Health

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

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

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

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

The Ombudsman recommends that the Board and Fife NHS Board:

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

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

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Practice:

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

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

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Practice:

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

Summary
Mr A had collapsed at home. He had phoned for an emergency ambulance and explained that he had a condition called idiopathic thrombocytopenic purpura (ITP - a disorder that can lead to excessive bruising and bleeding including bleeding into the brain which can be fatal).  Mr A also had alcohol-related health issues, and was in contact regularly with healthcare services.  When the ambulance arrived at his home, he explained to the paramedic and technician that he suffered from ITP.  After assessing him, the ambulance crew did not transport him to hospital.  The following day he was found dead at home, and ITP was recorded as one of the causes of death. Mrs C, who complained on behalf of Mr A's son, complained that the ambulance crew should have taken Mr A to hospital when they attended, and was concerned they did not do so because of his alcohol-related health issues and the fact that he had previously called for an ambulance on several occasions.  The ambulance service said that from the records, it appeared that Mr A had been observed appropriately, and he had declined hospital treatment.

I took independent medical advice on the complaint from a paramedic adviser, who told me that the assessment of Mr A was not reasonable, as Mr A's symptoms (along with the readings taken at the time and his pre-existing ITP diagnosis) indicated that he needed assessing at hospital, and he should have been advised of this.  The paramedic's statement that reflected on the number of Mr A's previous hospital visits should not have influenced the decision-making as to his treatment on that occasion.

Whilst my adviser recognised that the paramedic should not necessarily have had knowledge of the condition ITP, the records show no sign of them having tried to get more information about it: they should have sought more specialist advice before diagnosing a simple faint and advising Mr A, on that basis, that he did not need to go to hospital.  The advice I received is that the paramedic involved failed a significant number of professional standards, and this led to Mr A being given insufficient information, or a reasonable assessment to make a decision as to whether he should go to hospital.

It is also clear to me that the ambulance service's investigation into what happened was extremely poor.  They appeared to have taken the crew's statements at face value without further investigation, and they failed to recognise the clinical failings and take action to address them.  I upheld the complaint and made a number of recommendations.

Redress and recommendations
The Ombudsman recommends that the Scottish Ambulance Service:

• (i)  consider the Adviser's comments in relation to the paramedic and ensure they take appropriate action;
• (ii)  provide evidence they have procedures in place for paramedics to obtain clinical advice when on scene with complex patients;
• (iii)  inform us of how they intend to improve and monitor record-keeping;
• (iv)  inform us of how they intend to ensure their investigations into complaints are thorough and robust; and
• (v)  apologise to Mr A's family.

Summary
Miss C was suffering from a severe headache with associated flashing lights that was not relieved by painkillers.  Following referrals from her GP she twice attended an out-patient clinic at St John's Hospital where on both occasions she was reviewed by staff and sent home with medication.  She had a computerised tomography scan two days after the second appointment which showed that she had a brain abscess.  She was transferred to another hospital for emergency surgery, followed by another operation to further drain the abscess.  Miss C raised a number of concerns about the care and treatment she received while attending St John's Hospital, in particular, that the delay in undertaking investigations necessary to diagnose her condition may have led to a more serious outcome and unnecessary prolonged pain and distress.

When Miss C was transferred back to St John's Hospital, she was unhappy with the care she received, in particular the attitude of staff on the ward.  Miss C also complained to us about the delay in diagnosing her condition and the way the board handled her complaint.

I took independent advice from a general medical adviser and a senior nursing adviser.  On the initial diagnosis of Miss C's condition, my medical adviser said that there were sufficient red flag symptoms for Miss C's condition, which was deteriorating over time, to prompt clinicians to investigate further.  Although it is not possible to know if an earlier operation would have improved the outcome for Miss C, I found that the board failed to give her the care and treatment she could have reasonably expected.  I found that in terms of infection control on the ward, there was an unreasonable level of uncertainty from medical staff.  I also found that there was inadequate communication with Miss C and her family.  There had also been errors in relation to one of Miss C's prescriptions and her discharge medication which, whilst my medical adviser said would not have caused any harm, further reduced the confidence of Miss C in the ability of the ward to care for her.  I am also critical that whilst the board apologised, they did not explain how these errors occurred in the first place.  During my investigation, the board also failed to send copies of information sent by them to Miss C's GP. I was also critical of this, as this was relevant information given that Miss C also complained about poor communication between the board and her GP following her discharge from hospital.

