Health

Summary
Mrs C complained about the way her late mother Mrs A had been treated while in hospital.  Mrs A, who had dementia, was admitted to Borders General Hospital on 20 November and discharged on 4 December 2012.  She was readmitted on 6 December and then discharged again on 17 December 2012.  Mrs C was concerned about aspects of her mother's treatment while in hospital and that she was discharged too soon.  She felt that Mrs A had been treated poorly because of her cognitive impairment.  I sought independent expert advice from a nursing adviser and a medical adviser.  I did not find that Mrs C had been deliberately discriminated against because of her dementia.  However, my investigation identified a significant number of failings in her care, many of which related to a failure to provide appropriate care and support to someone with cognitive impairment or to follow the legislation that provides protection for someone with cognitive impairment who requires medical treatment.  As a result of these failings, it is likely that, taken together, the failings were such that Mrs A's rights as an NHS patient and a dementia patient were infringed.

Care seemed to be poorly led and coordinated.  There was no evidence of a full care plan and, despite the fact that she had been admitted to the hospital because of a fall and had five falls during her stay, there was no completed falls assessments in the clinical records or any evidence of a falls prevention plan.  There was limited evidence of the involvement of medical staff and communication with the family was sporadic and poor.  Pain and nutritional assessments were inadequate.  There was also a specific incident of which I am critical when Mrs A required but was not provided with adequate pain relief and this meant her journey to the care home on 4 December was very uncomfortable.  While the report identifies a number of medical and nursing failures, I did not uphold a complaint about physiotherapy and occupational therapy.  There was evidence in the records of appropriate physiotherapy involvement and while I am critical that an occupational therapy assessment was only carried out after prompting by the care home, I found that overall care in these areas had been reasonable.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) monitor practice to ensure national dementia standards are being met including specifically that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and provision of support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
• (ii) ensure that staff comply with adults with incapacity legislation, in particular completing section 47 certificates and accompanying care plans;
• (iii) take steps to ensure communication with relatives and carers of patients with cognitive impairment is proactive and systematic;
• (iv)  ensure that falls prevention clinical practice is administered within the Hospital in line with recognised good practice and Board policy;
• (v) ensure that nutritional care is carried out in line with national policy and that nutritional care plans are developed, implemented and evaluated for each patient as appropriate;
• (vi) explore all options to implement an observational pain assessment tool for use with patients with cognitive impairment;
• (vii) undertake an audit of record-keeping in wards caring for patients with cognitive impairment to ensure compliance with record-keeping guidelines and a reasonable standard of practice;
• (viii) review their discharge policy to ensure:  its continued relevance in light of the failings arising from this case; it meets the needs of people with cognitive impairment and the need to fully involve the family in decision-making; a more systematic approach to discharge planning; and pre-discharge assessments are clearly identified at an early stage and carried out within a reasonable time to inform follow-up care;
• (ix) ensure the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs particularly in relation to falls prevention and adults with incapacity legislation; and
• (x) apologise to Mrs C for the failures this investigation identified.

Summary
Mrs C was suffering from abdominal pain, and was seen at a gynaecology out-patient clinic following referral by her GP Practice in November 2012.  She was diagnosed with uterine fibroids in January 2013.  Mrs C was admitted to a ward at her local hospital (in another NHS board area) due to the pain.  In February 2013, Mrs C's GP contacted the consultant gynaecologist (Consultant 1) in charge of the out-patient clinic, requesting that she be placed on the list for surgery due to the impact her condition was having on her life.  Consultant 1 replied to say further discussion was required within the multi-disciplinary team; Mrs C was offered another appointment at the clinic on 2 April 2013.  Mrs C decided to seek private treatment, and had successful private surgery on 4 April 2013.

Mrs C made a complaint in June 2013 about the care and treatment she received, as well as communicative difficulties she had had when trying to contact Consultant 1.  She received a reply in August 2013, apologising for the administrative backlog that caused delay with her care and treatment.  The Board also said it was unlikely Mrs C would have been seen earlier than 2 April 2013 due to the gynaecology service's waiting times overall.  Mrs C complained again and the Board issued a final response in February 2014.  At this time, Mrs C was told that, in February 2013, Consultant 1 had made a decision that she should be referred for surgery.  An appointment for 4 April 2013 was to be offered; a telephone call was made by the Board to her GP Practice on 4 March 2013.  Consultant 1 told us that this had been left with the GP to discuss with Mrs C.

