Health

Overview 

The complainant (Mr C) was admitted to the Raigmore Hospital (the Hospital) following a car accident on 19 December 2004.  He suffered an injury to his shoulder.  Mr C was concerned that this was not correctly diagnosed or followed-up at the time.  He complained that subsequently he was seen by a number of different doctors at his General Practice (the Practice) and was not correctly diagnosed until May 2005. 

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) on 19 December 2004 there was a failure by the Hospital to diagnose the extent of his injuries or arrange appropriate follow-up care; (not upheld);
• (b) at subsequent appointments the the Practice failed to provide adequate care and treatment (not upheld); and
• (c) there was no continuity in the care provided by the Practice because MrChe was seen by so many different doctors. (not upheld).

Redress and recommendations

The Ombudsman recommends that :

during periods when the continuity of care may be problematic the Practice reinforce with all staff the desirability of clarifying, wherever possible, the patient's understanding of the full course of treatment at each contact.

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

Overview

The complainant (Mr C) raised a number of issues regarding the treatment and care provided to his late father (Mr A).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the treatment provided to Mr A was inadequate and this led to him sustaining a chyle leak (not upheld);
• (b) staff continued to replace Mr A's TPN lines despite them continually becoming infected (not upheld);
• (c) staff failed to ensure Mr A received adequate nutrition (not upheld);
• (d) staff failed to clean Mr A's room properly and this led to him becoming infected with MRSA (no finding); and
• (e) staff failed to adequately communicate with Mr A's family (upheld).

Redress and recommendations

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

• (i) remind staff of their responsibilities under the MRSA policy and ensure procedures are followed and audited for compliance; and
• (ii) remind staff to ensure a note is placed in the records where the patient has specifically refused the release of clinical information to relatives.

The Board have accepted the recommendations and have explained the action which has taken place since the complaint was raised.

Overview

The complainant (Mrs C) raised a number of issues regarding her treatment and care following an operation for a vaginal prolapse.

Specific complaint(s) and conclusion(s)

The complaints which have been investigated are that the Board:

• (a) failed to provide full information about the potential side-effects of the operationinadequate information about potential side-effects of operation (no finding);
• (b) failed to provide adequate post-operative careinadequate post-operative care (not upheld);
• (c) failed to communicate clearly information to Mrs C about her symptomsinadequate communication about Mrs C’s symptoms (not upheld); and
• (d) failed to handle properly Mrs C's complaint (not upheld).

Redress and recommendation

The Ombudsman recommends that the Board ensure their health professionals are aware of good practice in obtaining consent.

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

Overview

The complainant (Mrs C) raised concerns about a dentist (the Dentist)'s examination of her sons' teeth.  She also complained that, after raising this with the Dentist, she and her sons were removed from the Dentist's list.

Specific complaints and conclusions

The complaints which have been investigated are that the Dentist:

• (a) unreasonably removed Mrs C and her sons from her list (not upheld); and
• (b) did not perform an adequate examination of Mrs C's sons' teeth (not upheld).

Redress and recommendations

Although the complaint is not upheld, the Ombudsman has made a general recommendation.  The Ombudsman recommends that the Dentist reviews her procedures for handling removal of patients from her list, and that in future she takes into account the advice in any guidelines that are produced.

The Dentist has accepted the recommendation and will act on it accordingly.

Overview

The complainant (Mr C) raised a number of concerns that, following his father (Mr A)'s stroke in November 2004, his father became eligible for NHS funding of all his care in a Nursing Home rather than the limited funding he received from his local authority.  Ayrshire and Arran NHS Board (the Board) had not agreed to fund this care and Mr C raised a complaint that the matter had not been properly considered.

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a) properly assess Mr A's eligibility for NHS funded Continuing Care (upheld); and
• (b) properly review Mr C's application for NHS funded Continuing Care (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a retrospective, evidenced assessment of Mr A's continuing care needs and;
• (ii)ensure that where there is an application either for NHS Continuing Care Funding or to review a decision to refuse funding, the process for dealing with that application is explained to the applicant at the outset.

