Health

Overview
The complainant (Ms C) raised concerns that her late sister (Ms A) was not told of her diagnosis for three weeks after having a scan which showed she had cancer.  Ms A was then told she would be referred to oncology, but no appointment was offered for a further three weeks.  Sadly, Ms A died a few days before the appointment was offered.

Specific complaints and conclusions
The complaints which have been investigated are that Lanarkshire NHS Board (the Board) unreasonably delayed:

• in informing Ms A of her diagnosis (upheld); and
• in offering Ms A an oncology appointment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• undertake a specific internal enquiry to determine why the results of Ms A's scan were missed by both Accident & Emergency staff and radiology.  The investigation should identify process improvements to ensure this situation does not reoccur, and the results of the investigation should be shared with Ms A's family, if they wish;
• issue a written apology to Ms C and her family for the failings this investigation identified;
• raise the findings of this investigation with Consultant 1 for reflection as part of their next performance appraisal; and
• review the Board's complaints handling processes and templates to ensure that:  complaints involving more than one hospital are fully investigated and addressed, with input from all relevant staff (regardless of where the complaint is received); and any failings are clearly identified, and the causes for these, and any action to address them, explained.

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

Overview
The complainant (Mrs C) raised a number of concerns about the nursing care provided to her mother (Mrs A) after she was admitted to the Royal Infirmary of Edinburgh (the Hospital) for hip surgery.  Mrs C said that nursing staff had failed to adequately monitor Mrs A's condition and delayed in referring her to specialists.  Mrs A died a week after she was discharged from the Hospital.

Specific complaint and conclusion
The complaint that has been investigated is that staff failed to provide Mrs A with an appropriate standard of nursing care (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failure to provide reasonable and appropriate care to Mrs A in relation to nutrition, fluid, diabetes, pressure ulcers and her discharge from hospital;
• issue a reminder to the relevant staff involved in Mr C's care of the requirement to:  keep clear, accurate and legible records; promptly provide or arrange suitable advice, investigations or treatment where necessary; consult colleagues where appropriate; and, refer a patient to another practitioner when this serves the patient's needs;
• take steps to ensure that older adults admitted with fracture are assessed for specialist rehabilitation, including review by a consultant geriatrician;
• review their policies and procedures for patients with diabetes admitted to orthopaedic wards to ensure that adequate systems in the management of their care are in place;
• review the process for referral to the tissue viability nurse;
• take steps to ensure that discharge planning in relevant cases is in line with the Scottish Intercollegiate Guidelines Network guidelines for hip fracture in older people; and
• confirm to me that the matter will be discussed at the Orthopaedic Consultant's next annual appraisal.

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

Overview
The complainant (Ms C) raised concerns that her late mother (Mrs A) developed lithium toxicity during her admission to Pavilion 2, Ayrshire Central Hospital, as a result of inadequate fluid intake.  Ms C was also concerned that Mrs A had a heavy fall during her admission and suffered significant injuries.

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

• did not reasonably ensure that fluid intake was adequate (upheld); and
• did not take reasonable steps to ensure the patient's physical safety (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• identify and address any staff training needs in relation to lithium toxicity;
• remind nursing staff that action is required to address low fluid intake when the intake for a lithium patient falls below 1.2 litres;
• issue a written apology to Ms C, acknowledging the failings identified in this report;
• provide his office with a copy of the six-monthly review of the measures set out in the Quality Improvement Plan for improving falls assessments, fluid intake monitoring and record-keeping.  If the measures of effectiveness set out in the plan were not met, the Board should explain what further action will be taken;
• provide refresher training for staff involved in Mrs A's care on the requirements of the Falls Management Guideline for In-Patients; and
• raise the findings of his investigation with the staff responsible for Mrs A's care, for reflection as part of their next performance appraisal.

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

Overview
The complainant (Mr C) raised concerns about the treatment his late daughter (Ms A) received from Ayrshire and Arran NHS Board (the Board).  Ms A had attended University Hospital Crosshouse (the Hospital)'s Emergency Department and was admitted, but sadly passed away a couple of days later.  Mr C complained to my office about the clinical and nursing care his daughter had received and also the Board's handling of the complaint he and his wife (Mrs C) made to them.

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

• take appropriate steps to assess and treat Ms A's sepsis (upheld);
• provide appropriate nursing care for Ms A (upheld); and
• handle Mr C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their protocols for identification of sepsis, identification of deteriorating patients and sepsis management and audit their performance using the Scottish Patient Safety Programme;
• reduce the time to consultant review for on-call teams managing critical illness, in line with the relevant Royal College of Physicians' Guidance;
• improve access to intensive care advice for on-call clinical teams;
• use this case in educational / mortality review meetings in the emergency department and medical units;
• ensure this case will be included in the consultants' next appraisal;
• carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Ms A and the handling of Mr and Mrs C's complaint; and
• apologise to Mr and 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) 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.