Health

Summary
Miss C, who had a previous history of mental illness, had a psychotic episode and was taken by ambulance in the early hours of the morning to the emergency department at Wishaw General Hospital.  An initial mental health assessment was carried out identifying that she was seriously unwell and should be assessed by a doctor as soon as possible.  However, she was not assessed for over three hours.  A junior doctor examined her, took blood tests and contacted the on-call psychiatrist for advice.  The psychiatrist said that out-patient follow-up may be the best option and that they would review Miss C after her blood tests were done.  A couple of hours later, Miss C's parents were told that she was being admitted to the hospital for assessment.  However, Miss C was agitated, received sedation and was restrained by the police.  Later that morning her parents were told that she had been detained under mental health legislation.  She was transferred to Monklands Hospital as there were no beds available.

Miss C’s mother (Mrs C) complained that if Miss C had initially been properly assessed by a psychiatrist and admitted to Wishaw General Hospital, then the police would not have become involved and she would not have been detained.

As part of my investigation of Mrs C's complaint, I obtained independent advice from advisers in emergency medicine and psychiatry.  My adviser in emergency medicine considered that the triage nurse in the emergency department had appropriately assessed Miss C.  He said that the delay in assessment by a doctor was not ideal but, unfortunately, was not unusual in a busy emergency department at night.  My adviser found that the junior doctor's assessment was thorough and of a good standard, but that the junior doctor failed to recognise the severity of Miss C's illness.  Due to a lack of detail in Miss C’s records, my emergency medicine adviser could not state definitively that she required hospital admission but, in his opinion, it was highly likely that she did.  He said that the junior doctor should have questioned the advice of the on-call psychiatrist and insisted on an urgent psychiatric assessment in the emergency department, escalating this to a consultant if the request was refused.  He also said that when Miss C's condition deteriorated and three doses of sedatives were required, she should have been thoroughly re-assessed.

My psychiatric adviser considered that Miss C's psychiatric assessment was unduly delayed and that her condition was allowed to deteriorate during this delay.  He said that it had been unreasonable for the on-call psychiatrist to say that out-patient follow-up may be the best option for Miss C, and he also considered that the standard of note-keeping was inadequate.  In view of all of these failings, I upheld this aspect of Mrs C's complaint and made recommendations.

Mrs C also complained that the board's handling of her complaint was inadequate.  Having carefully considered their initial response to her complaint, I do not consider that it was an adequate response to the issues she had raised about Miss C's treatment, as they failed to show how these had been investigated.  After this, Mrs C met staff from the board, then wrote to them.  The board's response again did not acknowledge their failings or address all of Mrs C's concerns about Miss C's treatment in the emergency department.  Therefore, I also upheld this aspect of the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failure to provide reasonable care and treatment to Miss C in hospital on 18 September 2013;
• remind medical and nursing staff in the Emergency Department that acute mental health patients are high-risk patients;
• take steps to try to put a low threshold in place for the involvement of senior medical staff in decision-making regarding the discharge of such patients;
• take steps to ensure that the assessment and management of acute mental health presentations is discussed during the induction programme for new junior doctors in the Hospital's Emergency Department;
• take steps to ensure that it is emphasised in the induction programme of junior on-call psychiatrists that it should normally be the case that acute mental health patients attending the Emergency Department following an emergency should have a thorough psychiatric assessment;
• remind relevant psychiatric staff that patients being considered for discharge directly from the Emergency Department should have their follow-up and circumstances taken into consideration;
• consider if there should be a change to the process to allow the member of staff carrying out the triage to consider direct referral for psychiatric assessment in high-risk cases;
• emphasise to relevant staff involved in the complaint the importance of keeping accurate records that would be fully adequate for the purposes of later scrutiny;
• consider if there should be a protocol for emergency tranquilisation in the Emergency Department;
• issue a written apology to Mrs C for the failure to satisfactorily respond to her complaint; and
• make the staff involved in the handling of Mrs C's complaint aware of our decision on this matter.

Summary
Mr A was elderly and had several serious health problems, including a form of dementia.  He was admitted to the Royal Edinburgh Hospital from his nursing home due to worsening behavioural problems, including agitation and aggression.  His mental health assessment showed that he lacked awareness and insight into his problems, and had trouble with communication.  This, plus his aggression, meant that he was a risk to himself and other people.

Mr A was mobile with the help of a walking stick when he was admitted to hospital.  He fell two days later and suffered bruising, then fell again a few days later, and broke his hip.  He was transferred for surgery but died two days after the operation.

