Health

Overview
The complainant (Mrs C) complained about the treatment provided to Mr A, after he was admitted to the Aberdeen Royal Infirmary (the Hospital) with severe chest pain.  Mr A was initially treated as having acute coronary syndrome (a medical term used when doctors believe that the patient has a serious problem with the narrowing of one or more of the coronary arteries) because of an elevated serum troponin (this is present in the bloodstream when there has been damage to the heart).  However, approximately two and a half days after his admission, it was diagnosed that Mr A had a dissection flap (tear) in the ascending aorta (a portion of the large trunk artery that carries blood from the left ventricle of the heart to branch arteries).  Arrangements were made for Mr A to undergo surgery that day, but he died in the anaesthetic room before the operation could begin.

Specific complaint and conclusions
The complaint that has been investigated is that staff at the Hospital failed to provide Mr A with an appropriate level of treatment following his admission in January 2012 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mr A's family for:  the failure to identify that Mr A had aortic dissection when the bedside echocardiogram was carried out on 2 January 2012; and the delay in providing a copy of the bedside echocardiogram to his office; and
• provide evidence that they have taken steps to raise awareness of aortic dissection in their A&E, Emergency Medicine, General Medicine and Cardiology departments.

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

Overview
The complainant (Mr C) raised a number of concerns that his mother in law (Mrs A) had been inappropriately cared for in Perth Royal Infirmary.  Mrs A had been admitted on 15 February 2013, with a sudden loss of mobility.  She was discharged on 13 May 2013, but had not regained the ability to walk.  Mr C said that it was not until later that the family learned Mrs A had suffered a fractured hip.  Mr C said this was not properly diagnosed or treated and that Mrs A was never x-rayed during her stay in hospital.  Mr C was also unhappy with the way his complaints were handled by Tayside NHS Board (the Board), as he felt the internal review process lacked objectivity and dismissed the family's concerns.

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

• the Board provided inadequate care and treatment to Mrs A (upheld);
• the Board's reviews of Mrs A's care and treatment were inadequate (upheld); and
• the Board's handling of and response to Mr C's complaints was inadequate (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• remind all staff of the importance of discussing completion of the Do Not Attempt Cardio-Pulmonary Resuscitation form with either the patient or appropriate family members;
• review their processes to provide a failsafe to ensure that vulnerable patients are fully assessed to determine their capacity;
• remind all staff involved in geriatric care of the importance of considering hip fracture in elderly patients with loss of mobility;
• review their procedures to ensure that internal case reviews have objective clinical assessment of the available evidence;
• review their procedures to ensure that where additional medical opinion is required, this is obtained in a formal statement from the clinician;
• review its complaints procedure to ensure that all meetings with complainants are formally noted;
• review its complaints procedure to ensure that complainants are provided with notes of all meetings with Board staff conducted under the complaints procedure; and
• apologise in writing to Mr C for the failure to diagnose Mrs A timeously with a hip fracture and for the identified failures in dealing with his complaint.

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 her late brother (Mr A) received from Lanarkshire NHS Board (the Board) following his admission to Monklands Hospital on 27 February 2013.  Mr A was admitted with swallowing difficulties and died on 22 March 2013.

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

• the Board provided inadequate care and treatment to Mr A (upheld); and
• there were unreasonable delays in care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their results 'sign off' process at ward level to ensure all results are reviewed before filing;
• conduct a review of their complaints handling to analyse why this result from another health board was not identified as part of their investigation;
• apologise to Mrs C for the failure to diagnose Mr A properly, particularly with the information available from the blood test reported upon after his death; and
• investigate the delay in the time from referral to review by the neurologist and provide staff with advice about how to obtain specialist neurological advice for patients such as Mr A, when a consultant review may be delayed.

Overview
The complainant (Mrs C) raised a number of concerns that her late brother (Mr A) had been inappropriately assessed when he attended his GP Surgery (the Practice) on 29 July 2013.  She complained that Mr A should have been referred to hospital for further tests rather than being prescribed medication for an inflamed stomach.  Mr A died suddenly of a heart attack on 31 July 2013.

Specific complaints and conclusions
The complaint which has been investigated is that on 29 July 2013 the Practice failed to provide Mr A with appropriate medical care (upheld).