My investigation found that more prompt action should have been taken by the Board given Mrs C's worsening condition, and that there was a lack of urgency which meant Mrs C's care plan was not re-assessed.  I concluded that to expect Mrs C to wait for a further clinic appointment in April 2013 was not reasonable.  In addition, it was not reasonable that Consultant 1 had only contacted the GP Practice by telephone to advise of the offer of surgery; contact should have been made in writing to ensure Mrs C was aware of her options.  It was not reasonable to expect the GP Practice to pass on a message about the offer of surgery.  In my view, it was likely Mrs C would not have sought private treatment had she known the same procedure would have been available via the NHS at the same time.  I also found that the Board's responses to Mrs C's complaints were delayed, having been received well outwith the timeframes within the Board's complaints handling procedure.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  reimburse Mrs C for the cost of her private surgery on production of receipts;
• (ii)  apologise to Mrs C for the failures in communication identified in this investigation;
• (iii)  confirm that steps have been taken to address the administrative communication failings identified during their investigation of Mrs C's complaints;
• (iv)  review the gynaecology department's internal and external communication arrangements to determine what improvements can be made;
• (v)  review the management procedure for the care and treatment of patients like Mrs C who live in another NHS board area;
• (vi)  apologise to Mrs C for the delays in responding to her complaints;
• (vii)  confirm that a process has been put in place to ensure that a complainant's further comments are addressed timeously; and
• (viii)  review arrangements with Mrs C's local NHS board for management of similar joint complaints.

Summary
Mr A suffered from anxiety, depression and panic attacks for many years; he attended his GP regularly and was prescribed Citalopram and, on occasion, diazepam.  In March 2013, Mr A saw an out-of-hours GP, describing worsening symptoms and feeling suicidal.  He was prescribed lorazepam and told to see his GP the next day; Mr A attended the out-of-hours GP again the next day and reported suicidal feelings again; he was then seen by a Duty Psychiatrist and discharged with a plan to refer for a medication review.  Two days later, Mr A attended the Accident and Emergency Department at the Victoria Hospital after taking an overdose.  He was discharged, and his parents (Mr and Mrs C) contacted his GP to say they felt they could not leave him alone due to his state.  The following day, Mr A took his own life.

Mr and Mrs C complained to the Board and, along with Mr A's partner, met with Board staff.  The Board said that, because Mr A's suicidal thoughts had been fleeting and intermittent, a decision was made that he could be treated safely in the community.  He had also been declined further medication, which he had requested, due to the risk of overdose.  A Significant Events Analysis was then carried out, where it was identified that benzodiazepine withdrawal may have been a factor in Mr A's mental health deterioration.  It concluded that, in hindsight, Mr A's level of risk to himself had not been anticipated.  A number of recommendations were made.

My investigation was mindful that we were reviewing what happened with the benefit of hindsight; nevertheless, I found that although the initial assessment by the out-of-hours GP was reasonable, the Duty Psychiatrist's assessment did not detail suicide risk factors and there was no evidence that Mr A's partner, who had attended with him, was included in discussions.  Mr A was not told what to do should his condition deteriorate further.  When Mr A attended A&E, staff did not know that he had already presented twice to NHS services with suicidal feelings, which he was now acting upon.  Had staff known this, they would have been able to see that Mr A's condition was developing, and different, more urgent action may have been taken.  I upheld Mr C's complaint that the Board failed to provide Mr A with appropriate care, support and treatment following his visits to hospital in April 2013.

