Health

Summary
Mrs C complained about the care and treatment provided by the board to her late husband (Mr A).  Mr A was diagnosed with pseudomyxoma peritonei (a very rare type of cancer that usually begins in the appendix) and the clinicians involved in his care decided to arrange for scans to be carried out every six months to monitor any development of the cancer.  However, after two scans, further follow-up was not arranged.  Mrs C complained that Mr A did not receive treatment for the pseudomyxoma peritonei until four years after the initial diagnosis, by which point it had progressed considerably.

During the investigation, we took independent medical advice on Mr A's care and treatment from two consultants in colorectal surgery, one of whom has extensive experience in the treatment of pseudomyxoma peritonei.  We found that the delay in Mr A receiving treatment was largely due to a failure to review a scan that was carried out and make further appointments to monitor Mr A's condition.  However, we also found that there was a failure of board staff to discuss Mr A's case at a multi-disciplinary meeting when he was first diagnosed, and to discuss Mr A's case with a specialist pseudomyxoma peritonei unit.  We further found that there was a failure of the responsible consultant to communicate with Mr A and his GP regarding the diagnosis.

Mrs C also complained about the handling of her and Mr A's complaints.  Mr A's first complaint to the board did not receive a response.  When Mrs C later made a complaint, it did not receive a response for over a year, and Mrs C had to regularly contact the board for updates as they were not keeping her informed of progress.  The final response that Mrs C received was a copy of an investigation that had been carried out into Mr A's care, and did not address all of the issues raised in the complaint, apologise to Mrs C and Mr A for failings identified, or give information as to remedial action taken or proposed.  Additionally, details of how to contact the SPSO were not given to Mrs C.  I considered the large number of failings in basic and fundamental complaints handling principles to be unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a) in relation to the delay in treatment for Mr A's pseudomyxoma peritonei;
• provide evidence that MDT meetings are being held to discuss this type of cancer in line with their standards;
• review their processes for ensuring that scan results are reviewed and followed up, and ensure that current processes are sufficient to avoid a repeat of the failings identified by this investigation;
• consider implementing a policy to discuss the treatment options for all cases of proven or suspected pseudomyxoma peritonei with a specialist unit;
• draw the comments of Adviser 1 regarding communication of diagnoses to patients and GPs to the attention of the relevant consultant;
• apologise to Mrs C for the failings in complaints handling identified by this investigation;
• remind the relevant staff that formal complaints should be passed on to the complaints department; and
• review their handling of this complaint and identify areas for improvement.

Summary
Mr C complained on behalf of his sister (Miss A) who had amongst other things profound learning difficulties, type 2 diabetes and was blind.  He said that after falling out of bed and hurting her neck on 12 December 2015, she attended the Emergency Department (ED) of Glasgow Royal infirmary.  Although the board maintained that Miss A had been treated reasonably, Mr C said that staff did not take into account her serious disabilities when examining and treating her and she was discharged home.  Miss A's condition deteriorated and she returned to the ED where she was later given an x-ray and CT scan which showed fractures in her neck.  She was admitted to the National Spinal Injuries Unit.

We took independent advice from a consultant in emergency medicine and from a registered nurse.  We found that despite the fact that Miss A had serious and profound learning difficulties which were detailed in documentation that accompanied her to the ED, these were not properly taken into account, a senior opinion was not obtained nor were available objective assessment tools used.  Mr C's opinions were not sought to establish whether he could input into the findings of her examination.  We upheld the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mr C and Miss A for the shortcomings identified;
• staff involved in Miss A's care on the day concerned should be made aware of the content of this report to allow them the opportunity to reflect and also consider it at their next formal appraisal;
• apologise to Miss A (copied to Mr C) that when communicating with her, staff failed to take her learning difficulties into account;
• apologise to Mr C for not reverting to him for his assistance in this matter; and
• review their advice to staff members about treating people with disabilities to establish whether or not it is currently fit for purpose.  If it is not, they should provide updated advice and guidance.

Summary
Mrs C complained about the care and treatment her late husband (Mr C) received at Raigmore Hospital after he attended the Emergency Department (ED) by ambulance.  Despite Mr C being initially diagnosed with a chest infection, his condition deteriorated suddenly and he died the following day.  Mrs C questioned whether her husband was given appropriate treatment and complained that staff did not properly communicate with her.