His daughter (Mrs C) believed that Mr A's fall risk had been poorly assessed when he was admitted, and that he was not properly cared for after the first fall so the second fall was not prevented.  She was concerned that he was over-sedated and not eating or drinking enough, and that the management of his diabetes was inadequate.  She also felt Mr A's aggression had not been handled well and that he was blamed for his behaviour, when it was actually the result of his illness.

I obtained independent advice from a nursing adviser, who noted that the board's policy is to complete a falls risk assessment for all elderly patients and to review the patient's falls care plan if they fall.  The board's complaint investigation report said that this was all done, but my adviser found no evidence to support this and considered that the standard of record-keeping and falls prevention practice was poor overall.  I agreed with this view and, therefore, upheld the complaint and made recommendations.

Regarding Mrs C's complaint about sedation, my adviser said that the appropriate medication and dosage was prescribed and that quick action was taken when adverse effects were noted.  My adviser also considered that the board's response letter was balanced and did not blame Mr A for his behaviour.

However, the advice I received was critical overall of the standard of nursing provided to Mr A.  The record-keeping was inadequate and did not include care plans for Mr A's personal care or communication difficulties.  There was also a significant failure to monitor Mr A's blood glucose levels appropriately and a failure to adequately monitor his nutritional intake.  I noted that the board's complaint response states that blood glucose levels were not monitored following Mr A's admission and I was critical of their failure to act on this.  I upheld the complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:

• remind all staff that a falls risk assessment is a requirement on admission of an elderly patient;
• review the complaint investigation to establish why statements about Mr A's care not supported by the clinical record, were included in their formal response;
• review their admission procedures for elderly patients to ensure that a Malnutrition Universal Screening Tool assessment is recorded;
• remind all staff involved in Mr A's care of the importance of regular and accurate blood glucose monitoring for diabetic patients;
• remind all staff involved in Mr A's care of the importance of accurate and comprehensive care plans, which meet all a patient's needs; and
• apologise to Mr A's family for the failures identified in this report.

Summary
Mrs C had previously suffered from mouth cancer and was treated at Monklands Hospital.  After finding an ulcer in her cheek, she contacted the consultant previously in charge of her care, and was seen at Monklands Hospital again, where the ulcer was found to be cancerous.  Mrs C's case was discussed at the multi-disciplinary team (MDT) meeting, who decided to refer Mrs C to the Southern General Hospital for treatment.

However, this was not done until a week later.  The referral was by email from the consultant to his colleagues with details of Mrs C's (and other patients') cases, rather than a formal referral by letter.  It is not clear whether the email was received.  Around this time the head and neck / maxillofacial (the diagnosis and treatment  of diseases affecting the mouth, jaws, face and neck) consultants at the Southern General Hospital decided that, due to lack of capacity, they would no longer accept referrals of patients they considered could be treated locally (such as Mrs C).  It is unclear whether the management team instructed the consultants to do this, or whether the Southern General Hospital was required to accept Mrs C's referral under the existing funding arrangements.  Mrs C was not told that there was a problem with her referral.

Mrs C grew increasingly concerned about the delay, and phoned the consultant at Monklands Hospital several times over the next few weeks to follow this up.  Finally, about a month after the MDT, Mrs C emailed the consultant, outlining her strong concerns, and the consultant phoned the Southern General Hospital and arranged an urgent appointment for Mrs C.  Mrs C said that her treatment from Southern General Hospital staff was excellent from that point on.

Mrs C complained about the delay in the scan and the MDT meeting, as well as the delay in referring her to the Southern General Hospital.  Mrs C was concerned that the delay may have worsened her outcome, as she was initially told that surgery would be performed with the aim of providing a cure.  However, the surgery that she subsequently received significantly reduced her quality of life and gave her a low chance of surviving her cancer.  Mrs C also complained about the lack of communication from Monklands Hospital staff about what was happening.

My investigation found that the delay in arranging Mrs C's surgery was unreasonable, and outwith the national HEAT (Hospital Efficiency and Access Targets) standards.  I found it was unreasonable for the Monklands Hospital consultant to wait one week before referring Mrs C, and also that the email sent by the consultant was not an adequate referral.  I also found that there was a breakdown in the referral process between Monklands Hospital and the Southern General Hospital, which meant that no plans were made for Mrs C's surgery at either hospital until she followed this up repeatedly.  I am concerned that an important decision (not to accept certain referrals) could be made and implemented at NHS Greater Glasgow and Clyde without clear, recorded management approval.  I am also strongly critical of the poor communication between the consultants at both health boards, as they apparently discussed Mrs C's case without clearly agreeing who would be responsible for her treatment (both hospitals appeared to think the other would be responsible).  It was only through Mrs C's courage and perseverance in following up her own appointment that this matter was resolved.