In terms of the nursing care she received, my nursing adviser said that whilst there are notes documenting regular interaction between nursing staff and Miss C, some of the notes were poorly completed, so I have concerns about record-keeping.  There was also a breach in nursing protocol in relation to the disposal of a used syringe.  The board has accepted that this protocol had been breached and has assured us that action will be taken to address this.

Although there were some aspects of the board's complaints handling that could have been better, on balance I considered that Miss C received a reasonable level of service in this regard so did not uphold her complaint about the way her complaint was dealt with.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Miss C for the failings identified in this complaint;
• (ii)  report back to the Ombudsman on the outcome of the review of the discharge prescribing and drug ordering procedures at ward level and on any action taken to prevent similar errors occurring in the future;
• (iii)  remind nursing staff of the need to maintain full and accurate nursing records in line with NMC guidance;
• (iv)  explain how they will monitor compliance to protocols and ongoing improvements in relation to the safe disposal of clinical waste;
• (v)  report back on the outcome of the review of infection control procedures to evidence that learning and improvement has occurred; and
• (vi)  report back to the Ombudsman on the action taken as a result of this case in relation to communication to improve the service provided.

Summary
Mr A had an operation in May 2011 to remove half of his large bowel due to a malignant tumour.  In May 2012, Mr A had a follow-up appointment and his GP was contacted to say that blood tests had been taken, a scan was to be arranged, and that Mr A would be seen again in six months.  Mr A had his scan in July 2012.  No action was taken by the board as a result of the scan test, and Mr A did not have another appointment until September 2013.  It was at this appointment that he learned that the results from the July 2012 scan indicated that it was likely that cancer had spread to his liver and one of his lungs.  At this point a second scan was arranged, but there were further delays at this point in obtaining a scan.  Mr A's daughter (Mrs C) had to contact the board a number of times to get an appointment for her father.  She complained to the board but was not satisfied with their response, and so complained to my office.  Mr A began chemotherapy in late 2013, and died in August 2014.

As part of my investigation I took independent advice from a consultant physician and a consultant oncologist.

On Mrs C's first complaint about the delay in assessing her father's test results, I found that a combination of errors and inadequate systems resulted in a failure to assess and refer Mr A for treatment of his cancer.  My physician adviser noted that the board had not more thoroughly investigated the handling of the test and scan results in their response to Mrs C. Given that neither set of results had been handled correctly, the adviser was concerned that this reflected a more general failure of results gathering / scrutiny by the board.  Whilst some changes to test result handling procedures have been made by the board since the time period under investigation in this case (as a result of a recommendation in a previous SPSO case 201305802), further action will be required to fully address the concerns outlined in my investigation.  My adviser was also concerned to note that the board's response to Mrs C's complaint did not reflect on their role in regard to the long period between follow-up appointments. I am therefore concerned that this situation could arise again.

The delays in arranging a second scan were also unacceptable.  Whilst the board accepted that Mrs C had to make an unreasonable number of calls to chase an appointment, they have not apologised for this.  My advisers both noted that, given the circumstances surrounding the initial delay in communicating the scan results to Mr A, it was not reasonable to leave Mr A and his family waiting again for the second scan.  The board had also not apologised to Mrs C for the second delay, and I am very critical of this.