Redress and recommendations
I recommend that the Practice:

• issue an apology to Mrs C for the failings identified;
• review  the level of education and training required to carry out the NP role, particularly in relation to clinical assessment and diagnosis;
• review the assessment/supervision and on-going monitoring and appraisal requirements in place for the nurse practitioner; and
• submit a Significant Event Analysis (SEA) which is in the standard format used nationally.

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

Overview
The complainant (Ms C) raised concerns that her late sister (Ms A) was not told of her diagnosis for three weeks after having a scan which showed she had cancer.  Ms A was then told she would be referred to oncology, but no appointment was offered for a further three weeks.  Sadly, Ms A died a few days before the appointment was offered.

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

• in informing Ms A of her diagnosis (upheld); and
• in offering Ms A an oncology appointment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• undertake a specific internal enquiry to determine why the results of Ms A's scan were missed by both Accident & Emergency staff and radiology.  The investigation should identify process improvements to ensure this situation does not reoccur, and the results of the investigation should be shared with Ms A's family, if they wish;
• issue a written apology to Ms C and her family for the failings this investigation identified;
• raise the findings of this investigation with Consultant 1 for reflection as part of their next performance appraisal; and
• review the Board's complaints handling processes and templates to ensure that:  complaints involving more than one hospital are fully investigated and addressed, with input from all relevant staff (regardless of where the complaint is received); and any failings are clearly identified, and the causes for these, and any action to address them, explained.

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

Overview
The complainant (Mrs C) raised a number of concerns about the nursing care provided to her mother (Mrs A) after she was admitted to the Royal Infirmary of Edinburgh (the Hospital) for hip surgery.  Mrs C said that nursing staff had failed to adequately monitor Mrs A's condition and delayed in referring her to specialists.  Mrs A died a week after she was discharged from the Hospital.

Specific complaint and conclusion
The complaint that has been investigated is that staff failed to provide Mrs A with an appropriate standard of nursing care (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• issue a written apology to Mrs C for the failure to provide reasonable and appropriate care to Mrs A in relation to nutrition, fluid, diabetes, pressure ulcers and her discharge from hospital;
• issue a reminder to the relevant staff involved in Mr C's care of the requirement to:  keep clear, accurate and legible records; promptly provide or arrange suitable advice, investigations or treatment where necessary; consult colleagues where appropriate; and, refer a patient to another practitioner when this serves the patient's needs;
• take steps to ensure that older adults admitted with fracture are assessed for specialist rehabilitation, including review by a consultant geriatrician;
• review their policies and procedures for patients with diabetes admitted to orthopaedic wards to ensure that adequate systems in the management of their care are in place;
• review the process for referral to the tissue viability nurse;
• take steps to ensure that discharge planning in relevant cases is in line with the Scottish Intercollegiate Guidelines Network guidelines for hip fracture in older people; and
• confirm to me that the matter will be discussed at the Orthopaedic Consultant's next annual appraisal.

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

Overview
The complainant (Ms C) raised concerns that her late mother (Mrs A) developed lithium toxicity during her admission to Pavilion 2, Ayrshire Central Hospital, as a result of inadequate fluid intake.  Ms C was also concerned that Mrs A had a heavy fall during her admission and suffered significant injuries.

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

• did not reasonably ensure that fluid intake was adequate (upheld); and
• did not take reasonable steps to ensure the patient's physical safety (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• identify and address any staff training needs in relation to lithium toxicity;
• remind nursing staff that action is required to address low fluid intake when the intake for a lithium patient falls below 1.2 litres;
• issue a written apology to Ms C, acknowledging the failings identified in this report;
• provide his office with a copy of the six-monthly review of the measures set out in the Quality Improvement Plan for improving falls assessments, fluid intake monitoring and record-keeping.  If the measures of effectiveness set out in the plan were not met, the Board should explain what further action will be taken;
• provide refresher training for staff involved in Mrs A's care on the requirements of the Falls Management Guideline for In-Patients; and
• raise the findings of his investigation with the staff responsible for Mrs A's care, for reflection as part of their next performance appraisal.

