Health

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.

Overview
The complainant (Mr C) raised concerns about the care and treatment of his late mother (Mrs A) during a 12 week stay in three of Lothian NHS Board (the Board)’s hospitals.  During this period, Mrs A developed pressure ulcers on the heels of both her feet and at the base of her spine.  One of these pressure ulcers became very severe, and eventually became infected.  This infection spread to Mrs A's bone, and ultimately led to her death, six weeks after discharge.  Mr C has complained that, had she not developed pressure ulcers, she would have lived longer.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to take reasonable steps to prevent Mrs A developing pressure ulcers and they failed to adequately manage these (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• provide an update on the action that has been taken to implement recent recommendations from Health Improvement Scotland and my office on the care and treatment of patients in relation to the risk and treatment of pressure ulcers;
• conduct a peer review of the prevention, care and management of pressure ulcers in the ward in Hospital 2 where Mrs A stayed;
• develop an action plan for improvements identified through the peer review, including education and training, and share this with my office; and
• apologise to Mr C for the failures identified in this report in relation to Mrs A's care and treatment, for the pain and suffering experienced by Mrs A and for the inaccurate information provided to Mr C in the Board's initial response to his complaint.

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

Overview
The complainant (Mr C) raised a number of concerns that his General Practitioners (GPs) failed to take timely action to fully investigate the symptoms he was reporting during five visits to his GP Surgery (the Practice) between August and November 2012.  He complained that this led to a delay in the diagnosis of his testicular cancer.

Specific complaint and conclusion
The complaint which has been investigated is that the GPs failed to take the appropriate steps to diagnose Mr C's testicular cancer promptly (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• issues a written apology for the failings identified in this report; and
• ensures that GPs 1 and 3 reflect on their practice in relation to these events and discuss any learning points at their next appraisal.

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

Overview
The complainant (Mrs C) raised a number of concerns that treatment decisions, communication and level of support by healthcare professionals were not of a reasonable standard following her husband (Mr C)'s cancer diagnosis.

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

• (a) failed to provide a reasonable standard of care and treatment to Mr C following his cancer diagnosis (upheld); and
• (b) failed to clearly communicate with Mrs C regarding Mr C's prognosis and provide an adequate level of support to help Mrs C cope with his illness (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• provide a plan detailing the changes they have made to:  prevent a recurrence of failing to store medical records securely; and meet Scottish government emergency department targets;
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
• provide a plan detailing the changes they have made to prevent a recurrence of failings in their communication with Mr and Mrs C regarding chemotherapy treatment;
• ensure their responses to complaints are meaningful and appropriate in tone, use of language etc; and
• further apologise to Mrs C for the failures identified and offer to meet her to discuss in more detail the response she received to her complaint.

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

Overview
The complainant (Miss C) raised a number of concerns that her sister (Ms A) had been provided with inadequate care and treatment in that the symptoms with which she was presenting between October and November 2011 were not appropriately investigated and treated. 

A Critical Incident Review (CIR) of the events surrounding Ms A's care and treatment was held in May 2012 by Tayside NHS Board (the Board) following Ms A's death in April 2012.  Miss C complained that the Board failed to provide the family with a copy of the CIR report despite repeated requests and failed to arrange a meeting with the family.

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

• (a) between October and November 2011, staff at Ninewells Hospital failed to provide Ms A with appropriate medical treatment in view of the symptoms with which she presented (upheld); and
• (b) staff at the Board failed to provide the family with a copy of the CIR report despite them making repeated requests and failed to take steps to arrange a meeting with the family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provide evidence that appropriate action was taken to address the mis-reporting of the Magnetic  Resonance Imaging scan of 10 October 2011;
• (ii)  ensure that future Radiology Discrepancy and Complications Meetings are minuted and the minutes appropriately circulated;
• (iii)  review the application of the 'three day guidance' to ensure that staff appropriately assess patients before referring back to their GP and where necessary provide refresher training;
• (iv)  ensure that staff on the Acute Medical Unit are reminded of the need to be proactive in addressing patients pain;
• (v)  continue to work towards producing a care pathway to improve the treatment of patients who present with un-resolving and/ or deteriorating symptoms, including improved communication with primary care providers (GPs);
• (vi)  remind staff dealing with complaints about the usefulness of meetings at an early stage of the complaints process as per their Complaints Management Procedure; and
• (vii)  issue a written apology to Ms A's family 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 a number of concerns about her husband (Mr C)'s care and treatment when he was admitted to the Emergency Department of Aberdeen Royal Infirmary on 19 November 2012. 

She said that despite being assessed at 09:20 for transfer to the Acute Medical Assessment Unit he was not transferred there until 20:18.  In the meantime, he had been lying on a trolley.  Once transferred, Mrs C said that there was a delay in him seeing a doctor and that his condition continued to decline.  Regrettably, Mr C died at noon the next day and Mrs C further complained about Mr C's appearance when she arrived in hospital after his death.

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

• (a) the care and treatment given to Mr C on his admission to hospital in November 2012 were unreasonable (upheld);
• (b) Grampian NHS Board (the Board) unreasonably asked Mrs C to sign Mr C's death certificate before she had been given a chance to see him (upheld); and
• (c) the Board unreasonably failed to properly lay out Mr C before Mrs C saw him (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the fact that Mr C was not examined further by the medical team whilst he was still in the Emergency Department;
• provide a plan detailing the changes they have made to prevent such a recurrence (that is, missing target times and a failure to assess and treat in a timely manner);
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
• emphasise to all staff in the Emergency Department the importance of keeping accurate and timely clinical records;
• advise me of the steps they have taken to ensure that staff are aware of their responsibilities in similar circumstances and to be alert to the sensitivities of family members;
• take steps to ensure that this does not happen again and emphasise to all appropriate staff the necessity of preserving a patient's dignity in death; and
• be sensitive to the needs of close family members in such matters and advise appropriate staff accordingly.

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

Overview
The complainant (Mrs C) complained on behalf of her husband, Mr C.  She said that after Mr C fell down the stairs at home and an ambulance was called, staff failed to ensure that he was properly cared for.  She believed that the actions of the paramedics contributed to his resultant paraplegia (complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord).

Specific complaint and conclusions
The complaint which has been investigated is that the Scottish Ambulance Service (the Service) failed to ensure that their staff used a stretcher and neck brace when transferring Mr C to hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i)  make a formal apology to Mr and Mrs C for their failure to properly immobilise Mr C after the incident on 24 March 2012 and for the inadequacies of their internal investigation; and
• (ii)  externally audit their complaints handling processes to ensure that they are sufficiently robust and fit for purpose.

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