Health

Overview

The complainant (Ms C) raised a number of concerns that her spinal injury was not properly assessed by staff at the emergency department and that a log roll was performed improperly leading to further injuries, and that there were further unreasonable delays by staff at the orthopaedic ward she was admitted to in fully investigating and identifying her spinal injury.

Specific complaint and conclusion

The complaint which has been investigated is that Stirling Royal Infirmary's identification and treatment in mid-June 2011 of Ms C’s spinal injuries were below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  carry out an audit of the standard of their trauma management;

(ii)  ensure that the findings of National confidential enquiry into patient outcome and health report Trauma who cares? are implemented and amend their protocol accordingly, in particular to ensure that senior emergency department doctors will be available to initially assess and provide on-going advice for all victims of trauma;

(iii)  review the actions of Consultant 1 in light of this report and take appropriate action; and

(iv)  make a further formal apology to Ms C for the failures identified.

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

Overview

The complainant (Mr C) attended the Ear, Nose and Throat (ENT) Department of the Royal Infirmary of Edinburgh (the Hospital) on numerous occasions following referral by his GP in June 2010. During this period his symptoms, which included bleeding from the throat, worsened. After each examination, he was discharged and re-referred to his GP. On 28 September 2011, he was diagnosed at the ENT Department with throat cancer (a right tonsil mass).

Specific complaint and conclusion

The complaint which has been investigated is that staff at the ENT Department failed to investigate Mr C’s symptoms appropriately and this led to a delayed diagnosis of stage 2 cancer of the right tonsil (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  apologise to Mr C for the failings identified;

(ii)  carry out a Serious Clinical Incident Review; and

(iii)  review the procedure for GP referrals to ensure that where there have been repeated referrals this is taken into account by ENT clinicians when assessing and examining the patient.

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

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her husband (Mr C), who was admitted to Raigmore Hospital (the Hospital) on 4 January 2012 after suffering a seizure. She complains that during his stay, Mr C was not given appropriate care and treatment, nor was he properly assessed for rehabilitation prior to his discharge.

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

• (a) staff at the Hospital failed to provide Mr C with appropriate care and treatment following admission on 4 January 2012 (upheld); and
• (b) staff at the Hospital failed to assess properly whether Mr C would benefit from rehabilitation on discharge from hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make a formal apology to Mr and Mrs C for their failures;
• (ii) ensure that the consultant physician (Doctor 2)'s next appraisal includes this case, together with reflection on the Adults with Incapacity legislation and the specific rights of patients with dementia;
• (iii) conduct an audit on Ward 6C, relating to compliance with Adults with Incapacity legislation for patients with dementia, and satisfy themselves that all staff are fully apprised of its implications;
• (iv) formally apologise to Mr and Mrs C for failing to assess Mr C properly prior to his discharge from hospital; and
• (v) (with Mrs C's agreement) assess Mr C thoroughly to establish whether he would benefit from further physiotherapy input and, if he would, the Board arrange this.

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

Overview
The complainant (Mr C) raised a number of concerns with Grampian NHS Board (the Board) that the care given to his wife (Mrs C) and baby daughter (Baby C) at Aberdeen Maternity Hospital (the Hospital) was inadequate. Mrs C was admitted to the Hospital two weeks prior to Baby C's birth by caesarean section. Baby C died shortly after birth, having been born premature and very underweight. Mr C was particularly concerned about the refusal of medical staff to continue resuscitation on Baby C. It is of concern to me that a number of relevant and important clinical documents, including reference to the fact a post-mortem examination had been conducted, were not provided to my office by the Board until they were asked to highlight any factual errors in a draft version of this report. At this stage of our investigative process, the Board had already been asked, on two occasions, to provide all the relevant information they held. In addition, we had already obtained clinical advice, with my advisers providing comment on the clinical records and information as received. I am disappointed by the Board's decision not to provide such relevant information until this final fact checking stage. I expect all bodies to ensure that their responses to my office's enquiries are thorough and include all information which is of relevance to the complaints under investigation. The Board's omissions in this case undoubtedly hampered our investigations, caused increased stress and distress for the family involved, and are totally unacceptable, as well as unprofessional.