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

Overview

On 12 April 2005 the Ombudsman received a complaint from Mr C and his sister (Ms C) that Argyll and Clyde NHS Board (the Board) failed to provide their father (Mr A) with adequate clinical care and treatment at the Accident and Emergency Department (A&E) at the Inverclyde Royal Hospital (the Hospital) during his admission following a fall on 29 April 2004.  It should be noted that on 1 April 2006, Greater Glasgow and Clyde NHS Board took over responsibility for the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to provide adequate clinical care and treatment to Mr A within the A&E Department (not upheld);
• (b) the Board failed to provide adequate nursing care to Mr A within the A&E Department (upheld);
• (c) the nursing notes were not adequate (upheld); and
• (d) the Board failed to handle Mr and Ms C's complaints adequately (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) perform a full audit of A&E nursing records in the next three months and provide the Ombudsman's office with the results of this audit;
• (ii) take further action to ensure that the failings in the nursing documentation and communication my investigation identified are addressed, and that the Board provide the Ombudsman's office with details of who will take responsibility for this, and what action will be taken;
• (iii) provide evidence of educational programmes and systems of competency- based measurement for A&E nursing staff in relation to triage performance, record-keeping, nursing assessment, care planning and discharge planning;
• (iv) review their complaints handling; and
• (v) write to Mr and Ms C to apologise for the Board's failure to address their concerns satisfactorily.

The Board have accepted my recommendations and are already acting on them.

Overview

The complainant (Mrs C), supported by her family,  raised a number of concerns about specific elements of the care and treatment of her mother (Mrs A) in two NHS hospital settings and the overall care provided by an Independent Care Home where she was a fully-funded NHS Continuing Care Patient.  The complainant also questioned the oversight of the care provided in the Care Home by the NHS staff responsible for her mother.  The complainant was dissatisfied with the quality of the Greater Glasgow and Clyde NHS Board (the Board) investigation into her complaint and the number of bodies she had to raise a complaint with in order to address all her concerns.

Specific complaints investigated and conclusions

The complaints which have been investigated are that the Board:

• (a) failed in their care and treatment of Mrs A (partially upheld);
• (b) failed in their duty of care to Mrs A while she was in the Care Home (partially upheld); and
• (c) failed to adequately investigate Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) use this case to learn lessons about the use of observations and comments made by relatives in decisions about case management and treatment plans;
• (ii) ensure that procedures are in place to inform relatives about how to make contact with medical staff; and
• (iii) consider adopting a policy of informing the family of continuing care patients of the current system of proactive clinical review and invite their input as appropriate. The policy should also indicate how families can contact the appropriate clinician in-between periodic reviews.

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

Overview

The complainant (Mr C) was concerned that the failure of the Southern General Hospital in Glasgow (Hospital 1) to diagnose a trapped nerve in his neck caused him pain and stress that could have been avoided.

Specific complaint and conclusion

The complaint which has been investigated is that Hospital 1 failed to diagnose a trapped nerve in Mr C's neck when he attended Hospital 1 in February 2002 and March 2003 (not upheld).

Redress and recommendation

The Ombudsman has no recommendation to make.

Overview

The complainant raised concerns on behalf of his 72-year-old mother about her discharge from hospital and her condition at discharge, which he felt was worse than when she was admitted.  She died at home a few days later.

Specific complaint and conclusion

The complaint which has been investigated is the decision to discharge (not upheld).

Redress and recommendation

The Ombudsman has no recommendation.

Overview

The complainant (Mr C) raised a number of concerns about the time taken and number of appointments needed by the Tayside Orthopaedic and Rehabilitation Service to fit a replacement socket to his below the knee prosthesis.  The complainant also raised a concern that NHS Tayside Board (the Board) had failed to pay his associated travel expenses.

Specific complaints and conclusions

The complaints which have been investigated are that the Board unreasonably:

• (a)  delayed providing Mr C with an artificial limb (not upheld); and
• (b)  refused travelling expenses to Mr C (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.