When the board investigated Mrs C's complaint, they did not identify any failings in relation to the treatment provided to Mr C, although they acknowledged that staff could have communicated better with Mrs C.

We took independent advice from a consultant in emergency medicine and a consultant cardiothoracic anaesthetist.  We were concerned about significant failings the emergency medicine consultant adviser identified in relation to the treatment Mr C received whilst in the ED, including the fact that the board's local investigation of the complaint did not pick these up.  We accept that the treatment in the ED led to Mr C's abrupt and unexpected deterioration.

Whilst we found that the care provided in the Intensive Treatment Unit (ITU) was of a reasonable standard, we were critical of the communication with Mrs C about her husband's continuing deterioration.  We found that Mrs C had been waiting for a significant period of time in a side room in the ED when ITU staff were trying to contact her and that this was likely the result of poor documentation and communication by ED staff.

Redress and Recommendations
The Ombudsman recommends that the Board:

• conduct a Significant Event Analysis (SEA) into the care Mr C received in the ED in order to identify appropriate improvements in clinical practice and share these findings with the family and my office;
• ensure that the findings of this investigation and the outcome of the SEA are shared with the doctors involved in Mr C's care in the ED and discussed at their next appraisal for shared learning and improvement in clinical practice;
• conduct a review of the complaint in order to explore how the complaints handling failed to identify these issues;
• provide documentary evidence showing the steps that have been taken to improve triage record-keeping;
• apologise to Mrs C and the family for the failings this investigation has identified; and
• share these findings with relevant staff who had been involved in Mr C's care to highlight the importance of documenting conversations with relatives to ensure effective communication between hospital wards.

Summary
Mrs C complained via an advocacy service in relation to her husband (Mr A) who was receiving end of life care at home.  Mrs C had gone out one morning, expecting a visit from a district nurse (the nurse) to take place in her absence.  When Mrs C returned, she found Mr A deceased and in an inappropriate position.  Mrs C called her immediate family who lived within walking distance.  Her daughter (Mrs B) covered Mr A up and the family contacted the emergency services.

Paramedics attended and confirmed that Mr A had died.  A doctor from the family's GP practice attended to certify death.  Mrs C complained to the board shortly afterwards, saying that she believed the nurse had left the property whilst Mr A was dying or after he was dead.

In response to the complaint the board conducted an internal investigation.  They interviewed Mrs C, the nurse and other health professionals involved in the case.  The nurse accepted that they had left the property without recording their visit properly, but stated they had intended to return.  They denied strongly having left Mr A in an inappropriate condition.

The finding of the internal investigation was that the nurse's version of events was confused and contradictory.  It concluded the nurse had breached professional guidelines in terms of record-keeping and that the care they had provided had fallen below an acceptable standard.

The internal investigation recommended a disciplinary hearing be held.  Mrs C's advocate advised us that the family had not been kept informed of the board's actions.  The advocate said there had been an extended and unexplained delay in the investigation and when a formal complaint was made about this, the board's complaint response was entirely inadequate.

The advocate said the family were told they could not be given any details of what had happened to Mr A, though they were told the board were satisfied that the nurse had responsibility for the condition Mr A was found in.  We reviewed all the interviews and information considered by the board's internal investigation.  We also interviewed Mrs B, who said she felt she had been overlooked by the board's original investigation.  We took professional advice on the standard of nursing care provided to Mr A and whether this met the professional standard expected of a nurse.  We found that although it was not possible to determine exactly what took place, the likelihood was that the nurse performed some form of treatment on Mr A.

There was no suggestion this had contributed to his death, but the weight of the evidence pointed to Mr A being left in an inappropriate condition by the nurse.  We found the board's investigation had failed to interview family members, and that the board had not provided the family with an adequate explanation for their actions.  The advice we received was that the nurse's actions fell below acceptable professional standards and that the care provided to Mr A was unreasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• consider a referral to the Nursing and Midwifery Council, in view of the concerns raised over the Nurse's conduct and that an explanation for any decision reached is provided to this office;
• review the procedures for the management of lone working in the community to ensure an adequate level of communication is sustained between staff and managers;
• remind staff of the importance of giving consideration to interviewing all individuals involved in an the incident under investigation;
• provide evidence that the actions identified in their review of the handling of Mrs C's complaint have been implemented;
• provide evidence that all staff have been reminded of the need to identify and record complaints accurately; and
• apologise unreservedly for the failings identified in this report.

