Health

Overview

The complainant (Mr C) raised a number of concerns about his mother (Mrs A)'s treatment in Dumfries and Galloway Royal Infirmary prior to her death on 15 September 2005.

Specific complaints and conclusions

The complaints from Mr C which have been investigated are that:

• (a)  on 13 September 2005 his mother was inappropriately admitted to an assessment ward when her condition was already known (upheld);
• (b)  despite her agitated state and her family's request, she was not given any sedation or water (upheld); and
• (c)  there was delay in releasing his mother's body for cremation (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       confirms the palliative care nurse's recommendations to her with a view to their early introduction;
• (ii)      reinforce to nursing and medical staff the need for good assessment and evaluation for patients with pain and agitation and, to emphasise the importance of communicating to families;
• (iii)      formally apologise to Mr C for their failure to provide  Mrs A with water and for the delay in re-evaluating her medication; and
• (iv)      confirm their improved procedures concerning cremation forms and the date when they are introduced.

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

Overview

The complainant (Mr C) was concerned about the handling of the internal transfer of his brother (Mr A) at the Hospital where he was a long-stay patient.  Mr C felt that the transfer had been made because of staffing issues and not in response to Mr A's needs.  He has also complained it had been carried out too quickly and that, as a result of stress caused by the move, his brother had suffered five seizures.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)      the decision to move Mr A between units was made prior to discussion and on the basis of staffing levels rather than needs (partially upheld);
• (b)      the move was not made at Mr A's pace, was too fast and Mr A required to be medicated to facilitate the move (not upheld); and
• (c)      Mr A has since suffered seizures as a result of the stress incurred (not upheld).

Redress and recommendations

The Ombudsman recommends that if further reconfiguration is to occur, the Board should review their guidelines, and in particular their communication, individual patient review and risk management policies.

Overview

The complainant (Mr C) raised a number of concerns about the treatment his wife (Mrs C) received at the Western Infirmary, Glasgow in January 2005 including the failure of staff to take a wound swab and that his complaint was not dealt with through proper channels.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)    Mrs C was given inappropriate care and treatment (upheld); and
• (b)      the Board's complaints handling was inadequate (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       monitors compliance of the amended handover procedure to ensure that staff read patient documentation in addition to receiving a verbal report;
• (ii)      review their guidance on discharge procedures to ensure that planned care has been provided prior to discharge; and
• (iii)      reminds staff when receiving letters direct from patients to clarify and record whether they are making an enquiry or a formal complaint.

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

Overview

The complaint brought by Mrs C concerns an alleged failure to promptly diagnose her late father's abdominal aneurysm.  Mrs C believed that this delay made her father's condition inoperable and his death inevitable.

Specific complaint and conclusion

The complaint which has been investigated is that the Board failed to diagnose Mr A's abdominal aneurysm (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant raised a number of concerns that, following his stroke, a hospital did not assess his vision properly, did not carry out a carotid artery scan properly, did not communicate adequately with him and did not arrange his further care at a more local location.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)      assessment of vision (upheld);
• (b)      carotid artery scan (not upheld);
• (c)      communication (not upheld); and
• (d)      rehabilitation location (not upheld).

Redress and recommendations

The Ombudsman recommends to the Board that patients with neurological conditions, when initially assessed, should receive a full neurological examination, including the bedside assessment of visual fields.  If investigations point to a specific area of brain damage, the medical team should ensure that the appropriate clinical examination has been performed.  She also recommends that the Board apologise in respect of complaint (a).

