Health

Summary
Mr C, who had a history of surgery for colon cancer and treatment for depression and anxiety, had a heart attack. He was admitted to hospital for treatment, and transferred to another hospital for surgery. After surgery, Mr C was transferred back to the first hospital before being discharged around two weeks later. Mr C then had a number of consultations with staff from cardiology, and was seen on a regular basis by a heart failure nurse. Mr C developed a form of anaemia and a condition called myelodysplasia (an abnormality of the bone marrow, resulting in a lack of healthy blood cells). Hospital staff also investigated Mr C for a possible lung tumour, but scans did not confirm this. Mr C had eight admissions to hospital in nearly two years, until his general condition deteriorated and he died.

Mr C's wife, Mrs C, complained about: the follow-up care for Mr C's heart attack; the care Mr C received for his anaemia and myelodysplasia; coordination between different hospital departments in treating Mr C's various medical conditions; how hospital staff explained things to her and her husband; and how the board handled her complaint. We looked at Mr C's clinical records and took advice from three of our professional clinical advisers. We found that the care and treatment Mr C received was appropriate, that staff had explained things to Mr C, and the board had dealt properly with Mrs C's complaint.
 

Summary
Mr C raised a number of complaints, some about a pharmacy and one about the board's handling of his correspondence. In the circumstances of his complaint, we decided that we did not have the authority to investigate his complaints about the pharmacy. We upheld his complaint against the board because they did not acknowledge or respond to a letter he sent. We made no recommendations, because the board had already identified that the letter had not been responded to, provided an explanation for this, apologised to Mr C and provided him with a response. We did suggest to the board that they reflect on whether they could have managed Mr C's large volume of correspondence better by perhaps nominating a single point of contact.

When this report was first published on 21 September 2011, it was incorrectly categorised as being about Grampian NHS Board. This was due to an administrative error which we discovered on 22 September 2011, and for which we apologise.

Summary
In August 2009 Mrs C attended her GP complaining of a lump in her left breast. She was examined and asked to return for a follow up appointment a week later. She was seen by a different GP at the review appointment and was advised that the lump was most likely a cyst. She was told to monitor the lump over the course of a few menstrual cycles. No follow-up appointment was made. Mrs C said that the lump increased in size and she returned to her GP practice in August 2010. She was seen by a third GP, who was concerned by the lump and referred her to a breast clinic for further investigation. The lump was found to be cancerous. Each of the three GPs described the lump as being in a different location and the Practice concluded that different lumps had been examined.

Mrs C maintained that she had had the same lump since August 2009 and that it had increased in size. She complained that the first GP incorrectly noted the lump as being in her right breast, and that she should have been referred to the breast clinic by the second GP. Although it was not possible for us to confirm whether there had been three different lumps, or if the same lump had been described differently, we upheld both of Mrs C's complaints, as we found the first GP's record-keeping to be poor and possibly inaccurate. We found that the treatment plan proposed by the second GP was not in line with good practice guidance and that Mrs C could have been referred to the breast clinic significantly earlier, or had it confirmed whether her lump was just a cyst.

Recommendations
We recommend that the practice:
• add a note to Mrs C's records clarifying that she attended her examination on 14 August 2009 complaining of a lump in her left breast;
• draw their staff's attention to the guidance in SIGN 84 and the Scottish Primary Care Cancer Group's publication: Scottish referral guidelines for suspected cancer; and
• apologise to Mrs C for the failings identified by our investigation.

 When this report was first published on 21 September 2011, it was incorrectly categorised as being about Greater and Glasgow and Clyde NHS Board. This was due to an administrative error which we discovered on 22 September 2011, and for which we apologise.

Summary
Mrs C complained to the board about the delays encountered when she took her mother, Mrs A, to the Plastic Surgery Clinic at Wishaw General Hospital. Mrs C said that at recent appointments her mother had to wait over an hour from her scheduled appointment time to be seen and although the clinic ran until 13.00, patients did not arrive for appointments after about 11.00. Mrs C felt that the scheduled appointment times could be spread about more and this would cut down on the waiting times. The investigation revealed the board had taken action to keep the appointment times under review, but we found that there was also a problem with the consultant arriving at the hospital for the scheduled start time and this contributed to the delays.

Recommendation
We recommend that Lanarkshire NHS Board:
• take action to ensure that the consultant is able to attend the plastic surgery clinic at the scheduled start time.

Summary
Mr C complained about the physiotherapy treatment he received from the Board. We did not reach a decision on the issues involved in Mr C's case as we found that it was out of our jurisdiction under Section 7 of the Scottish Public Services Ombudsman Act 2002.
 

Summary
Ms C broke a bone in her foot and attended Accident and Emergency at hospital on 9 May 2010. A backslab plaster cast was fitted that day and she was asked to return on 10 May when a below the knee cast was applied. Replacement casts were fitted on 24 and 25 May but she had to return on 26 May because the cast had become loose and uncomfortable. The cast was removed by a nurse. Ms C alleged that she did this without proper consultation and that its removal was contrary to all the advice Ms C had been given previously. Ms C said that although she told the nurse this, she removed the cast regardless. Later, when Ms C complained about the circumstances, she says the nurse failed to provide a truthful account of what happened.

