Health

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.

Overview

The complainant (Ms C) was concerned that treatment to one of her teeth was inadequate and quickly failed.  She was also unhappy about the way her complaint about this had been handled by the dental practice.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the treatment given on 6 December 2004 was inadequate (not upheld); and
• (b) the complaint about this was not handled appropriately (partially upheld).

Redress and recommendation

The Ombudsman recommends that the Practice apologise to Ms C for any confusion caused by the letter of 30 June 2005.

The Practice have accepted the recommendation and will act accordingly.  The Ombudsman asks that the Practice notify her when the recommendations have been implemented.

Overview

The complainant (Ms C) raised a number of concerns that her mother (Mrs A) had not been properly supervised by staff resulting in a number of falls which were not properly recorded or notified.  Ms C also complained that she was not properly notified of her mother’s death and that Greater Glasgow and Clyde NHS Board failed to respond properly to her complaints.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Board failed to properly supervise Mrs A and allowed her to fall on a number of occasions which were not properly reported (not upheld);
• (b) the Board failed to properly notify Ms C of her mother’s death (not upheld); and
• (c) the Board failed to respond to her complaint accurately (no finding).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mrs C) raised concerns about a denture made by the dentist and about the dentist's attitude.

Specific complaint and conclusion

The complaint which has been investigated is about the fit of the denture (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complaint concerned the response time taken for an Ambulance to attend following an emergency telephone call.  The complainant (Miss C) was unhappy about the delay and the explanations given for this.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an inadequate response to a '999' call (partially upheld); and
• (b) there was excessive delay in responding to Miss C's complaint and in the review which followed (upheld).

 Redress and recommendations

The Ombudsman recommends that the Service:

• (i) provide the Crew involved in the incident with a copy of this report and ensure that steps are taken to identify and provide any training needs relating to responding to emergency calls;
• (ii) apologise to Miss C and her family for the delays experienced while pursuing her complaint; and
• (iii) review their complaint handling systems and procedure and, in particular, systems designed to track and monitor the progress of complaints.

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

Overview

The complainant (Mrs C) raised concerns about the supervision of her medication and that she could not discuss the matter with a GP.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Practice provided inadequate medication supervision (not upheld); and
• (b) there was communication failure (not upheld).

Redress and recommendation

The Ombudsman has no recommendations to make.