Mrs C had noted that when her father saw the cancer specialist after the second scan, he was told that even if the July 2012 scan result had been picked up earlier, he would not have been offered further surgery and that starting chemotherapy at an earlier stage would have been unlikely to make any difference to his prognosis.  However, the advice I received from my oncology adviser was that Mr A received very poor care: even if there was no treatment to cure his cancer at that time, being told of the results more than a year prior to when he actually found out would have given him and his family more time to know that he was terminally ill and to plan accordingly.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Mrs C for the delay in acting on the spread of cancer reported in July 2012;
• (ii)  ensure this case is raised with the Registrar and Consultant 1 for discussion at their annual appraisals;
• (iii)  review the process for the booking of out-patient clinic appointments;
• (iv)  take steps to ensure all laboratory staff are fully aware of the process for dealing with referrals without appropriate requesting clinician details;
• (v)  ensure radiology staff have a robust system in place for notifying referring clinicians of urgent and unexpected results;
• (vi)  consider the introduction of a safeguard whereby the radiology department copy unexpected results of malignancy direct to the relevant multi-disciplinary team; 
• (vii)  report on the outcome of the ongoing 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;
• (viii)  apologise to Mrs C for the delays in arranging the follow-up scan; and
• (ix)  ensure that all administrative and medical staff involved in this complaint are aware of the findings of this investigation.

Summary
Mr A was referred by his GP to the ear, nose and throat (ENT) clinic at his local hospital (in another NHS board area) in January 2014 with a swelling below his left ear.  This was found to be cancerous and Mr A was referred to the board for surgery.  The surgery, which resulted in extensive facial disfigurement, was carried out on 11 March 2014 and Mr A was discharged on 27 March 2014.

Mr A's daughter (Mrs C) complained to the board that they failed to explain the extent of Mr A's surgery and the possible impact on him.  Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.

The board noted that the process for obtaining consent for complex procedures such as this takes place over multiple visits, with information being given by different medical professionals.  This is to ensure that patients fully understand the information being given to them.  They said that Mr A appeared to understand the proposed procedure.  They also noted that Mr A was found to be competent and, therefore, able to give consent himself.  They said that staff always try to involve patients' families with this process though there was no formal obligation to do so.  They were sorry that Mr A's family felt they were not adequately involved.

I took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck).  My adviser said that, before such a major procedure, it is important that the patient has all the relevant information, and enough time to discuss it with family and friends, to make an informed decision.  He confirmed that a family presence during discussions is not a legal necessity but said it would be recommended by most doctors.  My adviser also explained that, although Mr A was diagnosed in another NHS board area, it was the board's responsibility to explain the procedure and get consent.  He said that there was a lack of evidence in Mr A's medical notes to show that this was done as it should have been.

In addition, my adviser informed me that most patients who have been diagnosed with head and neck cancer will be seen by a head and neck cancer nurse specialist (CNS), who can help reinforce the issues that have been discussed.

I upheld Mrs C's complaint.  It is crucial that patients are given enough information about planned procedures to allow them to make an informed decision.  They should also be given enough time to make a decision.  The advice I have received, which I fully accept, indicates that Mr A should have been seen earlier by the consultant who performed the surgery, preferably in an out-patient setting with his family and the CNS present.  There is no evidence of any involvement by the CNS, or of relevant patient information literature having been provided.  This may potentially have been provided by the CNS in Mr A's local NHS board area, but I can see no evidence of the board's CNS having taken action to confirm this.  There need to be clearer lines of responsibility when a patient is being referred from one health board to another.

Regarding the complaint about the delays in referrals, my adviser noted that records showed that all the relevant referrals were made within a few weeks of Mr A being discharged from hospital.  However, this was not done by the time of discharge.  This appears to have been as a result of confusion as to which health board was responsible.  I consider that the board ought to have taken steps to clarify this and ensure it was specified in the discharge plan, so I also upheld Mrs C's complaint about the support given to Mr A following his discharge.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  reflect on the failings highlighted in this report with a view to improving the process for obtaining informed consent and report back to me with their findings;
• (ii)  take steps to ensure that there is more involvement of the CNS in similar future cases and that this involvement is clearly documented;
• (iii)  apologise to Mr A and his family for the failings identified in the process for obtaining informed consent;
• (iv)  review their process for treating patients referred by other health boards, and discharging them back into their care, in order to ensure that clear lines of responsibility exist; and 
• (v)  apologise to Mr A and his family for the failings identified in the discharge process.