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

• (a) failed to adequately manage the later stages of Mrs C’s pregnancy including the birth of her baby (upheld);
• (b) failed to adequately assess the possible success of continued resuscitation (not upheld); and
• (c) failed to adequately communicate with Mr and Mrs C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider introducing guidelines for the management of small for gestational age foetuses, with reference to the Royal College of Obstetricians and Gynaecologists guidance of March 2013;
• (ii) undertake an assessment to ensure that the Obstetric Team has the correct training and equipment to perform assessments of extremely pre-term infants with abnormal umbilical blood flows, and prepare an action plan to address any shortcomings;
• (iii) provide evidence to demonstrate that following the death of a baby, full clinical examinations and investigations, including a post-mortem, are discussed with and offered to parents;
• (iv) demonstrate that the Board's guidelines about intrauterine death , which contain survival figures for babies of extreme prematurity, are referred to as appropriate by maternity and neonatal staff when discussing care with prospective parents;
• (v) remind all of the staff involved in Mrs C's care of the importance of obtaining signed consent forms for caesarean sections;
• (vi) issue a full apology to Mr and Mrs C for all of the failings identified in this report;
• (vii) draw this report to the attention of all neonatal, obstetric and maternity staff at the Hospital; and
• (viii) conduct a significant event analysis of Mrs C and Baby C's care from the point of Mrs C's admission until Baby C's delivery and treatment.

Overview
The complainant (Mrs C), an advocacy worker, raised a number of concerns on behalf of her client (Ms A) about Ms A's detention under the terms of a Short-Term Detention Certificate and her subsequent transfer, under nurse escort by ambulance, from the Royal Infirmary Edinburgh (Hospital 1) to the mental health unit at St John's Hospital (Hospital 2) in November 2011. Specifically, Mrs C complained about the way in which Ms A was transferred and that she did not receive appropriate information in relation to the detention and transfer.

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

• (a) Ms A was forcibly transferred from Hospital 1 to Hospital 2 without any prior knowledge or explanation of reasons (upheld);
• (b) Ms A was inappropriately told she was being detained under the Mental Health Act but has no recollection of being detained (upheld); and
• (c) the manner in which Ms A was wrapped in a blanket and strapped to a trolley, causing severe bruising to her shoulders, was unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that where detention and/or transfer is being considered, the matter is fully discussed with the patient and they are informed of the options available to them and the rationale underpinning the decision;
• (ii) ensure that in such cases discussions in relation to the patient's care and treatment and actions taken, including the use of medication, are clearly recorded in the clinical notes;
• (iii) ensure that, where restraint is required during the transfer of a patient, the appropriate incident report is completed in line with Board policy and the event clearly recorded in the clinical notes;
• (iv) feed back the learning from this complaint to all relevant staff in both hospitals;
• (v) ensure that all staff involved in taking decisions on short term and emergency detention are aware of the requirements of the Mental Health legislation and adhere to the appropriate process when carrying out any detention; and
• (vi) ensure that a physical examination is conducted on a patient on their arrival at a hospital, especially if the patient was the subject of a physical restraint en-route to the hospital; and

The Ombudsman recommends that:

• (i) this report be considered at a meeting of the Lothian NHS Board.

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

Overview
The complainant (Mrs C) raised a number of concerns with Lanarkshire NHS Board (the Board) concerning the care and treatment her father (Mr A) received for a gangrenous toe between 4 January and 12 March 2011 while a patient in three different hospitals, including Monklands General Hospital (Hospital 1), Hairmyres Hospital (Hospital 2) and Wester Moffat Hospital (Hospital 3). Mr A died from sepsis (a bacterial infection in the bloodstream) on 12 March 2011.

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

• (a) the treatment provided to Mr A for his gangrenous toe was inadequate and failed to address the infection and prevent him contracting sepsis (upheld);
• (b) during Mr A's admissions to the three hospitals, staff unreasonably failed to recognise, monitor and address his pain, agitation and confusion (upheld);
• (c) between 9 and 10 March 2011 Mr A's medication was inappropriately changed causing him to become very distressed and unresponsive (upheld);
• (d) there was an unreasonable delay in transferring Mr A to Hospital 1 on 12 March 2011 when his condition had deteriorated (upheld); and
• (e) during Mr A's hospital admissions from 4 January to 12 March 2011, the family constantly raised their concerns about Mr A's deteriorating condition but these were unreasonably ignored (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures that Doctor 1 reflects in his annual appraisal on Adviser 1's comments in terms of the lack of evidence in the medical records to show that all surgical options were considered and discussed with Mr A and the family where relevant;
• (ii) review the application of the MEWS chart in Hospital 3 to ensure that staff can readily identify patients who have deteriorated and require urgent attention;
• (iii) conduct a significant event analysis with regards to Mr A's transfer from Hospital 3 to Hospital 1, to ensure that in future patients who are significantly unwell and deteriorating are transferred in a timely manner. This should also take into account Mr A's pain management at Hospital 3; and
• (iv) apologise to Mrs C and the family for the failings identified in this report.