Summary
Mrs C complained about the care and treatment given to her young son (Master A) when he attended a hospital Emergency Department (ED) over a period of two days after he suffered a head injury at nursery.  Master A has hydrocephalus and had had a shunt fitted a few months after he was born to relieve the pressure caused by fluid accumulation.  Because of this, Mrs C said that as well as the usual checks and examination, he should also have been given a precautionary CT scan.  He was not and was discharged home.

A month later, Master A and his family went abroad on holiday and he became very ill and was taken to hospital.  A CT scan taken there showed that his shunt had become dislodged and he had suffered a bleed.  He remained in hospital for four days before being returned home.

Mrs A complained to the board who took the view that the care and treatment given to Master A on the two occasions he attended the ED was reasonable.  Our investigation showed that Master A's examination in the ED had been good, specific and relevant.  However, as he had attended again for the same problem within a short time, caution needed to be taken; on the second occasion his head injury should have been discussed with a senior member of staff and as there was reason to question a shunt malfunction, staff should have had a low threshold of suspicion and considered a CT head scan.  Alternatively, as his parents felt that Master A's condition had not returned to normal, he should at least have been admitted for observation.  For these reasons, we upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make Mrs C a formal apology recognising the identified shortcomings identified in this report; and
• ensure that the clinical staff involved in Master A's case make themselves fully aware of the relevant Scottish Intercollegiate Guidelines Network guidance ('Early management of children with a head injury', May 2009) to ensure that the same situation does not recur.

Summary
Mr C complained to us that the board had failed to provide his wife (Ms C) with appropriate clinical treatment following a GP referral to Perth Royal Infirmary for a suspected brain aneurysm.  Ms C had been referred to the hospital by a GP after becoming unwell.  In the referral letter, the GP referred to, amongst other things, a suspected subarachnoid haemorrhage (an uncommon type of stroke caused by bleeding on the surface of the brain).  Ms C had reported sudden onset of pain in her head and neck with some visual disturbance.  She was admitted directly to the acute medical unit in the hospital where she was medically assessed by a specialist trainee doctor.  She was then reviewed by a consultant physician.  She was subsequently discharged home with the problem felt to be musculoskeletal.

Ms C attended her GP on several occasions over the next few weeks.  She then collapsed at home and was taken to the intensive care unit with signs of acute subdural haematoma (a serious condition where blood collects between the skull and the surface of the brain).  Further treatment was not deemed appropriate and Ms C died in the hospital two days later.

We took independent advice on Mr C's complaint from a consultant physician.  The adviser noted that there were sufficient features to suggest that Ms C had a thunderclap headache and that a CT scan should have been performed at that time.  If this was negative, a lumbar puncture (a medical procedure where a needle is inserted into the lower part of the spine to test for conditions affecting the brain, spinal cord or other parts of the nervous system) should have then been performed and, if positive for subarachnoid haemorrhage, a neurological opinion would have been essential at that point.

We found that it was unreasonable that Ms C had been diagnosed with musculoskeletal neck pain.  The adviser said that a patient with no previous significant headache history who presents with sudden severe neck and occipital pain (pain at the back of the head) should be investigated as a thunderclap headache.  We also found that Ms C had not been monitored appropriately in the acute medical unit.

In view of the fact that Ms C's headache was not reasonably investigated, we upheld Mr C's complaint that the board failed to provide Ms C with appropriate clinical treatment on 7 January 2016.  Whilst we cannot say that Ms C's life would definitely have been saved if these tests had been carried out, the adviser has stated that it was probable that Ms C's condition was treatable.

Mr C also complained that the board had failed to address his complaint in a timely and professional manner.  We found that the board's response had not addressed all of the points Mr C had raised and that they should have provided a more detailed response to him in relation to his questions about the failure to take action in line with the relevant medical guidance.  The board also delayed in issuing the minutes to Mr C after meeting him to discuss the matter.  In view of these failings, we also upheld this aspect of Mr C's complaint.

Redress and Recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr C for the failure to provide reasonable treatment to Ms C when she attended the Hospital on 7 January 2016;
• provide evidence that steps have been taken in the Hospital to ensure that adult patients presenting with headache are investigated in line with SIGN 107 (the Scottish Intercollegiate Guidelines Network guidance on the Diagnosis and Management of Headache in Adults);
• provide evidence that steps have been taken in the Hospital to ensure that patients are monitored appropriately;
• provide evidence that steps have been taken in the Hospital to ensure that, in appropriate cases, patients are issued with a discharge note in line with SIGN 128 (the SIGN discharge document);
• confirm that this report will be discussed at the Consultant's next appraisal; and
• issue a written apology to Mr C for the failure to provide a satisfactory response to his complaints.

