Health

Overview
The complainant (Ms C), an advocate, raised a number of concerns on behalf of Mr A. Mr A’s late wife (Mrs A) was referred urgently by her GP for the investigation of symptoms suggestive of breast cancer on three occasions within a period of seven months. Mrs A was referred urgently to the Breast Clinic at the Western Isles Hospital (the Clinic) in Stornoway three times between May and November 2008 but she was not referred on to the Highland Breast Centre in Inverness (the Breast Centre) until December 2008. Cancer was diagnosed in January 2009. Mrs A was a young woman whose first child was under two years old when she first reported her symptoms to her GP. By the time the cancer was diagnosed, she was some 12 weeks pregnant with her second child. Although the child was delivered safely and Mrs A was treated for her cancer, the cancer later returned and she died aged 33 years in June 2011.

Specific complaint and conclusion
The complaint which has been investigated is that the Board unreasonably delayed diagnosing Mrs A's breast cancer (upheld).

Redress and recommendation
The Ombudsman recommends that the Board:

• (i) issues a written apology for the failings identified.

The Board have accepted the recommendation and will act on it accordingly.

Overview
The complainant (Mrs C) raised concerns about the failure by Tayside NHS Board (the Board) to provide a British Sign Language (BSL) interpreter for a patient (Ms A) in Ninewells Hospital (the Hospital).

Specific complaint and conclusion
The complaint which has been investigated is that it was unacceptable for the Board not to provide a BSL interpreter during Ms A’s 12-day in-patient admission to the Hospital in July 2011 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) consider amending their Interpretation and Translation Policy to highlight the legal duties staff have and to explain that using families, lipreading and pen and paper is not likely to be an adequate or reasonable response to the needs of a BSL user. This should make clear that BSL is a registered language and not simply signed English;
• (ii) produce further guidance for staff on: what the protocol is once a patient makes staff aware that they need a BSL interpreter; who is responsible for arranging this and how the interpreter's availability is to be coordinated with that of the health professionals involved; and how reassurance and progress on getting an interpreter should be communicated back to the patient;
• (iii) consider providing further training to staff on deaf culture, language and legal rights;
• (iv) consider seeking input from deaf people on the Board's Interpretation and Translation Operational Group to review the effectiveness of the implementation of the Interpretation and Translation Policy; and
• (v) offer to meet with Ms A and a BSL interpreter to answer any questions she has about her treatment and to apologise, explain and feedback how her complaint has helped them to develop their service.

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

Overview
The complainant (Ms C), acting as Independent Advocate for Miss A, raised a concern about the decisions taken by staff about artificial feeding by nasogastric (NG) tube for Miss A during a hospital admission from 25 June 2011 and 8 September 2011. Ms C also raised a concern about a lack of consultation with her about a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision in September 2011. Ms C also had concerns about the accuracy of Lanarkshire NHS Board (the Board)'s response to her complaint in October 2011.

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

• (a) during a hospital admission from 25 June 2011 to 8 September 2011, a flawed decision was taken to remove an NG tube (upheld);
• (b) a DNACPR decision was taken without appropriate consultation with Ms C as Miss A's advocacy worker (upheld); and (c) Lanarkshire NHS Board's complaint reply of 1 December 2011 inaccurately stated that a particular clinician had known Miss A since 2004 (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) use the circumstances of Miss A's case to review their practice in respect of patients with learning difficulties and/or suspected dementia, with particular focus on a review of the quality of decision making, the recording of decision making and the quality of record-keeping on admission and concerning DNACPR decisions; and
• (ii) review their procedures for investigating complaints to ensure that responses are both accurate and can be justified.

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

Overview
The complainant (Mr C) raised concerns about the care and treatment his wife (Mrs C) received from the GPs at the medical Practice (the Practice) from January to October 2013.  Mrs C subsequently attended Aberdeen Royal Infirmary, where she was diagnosed with bowel cancer.  Since the events within this complaint, Mrs C's condition deteriorated further, and she sadly died during the course of our investigation.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay by the Practice in 2013 in diagnosing Mrs C's cancer (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• apologise to Mr C for their failure to appropriately refer Mrs C for diagnosis of her cancer during the period from January to October 2013, and for the distress this caused her and her family;
• provide evidence that the actions set out in their Significant Event Analysis have been met, giving consideration to the NHS Education for Scotland Enhanced Significant Event Analysis approach;
• identify the training needs for the practice team relating to the issues raised in this complaint, and reflects these in appraisals and assessments; and
• explain what changes the Practice will introduce to ensure that, in future, their procedures for Significant Event Analyses are in line with national guidelines, and that they receive the prompt attention of the whole Practice.

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

Overview
The complainant (Mr C) raised concerns that his late mother (Mrs A) had not received adequate fluids and nutrition during her admission at Vale of Leven Hospital.  Mr C also complained that, following her diagnosis with oesophageal cancer, Mrs A did not receive palliative treatment for nearly three weeks until he raised his concerns with the consultant in charge of Mrs A's care.

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

• staff at Vale of Leven Hospital failed to ensure that Mrs A received an adequate level of fluids and nutrition despite her swallowing difficulties (upheld); and
• staff at Vale of Leven Hospital and Paisley Royal Alexandra Hospital failed to ensure that Mrs A received appropriate and timely clinical treatment in view of the symptoms which she presented with (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• review the processes for ensuring that fluid intake and balance is appropriately monitored and recorded on the Vale of Leven Hospital acute medical ward;
• issue a written apology to Mr C, clearly acknowledging the gravity of Mrs A's experience and the specific failings which led to the delay in her treatment; and
• take steps to ensure that the failings his investigation identified have been fully addressed in the revised pathway for onward speciality referral for upper gastrointestinal within Clyde, and explain what awareness raising has been undertaken in relation to this.

