Health

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.

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).