I also found that Monklands Hospital staff failed to communicate reasonably with Mrs C about her treatment.  Staff did not return her calls on at least one occasion and, although the consultant phoned the Southern General Hospital to follow up the referral and offered to perform the surgery himself, no-one contacted Mrs C to explain what was being done or to check that the appointment had come through.

In reporting on this complaint, I outlined significant concerns about the way in which both boards provided information during my investigation.  NHS Lanarkshire failed to provide a key piece of evidence relating to this complaint until after my investigation was concluded.  NHS Greater Glasgow and Clyde also provided new evidence at a late stage, which directly contradicted information they had previously given during the investigation.  This caused unnecessary difficulties and delays in completing the investigation, and undoubtedly added to Mrs C's distress.  I also raised concerns at the lack of appreciation both boards have shown of the impact these events have had on Mrs C, and of the value of her complaint.  This case involves a patient who was left without any plans for her cancer surgery for several weeks, as the boards were unable to effectively communicate about, and resolve, an administrative disagreement over who was responsible for the surgery.  In this context, I am disappointed that the boards were not more proactive about acknowledging that Mrs C's experience was unacceptable, and acting to prevent a recurrence.

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• issue a written apology to Mrs C for the failings I found; and
• bring my findings to the attention of Consultant 1, for reflection as part of his next annual appraisal.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• issue a written apology to Mrs C for the failings I found;
• feedback my findings to all staff involved, for reflection and learning; and
• ensure there is a clear procedure for authorising and recording any decisions not to accept referrals, and that staff are aware of this.

The Ombudsman recommends that both boards:

• conduct a joint significant event analysis to investigate and address the cause(s) of the delay in Mrs C's referral, and share the results with my office and with Mrs C, if she wishes.

Summary
Mrs C complained about her late mother (Ms A)'s interaction with NHS 24, in particular their main out-of-hours telephone service, the Unscheduled Care Service (UCS), and Breathing Space, which is a confidential telephone service for people experiencing low mood, anxiety or depression, and also part of NHS 24.

Ms A suffered from anxiety and depression.  One week after attempting suicide, she telephoned Mrs C and told her she needed help as she could not cope.  Mrs C called NHS 24, describing Ms A as a risk to herself, and an NHS 24 call handler rang Ms A directly.  Ms A was extremely distressed during the call.  She told the call handler that she might harm herself again and that she wanted to be taken away under mental health legislation.  The call was initially classified as 'serious and urgent' but, when no nurse was available to speak to Ms A, a senior nurse advised the call handler to downgrade the call, which set a three hour call back from a nurse practitioner.  They also offered Ms A assistance from Breathing Space whilst she waited for the call back, which she accepted.  The Breathing Space adviser (the BSA) spoke and did breathing exercises with Ms A, but she was still tearful when the call ended.  A nurse practitioner called Ms A around two hours later but there was no answer and the call was closed.  Mrs C called the police a few days later as she had been unable to contact Ms A.  They forced entry to Ms A's home and found that she had completed suicide.  It is understood that she died from an overdose of medication.

In investigating Mrs C's complaints, I took independent advice from a nursing adviser, a mental health adviser and a GP adviser with experience of NHS 24 and out-of-hours work.

Mrs C said that the classification of Ms A's call meant that a suicidal woman needing immediate help instead received a three hour call back.  NHS 24's own investigation report noted that it was unclear why the call was downgraded, and that there seemed to have been a disregard of mental health concerns by the senior nurse.  They also found that following the transfer to Breathing Space, the call should have been closed down within the UCS.  The advice I received was that, given the information taken by the call handler, contact with Ms A should not have been broken.  Allocating a three hour call back and leaving the call open after transferring to Breathing Space was not reasonable and, therefore, I upheld this complaint.

Mrs C complained that the BSA had not used Applied Suicide Intervention Skills Training (ASIST) during the call with Ms A and took no action to help her.  NHS 24 said that ASIST techniques were not used as the BSA knew that a nurse practitioner would be calling Ms A to make a full clinical assessment of her symptoms.  My mental health adviser said that this explanation was not reasonable as the BSA knew about Ms A's suicide attempt yet did not explore sufficiently the risk of suicide during the call.  My adviser said that the support offered by the BSA was ineffective.  The call recording showed that Ms A became increasingly distressed and my adviser commented that they would have expected the BSA to continue speaking with Ms A until her distress had reduced, instead of ending the call.  I found that Breathing Space did not offer a reasonable service to Ms A so I upheld this complaint and made several recommendations.

