Health

Overview
The complainant (Mrs C) complained that a delay in carrying out a Magnetic Resonance Imaging (MRI) scan resulted in her being left with permanent nerve damage, muscle wastage and bladder problems.

Specific complaint and conclusion
The complaint which has been investigated is that staff at the Southern General Hospital, Glasgow failed to assess Mrs C's symptoms as requiring an urgent MRI scan (upheld).

Redress and recommendations
The Ombudsman recommends that Greater Glasgow and Clyde NHS Board:

• apologise to Mrs C for the failings identified in this report; and
• ensure that proper and accurate records are kept of telephone referrals made to the Department of Neurosurgery and this report is shared with the relevant staff.

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board and Lanarkshire NHS Board:

• take steps to implement appropriate protocols, policies or guidance in order to regulate MRI scanning and spinal surgery referrals.

Greater Glasgow and Clyde NHS Board and Lanarkshire NHS Board have accepted the recommendations and will act on them accordingly.
 

Overview
The complainant (Mr C) complained on behalf of his wife, Mrs C.  He said that although Mrs C had an operation to her spine in June 2012, it was not until February 2013 that it was discovered that the operation had been undertaken in the wrong place.  Mr C said that, as a consequence, his wife suffered unnecessary pain and discomfort which impacted significantly upon her life, particularly as Mrs C was recovering from radiotherapy treatment in respect of breast cancer.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment provided in connection with surgery on Mrs C's spine was unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lothian NHS Board:

• ensure that the Consultant Neurosurgeon revisit her procedures for determining the level of surgery and consider doing two x-rays, one before incision and one with the wound open.  Alternatively, do only one x-ray but with the wound open and the spinal elements clearly visible.

The Ombudsman recommends that Borders NHS Board:

• ensure that Hospital 2 review their procedures concerning the timely dispatch of radiology reports.

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment given to his wife (Mrs C), after she was admitted as a voluntary patient to Crathes Ward (Ward 1) of the Royal Cornhill Hospital, Aberdeen (the Hospital).  He said that although she was experiencing suicidal thoughts, the means by which she could attempt to end her life were not removed from her.  He was also concerned that she was not placed under an appropriate level of observation and that she did not receive her required medication.

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

• (a) failed timeously to remove Mrs C's personal belongings for safe keeping (upheld);
• (b) failed to keep Mrs C under an appropriate level of observation (upheld); and
• (c) failed to ensure that Mrs C had an adequate supply of medication (upheld).

Redress and recommendations

The Ombudsman recommends that Grampian NHS Board:

• emphasise to staff on Ward 1 that when suicidal intent has been indicated, they must take action to mitigate the risk;
• ensure that action in this regard should be properly documented and timed;
• make a formal apology to Mr and Mrs C for their failures in this matter;
• take steps to ensure that their processes of risk assessment and risk assessment planning are robust and transparent; and
• ensure that transfer procedures take due account of medication issues, to ensure that any required medication is prescribed/given without undue delay.

Overview
The complainant (Mrs C) expressed concern that her late husband (Mr C) had not been given enough information prior to giving his consent to open heart surgery.  Mr C died during the operation, and Mrs C had said that, if they had been fully aware of the risks involved, Mr C would not have chosen to go ahead with the operation.

Specific complaints and conclusions
The complaint which has been investigated is that the consent process for cardiac surgery was not properly carried out in that Lothian NHS Board unreasonably failed to provide sufficient information about the potential complication of Mr C's heart being attached to the back of the sternum (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• ensure that staff refer to the General Medical Council Guidance, 'Consent:  patients and doctors making decisions together' when agreeing and recording consent and risk for cardiac surgical procedures;
• ensure that unacceptable delays between patients' deaths and subsequent Audit Meetings do not occur in the future;
• ensure that Doctor 2 is reminded of the importance of record-keeping in all elements of care and treatment; and
• apologise to Mrs C for the failure to inform her and her husband adequately of the risks involved in his operation, and for the suffering that Mrs C has endured as a result of this failure.

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

Overview
The complainant (Mrs C) alleged that the care and treatment given to her at St John's Hospital at Howden (the Hospital) during her admission of 18 to 21 November 2011 were below a reasonable standard.

Specific complaint and conclusion
The complaint which has been investigated is that the care and treatment given to Mrs C at the Hospital during her admission of 18 to 21 November 2011 were below a reasonable standard (upheld).

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

• (i) formally apologise to Mrs C for all their failures in the provision of care and treatment to her during the period between 18 and 21 November 2011;
• (ii) satisfy themselves that proper reflection (see paragraph 20) is carried out by the staff concerned;
• (iii) review their process of written and electronic note taking to ensure that the 'story' of an untoward, unusual or exceptional event is clearly recorded and that steps taken to mitigate the situation are highlighted; and
• (iv) take steps to ensure that missed vital signs observations and missed medication administration are alerted appropriately.

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

Overview
The complainant (Mr C) raised concerns about the loss of his clinical records and about the prescription of on-going medication for glaucoma by Lothian NHS Board (the Board)'s services delivered through the prison healthcare centre (the Healthcare Centre) at HMP Edinburgh (the Prison).

Specific complaint and conclusion
The complaint which has been investigated is that it was unreasonable that the Healthcare Centre lost Mr C's clinical records and did not prescribe his on-going medication (upheld).

