Health

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.

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.