Mr C also complained that the Board unreasonably failed to provide Mr C's family with sufficient information about Mr A's health to allow them to support him, and I upheld this complaint too.  The Board's SEA had already recommended that, in cases where suicide plans have been expressed and hospital admission is not taking place, it would be best practice to agree with patients that partners, family or carers are fully informed to help prevent harm.  We found that Mr A's partner, who had attended all the hospital assessments, did not appear to have been involved in decisions about treatment.  In addition, neither Mr A's partner nor Mr and Mrs C appeared to have been given any advice about how to deal with the on-going situation.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mr and Mrs C and Mr A's partner for the failings identified in this report;
• (ii)  provide me with evidence of the action taken in response to the recommendations of the Significant Event Analysis;
• (iii)  review Mr A's case with a view to improving the level and effectiveness of communication between frontline staff likely to deal with self-harm cases particularly where a patient has presented to multiple services with the same issue; and
• (iv)  review how patient records are maintained and shared between departments to ensure that escalating levels of risk are identified at the earliest opportunity.

Summary
Mrs C complained about the care and treatment provided to her late husband Mr A.  Mr A was admitted to Wishaw General Hospital on 24 February 2014 and died there on 6 March 2014.  Mr A had been unwell for some time prior to admission and cared for by family members at home.  In the days leading up to his admission his condition had deteriorated and he had been hallucinating and unable to swallow.  Mrs C complained about a number of the aspects of care provided to Mr A.  In their response to her complaint, the board accepted some failings and apologised.  Mrs C remained unhappy and asked the SPSO to investigate.  I took independent advice from a consultant physician and a nursing adviser.

My investigation found that although her complaint had been upheld, the complaints process had only looked at Mr A's care in a superficial manner.  Not all the clinical staff involved in the case had commented and may have been left unaware of the outcome of the board's investigation.  I also found a number of significant failings.  There was a lack of any overall plan for Mr A's care and treatment, and the treatment he did receive fell well below a level that Mr A should have expected on a number of points.  There was no specific assessment of his swallowing difficulties or monitoring of the dehydration that he presented with on admission.  Significantly, there was evidence of confusion between staff about whether Mr A was being provided with active or end of life care.  Mr A was being proposed for referrals and investigations just two days before palliative care and a possible transfer to a hospice was considered although there was no apparent change in his condition.  One doctor noted on file that Mrs C wrongly believed Mr A was dying.  However, there is also evidence that other staff did think Mr A was dying and the board acknowledged in their investigation that end of life care would have been more appropriate throughout this admission.  Mrs C told us she received conflicting information about his condition and received a call from occupational therapy about physical aids she may need to care for him at home when it should have been clear he would not be discharged.  Alongside the failings in the treatment and the confusion around this, I was also critical that there was no evidence Mr A's family were appropriately involved in decision-making.  On the day he died, Mr A had a gastroscopy to investigate some of his symptoms.  We found that there had been no clear assessment of the risks of such a procedure and further, that, at the time, Mr A did not have the capacity to consent to such a procedure.  A certificate of incapacity was in place that allowed medical staff to provide general treatment as Mr A could not legally consent to this.  It did not provide for this specific procedure which would normally require additional consent and Mrs C and her family should have been involved in this decision.  This means that Mr A was denied safeguards put in place by legislation to protect adults with incapacity when the decision whether or not to go ahead with the gastroscopy was made.  Mr A did not recover well from this procedure and, while there was some treatment following his return to the ward, there was little evidence this deterioration was properly assessed.

I found there were also failings around the very sensitive issue of when Mr A had died and who should be informed of his death.  The records indicate Mr A died around 13.40 to 13.50.  However the death certificate recorded the time as 15.13.  This difference happened because it was not until then that a doctor confirmed the death.  However, advice by the Chief Medical Officer makes it clear that this approach is wrong and that doctors should seek to put on the certificate as accurate an actual time as possible based on the available information and not simply the time they confirm the death.  Following Mr A's death, the decision was made not to notify the procurator fiscal.  This assessment was made using a standard checklist.  I found no problems with the checklist but it had been wrongly completed and said there were no reasons for Mr A's death to be reported.  In fact, Mr A potentially met two criteria – deaths which were clinically unexplained and which may be due to an anaesthetic.  Mr A died from unknown causes on the day he had had an invasive procedure and there was evidence he had deteriorated following that procedure.  I made a number of recommendations as a result of my investigation.  They reflect that some action had been taken by the board prior to my investigation and the significant changes to the procedures around certification of death introduced on 13 May 2015.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for the failure to report her husband's death to the Procurator Fiscal and the use of an inaccurate time of death;
• (ii)  notify the Crown Office and Procurator Fiscal Service of the omission to report Mr A's death to the Procurator Fiscal on 6 March 2014;
• (iii)  ensure that all relevant staff are aware of the current requirements for reporting a death to the Procurator Fiscal;
• (iv)  ensure that relevant staff are aware of the Code of Practice for practitioners authorised to carry out medical treatment under Part 5 of the Adults with Incapacity (Scotland) Act 2000;
• (v)  present this case and the findings of this report at a medical/respiratory departmental meeting; and
• (vi)  ensure that this case is included in the appraisals of the relevant consultants and the educational portfolios of relevant trainee staff.

