Health

Overview
The complainant (Mrs C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing her father (Mr A)’s bowel cancer.  Mr A was seen by a respiratory consultant (the Consultant) at an out-patient clinic at Monklands Hospital (the Hospital) on 24 July 2013 following a referral from his GP.  Mr A had been suffering from breathlessness for a number of months and had been treated for a lower respiratory tract infection.  The Consultant's diagnosis was that Mr A was suffering from mild asthma brought on by the lower respiratory tract infection and blood was taken for routine tests.

Tests of the blood taken by the Consultant showed that Mr A had a low level of haemoglobin (a protein found in red blood cells which carries oxygen around the body).  The laboratory noted that there were features of iron deficiency and that blood loss should be excluded as a possible cause.  The laboratory did not highlight the low haemoglobin level by telephone and the Consultant did not identify or act upon this abnormality when reviewing Mr A's results.

Due to his continuing symptoms, Mr A had further blood tests carried out by his GP on 9 September 2013 and was admitted to the Hospital the following day where he required a blood transfusion.  He was subsequently diagnosed with colon (bowel/large intestine) cancer and liver metastases (the spread of cancer).

Specific complaints and conclusions
The complaints which have been investigated are that the Board failed to:

• take appropriate action when Mr A's blood result showed an abnormally low haemoglobin level (upheld); and
• ensure that Mr A received timely follow up treatment when the abnormally low haemoglobin level was discovered (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• confirm the outcome of their review of this incident and advise what steps have been taken to prevent recurrence in future;
• review their governance arrangements for identifying systems errors like this in future;
• apologise for the failure to implement the Telephoning of Results Protocol;
• apologise for the delay in Mr A's diagnosis;
• confirm that this matter will be, or has been, discussed at the Consultant's annual appraisal;
• conduct a Board level review of the tracking of test results in both paper and electronic formats; and the role of individuals who order tests and report their results; and
• make the outcome of any recommendations arising from the Board level review available to us, Mr A and his family.

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

Overview
The complainant (Mr C) complained about the treatment he received following his referral to the Orthopaedic Department at Ninewells Hospital for an injury to a muscle in his chest. His GP (Doctor 1) referred him to a consultant orthopaedic surgeon (Doctor 2). Doctor 2 assessed him and concluded that no surgical treatment would improve his injury. He then suggested that if Mr C was worried about the look of the injury, Doctor 1 should refer him to plastic surgery services. Doctor 1 referred Mr C to plastic surgery services for cosmetic repair. A consultant plastic surgeon declined the referral prior to seeing Mr C as cosmetic augmentation of the pectoral muscle was not a procedure offered by the plastic surgery services.

Specific complaint and conclusion
The complaint which has been investigated is that Tayside NHS Board (the Board) have failed to provide appropriate clinical treatment following a GP referral for a chest injury (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that Mr C is referred for a second consultation with an orthopaedic surgeon;
• (ii) ensure this case and the identified failings are discussed with Doctor 2 at his next appraisal;
• (iii) ensure the Medical Director is made aware of the identified failure to facilitate the request for a second opinion; and
• (iv) issue a full apology to Mr C for the failings identified in this case.

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

Overview
The complainant (Ms C), an advocate, raised a number of concerns on behalf of Mr A. Mr A’s late wife (Mrs A) was referred urgently by her GP for the investigation of symptoms suggestive of breast cancer on three occasions within a period of seven months. Mrs A was referred urgently to the Breast Clinic at the Western Isles Hospital (the Clinic) in Stornoway three times between May and November 2008 but she was not referred on to the Highland Breast Centre in Inverness (the Breast Centre) until December 2008. Cancer was diagnosed in January 2009. Mrs A was a young woman whose first child was under two years old when she first reported her symptoms to her GP. By the time the cancer was diagnosed, she was some 12 weeks pregnant with her second child. Although the child was delivered safely and Mrs A was treated for her cancer, the cancer later returned and she died aged 33 years in June 2011.