Mrs C also complained that there was only one attempt to call Ms A back before closing the call, and that NHS 24 did not contact Ms A's GP.  My investigation found that NHS 24's procedure is to attempt to call patients up to two times before closing the call, unless there is a particular clinical concern.  However, there was enough evidence from Ms A's call to indicate a 'particular clinical concern' and I considered that further action should have been taken, including sharing information with Ms A's GP.  Therefore, I upheld this complaint.

This significant case has raised concerns about how effectively mental health crises are managed by the UCS.  The initial call handling is geared towards physical problems and gathering personal information.  However, the advice I have received highlighted that, for people experiencing mental health difficulties, this is ineffective and can exacerbate their symptoms.  More needs to be done to ensure that mental health is not treated with any less urgency than physical health, so I made a number of additional recommendations to address my wider concerns.

Redress and recommendations
The Ombudsman recommends that NHS 24:

• apologise to Mrs C for the allocation of a three hour call back;
• ensure that this complaint is included for discussion at the next appraisal of the Senior Nurse;
• ensure that all relevant staff are aware of the guidance on transferring calls to Breathing Space to avoid incorrect advice being offered to call handlers in future;
• apologise to Mrs C for the way this call was handled by Breathing Space;
• ensure that the findings of this report are discussed with the BSA for learning;
• ensure that Breathing Space staff are aware of when to use ASIST techniques;
• ensure that all Breathing Space staff are aware of the process to escalate calls;
• apologise to Mrs C for the failure to take appropriate action when Ms A could not be reached;
• ensure that this complaint is included for discussion at the next appraisal of the Nurse Practitioner;
• report to us on the implementation schedule of the new Patient Contact Management system system;
• and then again when the system goes live
• review their guidance for all staff on the management of suicidal thoughts and common mental health problems;
• review their procedures for triaging mental health difficulties, such as panic and depression, for patients who present in crisis; and
• review the questions used in the initial contact process to take mental health into account.

CSummary
Ms C was assessed as low risk during her pregnancy and it was, therefore, considered suitable for her to deliver her baby at the Community Midwifery Unit at Vale of Leven District General Hospital.  After going into labour she was admitted to the maternity unit but her labour was slow to progress.  Several hours after admission, an examination found that her baby was in a posterior position (when the back of the baby's skull is in the back of the mother's pelvis).  This meant that the delivery would be more complicated and would be likely to need a higher level of care than was available at the maternity unit.  Staff called an ambulance to transfer Ms C to the Royal Alexandria Hospital.  The ambulance service was particularly busy so the transfer took longer than expected.  There was also a delay in the ambulance team accessing the building as they did not know the maternity unit.  Ms C was given an episiotomy (a minor surgical cut that widens the opening of the vagina during childbirth) very shortly before she was transferred.  Her baby was unwell at birth and she was transferred to another hospital for specialist neo-natal treatment.

Mr and Ms C complained to the board that the maternity unit did not reasonably explain in advance the transfer arrangements to hospital from the unit in case of an emergency; did not provide a reasonable standard of maternity care; delayed making the decision to transfer Ms C to hospital; contributed to delays during the transfer process; and that the board did not handle their complaint in line with the complaints procedure.

The board conducted a Significant Incident Review following the complaint, identifying a number of failings in Ms C's care, and recommending improvements at the maternity unit.

I took independent midwifery advice on this complaint.  Regarding the information received about an emergency transfer to hospital from the maternity unit, it was clear that Ms C's understanding of the transport arrangements was not correct.  She had also not been given any written information.  The board acknowledged that Ms C should have been given clearer information, and they had amended a leaflet to include the transfer information.  However, my adviser noted that the leaflet should be provided to women before they have chosen where to give birth.

We found several failures in the maternity care provided to Ms C in the maternity unit.  This included a failure to properly assess her on admission or identify a clear plan of care; lack of monitoring throughout her labour; poor documentation, particularly of care planning and regarding handovers between staff; and also the episiotomy was undertaken inappropriately and possibly unnecessarily.  The poor standard of care put Ms C and her baby at unnecessary risk.

As a result of some of the failures above, the decision to transfer Ms C to hospital was delayed.  If her labour had been managed properly, she could have been transferred before it was an emergency.  I am critical that the board's SIR did not highlight this delay and that they have yet to apologise for it.

