Health

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.

Summary
Ms A, who suffered from a number of physical disabilities and other conditions, began to complain of headaches in December 2013.  She had surgery to remove a nasal ulcer, and a CT scan revealed no abnormality of her sinuses.

Subsequently, Ms A attended the practice on a number of occasions complaining of vomiting and headaches.  At the same time, Ms A’s mother contacted NHS 24 with concerns about Ms A and she was seen by the board’s out-of-hours service. Ms A’s medical practice prepared a referral letter to neurology.  In the meantime, Ms A was admitted to the surgical service at Raigmore Hospital with abdominal pain.  Ms A was seen by a neurologist on the ward and diagnosed with occipital nerve compression.  Following her discharge, Ms A was seen by GPs from the practice, again with headaches and other symptoms.  Ms A was given an appointment for an MRI scan.  Ms A died at home before this could be carried out.  A post-mortem found that the cause of death was a haemangioblastoma (a tumour of the central nervous system within the brain).

During the investigation, my complaints reviewer sought advice from a GP, a nurse, a neurologist, a neuroradiologist, and a neurosurgeon.

I found the practice did not provide a reasonable standard of care in relation to the examination and referral of Ms A’s headache symptoms.  I also found the board’s out-of-hours service failed to provide Ms A with appropriate care and treatment.  Regarding Ms A’s admission to hospital, I found failings in relation to the neurological examination recorded and a failure to review a CT scan of Ms A’s sinuses.

I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.

Redress and recommendations
The Ombudsman recommends that the practice:

• apologise to the family for the failings this investigation has identified;
• conduct a significant event analysis for review by this office; and
• confirm that the staff involved will discuss this issue as part of their annual appraisal, including identifying the relevant Scottish Intercollegiate Guidelines Network (SIGN) and Scottish Cancer referral guidance as a learning.

The Ombudsman recommends that the board:

• apologise to the family for the failings this investigation has identified;
• confirm the out-of-hours staff identified will discuss this case as part of their annual appraisal, including identifying the relevant SIGN and Scottish Cancer referral guidance as a learning point;
• assess the performance of the out-of-hours staff involved, and identify any training needs;
• confirm the neurologist will discuss this case as part of their annual appraisal;
• should review arrangements for ward consultations (including considering the availability of previous scans for review and encouraging consultants to dictate letters as if it were an out-patient consultation);
• conduct a significant event analysis for review by this office, given the seriousness of this case, and my findings;
• provide my office with an explanation of why a serious incident review was not undertaken in this case; and
• review complaints handling in this case to establish why the failings in care were not identified.

Summary
Miss C complained about how the board had treated her finger injury, and how they dealt with her complaint.  Miss C was employed on a dairy farm, where she suffered a crush injury to her left ring finger.  Miss C was taken to the Dumfries and Galloway Royal Infirmary where she underwent surgery.  Miss C said she had been told that her finger would undergo a partial amputation, which she had consented to.  This procedure would have allowed her to return to work in the shortest possible time period.

Miss C said that she had asked to speak to the board's complaints team to make a formal complaint whilst still on the ward, but that no action had been taken by the board.  She had subsequently submitted a formal complaint, but the board had maintained the surgery she underwent was the surgery she had consented to.

We took medical advice on Miss C's treatment and the consent process undertaken by the board.  The advice said that Miss C had not had her consent properly recorded.  The procedure that was undertaken was not that listed on the form.  Additionally no record had been made of any discussions with her, despite the form containing clearly marked sections for this.  The advice said no treatment plan was recorded, nor was the rationale for performing surgery other than a partial amputation recorded.  The advice stated the failure to perform a partial amputation on Miss C's finger had significantly prolonged the healing process and it was clear from her submissions that her primary motivation was to return to work as soon as possible.

We found the board's records of the consent process were inadequate and that the operation performed on Miss C was not the procedure she had consented to.  The board were unable to explain this, instead maintaining that Miss C had undergone the appropriate surgery.  We also found the board's investigation into Miss C's complaint had been inadequate.  It had failed to identify the lack of records supporting her consent as a concern and had failed to obtain a statement from the doctor responsible for documenting this and performing the surgery for his actions.  Additionally the board's complaint response misrepresented the records of Miss C's interactions with medical staff and failed to address Miss C's concerns about the financial impact of the surgery on her.

