Health

Overview

The complainant Mrs C raised a number of concerns about the treatment her daughter (Miss C) received from a GP (the GP) at her medical practice during 2005 and that the GP failed to diagnose that she was suffering from pneumonia.

Specific complaint and conclusion

The complaint which has been investigated is that during consultations in 2005 the GP failed to diagnose that Miss C was suffering from pneumonia (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make but asks that the GP reflect on the comments relating to the recording of relevant information at consultations.

Overview

The complainant (Mrs C) raised a number of concerns about the care of her father (Mr A).  She complained about aspects of Mr A's nursing care and also the amount of medication which he was given.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  management of Mr A's catheter was poor (upheld);
• (b)  nursing staff did not adequately monitor Mr A (not upheld);
• (c)  contradictory reasons were given for the bruising on Mr A's forehead (not upheld); and
• (d)  the quantity of drugs given to Mr A was excessive (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise to Mr A's family for their failure to adequately manage Mr A's catheter and for the distress which this caused to Mr A and his family.

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

Overview

The complainants raised a number of concerns relating to the cremation of their baby (Baby C) and the subsequent handling and investigation of their complaint by Forth Valley NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a)  denied the complainants the opportunity to attend Baby C's cremation (upheld);
• (b)  failed to provide adequate evidence that Baby C was cremated entire (upheld);
• (c)  failed to carry out a thorough investigation of the complaint (upheld); and
• (d)  treated the complainants with disregard for their emotional state (partially upheld).

Redress and recommendations

The Ombudsman notes that the Board and Mr and Mrs C have entered into discussion regarding appropriate alternative redress and I am satisfied with this approach.  Given the sensitivity and nature of this case, I have decided that the final redress arrangements should remain private to both parties.

Overview

The complainant, Mr C, raised a number of concerns about the care and treatment which he received following his private, triple heart bypass operation at Aberdeen Royal Infirmary in June 2003.  He also complained about the way in which his complaint about these events had been handled by Grampian NHS Board (the Board).  The bulk of Mr C's complaint was not within the jurisdiction of the Ombudsman's office, as it related to the contract for the private treatment, and it was, therefore, only possible to look at the aspect of the complaint relating to complaint handling.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the Board failed to deal with Mr C's request to receive minutes of meetings with medical staff at which his complaint was discussed in accordance with procedure (partially upheld); and
• (b)  the Board failed to deal with Mr C's request that his concerns be discussed with the surgeons and medical staff involved in accordance with procedure (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for failing to deal with his requests to be provided with minutes of the meetings with medical staff in which his complaint was discussed, and his subsequent complaints, in accordance with procedure;
• (ii)  take steps to ensure that, in future, the Board completes any internal enquiries required to respond to issues raised by complainants;
• (iii)  take steps to ensure that, in future, any potential Data Protection Act requests are identified as such and dealt with in accordance with procedure;
• (iv)  apologise to Mr C for failing to deal with his request to have his concerns discussed with the surgeons and medical staff involved in accordance with procedure; and
• (v)  take steps to ensure that, in future, all points of complaint are addressed in response letters issued by the Board.

The Board have accepted the recommendations and provided information to show that (i) and (ii) have been implemented.  The Board have indicated that they will now act on the remaining recommendations.

Overview

Ms C complained about the care and treatment provided to her father, Mr A, in the Royal Dundee Liff Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  it was incorrectly stated in Mr A's clinical records that he had been discharged from the Royal Victoria Hospital because he was unmanageable (upheld);
• (b)  there was a delay in diagnosing a sub-dural haemorrhage (upheld);
• (c)  Mr A's stick was taken from him inappropriately and no further mobility assessment was done (not upheld);
• (d)  Mr A was over-sedated (not upheld);
• (e)  there was a failure to diagnose a pseudo-obstruction (upheld);
• (f)  a restraint was used unnecessarily (not upheld);
• (g)  a restraint was used inappropriately (upheld); and
• (h)  there was an unexplained delay in transferring Mr A to Ninewells Hospital (upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)  the Board remind staff of the need to ensure that entries in clinical records are appropriate;
• (ii)  the Board remind staff of the need for clinical records to be updated each time a patient is seen by a doctor;
• (iii)  the Senior House Officers (SHOs) involved in Mr A's care raise the issue of record-keeping at their next appraisals;
• (iv)  the SHOs involved in Mr A's care raise the issue of failure to diagnose the return of pseudo-obstruction at their next appraisals;
• (v)  the Board develop and implement a policy on the use of restraints at the Hospital in line with Mental Welfare Commission guidelines;
• (vi)  the Board include patient and family communication as an item to be appraised in the regular appraisals on trainee doctors carried out by Educational Supervisors (Consultants) and, for nursing staff, that the Board demonstrate that communication has a high priority in the supervision of trainee nurses and is included in the programme for any review of nursing standards; and
• (vii)  the Board apologise to Ms C for the failures identified in this report.