Summary
Mrs C complained that her late husband (Mr A) was not provided with appropriate care and treatment after he was admitted to Dumfries and Galloway Royal Infirmary.  Mr A was admitted with a suspected stroke but developed severe diarrhoea.  His condition deteriorated significantly over the next few days and he developed a number of other symptoms, including problems with his oxygen levels, his heart and his breathing.  He was transferred to intensive care, but died some four weeks after he was admitted.  Mrs C said that although she was very concerned about her husband's condition, he was not seen by a consultant until about a week after he was admitted.  She repeatedly raised her concerns with staff, but felt these were dismissed.  Mrs C felt it took too long to recognise that Mr A had had a heart attack, and said he lost all his dignity while in hospital and suffered unnecessarily.

The board met with Mrs C some months after she first complained, and wrote two months after that to further clarify what had been said, acknowledging her concerns that the heart attack was not diagnosed sooner.  They said, however, that they hoped she was reassured that they had carried out a series of appropriate tests to diagnose Mr A's condition, although with hindsight this could have been done more quickly.  They apologised for Mrs C's experience.

The records did not show what was said at the meeting, but there were statements from two doctors within the complaints papers.  Both acknowledged that it was unfortunate that Mr A was not reviewed earlier, and that there were issues with availability of consultants.  I also took independent advice on the complaint from a consultant cardiologist, who said that Mr A died following a critical illness, which culminated in multi-organ failure.  Although he already had underlying health conditions, there was evidence of a recent heart attack and a related life-threatening condition.  My adviser identified a number of failings in Mr A's clinical care, including that the heart attack could have been diagnosed sooner, fluid therapy was not appropriately managed, and medical records were inadequate, with electrocardiogram (heart function monitor) results that were not properly labelled and that did not appear to have been compared in sequence.  This meant that Mr A was not adequately reviewed and his heart problems not considered early enough - critical omissions when planning his treatment.

I accepted this advice and upheld Mrs C's complaint.  I found that Mr A was not reviewed by a cardiac consultant early enough, and was placed on inappropriate fluid therapy, which compromised his treatment and meant that his care fell below a reasonable standard.  I also found the board's complaints handling and apology inadequate, given that two senior members of board staff identified failures in Mr A's care, and that I saw no evidence of the board taking action to improve procedures as a result of Mrs C's complaint.

Redress and recommendations
I recommended that the Board:

• (i)  carry out a critical incident review into Mr A's death;
• (ii)  remind all staff of the importance of contemporaneous, accurate and full medical notes;
• (iii)  provide evidence that the complaint investigation has been reviewed, to establish why failings by the Board identified by staff members were not acted upon;
• (iv)  remind all staff of the importance of discussing completion of the decision to designate a patient as 'not for resuscitation' with either the patient or appropriate family members;
• (v)  provide evidence that the full report has been discussed by the Board at the first meeting following its publication; and
• (vi)  apologise unreservedly to Mrs C for the failings identified in this report.