 Redress and recommendations
The Ombudsman recommends that the Board:

• (i) issue a full apology to Mr C for the loss of his clinical records, for the potential impact that his lack of medication may have had on his eyesight, and for the poor handling of his complaints;
• (ii) confirms that the healthcare centre now uses electronic clinical records which include lists of prescribed drugs for prisoners, and the date this was implemented;
• (iii) confirms their review of the process of transferring clinical records from establishment to establishment, which they referenced in a letter to Mr C;
• (iv) confirms the scope and findings of the NHS LEAN review of the pharmacy process, and if this is not yet complete, what the timescales for the review are; and
• (v) provides evidence that they have reviewed their complaints handling procedure in relation to complaints about their prison healthcare service, to ensure a proactive approach is taken and to ensure they receive complaints timeously.

Overview
The complainant (Mrs C) raised a number of concerns that her father-in-law (Mr A) had been subjected unreasonably to a prolonged period of surgery because staff failed to ensure all surgical equipment was available before proceeding, and that a member of nursing staff failed to alert medical staff of a delay in Mr A's being able to move his legs following surgery.  Mr A developed a serious complication and became paraplegic.

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

• Lothian NHS Board (the Board)'s delay in sourcing appropriate surgical equipment was unreasonable (upheld); and
• a nurse on duty unreasonably failed to report Mr A's inability to move his legs (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• provide a detailed action plan identifying the changes they have made to ensure a surgical safety checklist is completed by the surgical team in line with World Health Organisation guidelines;
• confirm the action plan also ensures that relevant guidance on consent is followed in relation to obtaining consent for surgical procedures;
• bring the failures in record-keeping to the attention of relevant staff and carry out regular audits to ensure compliance with guidelines;
• provide evidence that all relevant monitoring charts etc are in place for patients who receive an epidural to document normal return of motor function including a clear outline of actions to be taken if motor function has not returned with an expected timeframe;
• ensure that the failures identified are raised as part of the annual appraisal process of relevant staff and address any training needs;
• ensure protocols are in place which comply with Royal College of Anaesthetists guidelines on management of epidurals and demonstrate to the Ombudsman that they have been widely disseminated to and utilised by relevant staff; and
• apologise to Mrs C for the failures identified.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the care and treatment provided to their late son, Mr A, when he attended the Accident and Emergency (A&E) department of the Royal Infirmary of Edinburgh.  Mr and Mrs C also complained that staff unreasonably failed to admit Mr A for further assessment, and that the handling of their subsequent complaint was inadequate.

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

• Lothian NHS Board (the Board) provided inadequate care and treatment to Mr A in A&E (upheld);
• the Board unreasonably failed to admit Mr A pending further assessment (not upheld); and
• the Board’s handling of Mr and Mrs C's complaint was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• consult urgently with all relevant stakeholders to formulate an appropriate protocol for dealing with patients who attend A&E with substance misuse and co-morbid mental health illness;
• ensure that all staff dealing with complaints are reminded of the importance of keeping complainants informed and updated during the complaints process; and
• issue a written apology to Mr and Mrs C for the failings identified in this report.

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

Overview
The complainant (Mrs C) raised concerns about Grampian NHS Board (the Board)'s handling of her husband (Mr C)'s hip replacement operation.  Equipment problems caused complications during the procedure.  Following surgery, Mr C developed delirium.  Although this largely resolved with time, he was required to remain in hospital for several months following his surgery.

Specific complaint and conclusion
The complaint which has been investigated is that staff at Dr Gray's Hospital (the Hospital) in Elgin failed to conduct Mr C's hip replacement operation on 31 October 2012 in a reasonable and appropriate manner (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• conduct a review of the equipment available in their theatres to ensure that their surgical teams have access to any instruments which might be required in the course of an operation; and
• share my findings with their surgical staff for discussion at a suitable learning forum, with particular reference to the appropriateness of decisions made during Mr C's operation.

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 late mother (Mrs A) in Stirling Royal Infirmary (the Hospital) between 21 and 23 February 2011.  This included Mrs C's concerns: that hospital staff incorrectly diagnosed Mrs A with dementia rather than delirium, and failed to obtain proper consent for surgery; about how Mrs A's urinary tract infection was treated; and, about how Forth Valley NHS Board (the Board) responded to Mrs C's complaint.

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

• (a) the Board failed to explain how their diagnosis of dementia was reached (upheld);
• (b) the diagnosis of dementia was inappropriately used to obtain consent for an operation (upheld);
• (c) the approach to managing Mrs A's urinary tract infection was inappropriate (upheld); and
• (d) there was a failure to accept clinical failings or offer an apology despite the findings of an external review (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for incorrectly diagnosing Mrs A with dementia, and incorrectly completing a Certificate of Incapacity to obtain consent for Mrs A's operation;
• apologise to Mrs C for the poor standard of care provided to Mrs A;
• review their provision of specialist ortho-geriatric care for patients like Mrs A, who commonly present with fractures but have other medical conditions that need to be managed in an orthopaedic ward;
• apologise to Mrs C for their handling of her complaint, in particular their failure to accept the findings of the external review they commissioned; and
• carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Mrs A, the handling of Mrs C's complaint, and their response to the external review they commissioned.

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