Health

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment her son (Master A), then six and a half years old, received from the GPs at Master A’s medical practice (the Practice) from May to August 2011.  Master A subsequently attended Ninewells Hospital in Dundee and then the Royal Hospital for Sick Children in Edinburgh, where he was diagnosed with cancer (Burkitt's Lymphoma stage IV).  He received treatment but, sadly, died.

Specific complaints and conclusions
The complaints which have been investigated are that from May 2011 GPs at the Practice:

• (a) failed to provide Master A with appropriate clinical treatment in view of his reported symptoms (upheld); and
• (b) unreasonably delayed referring Master A for a specialist hospital opinion (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  provide Mrs C and her husband with a written apology for the failings identified in this report; and
• (ii)  provide my office with evidence that this case has been discussed with all GPs involved as a learning tool and that all learning points are taken forward as part of their continuous professional development.

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

Overview

The complainant (Mrs C) said that she and four of her family members were inappropriately removed from their GPs'' list.  Mrs C said that she had not received a warning that they were to be removed from the list.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C considers that she and four of her family members were inappropriately removed from their GPs'' list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) put a process in place to ensure that the relevant regulations and guidance are adhered to before they ask for a patient to be removed from their list; and
• (ii) apologise to Mrs C for not adhering to the relevant regulations and guidance before asking for her and her family members to be removed from their list.

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

Overview
The complainant (Miss C) raised a number of concerns about her late father's (Mr A) prostate cancer diagnosis.  This included Mr A's concerns at being advised that he did not have prostate cancer resulting in his treatment being stopped.  Miss C was also dissatisfied with the lack of information and support given to Mr A and the family about the diagnosis, prognosis and side effects of the treatment.

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

• (a) did not provide reasonable care and treatment to Mr A from May 2011 onwards (upheld);
• (b) unreasonably withheld information about his condition from Mr A and his family (upheld); and
• (c) did not reasonably handle Miss C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their prostate cancer guidance to ensure it is consistent with national guidelines for the management of patients with widespread prostate cancer when a biopsy is not indicated;
• ensure timely involvement by a specialist cancer nurse shortly after diagnosis of prostate cancer;
• ensure Doctor 4 discusses the failings identified in this report at his next appraisal;
• ensure clinical staff clearly record any verbal responses they provide to patient correspondence;
• apologise to Miss C and the family for the failings identified in this report; and
• ensure that complaint responses are consistent, accurate and set out in a structured manner.

Overview
The complainant (Mr C) raised a number of concerns that his mother (Mrs A) had received inadequate care and treatment in October 2011 resulting in a failure to diagnosis kidney failure or admit Mrs A to hospital.  Mrs A subsequently died on 2 November 2011.

Specific complaint and conclusion
The complaint which has been investigated is that between September 2011 and October 2011, doctors at Mrs A’s medical practice (the Practice) failed to take into account Mrs A's symptoms, previous medical history and family concerns and that they did not arrange an emergency hospital admission (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• review the GMC Guidance on record-keeping and evaluate a sample of their case notes to see if they are fulfilling the required standards;
• review with the doctors involved in Mrs A's care the SIGN guidance on chronic kidney disease and its management and identify this as a learning need within their appraisals;
• discuss this complaint and its evaluation with the doctors involved in Mrs A's care in their yearly appraisal;
• carry out a significant event analysis of this incident and discuss the results within the practice team; and
• apologise sincerely to Mr C and his family for the failures in the care and treatment provided to Mrs A.

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

Overview
The complainant (Mrs C) complained on behalf of her mother (Mrs A) to Grampian NHS Board (the Board) about the care and treatment her father (Mr A) received while a patient in Aberdeen Royal Infirmary (the Hospital) from 5 August to 23 September 2012.  Mr A had been admitted to the Hospital's Acute Stroke Unit after suffering a stroke at home.  Mr A died in the Hospital on 23 September 2012.

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

• Mr A's medical care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld); and
• Mr A's nursing care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• draw this report to the attention of all senior medical staff involved in Mr A's care;
• take steps to put in place an action plan to address the failings identified in this report;
• ensure that staff document relevant discussions they have with a patient's family or their carer;
• act upon the comments of Adviser 1 in relation to the introduction of a policy on the certification of a patient's death;
• draw to the attention of relevant staff, the importance of providing evidenced based complaints responses;
• share with relevant nursing staff the comments of Adviser 2 with regard to maintaining a patient's dignity;
• draw to the attention of relevant staff, Adviser 2's concerns about the Board's rationale for removing Mr A's pyjama bottoms; and
• apologise to Mrs A and her family for the failings identified in complaints (a) and (b).

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

Overview
The complainant (Mrs C) raised a complaint on behalf of Ms B about the care and treatment provided to her late mother (Mrs A) by Grampian NHS Board (the Board).

Specific complaint and conclusion
The complaint which has been investigated is that staff at Dr Gray’s Hospital (Hospital 1) failed to provide Mrs A with appropriate care and treatment following her admission on 6 April 2012 with severe chest pain (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Ms B for the failures identified;
• reflect on the failure to examine Mrs A’s chest and ensure that measures are in place to prevent a similar occurrence in the future;
• undertake an audit of record-keeping within Ward 8 to ensure medical records are completed timeously and comprehensively and report back to the Ombudsman; and
• bring this report to the attention of relevant staff during their appraisals to ensure lessons have been learned from this case.

