Health

Summary
Mrs C made a number of complaints about the care and treatment provided to her mother (Mrs A) when she was admitted to the Western Isles Hospital for two days. We found that although staff had recorded that Mrs A was allergic to plasters, they continued to apply them to her. We were satisfied with the action taken by the board in response to Mrs C's complaint about this. However, we found that the record-keeping in relation to the assessment of Mrs A was not satisfactory and that there was no evidence of a risk assessment.

We did not uphold a number of Mrs C's complaints. There was no evidence that staff had failed to use a hoist when lifting Mrs A. We also considered that it was reasonable for staff to decide to keep her in bed rather than hoisting her onto a chair, as she was due to be seen by a doctor. We found that after the initial assessment, there was evidence that the board had listened to the family's views in relation to their mother's care needs. There was no evidence that staff had failed to ensure that Mrs A had a means of summoning help.

Mrs C also complained about the board's handling of her complaint. However, we found that it was reasonable to interview her brother about an allegation that a member of staff had been rude to him. There was no evidence that the board had breached confidentiality when they spoke to him. We also found that the board had not blamed the family for the problems that had occurred, but had tried to provide an explanation about how they had arisen.

Recommendation
We recommended that the board:
• remind nursing staff in the hospital of the importance of good record-keeping in relation to the assessment of patients on admission. This should include risk assessment and should involve obtaining information from relatives and/or carers.

Summary
Mrs C's mother (Mrs A) fell at home and was taken to A&E at Ninewells Hospital. X-rays confirmed that Mrs A had broken her femur and she was transferred to a ward a few hours later. The plan was for Mrs A to have surgery the next morning so she was given no food. When Mrs C called the ward the following morning she was told that there had been an emergency and Mrs A had not yet gone to theatre.

Mrs A went to theatre for her operation that evening. Mrs C telephoned the ward the next morning and was told that her mother had had a satisfactory night and was fine apart from being 'a bit chesty'. When Mrs C and her daughter arrived that afternoon they were told that Mrs A's condition had deteriorated and a team were attempting to resuscitate her. The attempt was unsuccessful and Mrs A died.

When her family saw her, they believed that she had been dead for some time given her pallor and temperature. Mrs C also complained that Mrs A was not given something to eat when she was transferred to the ward and that there had been an unreasonable delay in getting her to theatre. Furthermore, Mrs C believed that no appropriate action had been taken to address her mother's condition following surgery and that it was inappropriate that the family were not alerted when her condition deteriorated. Finally, Mrs C complained about the delay by the board in responding to her complaint.

The board accepted that Mrs A should have been given something to eat when she was transferred to the ward and apologised for their failure to do so. They also acknowledged that there was an unreasonable delay in responding to the complaint and apologised.
In regards to the timing of the operation, we found that this was reasonable as Mrs A's operation began just over 24 hours after admission. We also found that Mrs A's deterioration was rapid and that the care and treatment she received following her operation was reasonable and timely and that the board's failure to alert the family was reasonable in the circumstances. Finally, we found that there was no evidence to bring the timing of Mrs A's death as recorded by the board into question.

Summary
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection.

We found that Mr C had been monitored appropriately following his admission to the hospital. The SEWS (the Scottish Early Warning Score) charts had been completed regularly and appropriately throughout his admission. There was no evidence to suggest that the monitoring, assessment and management of his pain was not reasonable.

Although Mr C complained that he was not provided with his regular prescribed medication until the day after he was admitted, the drug administration record showed that he had self-administered some of his medication on the day of his admission. We found that staff clearly failed to provide him with other medication that he needed, but had not taken to the hospital. We upheld Mr C's complaint about this. However, we did not make any recommendations, as the board had already apologised to Mr C and were taking action to reduce the likelihood of similar problems recurring.

Mr C also complained that the board did not provide him with oral antibiotics for 26 hours after he was taken off an intravenous antibiotic drip, despite his repeated requests and complaints. We upheld this complaint, as the records were not clear on the matter. It was not possible for us to say categorically whether there was a delay in providing him with oral antibiotics or whether the original intention was that the antibiotics should be stopped.
We did not consider that Mr C was asked inappropriate questions in A&E or that the questions were unnecessarily duplicated when he was transferred to a ward. Mr C also complained that the records of his stay in the hospital had
been fabricated. We found no evidence of this. In addition, we found that the board's handling of his complaint was satisfactory.