Redress and recommendations
The Ombudsman recommends that the board:

• review their process for obtaining informed consent, taking account of the failings this investigation has identified and relevant guidance in this area;
• provide evidence Doctor 1 has undergone training and suitable continuing professional development courses to improve their communication skills and understanding of the consent process;
• carry out a significant event analysis ensuring that Doctor 2 reviews his understanding of the consent process and the definition of a finger terminalisation procedure;
• provide evidence that both Doctor 1 and Doctor 2 have reflected on the failings identified in this report as part of their appraisal process;
• review their complaints investigation in light of the comments from the adviser;
• review their handling of Miss C's complaint in order to identify areas for improvement and ensure compliance with their statutory responsibilities as set out in the 'Can I Help You' guidance; and
• apologise for the failings identified in the report, acknowledging that the procedure performed on Miss C was not the one that she wished to have carried out.

Summary
Mr A, who had Alzheimer's disease (the most common cause of dementia), was admitted to a specialist ward at Royal Cornhill Hospital for assessment and treatment.  He had been displaying very challenging behaviour, and was no longer safe to be looked after at home.  He was sectioned under the Mental Health (Scotland) Act, and he remained in this hospital for the next ten months.  During this time his behaviour became more stable and he was transferred to a dementia assessment ward at Glen O'Dee Hospital.  This move was against the wishes of Mr A's partner and welfare power of attorney, Ms C.  Mr A died six weeks after being transferred, following a rapid deterioration in his physical condition.

Ms C raised concerns about a range of aspects of the nursing care that Mr A received in both hospitals.  In relation to his time at Royal Cornhill Hospital, she was concerned about Mr A's risk of falls and the staff response to this, his skin care, his oral health care, and provision of social activities for Mr A. She also raised concerns about communication with Mr A’s relatives, particularly with Ms C, given her position as his welfare power of attorney and his Named Person under the Mental Health (Scotland) Act.

In relation to the care and treatment Mr A had in Glen O’Dee Hospital, Ms C complained about the forms of restraint used to keep Mr A safe from falls, the lack of sufficient encouragement and assistance to mobilise him, and the impact of this on his skin care.  In relation to Mr A’s medical care, she was concerned that Mr A developed a sore throat that was not properly assessed, and this led him to stop eating and drinking.

When Ms C complained to the board, they identified no significant failings with the care and treatment given to Mr A, either in Royal Cornhill Hospital or Glen O’Dee Hospital.

During my investigation I sought advice from a psychiatric nursing adviser and a psychiatric adviser, who both identified failings in Mr A’s care and treatment.

This case has raised significant failings, particularly in the most standard elements of nursing care: effective care planning; keeping a patient safe; monitoring their condition; providing appropriate food and nutrition; record-keeping; and communication with relatives.  Caring for Mr A was not always made easy by Mr A’s challenging behaviour, but the planning and communication around his care were all the more necessary because of his behaviour and incapacities.  I am also particularly critical of the way the board handled this complaint and their lack of focus on their failings and ways to improve their services.  I upheld all Ms C’s complaints and made several recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaint handling failed to identify these issues;
• provide an action plan setting out improvements identified in the above Significant Event Analysis, with explanation of how they would be met, along with changes that have already taken place since these events;
• remind staff of the need to ensure that changes to visiting hours are mutually agreeable to staff, patients and relatives, and are recorded wider staff awareness;
• conduct a nursing audit in the appropriate ward to assess the current practices in relation to record-keeping, food, fluid and nutrition and vital signs monitoring;
• provide evidence that any actions identified from the nursing audit are implemented in full;
• conduct a Significant Event Analysis, aimed at exploring and understanding the causes of the care failures for Mr A, in order to identify appropriate improvements in clinical practice, and explore how complaints handling failed to identify these issues;
• draw together the findings from both Significant Event Analyses to identify any shared issues on the continuum of care and in complaints handling, to be addressed by the Board; and
• apologise to Ms C for the failings identified in this report, both in relation to Mr A's care and treatment and in relation to the responses Ms C received to her complaints.

Summary
Ms C complained about the care and treatment provided to her late daughter (Miss A) by the board's Intensive Home Treatment Team (IHTT), and about the way in which Miss A was discharged from their care.  Miss A, who had a history of low mood and self-harm, was referred to the IHTT following an attempted overdose.  She was discharged from their care after around six weeks and died at home a week later, having completed suicide.

