Health

Overview
The complainant (Mrs C) raised concerns that the standard of care and treatment provided to her late mother (Mrs A) from two hospitals following a fall was not reasonable and included concerns about communication, treatment decisions, discharge and provision of nutrition and fluids.

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

• the Western General's care and treatment of Mrs A in 2013 was unreasonable (upheld); and
• the Royal Infirmary of Edinburgh's care and treatment of Mrs A in 2013 was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board (the Board):

• ensure that any recorded assessment of a patient is accurate and a reliable source on which to base the planning of care and supervision;
• ensure that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
• take steps to ensure that communication with relatives or carers of patients with cognitive impairment is proactive and systematic;
• ensure the failures identified are raised with relevant staff;
• review their practice in relation to the pre-operative provision of nutrition and fluid in light of Nursing Adviser 2's comments;
• ensure that clinical practice, decision-making processes and clinical records in relation to DNACPR decisions are in line with the relevant policy; and
• apologise to Mrs C for the failures identified in this investigation.

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

Overview
The complainant (Mr C) raised a number of concerns that the diagnostic journey he underwent for an abdominal problem was unreasonable and has left him with on-going and debilitating symptoms.

Specific complaint and conclusion
The complaint which has been investigated is that Lanarkshire NHS Board's diagnostic actions were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• ensure, as a matter of priority, the Consultant reflects on the events investigated and discusses all learning points at  their next annual appraisal.  Including when and how a cancer diagnosis is made and communicated;
• ensure that all the medical staff involved in this case are reminded of the importance of adhering to the General Medical Council guidance on record-keeping;
• urgently review the diagnostic process used for colon cancer, including the use of Multi-Disciplinary Team discussions, taking into account national guidance;
• issue a written offer for Mr C to insert a note of clarification in his clinical records where necessary, as mentioned in the draft complaint response;
• review its monitoring process for the handling of complaints to ensure that a robust system is in place to prevent complaint responses that are due for issue being  delayed and that if unavoidable delays occur, complainants are kept informed; and
• issue a written apology to Mr C for the failings identified during this investigation.

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

Overview
The complainant (Mrs C) raised a number of concerns over the care and treatment she received from Lanarkshire NHS Board (the Board) between July and October 2013.  Mrs C had twice suffered from cancer and was alert to its possible return.  She complained that the Board's handling of her treatment in this time unreasonably delayed the cancer diagnosis she ultimately received in October 2013.  Mrs C was also dissatisfied with the accuracy of the Board's response to her complaint.

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

• (a) the Board did not provide reasonable care and treatment to Mrs C between July and October 2013 (upheld); and
• (b) the Board's response to Mrs C's complaint of 15 November 2013 was not reasonable due to its containing inaccuracies (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• raise this matter at Doctor 6's next appraisal as a learning point;
• carry out a significant incident review to ensure that the failings highlighted, including the lack of recognition of the severity and urgency of the situation and responsibility for taking the case forward, are fully addressed and acted upon to prevent recurrence;
• address the reasons for the inaccuracies in their response to Mrs C's complaint as part of the significant incident review; and
• apologise to Mrs C in writing for the failings identified in this report.

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

Overview
The complainant (Mrs C) complained that a lengthy list of errors and omissions by various specialist services and a failure to co-ordinate her care and treatment caused her stress and ultimately led to a delay in her being diagnosed with multiple sclerosis and her starting treatment.

Specific complaints and conclusions
The complaints which have been investigated are that Ayrshire and Arran NHS Board (the Board) unreasonably failed to:

• adequately assess Mrs C's condition (not upheld);
• ensure that the various departments involved in Mrs C's care monitored her care and treatment appropriately (upheld);
• ensure that the various departments involved in Mrs C's care co-ordinated and communicated appropriately with each other (upheld); and
• ensure that the responses Mrs C received to her complaints were accurate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failings identified in this report;
• provide evidence of the improvements that have been made to the Board's out-patient's appointment systems;
• consider developing a pathway regarding all suspected genetic disorders seen within Dermatology Services, so as to streamline access to geneticists;
• ensure that the comments of the Dermatology Adviser, in relation to record-keeping and the Board's action plan, are brought to the attention of the relevant staff within Dermatology Services;
• in cases involving several health boards, consider implementing the copying of clinical correspondence to a patient, so as to improve communication and provide the patient with the opportunity to be aware of the progress of their care;
• consider reviewing the systems for Radiology referrals between hospitals;
• review spinal magnetic resonance imaging (MRI) protocols to:  identify which part of the recall protocol failed in Mrs C's case; ensure where abnormalities are detected they are appropriately reported; and ensure appropriate consideration is given to examining the patient's whole spine in one scan;
• carry out an audit to ensure there is a clear system for prioritising MRI scan requests according to the degree of clinical urgency;
• ensure that communication protocols between Radiology Services and other clinicians are optimal;
• ensure that the comments of the Radiology Adviser and the Neurology Adviser are shared with the appropriate staff; and
• advise of the present position in respect of the planned move to digital case notes.

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

Overview
The complainant (Mrs C) raised significant concerns about delays and poor communication in decisions about her treatment for secondary liver cancer by Lothian NHS Board (the Board) from December 2012 to May 2013.  Mrs C sadly died in March 2014 and this complaint is taken forward on her behalf by her husband, Mr C.