Summary
Mr A had a history of mental illness and of self-harm, and had been in and out of hospital as a result.  He was admitted to the Royal Edinburgh Hospital for treatment after an apparent suicide attempt.  He was given a pass to walk unescorted in the hospital grounds, but did not return when expected.  Staff decided not to contact the police to report him missing until some two hours after his expected return time.  Mr A was found dead outwith the hospital a number of days later.  Ms C (Mr A's fiancée and carer) complained that Mr A was not provided with appropriate care and treatment, in that the decision to allow him off the ward unescorted was inappropriate.  She also complained that she was not properly involved in the decision making in Mr A's care.

The board carried out an internal review, which found that although the decision to issue the pass was high-risk, the professional judgment of staff was reasonable in the circumstances.  They also said that it was reasonable not to contact police earlier, but made five recommendations, including reviews of what should happen if a patient did not return when expected, of liaison with the police and of the risk assessment tool.  The board met with Ms C, who had also met the leader of the review team.  Ms C remained concerned that the board had failed in its duty of care to Mr A and wanted them to admit this.  She wanted a further, independent review.  The board did not agree to this, and said that they had taken appropriate action through the review recommendations.  They did, however, apologise to Ms C for failures in communication with her in relation to care planning.

I took independent advice on this case from a mental health nursing adviser and a consultant psychiatrist.  Mr A was recognised as having unpredictable behaviour, and had returned very late from a previous pass, so both advisers were critical of the assessment of risk, and that this was not updated during treatment, as his condition appeared to be fluctuating.  Poor risk recording made it difficult to understand how it had been taken into account when making decisions, there was no mention of what was done to reduce risk and there was no plan of what should happen if he did not return from a pass.  Both advisers came to the view that in the absence of a structured assessment of risk, it was unreasonable to grant Mr A an unescorted pass.

I upheld both Ms C's complaints. On the first, I accepted my advisers' view that Mr A's care fell below a reasonable standard in terms of the assessment and recording of risk. I also found that the board's review reached contradictory conclusions on whether it was reasonable for staff not to take action until two hours after Mr A failed to return.  Although I cannot say whether this led directly to Mr A's death, such omissions represent a significant failing, and I criticised the board for this.  As, however, the board's own review addressed many of these issues through an action plan I made limited recommendations.  On the second complaint, appropriate communication with carers is a requirement of the Mental Health (Scotland) Act 2003, and it was not clear from the records whether staff viewed Ms C's as Mr A's main carer.  Her status should have been documented so that staff could communicate appropriately with her.

Redress and recommendations
I recommended that the Board:

• (i)  provide evidence that the action plan produced following the SAER has been implemented in full;
• (ii)  ask the internal review team to reflect on our advisers' assessment of the care and treatment provided to Mr A;
• (iii)  provide evidence that they have reviewed the procedures for carer involvement in patient care and management decisions;
• (iv)  provide evidence that the procedural review includes a system for the timeous identification of the patient's carer or named person; and
• (v)  apologise for the failings identified in this report.

Summary
Ms C complained to us on behalf of her client (Mr A) that doctors did not reasonably diagnose that his late wife (Mrs A) had cancer.  In late 2012, Mrs A had breast cancer surgery, during which an extremely large high-grade tumour was removed.  She contacted the practice some seven months later complaining of back pain and spasms.  She also then developed a wheeze and cough.  Between 29 July 2013 and 19 August 2013 she had four telephone consultations with three GPs at the practice, who prescribed and adjusted pain relief medication, and later provided Mrs A with an inhaler.  The day after the last consultation, she contacted NHS 24 because she was having problems breathing.  They arranged for an out-of-hours doctor to visit, who diagnosed pneumonia and said Mrs A should contact her GP.  She did this the same day, and saw another GP from her practice, who referred her straight to hospital because of her history of breast cancer.  She was found to have cancerous growths and a build-up of fluid in her chest.  She was admitted to hospital but died before cancer treatment could be started.

When Mr A complained to the practice they concluded that they did not identify early enough that Mrs A was as unwell as she was, and that it would have been better if she had been more fully assessed.  They said that this might have been partly due to a breakdown in communications, apologised for the standard of care provided and said that they would carry out a Serious Event Analysis (SEA) of Mrs A's case.  Mr A was not satisfied with this, and took the complaint further, latterly with the help of Ms C.  The final outcome was that although the practice agreed that with hindsight things could have been done better, they said that they had found nothing that needed remedy.

