Health

Overview
The complainant (Miss C) raised a number of concerns about the level of care provided to Ms A by Highland NHS Board (the Board) during her pregnancy and subsequent delivery of her baby daughter who was sadly stillborn.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide Ms A with an appropriate level of care during her pregnancy and subsequent delivery at Raigmore Hospital in December 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  apologise to Ms A for the failings identified in this report;
• (ii)  review their guidance to staff on the antenatal management of women to ensure that the risks of recurrent shoulder dystocia are discussed with expectant mothers together with birthing options; and
• (iii)  draw to the attention of the antenatal midwife who looked after Ms A, the importance of documenting previous history of shoulder dystocia in the handover note to the labour midwife.

Overview
The complainant (Mrs C) raised a number of concerns that her late father (Mr A) received inadequate care and treatment while in hospital being treated for dizziness; a swollen leg; a 'blister' on his left big toe; and a general feeling of being unwell and tired.  Mrs C also complained that Mr A's falls risk was not properly assessed and monitored, resulting in a fall that caused a broken hip.  Mr A then waited some 54 hours before his broken hip was surgically repaired.  Mr A died in hospital nine days after his surgery.

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

• (a) unreasonably failed to reassess Mr A's falls risk when staff were informed that he had already fallen on the ward (upheld);
• (b) unreasonably delayed in taking Mr A to theatre when he fell and fractured his hip (not upheld);
• (c) failed to appropriately manage Mr A's intake of food and fluids (upheld); and
• (d) failed to communicate appropriately with the family following Mr A's death (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provides evidence that the falls risk assessment policy and procedures on the ward have been appropriately reviewed and any learning points form part of an action plan for improvement;
• (ii)  ensures that all nursing staff are fully aware of and trained in compiling falls risk assessments and the on-going monitoring of patients at medium or high risk;
• (iii)  reviews their procedures for assessing and monitoring patients awaiting surgery to ensure that a co-ordinated multi-disciplinary team approach is taken;
• (iv)  ensures that all staff are made aware of the importance of food and fluid intake management and take appropriate steps to ensure that patients are appropriately monitored;
• (v)  remind all staff of the importance of communicating effectively with patients, relatives and/or carers on all aspects of care, including food and fluid management;
• (vi)  ensures that all staff are made aware of the importance of good communication with families at all times, especially following a bereavement and considers providing training where necessary;
• (vii)  ensures that all staff are aware of the rules on reporting cases to the Procurator Fiscal's Office (PFO) and pass this information on to families where appropriate; and
• (viii)  considers making the leaflet 'What to do after a death in Scotland' available where appropriate.

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

Overview
The complainant (Mr C) raised concerns about delays by NHS Lanarkshire (the Board) in diagnosing his lung cancer and about the way that the diagnosis was communicated to him.  Mr C had been attending the Neurology Department at Monklands Hospital (Hospital 1), when a Computerised Tomography (CT) scan at Southern General Hospital in May 2012 showed a suspected nodule in his lung.  A second CT scan was requested in June 2012, but Mr C was not told about the suspected nodule in his lung.  On 14 August 2012 Mr C was attending his GP Practice about another matter, when he was informed that the May CT scan had shown a possible diagnosis of cancer.  There were repeated delays in arranging the second CT scan and Mr C did not undergo this CT scan until 7 September 2012 at Hairmyres Hospital, despite both he and his GP pursuing the matter.  Following the second CT scan, Mr C was not seen by the Neurology department until 18 September 2012, when he was told it was almost certain that he had cancer.  He was then seen by a respiratory consultant on 3 October 2012, and a biopsy was carried out on 4 October 2012.  It was confirmed to Mr C that he had cancer of the lung on 15 October 2012.

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

• (a) the Board failed to carry out appropriate tests in order to diagnose Mr C’s condition within a reasonable timescale (upheld); and
• (b) the Board failed to keep Mr C reasonably informed about the results of his tests (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  confirm when the order-comms system will be fully operational in all the hospitals they are responsible for;
• (ii)  provide evidence that they have reviewed with the clinical staff involved why no report of the failures identified in this report was made on the Datix system;
• (iii)  provide evidence that they have carried out a Critical Incident Review;
• (iv)  review the arrangements for providing cover for absent staff to ensure that urgent test results are reviewed timeously;
• (v)  review the procedures within the Radiology Department at Hospital 1 to ensure that urgent test requests are identified and treated appropriately to avoid undue delay to patients;
• (vi)  provide evidence that clinical staff have been reminded of the importance of effective communication with patients, especially when there may have been changes to their diagnosis; and
• (vii)  apologise in writing for the failures 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 the care and treatment provided to her late husband (Mr C) by Ayrshire and Arran NHS Board (the Board) between June 2011 and August 2011. Mr C, who was 80 years old, was admitted to Crosshouse Hospital (the Hospital) on three occasions during this period after breaking his hip. He had type 2 diabetes, hypertension, ischaemic heart disease and urinary incontinence and was on a number of medications before the series of admissions. He was finally discharged home on 8 August 2011, but died eight days later.