Summary
Mrs C was admitted to Glasgow Royal Infirmary in January 2013 to get treatment for a skin infection in her left leg.  Mrs C has spina bifida (a condition where the spine does not develop properly, leaving a gap in the spine) and lymphoedema (a build-up of fluid which causes swelling in an area of the body) which means that she has problems moving around.  She developed pressure ulcers on her left heel and calf, which were still there when she was discharged.  When she got home, Mrs C also found that a pressure ulcer had developed on her buttock.  She was readmitted to the hospital in February 2013 as one of the pressure ulcers was infected, and discharged a few weeks later.  She was again admitted in December 2013.

Mrs C felt that, each time she was admitted to the hospital, her risk of pressure ulcers was not properly assessed and that, due to her existing medical conditions, she should have been placed in the 'very high risk' category.  She said that the pressure ulcers developed because of the incorrect assessment and due to a lack of appropriate care.  She said that she had suffered a great deal of pain and discomfort, as well as scarring, which continued to cause her distress.  With the help of an advice worker, Mrs C complained to the board.

The board apologised that Mrs C felt that her pre-existing medical conditions were not taken into account.  They set out the timeline of events across her three admissions to hospital, stating that she had been assessed as requiring a low level of support.  When she had needed a pressure-relieving mattress when she left hospital on the second occasion, they said that this had been provided.

They said that she was assessed by a district nurse at home and continued to receive treatment for a pressure ulcer at the base of her spine until the end of July 2013.  The board said that the readmission notes for Mrs C's third admission to hospital state that her skin was healthy and, although she had previously developed pressure ulcers when she was unwell, she did not require pressure-relieving equipment because she was assessed as being able to adjust her own weight whilst in bed.  The board said it was documented that Mrs C's husband (Mr C) had insisted that a pressure-relieving mattress was ordered for Mrs C, and he had been extremely unhappy that one had not been provided.  Finally, they said that staff had carefully considered Mrs C's condition and treatment, and they were sorry that she had been dissatisfied with her care in the hospital.

Mrs C was dissatisfied with the board's response to her complaint and contacted my office, with the help of an advice worker.  I took independent advice from a nursing adviser who considered that, as Mrs C has spina bifida, she was at very high risk of developing pressure ulcers during her admissions to hospital.  The adviser found no evidence that the nursing staff took Mrs C's pre-existing conditions into account or put steps in place to prevent pressure ulcers occurring.  In particular, the Waterlow risk assessment charts (a pressure ulcer risk assessment tool) completed for each hospital admission were not marked properly.  The adviser said that, as Mrs C has reduced sensation below the waist (because of spina bifida), she should have had five extra points added to her Waterlow score.  This would have put her into the 'high risk' category.  During the second hospital admission, the adviser considered that the delay of several days for a tissue viability nurse to provide advice on Mrs C's care, and for a pressure-relieving mattress to be arranged, was unacceptable.  The adviser also noted that the nursing staff involved in an incident when Mr C was very angry about Mrs C's treatment and the delays experienced may benefit from education and training in front-line resolution.  The adviser also found it 'shocking' that the board had not determined and admitted their failings in Mrs C's care and treatment when they investigated her complaint.

The advice I have received is that nursing staff failed to take into account Mrs C's specific needs due to her spina bifida and, as a result, failed to appropriately assess and manage her pressure areas on each of her admissions to the hospital.  There was also a failure by the board to acknowledge these failings while carrying out their investigation of Mrs C's complaint.  I am critical of these failings and uphold the complaint.