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 by her medical practice (the Practice) since the beginning of 2012.  Mrs C believed that the doctor treating her failed to acknowledge or deal with the symptoms she was displaying and that the doctor failed to recognise a general decline in her health.  As a result she was not referred timeously for specialist assessment.  Mrs C was subsequently diagnosed with bowel cancer and she believes that earlier referral would have avoided the need for the emergency surgery she was required to undergo.

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

• provided inadequate care and treatment (upheld); and
• unreasonably failed to make the appropriate referrals (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• ensure that the doctor responsible for Mrs C's treatment reflects on their practice in relation to these events and discusses any learning points at their next appraisal;
• review with the doctor involved in Mrs C's care the SIGN guideline 126;
• review the General Medical Council guidance on record-keeping and evaluate a sample of their case notes to see that they are fulfilling the required standards;
• apologise in writing for the failures identified in this report.

The Practice 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 daughter (Mrs A) for mental health problems by Forth Valley NHS Board (the Board) prior to her death by suicide on 11 October 2012.

Specific complaints and conclusions
The complaints which have been investigated are that the Board did not:

• offer a reasonable diagnosis (not upheld); and
• provide a reasonable standard of care and treatment (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review the approach taken by the Intensive Home Treatment Team to the assessment of risk to ensure that presenting risk factors are systematically considered and recorded and that the rationale behind clinical decision making is transparent;
• remind medical staff of the importance of accurate and signed contemporaneous notes;
• review the process for communicating medical reviews of patients to IHTT staff, to ensure that all relevant information is made available timeously;
• review the process for discharging patients from the IHTT to ensure that medical staff's opinions are considered; and
• apologise for the failings identified in this report.

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

Overview
The complainant (Miss C) raised a number of issues about the service she received from Greater Glasgow and Clyde NHS Board (the Board) during 2004.  Miss C was admitted to Princess Royal Maternity Hospital on 11 June 2004 to undergo a feticide procedure on medical advice.

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

• failed to explain Miss C's rights to request a private burial or cremation (upheld);
• failed to show, or explain, the cremation forms prior to asking Miss C to sign them (upheld);
• asked Miss C to sign the cremation forms when she was sedated and prior to the delivery (upheld); and
• failed to provide an accurate explanation, when responding to Miss C's complaint, for the inconsistencies in the dates on the cremation forms (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• apologise to Miss C for the failings identified in this complaint;
• ensure that staff attending patients after a fetal loss follow the guidance notes;
• report back to the Ombudsman on how they will ensure that the options for disposal of remains will be published to parents, so that they are aware of the choices that are available to them;
• report back to the Ombudsman on steps they intend to take to ensure that any form to be completed by a patient after a fetal loss is fully explained to the patient, at a time when they are fully able to understand any explanation given;
• report back to the Ombudsman on steps they intend to take to ensure that patients, following a fetal loss, are not being asked to give consent while they lack the capacity to fully understand and recall what they are signing; and
• formally apologise for the inconsistencies provided in relation to the dates on the cremation forms.

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

Overview
The complainant (Mrs C) raised concerns that the standard of care and treatment provided to her late mother (Mrs A) from two hospitals following a fall was not reasonable and included concerns about communication, treatment decisions, discharge and provision of nutrition and fluids.

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

• the Western General's care and treatment of Mrs A in 2013 was unreasonable (upheld); and
• the Royal Infirmary of Edinburgh's care and treatment of Mrs A in 2013 was unreasonable (upheld).

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

• ensure that any recorded assessment of a patient is accurate and a reliable source on which to base the planning of care and supervision;
• ensure that the presence of cognitive impairment is given due regard in the planning of care, and that the level of observation, supervision and support provided to people with delirium and/or dementia is appropriate for their impaired capacity;
• take steps to ensure that communication with relatives or carers of patients with cognitive impairment is proactive and systematic;
• ensure the failures identified are raised with relevant staff;
• review their practice in relation to the pre-operative provision of nutrition and fluid in light of Nursing Adviser 2's comments;
• ensure that clinical practice, decision-making processes and clinical records in relation to DNACPR decisions are in line with the relevant policy; and
• apologise to Mrs C for the failures identified in this investigation.

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

Overview
The complainant (Mr C) raised a number of concerns that the diagnostic journey he underwent for an abdominal problem was unreasonable and has left him with on-going and debilitating symptoms.

Specific complaint and conclusion
The complaint which has been investigated is that Lanarkshire NHS Board's diagnostic actions were unreasonable (upheld).

Redress and recommendations
The Ombudsman recommends that Lanarkshire NHS Board:

• ensure, as a matter of priority, the Consultant reflects on the events investigated and discusses all learning points at  their next annual appraisal.  Including when and how a cancer diagnosis is made and communicated;
• ensure that all the medical staff involved in this case are reminded of the importance of adhering to the General Medical Council guidance on record-keeping;
• urgently review the diagnostic process used for colon cancer, including the use of Multi-Disciplinary Team discussions, taking into account national guidance;
• issue a written offer for Mr C to insert a note of clarification in his clinical records where necessary, as mentioned in the draft complaint response;
• review its monitoring process for the handling of complaints to ensure that a robust system is in place to prevent complaint responses that are due for issue being  delayed and that if unavoidable delays occur, complainants are kept informed; and
• issue a written apology to Mr C for the failings identified during this investigation.

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