Specific complaints and conclusions

The complaints which have been investigated are that staff at the Hospital:

(a)  failed to appropriately assess Mr C’s complex medical conditions (upheld);

(b)  wrongly decided to withhold Mr C’s numerous types of medication and failed to keep his medication under review (upheld); and

(c)  failed to provide Mr C’s GP with sufficient and timely information about his condition on discharge from hospital (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  review their policies and procedures for patients with diabetes admitted to non-specialist wards to ensure that adequate systems in the management of their care are in place;

(ii)  issue a reminder to the relevant staff involved in MrC'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;

(iii)  make the relevant staff involved in Mr C's care aware of our finding in relation to the failure to keep the decision to stop his medication under review;

(iv)  remind the relevant staff involved in Mr C's care that when an episode of care is completed, they should tell a patient’s GP about: changes to their medicines; the length of intended treatment; monitoring requirements; and any new allergies or adverse reactions identified; and

(v)  issue a written apology to Mrs C for the failings identified in this report.

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

Overview

The complainant (Ms C) raised a number of concerns that her spinal injury was not properly assessed by staff at the emergency department and that a log roll was performed improperly leading to further injuries, and that there were further unreasonable delays by staff at the orthopaedic ward she was admitted to in fully investigating and identifying her spinal injury.

Specific complaint and conclusion

The complaint which has been investigated is that Stirling Royal Infirmary's identification and treatment in mid-June 2011 of Ms C’s spinal injuries were below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  carry out an audit of the standard of their trauma management;

(ii)  ensure that the findings of National confidential enquiry into patient outcome and health report Trauma who cares? are implemented and amend their protocol accordingly, in particular to ensure that senior emergency department doctors will be available to initially assess and provide on-going advice for all victims of trauma;

(iii)  review the actions of Consultant 1 in light of this report and take appropriate action; and

(iv)  make a further formal apology to Ms C for the failures identified.

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

Overview

The complainant (Mr C) attended the Ear, Nose and Throat (ENT) Department of the Royal Infirmary of Edinburgh (the Hospital) on numerous occasions following referral by his GP in June 2010. During this period his symptoms, which included bleeding from the throat, worsened. After each examination, he was discharged and re-referred to his GP. On 28 September 2011, he was diagnosed at the ENT Department with throat cancer (a right tonsil mass).

Specific complaint and conclusion

The complaint which has been investigated is that staff at the ENT Department failed to investigate Mr C’s symptoms appropriately and this led to a delayed diagnosis of stage 2 cancer of the right tonsil (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

(i)  apologise to Mr C for the failings identified;

(ii)  carry out a Serious Clinical Incident Review; and

(iii)  review the procedure for GP referrals to ensure that where there have been repeated referrals this is taken into account by ENT clinicians when assessing and examining the patient.

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

Overview
The complainant (Mrs C) raised a number of concerns on behalf of her husband (Mr C), who was admitted to Raigmore Hospital (the Hospital) on 4 January 2012 after suffering a seizure. She complains that during his stay, Mr C was not given appropriate care and treatment, nor was he properly assessed for rehabilitation prior to his discharge.

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

• (a) staff at the Hospital failed to provide Mr C with appropriate care and treatment following admission on 4 January 2012 (upheld); and
• (b) staff at the Hospital failed to assess properly whether Mr C would benefit from rehabilitation on discharge from hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) make a formal apology to Mr and Mrs C for their failures;
• (ii) ensure that the consultant physician (Doctor 2)'s next appraisal includes this case, together with reflection on the Adults with Incapacity legislation and the specific rights of patients with dementia;
• (iii) conduct an audit on Ward 6C, relating to compliance with Adults with Incapacity legislation for patients with dementia, and satisfy themselves that all staff are fully apprised of its implications;
• (iv) formally apologise to Mr and Mrs C for failing to assess Mr C properly prior to his discharge from hospital; and
• (v) (with Mrs C's agreement) assess Mr C thoroughly to establish whether he would benefit from further physiotherapy input and, if he would, the Board arrange this.

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

Overview
The complainant (Mr C) raised a number of concerns with Grampian NHS Board (the Board) that the care given to his wife (Mrs C) and baby daughter (Baby C) at Aberdeen Maternity Hospital (the Hospital) was inadequate. Mrs C was admitted to the Hospital two weeks prior to Baby C's birth by caesarean section. Baby C died shortly after birth, having been born premature and very underweight. Mr C was particularly concerned about the refusal of medical staff to continue resuscitation on Baby C. It is of concern to me that a number of relevant and important clinical documents, including reference to the fact a post-mortem examination had been conducted, were not provided to my office by the Board until they were asked to highlight any factual errors in a draft version of this report. At this stage of our investigative process, the Board had already been asked, on two occasions, to provide all the relevant information they held. In addition, we had already obtained clinical advice, with my advisers providing comment on the clinical records and information as received. I am disappointed by the Board's decision not to provide such relevant information until this final fact checking stage. I expect all bodies to ensure that their responses to my office's enquiries are thorough and include all information which is of relevance to the complaints under investigation. The Board's omissions in this case undoubtedly hampered our investigations, caused increased stress and distress for the family involved, and are totally unacceptable, as well as unprofessional.