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  review the training for nursing staff on the assessment, prevention and care of pressure ulcers, particularly where a  patient has reduced sensation to the limbs;
• (ii)  ensure the tissue viability team review the mechanism for recording patients who are 'special risk', particularly patients with reduced sensation such as spina bifida;
• (iii)  carry out a review of the reasons why there was a delay in the involvement of the tissue viability team in Mrs C's care; and advise this office of the action taken to ensure that lessons are learned from this complaint;
• (iv)  review the education and training in early resolution skills for the nursing staff involved when dealing with patients and their families who have raised concerns about their care and treatment; and
• (v)  apologise to Mrs C for the failings identified in her care and treatment. 

Summary
Mr A had concerns about the care and treatment he received from his medical practice in diagnosing his kidney condition.  An advice worker (Ms C) complained to the practice on his behalf in April 2013.  When she had not received a response to her complaint, despite chasing a response and resubmitting her complaint, she complained to my office.  Ms C noted that the only contact she had with the practice was a reply from them asking her to pay £50 to release Mr A's medical records, which was not what she had asked for.  She was also concerned that the practice was operating outwith the NHS complaints procedure, as her complaint should have been acknowledged within three days and responded to within 20 working days.  My complaint reviewer considered the evidence available, upheld Ms C's complaint and made recommendations to the practice, which were to issue a response to Ms C's original complaint, apologise to Mr A and review their complaints handling procedure.  We published our decision on this case in March 2014.

There then followed several attempts from my office to ensure that the practice had complied with our recommendations.  The correspondence we received from the doctor at the practice noted that the practice had no idea what their mistake was or what they were to apologise for.  Eventually, after making several attempts to correspond with the practice, I wrote to the chief executive of the board to make them aware of the matter.  The chief executive noted that many of the statements made by the practice to my office during our investigation were inaccurate.  In particular, the chief executive confirmed that the mail system within the building in which the practice was located was not dysfunctional (the practice had said that the mail system had led to them not receiving Ms C's initial complaint).

I took independent advice from one of my clinical advisers who is a GP.  He noted that whilst Ms C presented a credible history, the practice appeared to contradict themselves and were less credible with the explanations and information they had provided to us.  My adviser commented that the practice did not appear to have correct and proper systems in place to ensure the safe running of the practice.  In addition, he said the chaotic way in which the practice dealt with Ms C's complaint including treating it as a request for copies of medical records and requesting a payment for £50 was worrying.  My adviser highlighted a number of sections of the General Medical Council (GMC)'s Good Medical Practice guidance, and noted where the practice appear to have failed to demonstrate their compliance with this guidance, including their failure to operate a credible complaints system.

The advice I have received, and accepted, is that the practice had deliberately complicated the issues around Mr A's complaint with the aim of not answering it, which was compounded by the poor systems they had in place for handling complaints.  The practice's failure to engage with the board to allow mediation and assistance to improve their situation led to the injustice of Mr A not having his complaint answered.

Finally, my adviser commented that the actions, and lack of action, taken by the practice were serious enough to threaten the reputation of the medical profession because they had repeatedly failed in the duties expected of them by the GMC.  The evidence available indicates that they failed to handle Ms C's complaint appropriately in line with the NHS 'Can I Help You?' guidance.  In addition, I have extreme concerns about the practice's resistance to accept that they failed to handle the complaint properly.  Their refusal to comply with my recommendations has resulted in my office having to issue this report when the complaint should have been finalised following the decision issued by my complaints reviewer over a year ago.  In light of my serious concerns, I have not only made further recommendations to the practice, but also recommended that the board consider the contract held with the practice, and consider whether to refer the practice to the GMC.

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  acknowledge acceptance of Mr A's complaint and answer it appropriately within 20 working days;
• (ii)  apologise to Mr A for failing to deal with his complaint appropriately in line with Can I help you?; and
• (iii)  provide the SPSO with a copy of its complaint handling procedure to demonstrate compliance with Can I help you?.

The Ombudsman recommends that the Board:

• (i)  consider referring the Practice to the GMC; and
• (ii)  consider its position in relation to the contract held with the Practice.