Ms C complained about a lack of continuity of care, noting in particular the absence of a key worker for Miss A.  I took independent medical advice from a consultant psychiatrist, who noted that in a crisis service such as the IHTT, it is difficult to avoid patients being seen by a number of different staff.  However, the adviser considered that much more could have been done to enhance the continuity of care provided to Miss A.  The IHTT policy indicates that every service user will be allocated a named worker and that complex case discussions will take place, but neither appears to have happened in Miss A's case. Ms C also complained about a lack of clarity surrounding Miss A's diagnosis. I was advised that the sharing of Miss A's diagnosis was reasonably consistent throughout, although differing terminology was used.  However, I noted that there was some ongoing uncertainty surrounding the extent of Miss A's unstable personality traits, which might have benefited from a psychological opinion.  The IHTT policy indicates that a psychological opinion can be sought within the IHTT but I found no evidence of this having been considered.  I was also advised that the IHTT policy might benefit from being updated to define clearly the role of medical staff in diagnosing patients.  I upheld this complaint.

Ms C complained about the appropriateness of Miss A's discharge from the IHTT, noting that she had ongoing suicidal thoughts.  I was advised that the decision to discharge Miss A was not in itself unreasonable, as the IHTT provide short-term input to patients in crisis and that chronic risk over the long-term is not managed in this setting.  However, I was advised that the process followed in discharging Miss A was unreasonable.  I found little evidence of discharge planning and no indication that plans were discussed with Miss A.  I was particularly concerned that there was a lack of evidence of medical input into Miss A's discharge. Ms C also expressed unhappiness with the follow-up plan that was put in place and said that Miss A felt lost and abandoned.  I agreed that the follow-up arrangements were not sufficiently robust.  Miss A was discharged into the care of her GP, with the noted involvement of a private counsellor she was seeing and the provision of crisis service contacts.  I concluded that Miss A should have been referred for psychiatric follow-up.  I was concerned that Miss A was discharged entirely from the board's care on the basis of her private counselling, when no steps were taken to contact the private counsellor to find out what was being offered in terms of follow-up.  I upheld this complaint.

Miss A attended A&E on three occasions while under the care of the IHTT, following further suicide attempts.  Ms C complained that during these attendances, Miss A was not afforded sufficient privacy and dignity in her distressed states.  She also complained that there was a four hour delay in Miss A receiving a mental health assessment and did not consider that enough had been done to ensure Miss A was supported following discharge from A&E.

I took independent medical advice from a consultant in emergency medicine.  I was advised that Miss A had been treated in line with normal practice in a busy A&E department and I could not conclude that there was a failure to afford her adequate privacy or dignity.  I was advised that a four hour wait is not unreasonable where a patient has taken an overdose and a detailed medical assessment is required prior to mental health assessment.  I was critical, however, that it was not documented who was accompanying Miss A and assuming responsibility for her when she was discharged following her third attendance.  In addition, I was advised that a mental health assessment form was only completed for Miss A's first attendance.  While I was assured that she was appropriately assessed, and that this omission made no material difference to the care she received, I concluded that it would be good practice for this form to be completed in every instance.  On balance I did not uphold this complaint but I made some recommendations.

Redress and recommendations
The Ombudsman recommends that the board:

• support the IHTT to implement and adhere to the IHTT Operational Policy, specifically with regard to named workers and facilitating complex case discussions;
• consider revising the IHTT Operational Policy to include a description of the roles of medical staff (including different grades of medical staff) within the IHTT;
• apologise to Ms C for the failings identified in the care and treatment provided to Miss A;
• review the discharge planning process in the IHTT, taking account of the considerations highlighted in this report;
• review the IHTT Operational Policy, setting out clear guidance for when patients should be seen by medical staff;
• provide detailed evidence of all action taken to implement the AER (adverse event review) recommendations;
• apologise to Ms C for the identified failings in the process for discharging Miss A and planning her follow-up care;
• consider introducing a system whereby completion of the A&E mental health risk assessment form is mandatory for all mental health patients; and
• highlight to A&E staff that it is good practice for them to document who vulnerable patients are accompanied by on discharge, and whether the accompanying persons are happy to accept responsibility for patient safety.

Summary
Mrs A complained about the care and treatment she received from the board. Mrs A died before I completed my investigations and so her complaint was taken on by her daughter (Mrs C).