Overview
The complainant (Mrs C) raised a number of concerns with Lothian NHS Board (the Board) about the care and treatment she received during her pregnancy, in particular, from her community midwife (the Midwife). Mrs C also raised concerns that medical staff, immediately following her son’s birth (Baby A) on 16 May 2011 when she had a haemorrhage, refused to allow her husband (Mr C) to push her bed to the theatre.

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

• (a) the Midwife failed to deal with Mrs C’s request for a caesarean section properly (upheld);
• (b) the Midwife unreasonably refused Mrs C antenatal appointments (not upheld);
• (c) the Midwife misled Mrs C about when she would be induced (not upheld); and
• (d) the Board unreasonably refused to allow Mr C to push Mrs C’s bed to theatre (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that the comments of the Adviser in relation to complaint (a) are shared with community midwives, in particular, that where there is any deviation from a normal uncomplicated pregnancy, the expectant mother should be referred to an obstetrician or other medical specialist as appropriate;
• (ii) ensure that the comments of the Adviser in relation to complaint (c) are shared with community midwives, in particular, that every case of an expectant mother must be considered individually and that relevant issues of a complex history, maternal age and personal anxieties are taken in to account;
• (iii) review the process of record-keeping by community midwives in relation to patients’ notes. In particular, to ensure that any discussions and advice given concerning requests by an expectant mother for any intervention, induction of labour or a C section are clearly and properly documented in her medical records; and
• (iv) apologise to Mrs C for the failings identified in this report.

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment her late daughter (Miss A) received at Raigmore Hospital (Hospital 1). Miss A was seen by an out-of-hours GP at Hospital 1 and thereafter returned 24 hours later where she was admitted as her condition had seriously deteriorated. The following day, Miss A was transferred to the Royal Hospital for Sick Children in Edinburgh (Hospital 2) and sadly died two days later.

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

• (a) the receptionist failed to obtain appropriate assistance when Miss A presented at Accident and Emergency with soiled clothing (upheld);
• (b) Miss A was inappropriately discharged by the out-of-hours GP on 5 March 2011 (not upheld); and
• (c) staff failed to adequately monitor or provide timely treatment to Miss A when she was admitted to Accident and Emergency on 6 March 2011 (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide the Ombudsman with evidence to support that they have reviewed their gown supplies in Accident and Emergency and informed relevant staff of the procedure to follow when alternative clothing is required;
• (ii) remind the out-of-hours GP of the GMC's guidance in relation to record-keeping;
• (iii) draw to the attention of relevant staff the comments by Adviser 2 and Adviser 3 regarding documenting more detailed information on intubation in this case; and
• (iv) conduct a review of their Significant Event Analysis procedures to ensure that a detailed and robust investigation is carried out in all cases.

Overview
The complainant (Mr C) and his wife (Mrs C) underwent a cycle of infertility treatment towards the end of 2011. This did not lead to pregnancy. Thereafter, the Greater Glasgow and Clyde NHS Board (the Board) told Mr and Mrs C that because the hormone that indicated Mrs C's ovarian reserve was low, they would not be offered a further cycle of treatment using her eggs. Instead, they were offered a further cycle with a donated egg. Mr C alleged that this decision was contrary to his and his wife's right of access to NHS treatment and against guidelines on the provision of fertility treatment in Scotland. He further complained that the delays in the process reduced their chances of success.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed unreasonably to provide a second cycle of fertility treatment of Mr C’s choosing (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the failures identified;
• (ii) offer him £6,000 in the event that he seeks assisted conception treatment privately;
• (iii) amend their policy on assisted conception to clarify that patients may not be eligible for further NHS treatment if response to treatment is poor; and
• (iv) consider introducing a protocol to fast track patients with a potentially poor ovarian reserve.

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