Specific complaint and conclusion
The complaint which has been investigated is that the Board unreasonably delayed diagnosing Mrs A's breast cancer (upheld).

Redress and recommendation
The Ombudsman recommends that the Board:

• (i) issues a written apology for the failings identified.

The Board have accepted the recommendation and will act on it accordingly.

Overview
The complainant (Mrs C) raised concerns about the failure by Tayside NHS Board (the Board) to provide a British Sign Language (BSL) interpreter for a patient (Ms A) in Ninewells Hospital (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that it was unacceptable for the Board not to provide a BSL interpreter during Ms A’s 12-day in-patient admission to the Hospital in July 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider amending their Interpretation and Translation Policy to highlight the legal duties staff have and to explain that using families, lipreading and pen and paper is not likely to be an adequate or reasonable response to the needs of a BSL user. This should make clear that BSL is a registered language and not simply signed English;
• (ii) produce further guidance for staff on: what the protocol is once a patient makes staff aware that they need a BSL interpreter; who is responsible for arranging this and how the interpreter's availability is to be coordinated with that of the health professionals involved; and how reassurance and progress on getting an interpreter should be communicated back to the patient;
• (iii) consider providing further training to staff on deaf culture, language and legal rights;
• (iv) consider seeking input from deaf people on the Board's Interpretation and Translation Operational Group to review the effectiveness of the implementation of the Interpretation and Translation Policy; and
• (v) offer to meet with Ms A and a BSL interpreter to answer any questions she has about her treatment and to apologise, explain and feedback how her complaint has helped them to develop their service.

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

Overview
The complainant (Ms C), acting as Independent Advocate for Miss A, raised a concern about the decisions taken by staff about artificial feeding by nasogastric (NG) tube for Miss A during a hospital admission from 25 June 2011 and 8 September 2011. Ms C also raised a concern about a lack of consultation with her about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision in September 2011. Ms C also had concerns about the accuracy of Lanarkshire NHS Board (the Board)'s response to her complaint in October 2011.

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

• (a) during a hospital admission from 25 June 2011 to 8 September 2011, a flawed decision was taken to remove an NG tube (upheld);
• (b) a DNACPR decision was taken without appropriate consultation with Ms C as Miss A's advocacy worker (upheld); and (c) Lanarkshire NHS Board's complaint reply of 1 December 2011 inaccurately stated that a particular clinician had known Miss A since 2004 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) use the circumstances of Miss A's case to review their practice in respect of patients with learning difficulties and/or suspected dementia, with particular focus on a review of the quality of decision making, the recording of decision making and the quality of record-keeping on admission and concerning DNACPR decisions; and
• (ii) review their procedures for investigating complaints to ensure that responses are both accurate and can be justified.

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

Overview
The complainant (Mr C) raised concerns about the care and treatment his wife (Mrs C) received from the GPs at the medical Practice (the Practice) from January to October 2013.  Mrs C subsequently attended Aberdeen Royal Infirmary, where she was diagnosed with bowel cancer.  Since the events within this complaint, Mrs C's condition deteriorated further, and she sadly died during the course of our investigation.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay by the Practice in 2013 in diagnosing Mrs C's cancer (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mr C for their failure to appropriately refer Mrs C for diagnosis of her cancer during the period from January to October 2013, and for the distress this caused her and her family;
• provide evidence that the actions set out in their Significant Event Analysis have been met, giving consideration to the NHS Education for Scotland Enhanced Significant Event Analysis approach;
• identify the training needs for the practice team relating to the issues raised in this complaint, and reflects these in appraisals and assessments; and
• explain what changes the Practice will introduce to ensure that, in future, their procedures for Significant Event Analyses are in line with national guidelines, and that they receive the prompt attention of the whole Practice.