I took independent advice from one of my medical advisers, who is a GP.  She said that the medical histories taken during the telephone consultations were sparse and that Mrs A's clinical history should have made doctors suspect that the cancer might have come back.  The surgeon had told the practice that it was not possible to say whether surgery had achieved a long term cure.  Given all the circumstances, my adviser said that Mrs A should have been physically assessed at the time of the first call, and certainly when the pain did not resolve after painkillers were provided.  My adviser had several concerns about the lack of assessment before prescribing treatments, and these are detailed in my report.  She also pointed out although that the SEA report showed some evidence of reflection on and learning from Mrs A's case, the practice also appeared to have suggested that some of the responsibility lay with Mrs A for not explaining just how much pain she was in.

I upheld Ms C's complaint, as I found that a combination of errors led to an unreasonable delay in diagnosing Mrs A's condition.  She should have been seen face-to-face and assessed much earlier, and elements of her care fell below General Medical Council standards.  Although the practice accepted that they did not physically assess her early enough and have introduced a new telephone protocol, my adviser identified some other serious failings, especially around prescribing medication without adequate knowledge of the patient's health.  I was also concerned that in handling the complaint the practice appeared to ascribe some of the blame to Mrs A, which suggests to me that they had not fully accepted that their handling of her case was not of a reasonable standard.  They also appeared to minimise fault on the part of the doctors, and I found the tone of some of their letters inappropriate.

Redress and recommendations
I recommended that the Practice:

• (i)  apologise to Mr A for the failure to identify the recurrence of Mrs A's cancer;
• (ii)  ensure that this complaint is discussed during the next annual appraisals of GP 1, GP 2 and GP 3;
• (iii)  raise awareness amongst all doctors at the Practice of the signs and symptoms of cancer recurrence; and
• (iv)  refer this case to the Board for further discussion with their clinical support group to avoid a recurrence of similar events in future.

Summary
Mrs C complained on behalf of her grandmother (Mrs A) about the time it took to provide Mrs A with treatment.  Mrs A had a long history of incontinence problems, and her GP referred her to the board in August 2012.  In November 2012, Mrs A had her first appointment at Wishaw General Hospital.  In May 2013, tests at a second appointment identified the problem as stress incontinence.  At a third appointment in October 2013 a doctor suggested that surgery might address this, and said that Mrs A would be referred to a specialist consultant.  This, however, did not happen and when by January 2014 nothing had been heard, Mrs A, her GP and Mrs C all contacted the hospital.  Mrs A was eventually referred to a consultant in February 2014, and was placed on a waiting list for surgery.

Meanwhile, in September 2013 new national guidelines had been produced for managing incontinence in women and subsequently the board formed a group to discuss the best way to treat patients like Mrs A.  The group discussed Mrs A's case at their first meeting in March 2014.  They decided that, per the guidelines, rather than her being on the waiting list, they should instead refer her to a specialist centre at another board (Hospital 2) to consider her treatment.  She eventually had surgery in February 2015, some two and a half years after her initial referral.

In February 2014, Mrs C had complained to the board about the delays.  They explained why these happened, acknowledged that they were unacceptable and apologised for this and for the distress caused.  Mrs C was unhappy with their response as it did not say whether anything had been done to stop this happening again.

I took independent advice from two advisers, a consultant physician and a consultant gynaecologist.  The consultant physician said that the delays after the first appointment were unacceptable, and that there was a failure of care when Mrs A was not referred to the specialist consultant in October 2013.  Both advisers found the delay in referring Mrs A to the specialist centre unacceptable, although the consultant gynaecologist confirmed that in Mrs A's case it was entirely correct to follow the guidelines and refer her there for consideration.

I found that there was a general lack of urgency in Mrs A's care, that there were unreasonable delays in investigating and assessing her condition, and that the board did not address these effectively when responding to Mrs C's complaint.  I was particularly concerned that Mrs A was not referred to a consultant in October 2013, and that when handling the complaint the board did not try to find out why this happened.  I upheld Mrs C's complaint and made four recommendations.