Summary
Mr C's wife (Mrs A) was admitted by ambulance to Monklands Hospital with increased breathlessness.  While visiting Mrs A, her daughter (Ms B) who is a nurse, reviewed Mrs A's medical records and noticed that it was recorded that Mrs A had been given Amoxicillin, a penicillin antibiotic, earlier in the day.  Mr C said that he had made both ambulance and hospital staff aware that Mrs A was allergic to penicillin and that, previously, penicillin had caused Mrs A to suffer anaphylactic shock.  Mr C said that thereafter Mrs A's condition deteriorated.

Mr C said that although Ms B had immediately informed a member of the nursing staff of the prescribing error, staff had failed to take corrective action and to conduct increased observations of Mrs A.  Mr C said there was also a failure to document the incident in Mrs A's medical records at the time and again when Mrs A was later transferred to the Intensive Care Unit (ICU). Mr C believed there had been unreasonable delay in transferring Mrs A to the ICU where she remained until her death.

Mr C considered that Mrs A had been denied proper treatment for the possible adverse effects of an anaphylactic reaction to the Amoxicillin.  Mr C said that he believed the error in administering Amoxicillin to Mrs A and the lack of an appropriate response could have hastened or brought about Mrs A's deterioration and death.  As a result, Mr C believed that Mrs A had not been provided with a reasonable standard of care and treatment.

The board acknowledged that Mrs A was unreasonably prescribed and administered Amoxicillin when she had a known allergy; that the response of medical and nursing staff was deficient; and there were failures in record-keeping.  The board said that, while Amoxicillin should not have been prescribed or administered to Mrs A, there was no suggestion that an allergic response was seen or was responsible for Mrs A's subsequent clinical course.

During the investigation, my complaints reviewer took independent advice from a consultant in respiratory medicine and a nurse.

Regarding Mr C's complaint that Mrs A was unreasonably given Amoxicillin when she had a known allergy to penicillin, the medical and the nursing advisers said that while what had occurred in Mrs A's case was a human error, the failure by staff to follow drug administration policies was a serious incident and represented serious failings in care.

In respect of Mr C's complaint that staff had failed to take appropriate steps when the prescribing error was reported to them, the medical adviser said that although the board had accepted there were failures in the response of nursing and medical staff to Mrs A wrongly being administered Amoxicillin, these failings fell below an expected standard of care that Mrs A should have received and represented serious failings in Mrs A's care.

Mr C also complained that there was a failure to provide Mrs A with a reasonable standard of treatment. The medical adviser said that the deterioration in Mrs A's condition was due to the worsening of an underlying condition and not to the administration of Amoxicillin.  However, the medical adviser said there were missed opportunities to identify the severity of the deterioration in Mrs A's condition earlier on in her admission and Mrs A should have been referred earlier to the ICU team.  All of which represented a serious failure in Mrs A's care.  I accepted the advice I received.

I was concerned by the serious failings identified in Mrs A's care and treatment and in view of these failings, I upheld all of Mr C's complaints.  I have, therefore, made recommendations to address this.

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise for the failings identified in complaint (a) in relation to the prescribing and administration of   Amoxicillin when Mrs A had a known allergy to penicillin;
• ensure the comments of Adviser 1 and Adviser 2 in complaint (a) about the action that requires to be taken to avoid a repetition of what occurred are brought to the attention of relevant staff and to report back on the action taken;
• carry out a review of the Action Plan and the Board's policies on drug administration in view of the comments of Adviser 1 and Adviser 2 referred to at paragraphs 31, 34 and 35 and to report back on the action taken;
• provide my office with an update on the work of the Patient Safety Programme;
• apologise for the failings identified in complaint (b) in relation to the failure to take appropriate action when it was reported that Mrs A had wrongly being administered Amoxicillin;
• ensure the comments of Adviser 1 and Adviser 2 in complaint (b) are brought to the attention of relevant staff and to report back on the action taken;
• carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraph 55 and to report back on the action taken;
• provide evidence to show how they encourage staff to report early when errors occur and how they share the learning from such errors with staff;
• apologise for the failings in Mrs A's treatment identified in complaint (c);
• ensure the comments of Adviser 1 and Adviser 2 in complaint (c) are brought to the attention of relevant staff and to report back on the action taken; and
• carry out a review of the Action Plan in view of the comments of Adviser 1 referred to at paragraphs 95; 96 and 97 and to report back on the action taken.

