Health

Overview
The complainant (Mr C) raised concerns that his late mother (Mrs A) had not received adequate fluids and nutrition during her admission at Vale of Leven Hospital.  Mr C also complained that, following her diagnosis with oesophageal cancer, Mrs A did not receive palliative treatment for nearly three weeks until he raised his concerns with the consultant in charge of Mrs A's care.

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

• staff at Vale of Leven Hospital failed to ensure that Mrs A received an adequate level of fluids and nutrition despite her swallowing difficulties (upheld); and
• staff at Vale of Leven Hospital and Paisley Royal Alexandra Hospital failed to ensure that Mrs A received appropriate and timely clinical treatment in view of the symptoms which she presented with (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• review the processes for ensuring that fluid intake and balance is appropriately monitored and recorded on the Vale of Leven Hospital acute medical ward;
• issue a written apology to Mr C, clearly acknowledging the gravity of Mrs A's experience and the specific failings which led to the delay in her treatment; and
• take steps to ensure that the failings his investigation identified have been fully addressed in the revised pathway for onward speciality referral for upper gastrointestinal within Clyde, and explain what awareness raising has been undertaken in relation to this.

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 by her medical practice (the Practice) since the beginning of 2012.  Mrs C believed that the doctor treating her failed to acknowledge or deal with the symptoms she was displaying and that the doctor failed to recognise a general decline in her health.  As a result she was not referred timeously for specialist assessment.  Mrs C was subsequently diagnosed with bowel cancer and she believes that earlier referral would have avoided the need for the emergency surgery she was required to undergo.

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

• provided inadequate care and treatment (upheld); and
• unreasonably failed to make the appropriate referrals (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• ensure that the doctor responsible for Mrs C's treatment reflects on their practice in relation to these events and discusses any learning points at their next appraisal;
• review with the doctor involved in Mrs C's care the SIGN guideline 126;
• review the General Medical Council guidance on record-keeping and evaluate a sample of their case notes to see that they are fulfilling the required standards;
• apologise in writing for the failures identified in this report.

The Practice 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 daughter (Mrs A) for mental health problems by Forth Valley NHS Board (the Board) prior to her death by suicide on 11 October 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• offer a reasonable diagnosis (not upheld); and
• provide a reasonable standard of care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review the approach taken by the Intensive Home Treatment Team to the assessment of risk to ensure that presenting risk factors are systematically considered and recorded and that the rationale behind clinical decision making is transparent;
• remind medical staff of the importance of accurate and signed contemporaneous notes;
• review the process for communicating medical reviews of patients to IHTT staff, to ensure that all relevant information is made available timeously;
• review the process for discharging patients from the IHTT to ensure that medical staff's opinions are considered; and
• apologise for the failings identified in this report.

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

Overview
The complainant (Miss C) raised a number of issues about the service she received from Greater Glasgow and Clyde NHS Board (the Board) during 2004.  Miss C was admitted to Princess Royal Maternity Hospital on 11 June 2004 to undergo a feticide procedure on medical advice.

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

• failed to explain Miss C's rights to request a private burial or cremation (upheld);
• failed to show, or explain, the cremation forms prior to asking Miss C to sign them (upheld);
• asked Miss C to sign the cremation forms when she was sedated and prior to the delivery (upheld); and
• failed to provide an accurate explanation, when responding to Miss C's complaint, for the inconsistencies in the dates on the cremation forms (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Miss C for the failings identified in this complaint;
• ensure that staff attending patients after a fetal loss follow the guidance notes;
• report back to the Ombudsman on how they will ensure that the options for disposal of remains will be published to parents, so that they are aware of the choices that are available to them;
• report back to the Ombudsman on steps they intend to take to ensure that any form to be completed by a patient after a fetal loss is fully explained to the patient, at a time when they are fully able to understand any explanation given;
• report back to the Ombudsman on steps they intend to take to ensure that patients, following a fetal loss, are not being asked to give consent while they lack the capacity to fully understand and recall what they are signing; and
• formally apologise for the inconsistencies provided in relation to the dates on the cremation forms.

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

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

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

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

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

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

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

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

Redress and recommendations
The Ombudsman recommends that the Board:

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

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