Health

Overview

The complainant (Ms C) raised a complaint that the South Glasgow University Hospital NHS Trust (the Trust) [now Greater Glasgow and Clyde NHS Board] had failed to provide her with an appropriate level of care during her stay in the Southern General Hospital (the Hospital) in Glasgow.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       Ms C was not supported to the bathroom and had to lie on a bed pad and urinate and defecate in bed (upheld);
• (b)       The above resulted in a deterioration in her skin condition (not upheld); and
• (c)       the Convenor failed to take appropriate professional advice on the nursing and clinical aspects of Ms C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Ms C for failing to take sufficient account of her needs when considering her care provision; and
• (ii)       ensure that it now has appropriate training in place to ensure staff are aware of the potential issues which may arise when treating patients who have communication difficulties.

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

Overview

The complainant (Mr C) raised concerns that Tayside NHS Board had refused to reimburse him for the costs of a private operation which he had arranged due to the time he would have had to wait for the operation to be funded by the NHS.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay by staff in placing Mr C's name on the waiting list for surgery (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) complained about the Greater Glasgow and Clyde NHS Board (the Board)'s delay in dealing with her complaint concerning the circumstances pertaining when she required to view her son's body in the Royal Alexandra Hospital (the Hospital)'s mortuary.

Specific complaint and conclusion

The complaint which has been investigated is that the Board delayed in dealing with Mrs C's complaint concerning the circumstances pertaining when she required to view her son's body in the Hospital's mortuary (upheld).

Redress and recommendations

The Ombudsman recommends that the Board re-emphasise to staff the importance of following the stated complaints procedure and that, in the event of investigations over-running target dates, the complainant must be contacted on day 20 and fully advised.  Further, that complainants' agreement to an extension should be sought and after 40 days, where they do not agree, complainants should be advised of their right to raise the matter with the Ombudsman.

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 which her son (Mr A) received from the GP Practice (the Practice) and that doctors failed to diagnose that he was suffering from pneumonia which resulted in an emergency hospital admission.

Specific complaint and conclusion

The complaint which has been investigated is that doctors at the Practice provided Mr A with inadequate treatment and failed to diagnose that he was suffering from pneumonia (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Practice shares this report with the GPs concerned to reflect on the lessons learned in relation to the importance of chest examination in diagnosing chest disease and the difficulties of assessment of patients with communication difficulties.  The Ombudsman further recommends that GP 2 shares the case with his/her appraiser at annual appraisal if this has not already been done.

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

Overview

The complainant (Mrs C) raised a concern about the treatment which her son (Mr A) received from a GP (the GP) from NHS Lothian Unscheduled Care Service (LUCS) on 25 April 2006.  Mrs C said the GP failed to diagnose that Mr A was suffering from pneumonia which resulted in an emergency hospital admission on 26 April 2006.

Specific complaint and conclusion

The complaint which has been investigated is that the GP provided Mr A with inadequate treatment and failed to diagnose that he was suffering from pneumonia (upheld).

Redress and recommendations

The Ombudsman recommends that the Board share this report with the GP to reflect on the lessons learned in relation to the importance of chest examination in diagnosing chest disease and the difficulties of assessment of patients with communication difficulties and share the case with his appraiser at annual appraisal if he has not already done so.

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

Overview

A MSP (Ms C) raised a number of concerns about the referral process that her constituent (Mr A) had been through after he was diagnosed with cancer.  Specifically, she raised concerns that Mr A's GP Practice (the Practice) had failed to identify that Mr A had not been informed of his referral to Oncology and that Lanarkshire NHS Board (the Board) failed to properly administer Mr A's referral and follow-up when he failed to attend the appointment.  Mr A died during the course of this complaint and his wife (Mrs A) continued to pursue the complaint on his behalf.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       the Board failed to properly administer Mr A's referral to the Medical Oncology Unit and to follow-up when Mr A did not attend his appointment (upheld);
• (b)       the Board did not respond appropriately to Mr A's complaint about their failings (upheld); and
• (c)       the Practice failed to identify that Mr A was not aware of his referral to the Medical Oncology Unit (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        apologise to Mr A's family for their failure to properly administer his referral; and
• (ii)       confirm to her that they have gained assurance that the new referral system functions properly.

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

Overview

The complainant, Mr C, alleged that between August and December 2005, his painful shoulder was not diagnosed or treated properly.

Specific complaint and conclusion

The complaint which has been investigated is that Mr C's painful shoulder was not diagnosed or treated properly (not upheld)

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the dental treatment she received prior to and following surgical extraction of teeth on 3 May 2005.  She also raised concerns that she had not given informed consent, there was a lack of communication from staff and poor complaints handling.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)       the treatment which was provided prior to and following surgical extraction of teeth on 3 May 2005 was inadequate and it was inappropriate to extract an additional tooth (not upheld);
• (b)       staff failed to obtain informed consent from Mrs C (not upheld);
• (c)       communication from staff was poor (partially upheld); and
• (d)       there were delays and communication failures when handling the complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board  remind staff of the timescales in the NHS Complaints Procedure Guidance and offer Mrs C an apology for the failings which have been identified.

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

Overview

The complainant (Mrs C) raised concerns about a delay by doctors at Monklands Hospital (the Hospital) in diagnosing that she had cancer of the cervix and that she should have been referred to the Colposcopy Clinic sooner.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay by doctors at the Hospital in diagnosing that Mrs C was suffering from cancer of the cervix (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        provide Mrs C with an apology for the failings which have been identified in this report; and
• (ii)       share this report with Gynaecologist 1 and his staff and encourage them to reflect on its findings.

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

Overview

Mrs C raised a number of serious concerns about the failure of staff at Ninewells Hospital (the to diagnose and treat her husband when he was admitted with heart failure.  Mr C died within 24 hours of being admitted to the Hospital.  Mrs C also raised a concern about a change in Mr C's medication shortly before his death.  A final complaint concerned the time taken by the Board to respond to Mrs C's complaint and the failure to fully address her concerns.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a)       failure to diagnose and provide treatment for Mr C's heart failure (upheld);
• (b)       inappropriate change in medication (not upheld); and
• (c)       failure in complaint handling (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)        undertake a review of the operation and knowledge of the two Chest Pain Protocols at the Hospital and consider the adoption of a single unified protocol;
• (ii)       review the events in this complaint at an MAU multi-disciplinary meeting to ensure lessons are learned from the failure to recognise the seriousness of Mr C's condition and to react promptly and appropriately to his deterioration;
• (iii)      apologise in writing to Mrs C for their failure to provide an adequate or timely response to her complaint; and
• (iv)      ensure that their complaints handling process both acknowledges any errors identified  and uses these to drive service improvement.

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