The delay in the ambulance arriving at the maternity unit was due to pressures on the ambulance service and therefore out of the board's hands.  However, the difficulties the crew experienced getting into the building were avoidable, and I am critical of the lack of action from the maternity unit staff.

The board clearly did not deal with Mr and Ms C's complaints within the timescales of their guidance (Guidance to Staff in Dealing with Complaints).  Additionally, the board's final response to their complaints was in the form of notes from meetings, rather than a formal letter clearly stating whether complaints were upheld and providing a meaningful apology.

I upheld all of the complaints.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  ensure that the leaflet entitled 'Having your baby at the Vale of Leven CMU' is given to women before they have made a decision about where they would like to give birth, and revise the wording of the leaflet as appropriate; 30 November 2015
• (ii)  consider the need to review the NHS Greater Glasgow and Clyde Obstetric Guidelines, in line with National Institute for Health and Care Excellence Guidelines on Intrapartum Care (2014); 30 November 2015
• (iii)  reflect on the findings of this case, and consider whether the provision of aromatherapy at the Unit should be offered on a 24 hour basis; 30 November 2015
• (iv)  extend the use of the new tool for handover of care, so that it is applied to telephone handovers when transferring care from the Unit to Royal Alexandria Hospital; 30 November 2015
• (v)  consider implementing a system for staff rotations from the unit to Royal Alexandria Hospital on an annual basis, if this is not already in place; and 7 January 2016
• (vi)  apologise to Ms and Mr C for the failings identified in this report, and the distress this caused them and Baby C. 30 October 2015

Summary
Mr C complained to the board following treatment he received at Raigmore Hospital.  He was admitted for a haemorrhoidectomy (surgery to remove haemorrhoids) and flexible sigmoidoscopy (a procedure to look inside the back passage and lower part of the large bowel).  Polyps (small growths on the inner lining of the bowel) were found and removed during the sigmoidoscopy.  Mr C was readmitted two days later, after experiencing considerable pain, and it was found that he needed emergency surgery for two holes in his bowel.  Mr C said he was told that, if this second operation was not successful, he would need more surgery and a temporary colostomy bag.  He said that the procedure caused him further pain, stress and anxiety.

Mr C said that he consented to surgery for haemorrhoids and to a flexible sigmoidoscopy on the understanding that the sigmoidoscopy was investigatory, and that he was not told polyps may be removed if identified.  He said that, if he had known of the possibility of damage to his bowel, he may not have had the original procedure done.  He was also concerned that, due to annual leave, the surgeon he had seen before his original day surgery did not perform the operation.

In investigating Mr C's complaints, my complaints reviewer obtained independent medical advice from a consultant colorectal surgeon who is experienced in carrying out the surgery Mr C had done.

My adviser noted that the board’s response to Mr C’s complaint said that the risk of bowel perforation from flexible sigmoidoscopy is low but increased with treatment for polyps.  My adviser referred to General Medical Council guidance on consent which says that doctors must tell patients if an investigation or treatment could result in a serious adverse outcome.  He said that, as the risk of perforation (and, therefore, a hospital admission) is a serious adverse outcome, not having discussed or made a record of such a discussion was unreasonable.  He felt the question of whether polyps should have been removed was irrelevant as the consent process was inadequate.

Regarding Mr C's transfer from the care of the surgeon he had seen before his original day surgery to another surgeon, my adviser explained that it was the responsibility of the surgeon in charge of the case on the day to ensure that a procedure's risks had been explained.  He said that the second surgeon should have ensured that the first surgeon had properly discussed the procedure with Mr C but the evidence did not show that this was done.

In light of the clear medical advice, I uphold the complaints and have made recommendations to the board.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr C for the failings identified in this report; 28 October 2015
• (ii)  consider introducing pre-printed consent forms for common procedures like this to ensure that such rare (but serious) complications are not missed, and report their findings back to the Ombudsman; and 25 November 2015
• (iii)  consider introducing a review of case notes by the operating surgeon (before the day of surgery) where the patient has been transferred from another surgeon's list, to ensure that the operating surgeon is satisfied the appropriate consent is in place, and report their findings back to the Ombudsman. 25 November 2015

Summary
Mrs C complained about how a health board responded to concerns raised by the family of her infant granddaughter (Miss A).  The family were concerned about a change in Miss A's behaviour when she was around 17 months old, which they believed were due to possible abuse or maltreatment whilst Miss A was in the care of her father.  The family had approached their GP, who referred them to a consultant paediatrician.  The paediatrician had examined Miss A, but reported no concerns.  Mrs C and Miss A's mother felt that the child had not been properly assessed and that the report produced did not provide an accurate account of the examination.