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

Overview
Miss C complained on behalf of her siblings and herself.  She alleged that when her mother (Mrs A) was admitted to hospital, she was not properly assessed.  In particular that FALLS assessments (a risk assessment tool for the prevention of falls in older people) which were carried out failed to take account of Mrs A's medical conditions.  Miss C said that if a proper assessment had been made, Mrs A would not have been left alone on a commode.  Miss C further complained about the way in which the Lothian NHS Board (the Board) subsequently handled her complaint.

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

• (a) the Board failed to conduct an appropriate risk assessment on Mrs A's admission to the Royal Infirmary of Edinburgh (upheld); and
• (b) the Board failed to address Miss C's concerns adequately (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• make a formal apology to Miss C and her siblings for their failure in this matter;
• look again at the FALLS assessment to ensure that staff exercise clinical judgement when assessing risk;
• emphasise to staff the importance of keeping accurate and timely records which would be fully adequate for the purposes of later scrutiny; and
• make a formal apology to Miss C and her siblings for the omissions in their correspondence.

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

Overview
On 2 April 2013, the complainant (Miss C) telephoned her mother (Mrs A)'s medical practice (the Practice) and requested a house call Mrs A.  However, she said that when the GP (the Doctor) visited, she failed to examine Mrs A or ask her whether she was in pain.  Miss C said that the Doctor disregarded the symptoms she reported; refused to give Mrs A anything to help her sleep; and called her by an incorrect name.  Miss C complained that had Mrs A been examined and told treatment in hospital was necessary, the outcome for her could have been different.  Mrs A was subsequently taken to hospital where she died.

Specific complaint and conclusion
The complaint which has been investigated is that, in relation to a house call on 2 April 2013, the Doctor unreasonably failed to examine Mrs A, leading to a delay in admitting her to hospital for tests and treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• ensures that the Doctor make a formal apology to Miss C for her failure in this matter; and
• ensures that the Doctor completes appropriate professional training so that she is fully appreciative of the seriousness of abdominal pain in the elderly and the importance of conducting a thorough history and examination.

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

Overview
The complainant (Ms C) who was an Advocate acting on behalf of Mrs A, raised a number of concerns that the care and treatment provided by his General Practitioner (GP) to Mrs A's husband (Mr A) were inappropriate.  Ms C also complained that Mr A’s medical practice (the Practice) failed to provide an adequate response to the complaint about Mr A's treatment.

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

• (a) the Practice failed to provide appropriate care and treatment for Mr A's reported symptoms of headaches; dizziness; and disorientation; in April and May of 2012 (upheld); and
• (b) the Practice failed to provide an adequate response to the complaint about Mr A's treatment (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• conducts a Significant Event Analysis of these events and that any learning outcomes are discussed at the GP's annual appraisal;
• conducts a review of a sample of clinical records to assess whether they meet the standards recommended by the GMC.  Any learning outcomes to be addressed at the GP's annual appraisal and/or with appropriate training;
• conducts a review of the Practice's monitoring protocol for patients taking warfarin to ensure that it is fit for purpose;
• conducts a review and revision of its complaints procedure to ensure it complies with current NHS complaints handling guidance;
• ensures that all staff have received appropriate training on handling complaints; and
• issues a written apology to Mrs A for all the failings identified in this report.

Overview
The complainant (Mr C) raised a number of concerns about the care and treatment provided to his son (Mr A) for mental health problems by Tayside NHS Board (the Board) prior to his death by suicide in July 2010. Mr C also raised concerns about the level of the family's involvement in the Board's Adverse Significant Incident review and their root cause analysis after Mr A's death.

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

• (a) mental health care and treatment from June 2009 until Mr A's death in July 2010 were below an acceptable standard (upheld); and,
• (b) the level of family involvement in the Board's Adverse Significant Incident review and their root cause analysis was below an acceptable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) take steps to ensure that systems are in place in order that the care of vulnerable people is co-ordinated effectively and with due urgency, to minimise the danger of people at risk inappropriately disengaging or being lost to follow up;
• (ii) take steps to ensure that systems are in place in order that therapeutic engagement is planned with the patient's full participation. One-to-one therapeutic time should be negotiated and agreed on an individual basis and solitary, withdrawn and /or difficult to engage patients should have access to a range of interventions matched to their needs and wishes. They should also be consistently encouraged to engage with agreed interventions;
• (iii) ensure that clinical observation practice is in line with national guidance;
• (iv) take steps to ensure that no patient is de facto detained;
• (v) take steps to ensure that the eligibility criteria for engagement with secondary community mental health services are sufficiently flexible to allow vulnerable people to access appropriate services in situations where the person does not wish to (or does not require to) go into hospital but has complex needs which may be receptive to psycho-social interventions and which require a greater intensity of input than can reasonably be provided in the primary care setting;
• (vi) take steps to ensure that systems are in place in order that people who are vulnerable and difficult to engage are proactively followed-up by community services and all reasonable and appropriate steps are taken to minimise the risk of scheduled appointments being missed;
• (vii) ensure that the care plans of vulnerable patients, especially those who are difficult to engage or have a history of defaulting from care, include steps to be taken when scheduled appointments are missed;
• (viii) take steps to ensure that discharge letters which promote the delivery and continuity of safe and effective care are timeously received by GPs;
• (ix) take steps to ensure that up-to-date training records are maintained which enable performance against national or internal training targets to be judged; and
• (x) issue a written apology to Mr C for the failings identified in this report.

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