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

• (a) failed to adequately manage the later stages of Mrs C’s pregnancy including the birth of her baby (upheld);
• (b) failed to adequately assess the possible success of continued resuscitation (not upheld); and
• (c) failed to adequately communicate with Mr and Mrs C (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider introducing guidelines for the management of small for gestational age foetuses, with reference to the Royal College of Obstetricians and Gynaecologists guidance of March 2013;
• (ii) undertake an assessment to ensure that the Obstetric Team has the correct training and equipment to perform assessments of extremely pre-term infants with abnormal umbilical blood flows, and prepare an action plan to address any shortcomings;
• (iii) provide evidence to demonstrate that following the death of a baby, full clinical examinations and investigations, including a post-mortem, are discussed with and offered to parents;
• (iv) demonstrate that the Board's guidelines about intrauterine death , which contain survival figures for babies of extreme prematurity, are referred to as appropriate by maternity and neonatal staff when discussing care with prospective parents;
• (v) remind all of the staff involved in Mrs C's care of the importance of obtaining signed consent forms for caesarean sections;
• (vi) issue a full apology to Mr and Mrs C for all of the failings identified in this report;
• (vii) draw this report to the attention of all neonatal, obstetric and maternity staff at the Hospital; and
• (viii) conduct a significant event analysis of Mrs C and Baby C's care from the point of Mrs C's admission until Baby C's delivery and treatment.

Overview
The complainant (Mrs C), an advocacy worker, raised a number of concerns on behalf of her client (Ms A) about Ms A's detention under the terms of a Short-Term Detention Certificate and her subsequent transfer, under nurse escort by ambulance, from the Royal Infirmary Edinburgh (Hospital 1) to the mental health unit at St John's Hospital (Hospital 2) in November 2011. Specifically, Mrs C complained about the way in which Ms A was transferred and that she did not receive appropriate information in relation to the detention and transfer.

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

• (a) Ms A was forcibly transferred from Hospital 1 to Hospital 2 without any prior knowledge or explanation of reasons (upheld);
• (b) Ms A was inappropriately told she was being detained under the Mental Health Act but has no recollection of being detained (upheld); and
• (c) the manner in which Ms A was wrapped in a blanket and strapped to a trolley, causing severe bruising to her shoulders, was unreasonable (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure that where detention and/or transfer is being considered, the matter is fully discussed with the patient and they are informed of the options available to them and the rationale underpinning the decision;
• (ii) ensure that in such cases discussions in relation to the patient's care and treatment and actions taken, including the use of medication, are clearly recorded in the clinical notes;
• (iii) ensure that, where restraint is required during the transfer of a patient, the appropriate incident report is completed in line with Board policy and the event clearly recorded in the clinical notes;
• (iv) feed back the learning from this complaint to all relevant staff in both hospitals;
• (v) ensure that all staff involved in taking decisions on short term and emergency detention are aware of the requirements of the Mental Health legislation and adhere to the appropriate process when carrying out any detention; and
• (vi) ensure that a physical examination is conducted on a patient on their arrival at a hospital, especially if the patient was the subject of a physical restraint en-route to the hospital; and

The Ombudsman recommends that:

• (i) this report be considered at a meeting of the Lothian NHS Board.

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

Overview
The complainant (Mrs C) raised a number of concerns with Lanarkshire NHS Board (the Board) concerning the care and treatment her father (Mr A) received for a gangrenous toe between 4 January and 12 March 2011 while a patient in three different hospitals, including Monklands General Hospital (Hospital 1), Hairmyres Hospital (Hospital 2) and Wester Moffat Hospital (Hospital 3). Mr A died from sepsis (a bacterial infection in the bloodstream) on 12 March 2011.

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

• (a) the treatment provided to Mr A for his gangrenous toe was inadequate and failed to address the infection and prevent him contracting sepsis (upheld);
• (b) during Mr A's admissions to the three hospitals, staff unreasonably failed to recognise, monitor and address his pain, agitation and confusion (upheld);
• (c) between 9 and 10 March 2011 Mr A's medication was inappropriately changed causing him to become very distressed and unresponsive (upheld);
• (d) there was an unreasonable delay in transferring Mr A to Hospital 1 on 12 March 2011 when his condition had deteriorated (upheld); and
• (e) during Mr A's hospital admissions from 4 January to 12 March 2011, the family constantly raised their concerns about Mr A's deteriorating condition but these were unreasonably ignored (not upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensures that Doctor 1 reflects in his annual appraisal on Adviser 1's comments in terms of the lack of evidence in the medical records to show that all surgical options were considered and discussed with Mr A and the family where relevant;
• (ii) review the application of the MEWS chart in Hospital 3 to ensure that staff can readily identify patients who have deteriorated and require urgent attention;
• (iii) conduct a significant event analysis with regards to Mr A's transfer from Hospital 3 to Hospital 1, to ensure that in future patients who are significantly unwell and deteriorating are transferred in a timely manner. This should also take into account Mr A's pain management at Hospital 3; and
• (iv) apologise to Mrs C and the family for the failings identified in this report.