Miss A was referred to Child and Adolescent Mental Health Service (CAMHS), but the family felt that again Miss A was not appropriately assessed.  The family requested a second opinion, but did not receive one.  We investigated, and upheld, Mrs C’s complaints that the board failed to respond appropriately to serious concerns raised about a child, and that they unreasonably failed to explain to Mrs C their role and remit in this matter.

This report concerns issues around child protection.  I am conscious this is a highly complex and emotive area both for families and the professionals involved.  It is important, therefore, to be clear about the remit and scope of the investigation and subsequent report. In this investigation, I have only considered the information provided by the board, in the form of Miss A's medical records.  Child protection is a multi-agency responsibility and it should not be inferred from this report that the board was the lead agency with responsibility for child protection.  It also should not be inferred that this report proves that abuse was perpetrated on a child.  Although I accept the board did not have the lead role in child protection, however, it became clear from the advice provided that there were failings in its involvement for which it should take responsibility.

The failings identified relate primarily to the failure to record and document examination of a child to the requisite standard.  Although my office can and does consider clinical judgement, that is not the area that is criticised in this report.  I have taken the decision to stress this, in view of the subject matter and to forestall any misinterpretation or extrapolation from the report itself.

In order to investigate these complaints, I took independent advice from a consultant paediatrician and a consultant psychologist.  I decided to issue a public report on this complaint due to the evidence that the family have suffered a significant personal injustice as a result of the board's failings.  Given the sensitivity of the matters raised in the report, I also decided to anonymise the board in order to protect the identity of the family.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  carry out a review of Miss A's assessments by both the paediatric and psychology services; 8 December 2015
• (ii)  include the findings of these reviews in the subsequent appraisals of the doctors who carried out Miss A's appraisals; 29 February 2016
• (iii)  remind all staff involved in child protection work of the importance of following current guidance on examining and recording findings when assessing children; 3 November 2015
• (iv)  review the investigation of Mrs C's complaint in light of the failure to respond to it fully; 17 November 2015
• (v)  review what information is provided to families about the CAMHS service prior to referral, to ensure the reasons for referral are clear; and 17 November 2015
• (vi)  apologise unreservedly to the family for the failings identified in this report. 3 November 2015

Summary
Mrs A was transferred from Victoria Hospital, Kirkcaldy, which is the responsibility of Fife NHS Board, to the Royal Infirmary of Edinburgh for heart surgery.  Following one postponement in mid-December, the operation went ahead on 21 December 2012.  Mrs A's niece (Mrs C) said that two days after the operation, her aunt was having a blood transfusion shortly after which she began to very rapidly decline.  Mrs A was admitted to intensive care and died on 26 December 2012.  The cause of Mrs A's death was recorded as multi-organ failure due to sepsis of unknown source in association with recent prosthetic aortic valve replacement and known ischaemic heart disease (a condition that affects the supply of blood to the heart).  Mrs C complained that her aunt did not receive appropriate care and treatment from Lothian NHS Board.

In investigating this complaint, I took independent clinical advice from a cardiothoracic surgeon (specialising in chest, heart and lung surgery).  The advice I received was that the heart surgery appeared to have been performed to a high standard, and Mrs A's initial recovery was good.  Following a routine observation, Mrs A was recommended to have a blood transfusion.  Her condition quickly deteriorated, and the board said that staff suspected a transfusion reaction and implemented their procedures for this.  My adviser said that all teams reacted appropriately and promptly in response to Mrs A's condition.

Tests were taken to determine the cause of Mrs A's change in condition and I am satisfied that the blood Mrs A received was not contaminated.  Her deterioration was coincidental with her developing a bacteria entering into her blood stream in association with sudden acute liver failure.  However, I understand that it must have been very distressing for Mrs A's family to witness her sudden deterioration given the early signs that her heart surgery had been successful.

My investigation identified a number of areas that I am critical of.  My adviser told me that communication between the two hospitals treating Mrs A should have been better given her status as a high-risk patient with other pre-existing medical conditions and a history of previous heart surgery.  Related to this, given Mrs A's case was a high-risk and complex case, this should have been discussed at a pre-operative multi-disciplinary team meeting, which did not happen – the board said that when Mrs A was transferred to the Royal Infirmary she was fit for surgery and there were no alternative treatments to discuss.