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

Overview
The complainant (Mr C) raised concerns that his late mother (Mrs A) had not received adequate fluids and nutrition during her admission at Vale of Leven Hospital.  Mr C also complained that, following her diagnosis with oesophageal cancer, Mrs A did not receive palliative treatment for nearly three weeks until he raised his concerns with the consultant in charge of Mrs A's care.

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

• staff at Vale of Leven Hospital failed to ensure that Mrs A received an adequate level of fluids and nutrition despite her swallowing difficulties (upheld); and
• staff at Vale of Leven Hospital and Paisley Royal Alexandra Hospital failed to ensure that Mrs A received appropriate and timely clinical treatment in view of the symptoms which she presented with (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• review the processes for ensuring that fluid intake and balance is appropriately monitored and recorded on the Vale of Leven Hospital acute medical ward;
• issue a written apology to Mr C, clearly acknowledging the gravity of Mrs A's experience and the specific failings which led to the delay in her treatment; and
• take steps to ensure that the failings his investigation identified have been fully addressed in the revised pathway for onward speciality referral for upper gastrointestinal within Clyde, and explain what awareness raising has been undertaken in relation to this.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her by her medical practice (the Practice) since the beginning of 2012.  Mrs C believed that the doctor treating her failed to acknowledge or deal with the symptoms she was displaying and that the doctor failed to recognise a general decline in her health.  As a result she was not referred timeously for specialist assessment.  Mrs C was subsequently diagnosed with bowel cancer and she believes that earlier referral would have avoided the need for the emergency surgery she was required to undergo.

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

• provided inadequate care and treatment (upheld); and
• unreasonably failed to make the appropriate referrals (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• ensure that the doctor responsible for Mrs C's treatment reflects on their practice in relation to these events and discusses any learning points at their next appraisal;
• review with the doctor involved in Mrs C's care the SIGN guideline 126;
• review the General Medical Council guidance on record-keeping and evaluate a sample of their case notes to see that they are fulfilling the required standards;
• apologise in writing for the failures identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment provided to her daughter (Mrs A) for mental health problems by Forth Valley NHS Board (the Board) prior to her death by suicide on 11 October 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• offer a reasonable diagnosis (not upheld); and
• provide a reasonable standard of care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review the approach taken by the Intensive Home Treatment Team to the assessment of risk to ensure that presenting risk factors are systematically considered and recorded and that the rationale behind clinical decision making is transparent;
• remind medical staff of the importance of accurate and signed contemporaneous notes;
• review the process for communicating medical reviews of patients to IHTT staff, to ensure that all relevant information is made available timeously;
• review the process for discharging patients from the IHTT to ensure that medical staff's opinions are considered; and
• apologise for the failings identified in this report.

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

Overview
The complainant (Miss C) raised a number of issues about the service she received from Greater Glasgow and Clyde NHS Board (the Board) during 2004.  Miss C was admitted to Princess Royal Maternity Hospital on 11 June 2004 to undergo a feticide procedure on medical advice.

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

• failed to explain Miss C's rights to request a private burial or cremation (upheld);
• failed to show, or explain, the cremation forms prior to asking Miss C to sign them (upheld);
• asked Miss C to sign the cremation forms when she was sedated and prior to the delivery (upheld); and
• failed to provide an accurate explanation, when responding to Miss C's complaint, for the inconsistencies in the dates on the cremation forms (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Miss C for the failings identified in this complaint;
• ensure that staff attending patients after a fetal loss follow the guidance notes;
• report back to the Ombudsman on how they will ensure that the options for disposal of remains will be published to parents, so that they are aware of the choices that are available to them;
• report back to the Ombudsman on steps they intend to take to ensure that any form to be completed by a patient after a fetal loss is fully explained to the patient, at a time when they are fully able to understand any explanation given;
• report back to the Ombudsman on steps they intend to take to ensure that patients, following a fetal loss, are not being asked to give consent while they lack the capacity to fully understand and recall what they are signing; and
• formally apologise for the inconsistencies provided in relation to the dates on the cremation forms.

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