Health

Summary
Ms C complained to the Ombudsman about the length of time that her late mother (Mrs A) had been prescribed medication (Mogadon/Nitrazepam). Ms C had read literature which mentioned that Nitrazepam should not be prescribed for more than nine months. She wondered whether the medication could have been the cause of Mrs A's obsessional episodes and led on to her suffering from dementia and Alzheimer's disease.

Our investigation found that medical opinion had changed over the years and that currently it would not be best practice to prescribe Nitrazepam for a prolonged period. However, withdrawal of the medication is quite complex and requires the risks to be balanced against the benefits. In Mrs A's case our medical adviser said that long term prescription of the medication was appropriate.

Summary
Mr C had a number of health problems. When he fell and hurt himself in hospital, a support worker complained on his behalf that the board provided him with inadequate care. As a result of the fall, Mr C hurt his knee, and had mobility problems. Mr C had found it difficult to adopt a comfortable resting position in bed. He said he told nursing staff that he considered himself to be in danger of falling but they did not assist him and were to blame for his fall. Nursing staff said they were concerned that Mr C's position in bed was precarious, so they assisted him to a safer and more comfortable position and advised him not to try to stand up.

We did not uphold this complaint. There was no evidence to support either Mr C's account or the nursing staff's account of this, and so we could not determine exactly what was said. From looking at the records and taking advice from our nursing adviser, we found that the nursing notes did not record staff concerns about Mr C's position in bed, although the adviser noted this may not have been possible on a busy ward. The notes also did not record Mr C's apparent failure to comply with advice from nursing staff. This information was recorded in statements from nursing staff in response to Mr C's complaint. While we accepted our adviser's view about a busy ward, we drew the board's attention to our view that we would normally expect staff concerns to be noted in the records at the time. However, an appropriate risk assessment was carried out and a care plan was in place to look after Mr C, and our adviser concluded there was not enough evidence to suggest that the care provided to Mr C was inadequate.

Summary
Mr C complained that the board failed to provide his daughter (Ms A) with continuous intensive support and treatment for her mental health issues. Mr C said that Ms A had a complicated medical history and had been left with psychological problems that include severe anxiety and obsessive/compulsive behaviour (OCD) and emetophobia (fear of sickness or vomiting) that has a negative impact on all aspects of her daily living. She cannot work or live alone and, two years on, has made little or no progress under the care of local mental health teams at the board despite her trying to work with the partnership team. Mr C felt that Ms A was not given adequate support, or funding for specialist help that he believes she needs at a national unit in London. When Mr C brought his complaint to us he said that the board had not adequately addressed his complaint, appeared disinterested and lacked concern about the situation.

After taking advice from one of our medical advisers, we did not uphold Mr C's complaint. Our adviser considered the management of OCD, and the core interventions and treatment in the National Institute of Health and Clinical Excellence guidelines. He concluded that Ms A was given a suitably intensive service in that she had been offered appropriate interventions. He said that the records showed that Ms A had a number of clear clinical plans of care and had received multi-disciplinary input from a variety of clinicians and services. The adviser also considered there were no unreasonable delays in the provision of treatment. We decided that there was no evidence to support Mr C's view that Ms A had not received a suitably intensive service from the board.

The adviser also said that the general rule that applies both in Scotland and England is that Ms A would only be referred to external services if and when available options within local services were exhausted. We decided that there were justifiable reasons why the board did not refer Ms A to the national unit, as she was at the early stage of her care and treatment when the request was made and the services offered by the board were not exhausted.

We found that Ms A's overall care and level of input from clinicians and services were appropriate.

Summary
Mrs C had fertility treatment which began in 2008. She had a successful pregnancy in 2009 and in 2011 was invited back for further treatment. On attending the appointment, she was advised there had been an administrative error, and she should not have been invited for further treatment as she had already had a child. Mrs C complained that she was never told that this would be the case. The board considered whether to make an exception to the criteria for treatment in Mrs C's case, but decided there was no basis to deviate from them.

The board explained that, under their policy, couples were entitled to a maximum of two cycles of treatment. Mrs C had become pregnant during the first cycle. She had frozen embryos remaining from that cycle, which were implanted in 2010 but did not result in a further pregnancy. The board said this was the stage at which the first cycle of treatment ended, and Mrs C was not entitled to a second cycle of NHS treatment as she had already had a child as a result of the first.

We found that the correspondence sent to Mrs C about the criteria for treatment had not been clear. On that basis we upheld her complaint. We made no recommendations as we found that, as a result of Mrs C's case, the board had undertaken a range of measures to prevent a similar error happening again. These included reviewing the correspondence sent to patients, developing a new consent form and ensuring that review meetings took all previous treatment outcomes for patients into account.

Summary
Miss C complained about how the board handled her complaint. Our investigation established that there had been some delay by the board in replying but that their complaint file showed that they had been actively working on the complaint the whole time. They had also replied very promptly to two further complaint letters from Miss C on the same subject. Other aspects of their complaints handling were good. For example, it was clear they had investigated thoroughly. Although we would not condone delay, we did not consider, in the circumstances of this case, that there were sufficient grounds to uphold the complaint.

Summary
After a road traffic accident, Ms C attended the accident and emergency department of a hospital. She received care and treatment for her injuries in the accident and emergency department. Within 24 hours she was admitted to a ward for further treatment, then transferred to an orthopaedic ward before being discharged. She continued to be seen by an orthopaedic consultant as an out-patient.