My adviser noted that some documentation was not completed appropriately, particularly around consent for the procedure.  Following Mrs A's death, there is no evidence that her GP was notified, as should have happened.  I also acknowledge that there was an early retraction of Mrs A's death certificate which, according to my adviser, had been inappropriately completed by a junior doctor.  I recognise the additional distress that this would have caused Mrs A's family.

Finally, during the course of my investigation I identified that there was a positive result from an umbilical (navel) swab taken on 12 December 2012, the day of the initial scheduled operation, which may have been the source of the subsequent bacteraemia (the presence of bacteria in the blood) and septicaemia responsible for Mrs A's death.  My adviser said that although the positive result was acted upon and antibiotics prescribed to Mrs A, it is not apparent that the potential relevance of this positive finding for Mrs A, who was who was due to undergo high-risk re-do cardiac surgery, was fully realised by the cardiac team treating her and whether consideration was given to potentially delaying Mrs A's surgery in view of the risk of the subsequent sepsis.

I made a number of recommendations to address the failings I identified in the care and treatment provided to Mrs A.  I also found that the board's handling of Mrs C's complaint was not reasonable.  There were delays in responding which I accept the board have apologised for, but the apology letter was brief, lacked empathy and did not fully address the reasons for the delay.  I note, however, that process changes have since been implemented so I have not made a recommendation about this.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  ensure that the comments of the Adviser in relation to the issues of consent and proper and accurate record-keeping are brought to the attention of the relevant staff and a review is carried out; 30 November 2015
• (ii)  ensure the comments of the Adviser in relation to the positive umbilical swab taken from Mrs A on 12 December 2012 are brought to the attention of relevant staff and they reflect on this; 30 November 2015
• (iii)  apologise to Mrs C and the other members of Mrs A's family for the failings identified in complaint (a); and 30 October 2015
• (iv)  apologise to Mrs C and Mrs A's daughter for the failings identified in the apology letter initially issued to Ms A's family. 30 October 2015

The Ombudsman recommends that the Board and Fife NHS Board:

• (v) ensure the comments of the Adviser in relation to the lack of clear cardiology referral documentation between Hospital 1 and Hospital 2 are brought to the attention of relevant staff. 30 November 2015

Summary
After suffering a stroke earlier in the year, Mr A was discharged from a hospital to a Step Down Unit in May 2014.  This is a unit in a nursing home for elderly patients who are fit for discharge from hospital but need further rehabilitation before they can return home.  Following a fall at the unit in early July 2014, Mr A's condition deteriorated.  Over a number of weeks, he developed reduced mobility, reduced food intake and increasing pain.  Mr A's daughter (Miss C) complained that, from the time of his fall until his readmission to hospital in early August, the care and treatment he received from GPs at his medical practice was unreasonable.  She considered that Mr A should have been admitted to hospital earlier, and that it was unreasonable for a GP to suggest that one of the options was not to intervene, but to keep Mr A comfortable in the unit.

I took independent advice from one of my medical advisers who is a GP.  The adviser had a number of concerns about the practice's failure to properly assess Mr A's condition.  She said that the clinical records were sparse and lacked evidence of examination, of thorough clinical assessment, and of thorough assessment of Mr A's pain.

With regard to Mr A's food and fluid intake, she said that records showed that he lost 8.7 kilograms over a two-month period, or 16.5 percent of his body weight.  This was a significant amount and she would have expected a GP to physically examine their patient to rule out any underlying cause for weight loss.  She would also have expected a GP to have either made urgent arrangements for a dietician to assess the patient or to have provided simple food supplements until the dietician could attend.  She noted that, under the Lothian Joint Formulary Guidelines, Mr A should have been given a MUST score ('Malnutrition Universal Screening Tool', British Association for Parenteral and Enteral Nutrition).  As he had lost so much weight, he would have received the maximum MUST score, identifying the necessity of food supplements and regular monitoring.

It was thought that Mr A may have been suffering from dehydration and also possibly have a urine infection.  The adviser considered that the care and treatment for these issues were not reasonable, as there was a delay in prescribing an antibiotic to treat the suspected urinary tract infection and the management plan to deal with the dehydration was not changed despite there being no improvement for weeks.

With regard to the GP's suggestion of not intervening but keeping Mr A comfortable in the unit, the adviser commented that the diagnosis of dehydration and a possible urinary tract infection were both easily treatable.  She added that Mr A was malnourished and losing weight, yet there was no evidence of investigation or examination.  The adviser said that the suggestion of not actively investigating or treating these potentially reversible conditions, in a patient in a unit that aims to rehabilitate patients for home, was not a reasonable standard of care.