Mrs A attended University Hospital Crosshouse. She was told that she may need a heart valve replacement but that before this could go ahead, she would need to undergo a cardiac angiogram (a type of x-ray used to examine blood vessels), which is an invasive procedure.  Mrs A gave consent and underwent an angiogram in a second hospital run by the board.  Mrs A said that she experienced pain during the procedure and asked for it to be stopped.  The procedure continued but Mrs A did not recover well and while no abnormality was obvious, her condition did not improve.  Mrs A's level of consciousness declined and a few days later she was noted to have lost power in her lower limbs.  A scan of her spine showed evidence of an ischaemic event (like a stroke) within her spinal cord.

Mrs A was transferred to a third hospital (in a different NHS board), where her scan was reviewed.  This showed the appearance of a stroke on the surface of the brain. Mrs A did not recover the use of her lower limbs.

Mrs A complained that she had not been warned of the possible risks associated with an angiogram.  She also complained of an unreasonable delay in confirming a stroke and that as a result her treatment was delayed.

The board said that Mrs A had made informed consent for the procedure and  recognised that there had been a delay in diagnosis.  They added that even if a stroke had been confirmed sooner, it was unlikely there would have been a different outcome regarding surgery or spinal cord recovery.

I took independent advice from a consultant cardiologist and from a consultant neuroradiologist (a specialist in the analysis of injuries of the brain). The advisers found no evidence that all the risks and benefits of an angiogram had been discussed with Mrs A, including that bleeding and vascular damage that could cause a possible stroke or heart attack are a recognised complication.  I also found the board's consent forms and printed information to have been inadequate.  I established that there was an error in interpreting Mrs A's scan and that her diagnosis had been delayed, although Mrs A's treatment and outcome were likely to have been the same had an earlier diagnosis been made. I therefore upheld the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• make a formal apology to Mrs C for their failure to consent Mrs A properly;
• review their consenting procedure and update it in accordance with General Medical Council guidelines.  They should demonstrate to me that they have done so;
• review their relevant information booklet/sheet to ensure that they reflect the appropriate guidelines; and
• apologise to Mrs C for the delay in Mrs A's diagnosis.

Summary
Mrs C's husband (Mr A) had been diagnosed with lung cancer and discharged to the care of his medical practice.  To help manage Mr A's pain at the end of his life, Mrs C was allowed to administer a controlled drug.  Despite this arrangement, Mrs C said that the practice failed to manage Mr A's pain reasonably and to make reasonable arrangements to ensure a sufficient amount of pain relief was available.  Mrs C also said that the practice failed to communicate with her in a reasonable way about administering pain relief and to keep accurate records.  Mrs C said that as a result of this, Mr A suffered intolerable pain before his death, which caused her extreme distress.

I took independent advice from a GP adviser.  The adviser considered that in relation to treatment decisions and pain management, the standard of care and treatment provided was reasonable.  Moreover, while there were administrative shortcomings in relation to record-keeping, these were not significant and had no detrimental clinical effect on Mr A's care.  I accepted that advice. With regard to the governance arrangements in relation to Mrs C's administration of the medication,  I found that there was effectively an informal arrangement between the practice and Mrs C which allowed Mrs C to administer a controlled drug without the practice first putting adequate safeguards in place or seeking guidance from a specialist.  I agreed with the adviser that it was of concern that GPs continued to prescribe a controlled drug after expressing concerns that Mrs C had administered the medication without clinical advice.  Furthermore, the practice failed to ensure that Mr A consented to the arrangement. I upheld this part of Mrs C's complaint and made recommendations.

Mrs C also said that the practice did not respond reasonably to her complaints. I found that the practice's handling of Mrs C's complaints was reasonable and so did not uphold this complaint.

Redress and recommendations
The Ombudsman recommends that the practice:

• ensure the GPs who instructed Mrs C in relation to breakthrough medication and the other GPs who subsequently issued prescriptions for oxycodone seek support from the board's clinical support group, in relation to responsibilities for prescribing and consent under GMC (General Medical Council) guidance;
• ensure the relevant GPs discuss the findings of this investigation at their annual appraisal;
• ensure the relevant GPs familiarise themselves with the GMC guidance as a priority;
• draft a protocol in conjunction with the board to support patients and/or carers to administer prescribed subcutaneous medication by injections; and
• apologise for the failings this investigation identified.