Health

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment given to her late husband (Mr C) by a locum doctor (the Locum GP) at his GP Practice (the Practice) between 17 September 2013 and his death on 24 September 2013.  She said that the Locum GP did not visit Mr C but, nonetheless, overruled the suggested treatment by an out-of-hours doctor who had visited; he made decisions about Mr C's care and treatment which were contrary to her and Mr C's wishes; he made an error in writing a prescription; and he failed to attend their home to sign the death certificate.

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

• (a) the Locum GP at the Practice provided inadequate care and treatment to Mr C (upheld); and
• (b) the Practice's response to Mrs C's complaint was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Locum GP:

• make a full and formal apology to Mrs C for the omissions and failures identified in this investigation;
• ensure that he discusses all the issues that have been identified above at his next formal appraisal; and
• demonstrate that he has learned lessons as a consequence of this complaint by completing appropriate professional training.

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her late husband (Mr C) about delays in him receiving an appointment from Hairmyres Hospital (the Hospital) to have his abnormal bowel symptoms investigated.  Mrs C also complained about the lack of information given to Mr C about delay in a sigmoidoscopy (a procedure to investigative the bowel) going ahead at the Hospital’s Day Surgery Unit.

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

• (a) there was an unreasonable delay in offering appointments following a GP referral on 31 March 2011 (upheld); and
• (b) Mr C was kept waiting for an unreasonable length of time when he attended the Day Surgery Unit (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• share the failings in this case with the Patient Focus Booking Service;
• as a matter of urgency, audit a sample of patients that have been removed from the waiting list for not responding to the Patient Focus Booking Service to ensure the appointment protocol has been followed.  In addition, consider changes to the protocol to prevent the error recurring;
• provide evidence to show that the lack of communication regarding the delay and postponement in the sigmoidoscopy going ahead has been fed back to relevant staff; and
• apologise to Mrs C for the failings identified in this letter.

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

Overview
The complainant (Mrs C) raised concerns about inadequate consultation and involvement of her as a carer for her husband (Mr C) during his admissions to two hospitals run by Highland NHS Board (the Board) in 2011.

Mrs C had Financial and Welfare Power of Attorney (POA) for Mr C and was also Mr C's Named Person for the purposes of the Mental Health (Care and Treatment) (Scotland) Act 2003.  Mr C had a diagnosis of Advanced Alzheimer's Disease.

Specific complaint and conclusion
The complaint which has been investigated is that the Board did not reasonably include Mrs C in decisions about Mr C's care and treatment from February 2011 onwards (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Mrs C for the repeated failures to adequately and properly involve her in decision making around Mr C's care and treatment;
• review their approach to carer communication and participation for people with dementia to ensure a coherent, bespoke and planned approach in all cases.  This should be carried out with due regard to the national Dementia Standards, the principles under-pinning the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults with Incapacity Act 2000, and the rights of 'Named Persons' and those with POA status.  The Board should advise this office of the outcome of this review; and
• review their current documentation of carer involvement in light of the record-keeping failings identified in this report and advise this office of the steps taken to address these omissions.

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

Overview
The complainant (Mr C) raised concerns about the time it took to diagnose Mr A with liver cancer.

Specific complaint and conclusion
The complaint which has been investigated is that there was an avoidable delay in diagnosing that Mr A was suffering from liver cancer (upheld).

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

• review their processes for communicating abnormal results to include referral to an appropriate lead clinician in the hospital as well as the referring doctor in light of the Medical Adviser's comments; and
• apologise for the failures identified.

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

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.