My investigation found that the overall care provided to Mr A during the period following his fall until his readmission to hospital was not of a reasonable standard and so I upheld Miss C's complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  carry out a further significant event analysis in partnership with their local clinical director.  This should include consideration of:  how they ensure continuity of care for their patients and regular review of those most vulnerable; GP1's suggestion of keeping Mr A comfortable in the Unit, rather than addressing his potentially reversible conditions; the need for good record-keeping and ensuring thorough recording of clinical information in a patient's medical record, so as to assist in continuity of care; and consideration of the Lothian prescribing guidelines for urinary tract infections.
  They should also consider referring this significant event analysis to NHS Education for Scotland for review; 31 December 2015
• (ii)  familiarise themselves with the MUST scoring and Lothian guidelines for prescribing oral nutritional supplements; 30 October 2015
• (iii)  take steps to ensure that  other patients they care for in the Unit are receiving adequate treatment for  malnutrition in line with the Lothian guidelines, where appropriate; and 27 November 2015
• (iv)  issue a written apology to Miss C for the failings identified in this report. 30 October 2015

Summary
Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) received from her medical practice over the two-year period before her death.  Mrs A first contacted the practice in November 2011 about her hip pain.  She was prescribed painkillers but the pain persisted, and an x-ray was taken in summer 2012 which suggested that she had osteoarthritis.  Mrs A's pain increased so, in October 2012, the practice made a referral for her to see an orthopaedic consultant (who specialises in the musculoskeletal system).

In January 2013, Mrs A reported to the practice her weight loss of ten kilograms over two to three weeks.  She saw the orthopaedic consultant, who thought that her pain was muscular and at the base of her spine, rather than caused by arthritis in her hip.  Mrs A received physiotherapy and stronger painkillers, neither of which helped to reduce her worsening pain.  She was re-referred to orthopaedics, and saw the consultant, who arranged a scan for the end of August 2013.  Before the scan, Mrs A's condition deteriorated further.  She was in regular contact with the practice, and prescribed different pain medications.  She found the scan very painful and did not get the results in the time-frame she was expecting.

Mrs A's mobility decreased in September 2013 until she was mostly bed-bound, and a home visit from the practice was requested.  The scan results showed an abnormality at the base of her spine and, in light of her deterioration, the practice arranged Mrs A's hospital admission.  She was told soon after that she had widespread secondary cancer to her hip and pelvic bone area.  She died in October 2013.

In investigating Mrs C's complaints, I obtained independent advice from a GP adviser.  She was concerned that Mrs A's pattern of contact with the practice, her symptoms and abnormal test results should have led to a referral for an assessment for a potential underlying problem.  The adviser said that Mrs A's rapid weight loss should have been investigated as it was unlikely to be only caused by nausea from her medication.  The Scottish Referral Guidelines for Suspected Cancer say that unexplained or persistent weight loss of over three weeks should be referred for investigation, which did not happen.  She also noted that Mrs A's haemoglobin level and liver function should have been rechecked after getting abnormal test results.

My adviser said that Mrs A's medical records showed her increased rate of contact with the practice during the two-year period before her death and, particularly, between July and September 2013.  She said that the practice should have been alert to this pattern of contact.  She also noted that over half of Mrs A's consultations in this period were over the telephone.  She recognised the established place in patient care for telephone contact, but she felt the symptoms Mrs A described (increasing pain, reduced function and increased weight loss) meant that she needed clinical re-examination.  She felt Mrs A's symptoms were sufficient for the practice to have considered an alternative diagnosis and further investigation.

In view of the clear medical advice I received about Mrs A's pattern of contact with the practice, her symptoms and her test results, I consider more could reasonably have been done by the practice to reassess her diagnosis and investigate other possible causes of her condition.  I upheld this complaint and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  apologise to Mrs C for the shortcomings identified in this report; 28 October 2015
• (ii)  discuss this matter as a significant event within the Practice (with particular reference to Mrs A's pattern of contacts, the number of telephone consultations and Mrs A's increasing pain and immobility prior to her hospital admission); 25 November 2015
• (iii)  review and consider their use of telephone consultations to ensure they are not overly dependent on them; and 25 November 2015
• (iv)  ensure they are familiar with the Scottish Referral Guidelines for Suspected Cancer and also the Scottish Intercollegiate Guidelines Network Guidance for pain management. 25 November 2015