Summary
Mr C, an advocacy worker, complained about the care and treatment Mr A received during and following an admission to Dr Gray's Hospital, Elgin.  Mr A was admitted in a critically ill state, suffering from sepsis due to a chest infection; alcohol withdrawal; and possible effects of malnutrition.  The sodium levels in his blood were noted to have been dangerously low and he was prescribed intravenous (IV) fluids to try to raise them.  However, as a result of the sodium levels rising too quickly, Mr A developed a neurological condition known as osmotic demyelination syndrome and was left profoundly incapacitated.  Mr C complained that Mr A's incapacity, which includes profound speech problems and walking difficulties, was as a result of inappropriate administration of IV fluids.

We took independent medical advice from a consultant physician, who did not consider that Mr A's sodium levels were adequately monitored.  They noted that there were long periods between reviews of blood tests and no evidence that Mr A's fluid prescription was ever adjusted according to his sodium levels.  They said that the rapid rise in sodium levels did not appear to have been considered at all until neurological deterioration was apparent.  We accepted this advice and upheld the complaint.  We were critical of the board for not having proactively arranged to formally review Mr A's care given the unfortunate outcome, and for not having identified learning points following their investigation of Mr C's complaint.

Mr C also complained that, when Mr A was formally certified as not having had capacity to make decisions about his medical treatment, the board did not appoint an advocate.  We noted that subsequent discussions about Mr A's care and treatment were documented with his daughter (Miss A) and other relatives.  We were advised that, as Mr A had living relatives and was not without representation, there was no requirement to appoint an advocate.  We did not uphold this complaint.  In addition, Mr C complained that a decision not to resuscitate Mr A in the event of heart or lung failure was not discussed with Miss A.  Although the extent to which this was discussed with Miss A was not clear, it appeared that she was made aware of the decision retrospectively.  We were advised that it would be reasonable for medical staff to take such a decision, and discuss it with family afterwards, if there is sudden deterioration at a time when family could not be reached.  However, this was not the case with Mr A and his poor health was chronic in nature, with no signs of recovery over time.  We, therefore, concluded that there was an opportunity for the decision to have been discussed and agreed with Miss A prior to it being taken.  Given this, and the fact that there was no clear evidence of an explicit discussion afterwards, we upheld this complaint.

Finally, Mr C also complained about a lack of medical review following Mr A's discharge, noting that he had not had any further contact from the hospital.  We were advised that hospital follow-up would only be arranged if there was any potential benefit from review in a specialist led clinic.  In Mr A's case, we were informed that there was no routine requirement for further medical input and that any necessary medical interventions for complications could reasonably be handled by his GP.  We, therefore, did not uphold this complaint.  However, we noted that the discharge arrangements did not appear to have been made clear to Mr A.  While these were set out in the discharge letter that was sent to his GP, we identified that this was not sent until almost four months after discharge.  We considered this unacceptable and made some further recommendations.

Redress and recommendations
The Ombudsman recommends that the Board:

• carry out an adverse event review of this care episode, taking account of the failings this investigation has identified, and inform us of the steps they have taken to avoid a similar future occurrence;
• apologise to Mr A for their failure to appropriately manage his fluid intake and for the serious impact this failing has had on his health and quality of life;
• carry out a review of the DNACPR process and take steps to ensure that these decisions are appropriately discussed with patients' representatives, where possible;
• apologise to Mr A and Miss A for failing to appropriately discuss the DNACPR decision with Miss A;
• provide us with an assurance that processes are in place to avoid similar future delays in discharge summaries being sent to GPs; and
• apologise to Mr A for the delay in sending the discharge summary to his GP.

