspected deep vein thrombosis.  He also said that he was unhappy about the care and treatment Mrs C had received following her admission to Inverclyde Royal Hospital (the Hospital) and felt that the communication both to Mrs C, her family and between the Hospital staff had been inadequate.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a delay in the initial diagnosis of Mrs C's condition (upheld);
• (b)  the treatment given to Mrs C was inappropriate (partially upheld); and
• (c)  there were significant failures of communication, concerning her treatment and care, both to Mrs C and her family and between the Hospital staff (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mr C and his family for the delay in diagnosis and share this report with the clinical staff responsible for Mrs C's care;
• (ii)  review their pain assessment and management procedures and ensure that these include a full explanation of the role and involvement of specialist or palliative care teams in the care of patients with non-surgical pain;
• (iii)  apologise to Mr C and his family for not fully explaining Mrs C's pain management regime and for any unnecessary pain that Mrs C suffered as a result of this;
• (iv)  review their policies and procedures to ensure that there is suitable monitoring of nutritional care and management;
• (v)  provide evidence that standards of communication have improved and, in particular, that there are policies and procedures in place to ensure that patients who are terminally ill and their families are fully supported and treated with appropriate dignity;
• (vi)  emphasise to staff responsible for responding to complaints the importance of doing so in a non-defensive and open manner; and
• (vii)  apologise to Mr C and his family for all the failures identified in record keeping and communication; for failing to provide adequate support to them and Mrs C during her final illness; for the confusion about the circumstances surrounding Mrs C's death; and for failing to respond with appropriate care and sensitivity to the concerns raised by Miss C on their behalf.

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 mother (Mrs A) received at the Southern General Hospital, Glasgow in November and December 2005.  Her concerns included that Mrs A should have been treated in a High Dependency Unit; nursing staff failed to maintain Mrs A's oral and personal hygiene; staff failed to react when Mrs A's condition deteriorated; and poor communication.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Mrs A received inadequate clinical treatment (not upheld);
• (b)  staff failed to provide Mrs A with basic nursing care (not upheld); and
• (c)  staff failed to communicate adequately with Mrs A's relatives (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Ms C) raised a number of concerns about clinical treatment and delays in appointments and results.

Specific complaints and conclusions

The complaints which have been investigated are that Greater Glasgow and Clyde NHS Board (the Board) failed to:

• (a)  perform the correct biopsy in the first instance (upheld);
• (b)  arrange timely follow-up (upheld); and
• (c)  report biopsy results in a timely manner (upheld).

Redress and recommendations

The Ombudsman recommends that the Board make a written apology to Ms C for all the identified failures.

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

Overview

The complainant (Mrs C) complained that administrative and complaint handling errors by Greater Glasgow and Clyde NHS Board (the Board) had resulted in an unreasonable delay in her referral for treatment from the NHS and that consequently she felt it necessary to obtain the treatment privately.  Mrs C sought reimbursement of the costs directly incurred by her in having her surgery performed outwith the NHS.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to properly administer Mrs C's referral for non-cosmetic plastic surgery (upheld).

Redress and recommendation

The Ombudsman recommends that the Board reimburse Mrs C's invoiced treatment costs.

The Board have accepted the recommendation and have acted on it accordingly.