Recommendation
We recommended that the board:
• remind the medical staff involved in Mr C's care and treatment of the need to keep clear, accurate and legible records, which report the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigations or treatment.

Summary
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection.

We found that Mr C had been monitored appropriately following his admission to the hospital. The SEWS (the Scottish Early Warning Score) charts had been completed regularly and appropriately throughout his admission. There was no evidence to suggest that the monitoring, assessment and management of his pain was not reasonable.

Although Mr C complained that he was not provided with his regular prescribed medication until the day after he was admitted, the drug administration record showed that he had self-administered some of his medication on the day of his admission. We found that staff clearly failed to provide him with other medication that he needed, but had not taken to the hospital. We upheld Mr C's complaint about this. However, we did not make any recommendations, as the board had already apologised to Mr C and were taking action to reduce the likelihood of similar problems recurring.

Mr C also complained that the board did not provide him with oral antibiotics for 26 hours after he was taken off an intravenous antibiotic drip, despite his repeated requests and complaints. We upheld this complaint, as the records were not clear on the matter. It was not possible for us to say categorically whether there was a delay in providing him with oral antibiotics or whether the original intention was that the antibiotics should be stopped.
We did not consider that Mr C was asked inappropriate questions in A&E or that the questions were unnecessarily duplicated when he was transferred to a ward. Mr C also complained that the records of his stay in the hospital had been fabricated. We found no evidence of this. In addition, we found that the board's handling of his complaint was satisfactory.

Recommendation
We recommended that the board:
• remind the medical staff involved in Mr C's care and treatment of the need to keep clear, accurate and legible records, which report the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigations or treatment.

Summary
Ms C complained about the board's treatment of her wrist injury. She complained that the investigation of her injury and treatment had not been reasonable, and that the treatment had not been undertaken within a reasonable timescale. We upheld both complaints.

We found that a failure to assess Ms C's symptoms from the outset and to treat them with a high level of suspicion had led to failings in her care. We were critical of a number of aspects of the care, including the decision to treat her with a splint initially rather than a cast (whilst acknowledging this may not have impacted upon the healing of Ms C's fracture, we found more consistent immobilisation would have assisted in easing Ms C's pain and discomfort, as throughout the course of her treatment she had splints and casts fitted and removed on several occasions). We also criticised the board's failure to send Ms C for specific wrist x-rays and the decision to discharge her on three occasions without appropriate follow-up care.

In relation to treatment being undertaken within a reasonable timescale, we found that Ms C should have been referred for physiotherapy at around the time she was diagnosed with the fracture. Instead, Ms C did not begin to receive physiotherapy until around six months later after she self-referred. We found this delay may have impacted upon her long term recovery.

Recommendations
We recommended that the board:
• provide a full apology to Ms C for the failures in identified in her treatment;
• review their Minor Injury Wrist and Forearm protocol to ensure that a patient presenting with symptoms potentially indicative of a scaphoid (wrist) fracture are appropriately investigated and managed; and
• ensure staff involved in Ms C's case are made aware of the need to arrange follow-up appointments when necessary, to give consideration toa physiotherapy referral for patients if appropriate, and that the board take these issues into account when reviewing their Minor Injury Wrist and Forearm protocol.
 

Summary
In 2011, Miss C viewed her maternity records relating to the death of her son in 1993. She submitted a list of clinical questions and asked to meet with someone to discuss these. However, there was a delay in this request being processed, which Miss C complained about to the board. She later also complained about the way in which her complaint was handled.

Miss C's questions and meeting request were submitted in early September 2011 and were not passed to clinical staff to address until mid-December 2011. We agreed that this was an unreasonable delay and upheld Miss C's complaint. However, as the board assured us reasonable steps had been taken to avoid a similar future occurrence, and as they had already apologised to Miss C, we did not make any recommendations.

Miss C submitted her complaint about the delay in late November 2011 but it appears to have then been confused with her original clinical request which had yet to be addressed. This resulted in further delays and ambiguity and we, therefore, considered that the board had not responded to Miss C's complaint in an accurate and timely manner. We, therefore, upheld this complaint. However, we were satisfied that this was an isolated incident and that appropriate remedial action had been taken by the board and we did not make any recommendations.