Our investigation showed that Ms C had an unusual fracture which needed to be held in a cast for up to eight weeks. After taking advice from one of our professional medical advisers, we found that the cast was removed too early and that there were deficiencies in the record-keeping. We also confirmed that Ms C's complaints about this were not properly investigated and that there was delay in responding to her. We did not uphold the complaint about the nurse’s account of events as, although there was some doubt about it, there was no evidence that it was untruthful.

Recommendations
We recommend that Highland NHS Board:
• apologise to Ms C for any pain and inconvenience she suffered as a consequence of her cast being removed on 26 May 2010;
• remind staff of the importance of listening to their patients and to be alert to the fact that their initial assumptions of a situation may not be correct;
• emphasise to staff the necessity and importance of maintaining a full and correct clinical record of patients' care and treatment; and
• apologise to Ms C for their failure to investigate her complaint properly.
 

Summary
Mr A complained that, as a result of inadequate administration systems in an Orthopaedics Department in an NHS hospital, he experienced a delay in receiving surgery. Mr A suffered from Dupuytren's contractures in both hands. He was referred to hospital by his GP for surgery to his right hand. At that time, the NHS hospital had an agreement with a private hospital to undertake treatments. Mr A was referred to the private hospital where it was established that in fact surgery should take place on his left hand first. He had that surgery in July 2010. At a follow up appointment, the consultant gave him post-operative clearance for surgery to his right hand. However, by that time the agreement between the NHS and the private hospital had come to an end. The private hospital contacted the NHS hospital and were told to re-refer Mr A back to the NHS for treatment to his right hand.

Mr A contacted his GP in November 2010 because he had not received an appointment from the NHS hospital. Mr A’s GP re-referred him to the NHS but the hospital said they had never received a re-referral from the consultant at the private hospital. Mr A eventually had surgery on his right hand in March 2011.

We found that Mr A was originally referred for surgery to one hand, his right hand. It was not established until his appointment at the private hospital that he would require surgery to both, so the Board could not have been aware of this. The private hospital was given instructions by the NHS hospital to make a re-referral. We found no evidence that this was done, as the consultant wrote a letter addressed to Mr A's GP but did not write to the NHS hospital directly. We could not, therefore, say that the delay in operating was due to inadequate administration systems within the Orthopaedics Department at the NHS hospital.
 

Summary
Mrs C entered into an agreement with the board for IVF treatment in accordance with the criteria in place at that time. She waited from December 2008 until 2010 to reach within the top places on the waiting list, however by that time the board’s IVF treatment policy had changed. Ms C said that this policy change (reducing the number of rounds of treatment) had disadvantaged her and should not have applied to her.

Our investigation found that although Mrs C was on the IVF programme pathway, she been told of the policy change before her actual IVF treatment had started. Furthermore we did not have the authority to intervene in professionally based medical judgements coupled with funding issues.

We noted that before Mrs C brought her complaint to us the board had apologised to her for a delay in formally informing her of the policy change.
 

Summary
Ms C was concerned at the level of care and treatment given to her late mother (Mrs A) while she was in hospital immediately prior to her death. When Mrs A was admitted to hospital she was suffering from shortness of breath, a respiratory infection and heart failure. She had ankle oedema. Regrettably, while she was in hospital she became increasingly unwell despite episodes of care in the Coronary Care Unit. She was also diagnosed as having clostridium difficile. Mrs A died just over a year later, and Ms C complained that the care and treatment her mother had received was totally inadequate in that she was not kept clean and comfortable, nor was she given proper nutrition. She alleged that some staff appeared unhelpful and uncaring.

Our investigation established that the board failed to ensure that Mrs A was clean and comfortable and they did not communicate appropriately with her, or with Ms C and her family (which meant that Ms C was unaware of a fee due to the Procurator Fiscal because of the board’s contact with that office). However, we were satisfied that Mrs A's nursing care was reasonable and that her food intake had been properly monitored and recorded.

Recommendation
We recommend that Greater Glasgow and Clyde NHS Board:
• reimburse Ms C the cost of any separate fee required by the Procurator Fiscal in connection with her complaint.
 

Summary
Mr C complained that Tayside NHS Board's out-of-hours GP service refused to visit him when he had kidney stones, a very painful condition. Our investigation revealed that weather conditions at that time were such that police and weather forecasters were advising motorists not to travel unless absolutely necessary, and that the board's four-by-four out-of-hours vehicles were having great difficulty. The board said that, after careful thought, they had decided not to attempt home visits unless absolutely essential. As Mr C's own medical practice was due to open about half an hour after the call (when the out-of-hours GP service would, therefore, be closing for the day), it was also considered that someone from the medical practice would be able to reach Mr C earlier than the out-of-hours service. Given all the circumstances, including Mr C's medical condition, we considered the board's decision had been appropriate.