Ms C complained about the care and treatment she received from the board for her injuries arising from the accident and said that she was not kept informed about her condition. She also complained about the board's actions in relation to requests from her insurers and a UK government department for information about her injuries and disability.

We found no evidence to show that the board's care and treatment of Ms C was unreasonable or that they failed to keep her informed about her condition. We also found no evidence that the board responded unreasonably to requests for information about her injuries and disability.

Summary
Miss C complained to the board about aspects of the care and treatment that her late father, Mr A, received in hospital. Mr A, who had irreversible chronic obstructive airways disease (COAD), suffered a cardiac arrest at home. He was resuscitated by paramedics and taken to the hospital's intensive care unit. Initially he was on a ventilator to help him breathe, but this was discontinued the day after he was admitted. The same day, Miss C spoke to a doctor who told her that she had spoken to Mr A and that he had said he did not want to be put on a ventilator. The doctor also told Miss C that Mr A's health was too poor for him to benefit from ventilation and that he would not survive. Although initially Mr A had improved, his condition later deteriorated and he died a week after being admitted to hospital. In her complaint, Miss C said the family contested the fact that Mr A's health was too poor for him to have benefitted from ventilation.

We took advice from one of our medical advisers, who said that as an emergency admission, it was appropriate to initially place Mr C an a ventilator until his condition stabilised. He was taken off the ventilator once his condition improved. However, when his condition deteriorated staff had to take into account Mr A's irreversible COAD. We found that the records show that staff took steps to explain the situation to Mr A and decided that further ventilation would not be of benefit to him. We found that the decision not to place Mr A on ventilation was appropriate in view of the poor prognosis, that staff had fully consulted with Mr A in the process and that he was in full agreement.

Summary
Miss C complained that her dentist had removed her from the dental practice's list of patients. However, dentists can do this, as long as they give three months' notice to the patient (unless the patient has shown violence). As the dentist had given adequate notice, there were no grounds for us to uphold the complaint.

Summary
Mrs A had been receiving treatment for high blood pressure for a number of years. She had three strokes within six months. Mrs A's husband, Mr C, complained that their GP practice failed to provide appropriate advice to him when he contacted them about the first and second strokes. Mr C also complained that the practice failed to respond within a reasonable timescale when Mrs A's stroke nurse reported high blood pressure results shortly before the third stroke.

In looking at the records, we could not determine exactly what was said when Mr C spoke to the practice on the day Mrs A had her first stroke, as there was no direct objective evidence. However, the records did show that the practice's advice to bring Mrs A to the evening surgery on the day of her first stroke was reasonable. While we acknowledged this, there was no record of advice given to Mr C about what to do if Mrs A's symptoms worsened. In addition, one of our medical advisers was of the view that Mrs A should have been taken to hospital that evening by emergency ambulance. In relation to the day of Mrs A's second stroke, the practice advised Mr C to bring her in for a consultation the following morning. In our view, she should have been seen and assessed on the same day, given her history and unresolved symptoms. Taking all of this into account, and noting the views of our adviser, on balance we upheld this complaint.

In relation to Mr C's second complaint, the records showed that the practice discussed Mrs A's high blood pressure results with the stroke nurse, and arranged for further review and a home visit. Our adviser's view was that the practice acted appropriately in the circumstances. Taking this into account, we concluded that the practice did respond within a reasonable timescale and, therefore, we did not uphold this complaint.

Recommendation
We recommended that the practice:
• review their protocol for the management of hypertension, in terms of the threshold for referring patients to a hospital consultant. This would include urgent referral and emergency ambulance transfer to hospital of patients suspected of stroke if symptoms persist on assessment.

Summary
Ms C was admitted to hospital on two occasions. She said that before each admission she had lodged an advance decision with the board to cover the care and treatment she was prepared to accept. She was unhappy with the care and treatment she received. She said it did not agree with her advance decision; that the advance decision was not recorded in her notes until after the first admission; she waited around six hours before receiving treatment; she was incorrectly told to take her own medication; staff took offence at her; her advance decision was not respected and it was inappropriate for staff to ask about her mental health problems.

Our investigation took account of all the available information, including Ms C's medical records. We obtained medical advice from two medical advisers.

A medical adviser said that advance decisions are drawn up to indicate how an individual would wish to be treated, should they be unable to make that decision at the time. There was no indication in the medical records that Ms C was in that position at the times concerned. However, we found that the advance decision was not inserted in her records at the right time and that on admission, she waited too long before receiving treatment and we upheld her complaints about these matters. We also found that staff told her, incorrectly, to continue taking her own medication once she was admitted to a ward and that in view of this a member of the medical team (correctly) refused to continue to give her strong apin relief. There was, however, no evidence to show that a member of staff took any offence at Ms C or her requests. We also found that it was appropriate for staff to discuss Ms C's mental health with her even though it had no apparent bearing on her physical presentation at the time.

Recommendations
We recommended that the board:
• apologise for the delay in 2010 in attaching the advance decision to the relevant notes;
• audit their current process to lodge records information and act on any recommendations subsequently made; and
• review the means, in Crosshouse Hospital, by which they ensure that acute admissions are promptly assessed by medical and surgical staff in their acute wards and that actions taken to ensure attainment of the four hour target do not compromise patient care. An audit of time from presentation at Accident and Emergency to review by medical staff would support such an aim.