Summary
Mrs C's child (Child A) had been suffering from vomiting and headaches and was referred to a paediatrician at Forth Valley Royal Hospital in January 2014.  The paediatrician saw Child A on three occasions from January 2014 until July 2014.  In August 2014, Child A collapsed at home and was admitted to Forth Valley Royal Hospital as an emergency.  Child A was diagnosed with a brain tumour. They underwent lengthy and difficult surgery to remove the tumour, but it was impossible to remove it completely.  Mrs C said that despite the evidence of Child A's deteriorating condition, the paediatrician failed to record their symptoms and carry out appropriate tests, referrals and investigations.  Mrs C also said that the paediatrician failed unreasonably to consider a serious cause of Child A's symptoms.  As a result, Mrs C believed that Child A's brain tumour should have been detected much earlier and that they suffered unnecessarily.

During the investigation, my complaints reviewer took independent advice from a specialist in paediatrics and a specialist in paediatric neurosurgery.  The first adviser considered that Child A should have been referred for a brain scan in April 2014 (at the least) and that the paediatrician's failure to consider that Child A may have a brain tumour and arrange appropriate scans and referrals was below an acceptable standard of care.  I accept that advice.  I am particularly concerned about the paediatrician's failure to act in July 2014 given that they had documented their awareness of headaches in addition to ongoing vomiting.  The second adviser said that it was likely an earlier diagnosis would have meant a smaller tumour and a shorter, less challenging operation.  My view is that these failures led to a significant personal injustice to Child A.  The unreasonable delay meant that an opportunity to completely remove the tumour was missed, and in this respect I note that Child A required additional treatment (chemotherapy) with significant risks and was left with neurological defects.  In addition, Child A's collapse was very traumatic for them and their family.  Given the evidence and information available to the specialist about Child A's condition (from January 2014 onwards), I am extremely concerned about their failure to properly assess and investigate Child A's symptoms, and their failures raise questions about their competence.  In view of the failings identified, I upheld the complaint about the clinical care and treatment provided and made recommendations.  However, I did not make recommendations that relate directly to the paediatrician because they are no longer an employee of the health board.

Redress and recommendations
The Ombudsman recommends that the board:

• ensure that all relevant healthcare professionals are aware of the guidelines relating to the diagnosis of brain tumours in children and young people (the HeadSmart programme); and
• apologise to Mrs C for the failures identified.

Summary
Mr A was admitted to A&E at the Royal Infirmary of Edinburgh after being found at the bottom of a flight of stairs with a suspected head injury.  He was assessed as having a reduced level of consciousness but this was attributed to intoxication.  It was therefore decided that he would be observed in A&E overnight to ensure his symptoms improved.

Mr A was discharged the following morning and collected by his mother, who found him to be confused and disorientated.  However, after discussion with reception staff, she was assured that he was medically fit to leave.  On their return home, Mr A's mother remained concerned about his condition, so they attended A&E at Wishaw General Hospital, where a CT scan was carried out. This indicated that Mr A had suffered a brain haemorrhage.  He was then transferred to the Southern General Hospital for emergency surgery.

Mr A's sister (Mrs C) complained that Mr A had failed to receive appropriate treatment for his head injury at the Royal Infirmary of Edinburgh.  Mrs C felt that Mr A should not have been discharged, given his condition.  The board apologised for failing to provide a correct diagnosis and accepted that they had wrongly attributed signs of disorientation and incoherence to intoxication rather than a developing bleed on the brain.  The board stressed that assessing patients who have head injuries but are also intoxicated can be very difficult.

During the investigation, my complaints reviewer took independent medical advice on Mr A's treatment from consultants in both emergency medicine and neurosurgery.  The advice received was that, under Scottish Intercollegiate Guidelines Network (SIGN) guidance, Mr A should have received a CT scan on admission to the Royal Infirmary of Edinburgh based on his recorded symptoms and that it was not reasonable to attribute those symptoms to intoxication in the circumstances.

My investigation also highlighted a poor level of record-keeping for Mr A's admission.  According to records, Mr A appeared to have undergone significantly fewer neurological observations than were required by the board's internal procedure for managing patients with head injuries.  We also found that this procedure was not in line with SIGN guidance and that there was no record made of any assessment prior to Mr A's discharge.

Redress and recommendations
The Ombudsman recommends that the board:

• apologise to Mr A and Mrs C for the failings identified in this report;
• review their procedure for the management of patients with a head injury to bring it in line with SIGN guidance;
• carry out an audit of a sample of recent cases of this kind, to ensure they are being dealt with appropriately; and
• carry out a root cause analysis to identify why the medical and nursing staff on duty did not follow the systems in place.