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 provided to her husband (Mr C) by Ambulance staff on 7 January 2005 during his discharge home from hospital.  Mr C was terminally ill with advanced cancer at this time.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the ambulance crew failed to take adequate care in carrying Mr C from the ambulance to his home (upheld);
• (b)  a crew member spoke aggressively to Mr C's family when they challenged the crew about how they were carrying Mr C (no finding); and
• (c)  there was an excessive and uncomfortable delay while waiting for a new crew to arrive (not upheld).

Redress and recommendations

The Ombudsman recommends that the Service:

• (i)  apologise in writing to Mrs C for the distress and anxiety caused by the failure to provide suitable equipment to staff and ensure that staff had been adequately trained in manual handling techniques for the equipment available; and
• (ii)  consider the recommendations from the Specialist Adviser and provide the Ombudsman's office with an action plan arising from consideration of the recommendations.

The Service have accepted the recommendations and will report back to the Ombudsman on progress towards achieving them.

Overview

Ms C complained about the care and treatment provided to her brother (Mr A) by the Royal Cornhill Hospital, Aberdeen (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are about:

• (a)  Mr A's loss of weight was not dealt with appropriately (upheld);
• (b)  the response to Mr A's falls was poor (upheld);
• (c)  poor communication between staff and relatives (not upheld); and
• (d)  poor hygiene (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  review how eating and drinking/weight problems are dealt with in the Hospital and take action to ensure that a plan is drawn up and implemented in each relevant case;
• (ii)  review care planning in the Hospital;
• (iii)  implement their new policy on patient falls if they have not already done so;
• (iv)  develop and implement a policy on the use of restraints at the Hospital in line with Mental Welfare Commission Guidelines; and
• (v)  take steps to ensure that the guidelines on pressure ulcer prevention are followed in the Hospital.

The Board have accepted the recommendations and are acting on them accordingly.

Overview

The complainant (Ms C) raised a number of concerns about surgery she underwent for removal of a breast tumour at the Western Infirmary, Glasgow, (the Hospital) and about the subsequent radiotherapy treatment at the Beatson Oncology Centre (the Centre).  She believed that both had been more extensive than she had been advised and that, as a result, she was at a greater risk of developing lymphoedema.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  on 24 March 2004 at the Hospital, during surgery to remove the tumour, all lymph nodes in Ms C's armpit were removed against her express wishes (partially upheld to the extent that consent was not correctly taken) ; and
• (b)  during subsequent radiotherapy treatment at the Centre, the total armpit area was irradiated (not upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i)  when launching the new policy on consent, the Board arrange appropriate training for staff to ensure it is fully implemented and audit its implementation to confirm that it is being followed consistently; and
• (ii)  the Board ensure that all staff are aware of the need to provide full explanations when responding to complaints and that staff dealing with complaints contact all appropriate staff for comment when doing so.

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

Overview

The complainant (Mr C) raised two specific complaints regarding a Clinician (Clinician 1)'s diagnosis of his condition and the quality of the records taken by Clinician 1 during a consultation.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Clinician 1's diagnosis did not take into account all of the complainant's conditions and symptoms (upheld); and
• (b) the notes taken at a consultation were inaccurate and of poor quality (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) raised a number of concerns about the treatment and care his mother (Mrs A) received at the Royal Alexandra Hospital, Paisley (Hospital 1) in October 2004.  Mr C also complained about delay by Argyll and Clyde NHS Board, now Greater Glasgow and Clyde NHS Board (the Board), in dealing with his complaint.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mrs A was left alone without adequate clothing and bedding in a cold room (upheld);
• (b) Mrs A's family were not told about the circumstances which led to Mrs A gashing her legs until after they had enquired about them (upheld);
• (c) Mrs A's medical records did not accompany her when she was transferred from Hospital 1 to Hospital 2 and that there was subsequent delay thereafter in forwarding the records (upheld); and
• (d) there was a delay by the Board in dealing with Mr C's complaint (partially upheld).

Redress and recommendations

The Ombudsman recommends that:

• (i) the Board issue Mr C and his family with a full formal apology for the failures identified in complaints (a) and (b) of this Report;
• (ii) the Board should audit their care planning document in one year and share the findings with the Ombudsman's office;
• (iii) when a hospital patient is being transferred internally or externally, a 'tick list' of what needs to go with that patient should be completed before the patient leaves the ward;
• (iv) when a hospital patient is being transferred externally, staff transporting the patient should also check that all the items contained on the 'tick list' accompany the patient;
• (v) the 'tick list' should then be immediately checked by the receiving ward or hospital when the patient arrives there;
• (vi) the Board issue Mr C with a formal apology for the errors contained in their letter of 21 January 2005, as identified in paragraph 41 of this report; and
• (vii) the apology in recommendations (i) and (vi) 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 and will act on them accordingly.