Overview

The complainant (Mrs C) raised concerns that staff failed to monitor her son (Mr A) following an operation and that when his condition deteriorated they failed to telephone her although staff had been advised of current contact numbers.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)      staff failed to monitor Mr A appropriately following the operation (partially upheld);
• (b)      staff did not take adequate action to inform Mrs C that Mr A''s condition had deteriorated (upheld); and
• (c)      staff hid in Mr A's room and watched television (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)       undertake an audit of the standards of record keeping on Ward 15 and review whether there is a training requirement to make staff aware of the role of the Diabetes and Gastroenterology specialist nurses;. The Ombudsman further recommends that in view of the poor standard of documentation, that the Board implements a strategy to monitor and review patient dependency levels and nurse staffing in order that the quality of nursing records do not suffer as a result of a disparity in patient cohorts
• (ii)      adopt a process to ensure that current contact details are recorded accurately on admission and in particular that when a patient is transferred, that the details are reviewed.  Secondly that the Board ensures that communication with carers (when a patient’s condition deteriorates) is raised with staff as being a key and integral aspect of documentationremind staff to ensure that current contact details are easily identifiable in clinical records particularly when patients are transferred from one area to another; and; and
• (iii)      adopts a process by which the nurses allocated to a patient’s care on each shift are easily identifiable within the records and that any discussion with those staff as a result of a complaint are routinely documented.

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

Overview

The Complainant (Mr C) raised a number of concerns about the care and treatment he received for his broken leg at Ninewells Hospital, Dundee between September 2001 and January 2002.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the original external fixator in his leg should not have been removed without pain relief, and should not have been removed from Mr C’s leg while there was non-union of bones (not upheld);
• (b) the shortness in Mr C’s right leg should have been corrected (not upheld); and
• (c) inappropriate advice was given in January 2002 that Mr C's bones were united enough to benefit from intensive physiotherapy, and that an x-ray should have been taken before such advice was given (not upheld).

Redress and recommendations

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

• (i) should include doctors' note keeping as part of their yearly appraisal; and
• (ii) perform an audit to ensure that record keeping at the Hospital is of a sufficiently high standard and complies with the standard set down by the General Medical Council's Good Practice Guidelines.

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

Overview

Mrs C complained that Medical Practice 1 had failed to diagnose the cause of her back-pain accurately or in a timely manner.  She also complained that the Practice had not dealt with her complaint in accordance with the NHS Complaints Procedure and that GP 1 had made inaccurate entries in her medical record.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Medical Practice 1 failed to properly or promptly diagnose the cause of Mrs C's back-pain (not upheld);
• (b) Medical Practice 1 failed to handle her complaint in accordance with the NHS Complaints Procedure (upheld); and
• (c) GP 1 made an inaccurate entry in her medical record (not upheld).

Redress and recommendations

The Ombudsman recommends that Medical Practice 1:

• (i) reflect on the Advisers' comments regarding the recording of examination findings and use such advice to inform good practice; and
• (ii) provide Mrs C with a written apology for their failure to properly follow the NHS Complaints Procedure.

Overview

The complainant was concerned that he had been removed from his Dental Practice's patient register.

Specific complaint and conclusion

The complaint which has been investigated is about Mr C's de-registration from the dental list (not upheld).

Redress and recommendations

The Ombudsman has no recommendations in respect of this complaint.  However, she considered (see paragraph 9) that dentists in general and patients could find it helpful to have guidance on removing patients from dental lists.  The matter was raised with the Scottish Executive Health Department, and the Ombudsman is pleased to report that they have agreed to consider this.

Overview

The complainant (Ms C) suffers from seronegative spondyloarthritis.  She also had sinus problems.  Her GP referred her to an Ear, Nose and Throat Consultant at Borders General Hospital.  Ms C's complaints arise from that consultation and subsequent events.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was confusion over the diagnosis:  the Consultant did not mention pharyngitis or her high neutrophil count in his initial letter to her GP (partially upheld);
• (b) there was a failure to explain an entry in the Consultant's hand written notes (upheld); and
• (c) there was confusion about an appointment for a second opinion (upheld).

Redress and recommendations

The Ombudsman recommends that Borders NHS Board:

• (i) apologises to Ms C for confusion over the diagnosis;
• (ii) reminds staff dealing with complaints that explanations should be provided when requested; and
• (iii) apologises to Ms C for failures in communication and takes steps to ensure that patients are clear about what appointments they can expect.