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

• (a) clinicians in NHS Lothian failed to deal with a referral for treatment in a timely and appropriate manner (upheld); and
• (b) clinicians in NHS Lothian failed to communicate adequately with Mrs C and other health professionals about her condition and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review the timelines for the current system in place for multi-disciplinary team (MDT) discussion and subsequent clinic review with a view to improving the timescales identified in this case;
• review the system for obtaining scan results to ensure that significantly more prompt MDT review is possible;
• review the communications with Mrs C in light of failings identified in this report to establish areas of improvement; and
• apologise to Mrs C’s family for the failure to adequately and promptly communicate discussions and decisions about her treatment.

Overview
The complainant (Ms C) raised a number of issues about the service she received from Lothian NHS Board (the Board)’s Mental Health Services in 2011.  Ms C was admitted to Meadows Ward of the Royal Edinburgh Hospital on 8 December 2011.  Ms C said that, despite her sleeplessness, erratic and strange behaviour and despite her friends' concerns that she was clearly not herself, she was diagnosed with a personality disorder and discharged on 14 December 2011 without any medication.

Specific complaints and conclusions
The complaints which have been investigated are that the Board's staff:

• (a) unreasonably diagnosed that Ms C was suffering from a personality disorder (upheld);
• (b) inappropriately discharged Ms C from hospital on 14 December 2011 (upheld); and
• (c) failed to prescribe Ms C with medication on discharge from hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a formal written apology to Ms C for the failings identified in this investigation;
• further annotate Ms C's clinical records from Meadows Ward, to clarify that: the letters referred to in the clinical note of 9 December 2011 did not exist and no diagnosis of personality disorder had been made by the perinatal psychiatrist;
• raise the findings of this investigation with the relevant clinical staff for consideration as part of their next annual performance appraisals;
• develop a strategy for improving carer involvement and communication on Meadows Ward;
• develop a strategy for improving information sharing within multi-disciplinary teams on Meadows Ward;
• develop a strategy for ensuring multi-disciplinary discharge planning on Meadows Ward;
• review record-keeping practices on Meadows Ward, to ensure that communication with carers and family is appropriately recorded; and
• meet the outstanding treatment costs Ms C incurred while in France, prior to her discharge on 13 January 2012.

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 given to her late husband (Mr C) by a locum doctor (the Locum GP) at his GP Practice (the Practice) between 17 September 2013 and his death on 24 September 2013.  She said that the Locum GP did not visit Mr C but, nonetheless, overruled the suggested treatment by an out-of-hours doctor who had visited; he made decisions about Mr C's care and treatment which were contrary to her and Mr C's wishes; he made an error in writing a prescription; and he failed to attend their home to sign the death certificate.

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

• (a) the Locum GP at the Practice provided inadequate care and treatment to Mr C (upheld); and
• (b) the Practice's response to Mrs C's complaint was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Locum GP:

• make a full and formal apology to Mrs C for the omissions and failures identified in this investigation;
• ensure that he discusses all the issues that have been identified above at his next formal appraisal; and
• demonstrate that he has learned lessons as a consequence of this complaint by completing appropriate professional training.

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her late husband (Mr C) about delays in him receiving an appointment from Hairmyres Hospital (the Hospital) to have his abnormal bowel symptoms investigated.  Mrs C also complained about the lack of information given to Mr C about delay in a sigmoidoscopy (a procedure to investigative the bowel) going ahead at the Hospital’s Day Surgery Unit.

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

• (a) there was an unreasonable delay in offering appointments following a GP referral on 31 March 2011 (upheld); and
• (b) Mr C was kept waiting for an unreasonable length of time when he attended the Day Surgery Unit (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• share the failings in this case with the Patient Focus Booking Service;
• as a matter of urgency, audit a sample of patients that have been removed from the waiting list for not responding to the Patient Focus Booking Service to ensure the appointment protocol has been followed.  In addition, consider changes to the protocol to prevent the error recurring;
• provide evidence to show that the lack of communication regarding the delay and postponement in the sigmoidoscopy going ahead has been fed back to relevant staff; and
• apologise to Mrs C for the failings identified in this letter.

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

Overview
The complainant (Mrs C) raised concerns about inadequate consultation and involvement of her as a carer for her husband (Mr C) during his admissions to two hospitals run by Highland NHS Board (the Board) in 2011.

Mrs C had Financial and Welfare Power of Attorney (POA) for Mr C and was also Mr C's Named Person for the purposes of the Mental Health (Care and Treatment) (Scotland) Act 2003.  Mr C had a diagnosis of Advanced Alzheimer's Disease.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not reasonably include Mrs C in decisions about Mr C's care and treatment from February 2011 onwards (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the repeated failures to adequately and properly involve her in decision making around Mr C's care and treatment;
• review their approach to carer communication and participation for people with dementia to ensure a coherent, bespoke and planned approach in all cases.  This should be carried out with due regard to the national Dementia Standards, the principles under-pinning the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity Act 2000, and the rights of 'Named Persons' and those with POA status.  The Board should advise this office of the outcome of this review; and
• review their current documentation of carer involvement in light of the record-keeping failings identified in this report and advise this office of the steps taken to address these omissions.

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

Overview
The complainant (Mr C) raised concerns about the time it took to diagnose Mr A with liver cancer.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay in diagnosing that Mr A was suffering from liver cancer (upheld).

Redress and recommendations
The Ombudsman recommends that:  Fife NHS Board (the Board):

• review their processes for communicating abnormal results to include referral to an appropriate lead clinician in the hospital as well as the referring doctor in light of the Medical Adviser's comments; and
• apologise for the failures identified.

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