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

Overview
The complainant (Mr C) raised concerns about the treatment his late daughter (Ms A) received from Ayrshire and Arran NHS Board (the Board).  Ms A had attended University Hospital Crosshouse (the Hospital)'s Emergency Department and was admitted, but sadly passed away a couple of days later.  Mr C complained to my office about the clinical and nursing care his daughter had received and also the Board's handling of the complaint he and his wife (Mrs C) made to them.

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

• take appropriate steps to assess and treat Ms A's sepsis (upheld);
• provide appropriate nursing care for Ms A (upheld); and
• handle Mr C's complaint appropriately (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their protocols for identification of sepsis, identification of deteriorating patients and sepsis management and audit their performance using the Scottish Patient Safety Programme;
• reduce the time to consultant review for on-call teams managing critical illness, in line with the relevant Royal College of Physicians' Guidance;
• improve access to intensive care advice for on-call clinical teams;
• use this case in educational / mortality review meetings in the emergency department and medical units;
• ensure this case will be included in the consultants' next appraisal;
• carry out a Significant Event Analysis, with reflective commentary, of the care and treatment provided to Ms A and the handling of Mr and Mrs C's complaint; and
• apologise to Mr and 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) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing her father (Mr A)’s bowel cancer.  Mr A was seen by a respiratory consultant (the Consultant) at an out-patient clinic at Monklands Hospital (the Hospital) on 24 July 2013 following a referral from his GP.  Mr A had been suffering from breathlessness for a number of months and had been treated for a lower respiratory tract infection.  The Consultant's diagnosis was that Mr A was suffering from mild asthma brought on by the lower respiratory tract infection and blood was taken for routine tests.

Tests of the blood taken by the Consultant showed that Mr A had a low level of haemoglobin (a protein found in red blood cells which carries oxygen around the body).  The laboratory noted that there were features of iron deficiency and that blood loss should be excluded as a possible cause.  The laboratory did not highlight the low haemoglobin level by telephone and the Consultant did not identify or act upon this abnormality when reviewing Mr A's results.

Due to his continuing symptoms, Mr A had further blood tests carried out by his GP on 9 September 2013 and was admitted to the Hospital the following day where he required a blood transfusion.  He was subsequently diagnosed with colon (bowel/large intestine) cancer and liver metastases (the spread of cancer).

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

• take appropriate action when Mr A's blood result showed an abnormally low haemoglobin level (upheld); and
• ensure that Mr A received timely follow up treatment when the abnormally low haemoglobin level was discovered (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• confirm the outcome of their review of this incident and advise what steps have been taken to prevent recurrence in future;
• review their governance arrangements for identifying systems errors like this in future;
• apologise for the failure to implement the Telephoning of Results Protocol;
• apologise for the delay in Mr A's diagnosis;
• confirm that this matter will be, or has been, discussed at the Consultant's annual appraisal;
• conduct a Board level review of the tracking of test results in both paper and electronic formats; and the role of individuals who order tests and report their results; and
• make the outcome of any recommendations arising from the Board level review available to us, Mr A and his family.

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

Overview
The complainant (Mr C) complained about the treatment he received following his referral to the Orthopaedic Department at Ninewells Hospital for an injury to a muscle in his chest. His GP (Doctor 1) referred him to a consultant orthopaedic surgeon (Doctor 2). Doctor 2 assessed him and concluded that no surgical treatment would improve his injury. He then suggested that if Mr C was worried about the look of the injury, Doctor 1 should refer him to plastic surgery services. Doctor 1 referred Mr C to plastic surgery services for cosmetic repair. A consultant plastic surgeon declined the referral prior to seeing Mr C as cosmetic augmentation of the pectoral muscle was not a procedure offered by the plastic surgery services.

Specific complaint and conclusion
The complaint which has been investigated is that Tayside NHS Board (the Board) have failed to provide appropriate clinical treatment following a GP referral for a chest injury (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that Mr C is referred for a second consultation with an orthopaedic surgeon;
• (ii) ensure this case and the identified failings are discussed with Doctor 2 at his next appraisal;
• (iii) ensure the Medical Director is made aware of the identified failure to facilitate the request for a second opinion; and
• (iv) issue a full apology to Mr C for the failings identified in this case.

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