Redress and recommendations
I recommended that the Board:

• (i)  conduct a detailed review of the failings around the out-patient appointment of 28 October 2013, particularly treatment time targets and the lack of referral/clinic letter; 
• (ii)  conduct a review of appointment allocation and waiting times for patients within the uro-gynaecology speciality;
• (iii)  apologise and provide an explanation for the delay in referring Mrs A to Hospital 2; and
• (iv)  apologise to Mrs C for failing to provide a reasonable response to her complaint.

Overview
The complainant (Mrs C) complained to Western Isles NHS Board (the Board) that a locum consultant gynaecologist (Consultant 1) had not carried out the operation originally agreed between her and her consultant gynaecologist (Consultant 2).  She was further concerned that Consultant 1 incorrectly told her the agreed operation had been carried out; she later discovered it had not been.

Mrs C also complained that she had been given inaccurate information about her post-operative complications.

Specific complaints and conclusions

The complaints which have been investigated are that:

• Consultant 1 unreasonably failed to carry out a full hysterectomy as agreed with Consultant 2 (upheld);
• Consultant 1 provided inaccurate information about the procedure he had carried out (upheld); and
• the Board provided an inadequate explanation concerning the complications which arose during Mrs C's surgery (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the failings identified in complaint (a); in particular, that they did not afford her the opportunity to have the operation she had previously agreed with Consultant 2;
• ensure that the comments of the Adviser, in relation to the issue of consent; are brought to the attention of the relevant staff;
• review the procedures for arranging locum surgical cover, so as to ensure that the locum has the requisite surgical skills and expertise;
• apologise to Mrs C for the failing identified in complaint (b), that Consultant 1 provided her with incorrect information about her operation;
• review their current significant adverse event guidance in light of the Adviser's concerns detailed in this report and share the Adviser's comments with the relevant staff; and
• ensure they have a clear policy in place concerning the transfer of patients from one consultant's care to another.

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

Overview
The complainant (Ms C) raised concerns about the Medical Practice (the Practice) on behalf of her client (Mrs A).  Mrs A's complaints relate to her son (Mr B) and attempts to register him at the Practice.  Mr B was in prison but was due for liberation on 18 January 2013.  Whilst Mr B was still a prisoner, Mrs A visited the Practice and completed registration forms for him.  She also made an appointment for the day of his release so that he could obtain antipsychotic medication (medicines used to treat mental health conditions) to alleviate methadone (a drug used medically as a heroin substitute) withdrawal.  Mrs A contacted the Practice on 16 January 2013 and confirmed that Mr B's appointment was booked for 18 January 2013.  Also on 16 January 2013, the Practice Manager received a call from Greater Glasgow and Clyde Patient Registrations advising that Mr B was still registered as 'care of HMP' (care of Her Majesty's Prison) and that he could not be registered elsewhere until he was liberated.  The Practice Manager thereafter cancelled the registration on the system and advised two members of staff to update Mrs A and Mr B.  Neither of the staff members provided the update.  Mr B was released as planned on 18 January 2013.  He attended at the Practice for his appointment and was advised that there was none on the system.  The Practice Manager gave him contact details for the community mental health team, community addictions team and NHS 24.  Mr B left the Practice without seeing a GP.  He died from pneumonia (an infection of the lungs) three days later on 21 January 2013.

Specific complaints and conclusions
The complaints which have been investigated are that:

• Mr B was unreasonably refused access to a GP (upheld); and
• the Practice unreasonably did not respond to further letters related to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mrs A and acknowledge that they should have seen and assessed Mr B properly on 18 January 2013;
• provide us with copies of their Significant Event Analysis and Enhanced Significant Event Analysis with their reflections on what happened and why this occurred;
• provide us with their written policies on the registration of new patients and the provision of immediately necessary treatment;
• ensure that all staff within the Practice are fully trained on patient registration and provision of immediately necessary treatment;
• apologise to Ms C and Mrs A for their failure to deal with further complaint correspondence appropriately;
• work with the Board to create a new complaint handling procedure and provide a copy to us for review; and
• ensure that all staff are fully trained on the complaint handling procedure.

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