Summary
Mr C attended the practice for an appointment with his GP. During the consultation, he said that the GP told him off for failing to attend or cancel a hospital appointment that he had been referred to. Mr C did not like the GP's tone and walked out of the consultation. He complained to the practice manager and a further appointment was made for later the same day with another GP. Mr C explained to the second GP that he had been suffering from low mood over a period of days and had thought of taking his life. As Mr C was not diagnosed as being biologically depressed, it was not considered appropriate to give him medication. Counselling was offered, but declined by Mr C as he was already attending counselling sessions and did not find these to be beneficial. The practice were unable to offer him any alternative treatment and he was eventually asked to leave the premises.

Mr C complained about the practice's failure to address his feelings of low mood on the day of his appointments. We found that it was not appropriate for Mr C to be offered medication and that counselling was the correct course of action. Mr C had commented that he had thought about suicide. We were satisfied that he was appropriately assessed as being a low risk of suicide and that it was, therefore, reasonable for the consultation to end without any further treatment or referrals being proposed. We did not uphold his complaints.
 

Summary
Ms C fell and slipped on ice. Some days later, she began to feel pain and her GP diagnosed a fractured tailbone. Approximately two weeks after the fall, she was rushed to hospital where she was diagnosed with an abscess. As a result of the abscess, she had to have surgery and it was some time before she made a full recovery.

Ms C complained to the practice about the misdiagnosis and also about the attitude of the GP during the visit. We sought advice from our independent medical adviser who confirmed that, from a clinical standpoint, the initial consultation had failed to achieve the correct diagnosis. However, the practice's response to the complaint provided a full explanation, apologies where necessary and also the offer to meet with Ms C to discuss the matter. Although we upheld this aspect of this complaint, we did not consider that there was anything more that we could reasonably expect the practice to do as a result of the complaint and so did not make any recommendations.

In relation to Ms C's complaint about the attitude of the GP, we noted that the practice acknowledged that there was an initial difficult telephone conversation and the GP apologised for this and for the way in which they came across to Ms C. On balance, in the absence of evidence to confirm exactly what was said and, as importantly, the way in which it was said, we were unable to uphold this aspect of Ms C’s complaint.

Summary
Ms C complained that obstacles were put in her way when she attempted to register with a GP. Ms C complained that the systems in place at three medical practices to which she applied were obstructive and were not properly applied. She claimed that as a result she was prevented from registering with a GP.

Our investigation established that the systems in place at all three practices reflected national standards and were, therefore, found to be reasonable. In addition, in trying to resolve Ms C's complaint the board offered firstly to register Ms C at a practice of her choice. Ms C declined this offer as she felt it would negate her purpose in complaining.

Subsequently, when Ms C was dissatisfied with the responses from the individual practices, the board offered four months later to facilitate a new patient appointment at one of the practices. Again Ms C declined the offer on the basis that it would negate her complaint.

We found that the offers made by the board were a reasonable attempt to resolve not only Ms C's complaint but the difficulties she had found in registering with a GP. We expect complainants to co-operate with bodies in trying to resolve complaints and that where a reasonable offer to do so is made, we consider it appropriate for the complainant to accept such an offer. The board have confirmed that the offer to register Ms C at a practice of her choice is still open to her. We have encouraged Ms C to contact the board to discuss this.

Summary
Ms C complained that the board failed to take adequate care of her jewellery when she was taken to theatre at Monklands Hospital. Ms C explained that she was prepared for surgery in the ward before being taken to theatre and a nurse taped a ring on her finger. She said that just outside theatre, nursing staff noticed that she was still wearing a necklace and medal and removed them as they were not allowed in theatre. Ms C said she never saw the items again.

During our investigation of the complaint, we reviewed copies of Ms C's medical records and her complaint file, including notes of the board's investigation of her complaint and interviews with the nursing staff involved. We also reviewed the board's internal procedure for dealing with enquiries/claims and their procedures on the handling of, or checks for, jewellery. In addition, we obtained a copy of the disclaimer notice displayed in the hospital wards and a copy of the in-patient booklet which contains advice on bringing valuables into hospital.

The documentary evidence showed that the board followed their normal procedure in this case. The documentation completed at the three separate stages for Ms C's admission to theatre clearly stated that she was only wearing her wedding ring. It was, therefore, not possible to prove that Ms C was wearing the additional jewellery at the time she went to theatre and that the board failed to take adequate care of her jewellery. We did not uphold the complaint.