Health

Overview

The complainant (Mrs C) raised concerns that her daughter (Baby C) had developed an infection in her leg after receiving her immunisations on 9 February 2006.  However, doctors at the practice (the Practice) told her on 20 February 2006 and 21  February 2006 that it was not an infection.  Mrs C took her daughter back to the Practice on 24 February 2006 and it was then that Baby C was referred to hospital for treatment to the infected wound.

Specific complaint and conclusion

The complaint which has been investigated iswas that there was a delay in diagnosing that Baby C had a leg infection and that as a result a hospital referral was required (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the care which her diabetic husband (Mr C) had received when he attended the Western Isles Hospital (Hospital 1) with serious foot ischaemia.  Mrs C complained about a consultant’s (Consultant 1) behaviour, the delay in referring Mr C to the Consultant Vascular Surgeon (Consultant 2) and that unsuitable medication was prescribed to her husband.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  Consultant 1's behaviour was inappropriate when he explained the results of his examination to Mr and Mrs C (no finding);
• (b)  Consultant 1 delayed writing to Consultant 2 after seeing Mr C (not upheld);
• (c)  Consultant 1 did not reflect the urgency of Mr C's condition in his referral to Consultant 2 (upheld); and
• (d)  Consultant 1 prescribed Voltarol to Mr C and this is not suitable for diabetics (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  review its procedures for urgent referrals; and
• (ii)  apologise to Mr and Mrs C for their failure to adequately convey the urgency of Mr C's condition in their letter of referral.

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 husband (Mr C) received at Crosshouse Hospital, Kilmarnock in February 2005.  In particular she was concerned that there was a delay by staff in reaching a diagnosis and that medication which was administered was not written in the medical records.  Mrs C also complained about the way her complaint was handled.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a delay in reaching a diagnosis (not upheld);
• (b)  staff failed to record when medication was administered to Mr C (not upheld); and
• (c)  there was inadequate complaints handling (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  bring to the attention of staff the comments made by Adviser 1 in regard to the failure to recognise the decrease in Mr C's kidney function from 17 February 2005 and the monitoring of his Gentamicin levels;
• (ii)  conduct an audit of the nursing records for Ward 3A to ascertain if they are in accordance with the standards as set out by the Nursing and Midwifery Council; and
• (iii)  conduct a review of their complaints procedure to ensure that staff are acting in accordance with the National Guidance.

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

Overview

The complainant Mr C raised a number of concerns regarding his dental treatment and the preparation and fitment of a dental bridge and a temporary denture.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the Dental Practice failed to provide Mr C with an appropriate bridge (not upheld);
• (b)  the dentist incorrectly drilled into the root of Mr C's tooth at an angle, leading to the tooth requiring extraction (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The aggrieved (Mr A) raised a number of concerns, through his Member of the Scottish Parliament (Mr C), about the treatment received by his wife (Mrs A) prior to and during an admission to Raigmore Hospital (the Hospital) in 2000.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the hospital admission was caused by the staff's failure to ensure that Mrs A received vitamin B12 injections (not upheld); and
• (b)  staff incorrectly stated there were traces of benzodiazepines in Mrs A's urine samples and this led to Mr A being interviewed by the police (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised a number of concerns about the care and treatment of her husband (Mr C) at a number of hospitals in Greater Glasgow between June 2004 and his death from mesothelioma in September 2004.  Mrs C complained that Mr C was not given information about his prognosis and delays occurred which prevented his being given any useful treatment.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr C with timely and appropriate care and treatment between June and September 2004 (partially upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for communication failures;
• (ii)  consider using the events of this complaint to inform practise in communicating with patients affected by cancer; particularly when a number of different specialists are involved in care; and
• (iii)  gives consideration to improving written recording of discussions with patients and their elatives especially in situations where there are a number of clinicians involved in delivering care.

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

Overview

The complainants, a firm of solicitors (the Solicitors) raised a concern on behalf of their clients, the family of Mr A, that Mr A had not been properly assessed by  Fife NHS Board (the Board) and consequently was not receiving funding for NHS Continuing Care.  The family were also concerned that they had not been able to appeal against the decision not to fund Mr A's care.

Specific complaints and conclusions

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

• (a)  properly assess Mr A for his continuing health needs and to provide details of the criteria used in deciding to discharge Mr A from in-patient care (not upheld); and
• (b)  consider an appeal against the decision to refuse funding (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  make a formal, evidenced record of decisions to discharge and that this record is provided to the patient and/or family in a timely manner; and
• (ii)  ensure that when a decision to discharge is reached such a decision is made known to the patient and/or family at the time the decision is taken and that where objections are presented the process for appealing against such a decision is clearly and fully explained.

Further Action

This and other complaints to the Ombudsman indicate an urgent need to review the guidance on NHS Funded Continuing Care which was issued more than 11 years ago.  This is not a matter which an individual Health Board is able to address so cannot be resolved within this report.  The Ombudsman will instead draw this matter to the attention of the Scottish Executive Health Department.

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 his late wife, Mrs C, received in hospital where she received surgery and subsequently died.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  the full risks of surgery were never explained to Mrs C or Mr C (upheld);
• (b)  the Hospital failed to explain why Mrs C's drips were removed on 24 August 2004 (upheld);
• (c)  the Hospital failed to investigate adequately the cause of Mrs C's confusion and agitation displayed the week before her deterioration (not upheld); and
• (d)  the Hospital did not let Mr C know at the first opportunity that his wife was going into final decline and, as a result, he was denied the chance to spend valuable time with her before her death (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board audit their practice in obtaining informed patient consent and implement any necessary change.

The Board have accepted the recommendations and have acted on them accordingly.

Overview

The complainant (Ms C) raised a complaint that she visited her General Medical Practice's Well Woman Clinic and a smear test was carried out without a reasonable degree of care.

Specific complaint and conclusion

The complaint which has been investigated is that a smear test was performed without a reasonable degree of care (not upheld).

Recommendations

The Ombudsman has made no recommendations.

Overview

The complainant (Ms C) raised a number of concerns in respect of her attendance at the Breast Screening Service for tests and subsequent correspondence relating to her results.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a)  there was a lack of information at the screening appointment (not upheld);
• (b)  the discharge letter was unclear (upheld);
• (c)  the Breast Screening Service failed to fully address Ms C's concerns (upheld); and
• (d)  the Breast Screening Service failed to issue a letter notifying Ms C that she was clear of breast cancer (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i)  consider reviewing the wording of the discharge letter; and
• (ii)  review procedures to ensure that telephone calls to the Breast Care Service are responded to appropriately.

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