Health

Summary
Ms C raised concerns about the treatment she received at Dr Gray's Hospital, Elgin. She said that there was a delay in diagnosing that she had a pancreatic cyst and that she was only informed of the true diagnosis when she was transferred to Aberdeen Royal Infirmary. Our investigation concluded that it was reasonable for staff to initially believe that Ms C was suffering from an ovarian cyst and the true diagnosis was only discovered once the pathology results had been reported on. By this time, Ms C had already been transferred to Aberdeen Royal Infirmary.
 

Summary
Mrs C complained that her daughter (Mrs A) received inadequate care and treatment from Surgical Services in Stirling Royal Infirmary. Mrs C said it took the hospital six weeks to diagnose Mrs A's medical condition and that this delay could have been avoided had medical staff seen her earlier. Our investigation concluded that from Mrs A's several admissions through to her in-patient care and subsequent discharges she received appropriate care and treatment from the hospital. Although the results of a Malnutrition Universal Screening Tool (MUST) test could have been recorded in more detail, our medical adviser said that Mrs A was eventually diagnosed with a rare and complex medical condition and the investigations that were carried out were appropriate. We also did not uphold the complaint that the Board failed to respond reasonably to Mrs C's complaints about this. We noted that before she brought this complaint to us the Board had already apologised for some of the issues Mrs C had raised.

Recommendation
We recommend that Forth Valley NHS Board ensure that a written record of every MUST test is completed and filed to comply with NHS record-keeping guidelines.

Summary
Ms C took her son to see her GP. The GP diagnosed tonsillitis and prescribed penicillin. When Ms C read the patient information leaflet that came with the penicillin, it said that the dosage for a child aged five or under was less than that prescribed by the doctor. The following morning at 08:00, Ms C telephoned the surgery to explain her concerns about the dosage. She said she was told that her GP would call her back at midday. Ms C said that at 17:00, having had no response, she telephoned again. Ms C said her GP eventually called her back at 18:00, apologised for the delay and advised her to amend the dosage. It was clear from the complaint correspondence that the GP accepted that he made an error in this case, and that he had reflected on and apologised for his mistake. In order to try to provide Ms C with some reassurance on the effects of the over prescription on her son, the GP also discussed the prescribing error with a consultant paediatrician. In investigating the complaint, we took advice from one of our medical advisers about the mistake. They said that although the dose was higher than recommended it was unlikely that the prescribing error would result in any lasting harm to Ms C's son. They did, however, suggest that we made recommendations about this.

Recommendations
We recommend that the medical practice conduct a Significant Event Audit around the prescribing error.
We recommend that the GP discusses the complaint and management of paediatric problems at his next appraisal.

Summary
Mrs C raised concerns about the treatment she received at a hospital before and after the stillbirth of her daughter. These included an incorrect decision to reduce Mrs C's medication; a lack of support from midwifery staff; and that the board's response to her complaint contained factual inaccuracies. Mrs C also told us that she believed the reduction in medication had caused the stillbirth. When we investigated and took advice from our medical adviser we found that in general Mrs C's pregnancy was managed appropriately, but that there were problems after a doctor misinterpreted a blood test result. We upheld all of Mrs C's complaints, although our adviser pointed out that research did not support the view that a reduction in medication would cause stillbirth. We noted that the board had already accepted that there were failings and had taken action in an effort to prevent any repetition of Mrs C's experience. As a result of our investigation, however, we considered it appropriate to make further recommendations.

Recommendations
We recommend that Fife NHS Board:
• consider, when confirming blood results that have been passed on by telephone, providing additional confirmation such as an internal email or fax; and
• remind staff of the need to provide patients with information about support services and to record what has been provided.

Summary
Mrs C complained about the care and treatment provided to her late father, Mr A. Mr A was diagnosed with myelodysplasia and acute myeloid leukaemia. He was admitted to hospital and treated with chemotherapy. He also agreed to take part in the clinical trial of a new drug and signed the relevant consent form. After he started treatment with the trial drug mylotarg, Mr A developed gastrointestinal bleeding and fever. An ultrasound scan showed that he was suffering from veno-occlusive disease (an inflammatory condition of blood vessels in the liver). He deteriorated further, suffered multiple-organ failure and died. A post mortem established that the cause of death was acute myeloid leukaemia and its complications. Mrs C complained that Mr A had not been properly warned about the risk of developing veno-occlusive disease, that pain relief was not effective and that the board failed to communicate adequately. Our investigation found that the board did not specifically discuss with Mr A the risk of developing venal-occlusive disease from the drug trial. However, the risk was small and the information sheet provided to him before he took part in the trial referred to the risk, so we did not uphold this complaint. We did, however, uphold Mrs C's complaint about failures in the end of life care provided to Mr A in that the board failed to manage his pain in a reasonable way (although we recognised the difficulties they faced in doing so) or to properly communicate with Mrs C and her family.

Recommendations
We recommend that Fife NHS Board:
• ensure staff record discussion with patients when they are obtaining consent for treatment;
• review its procedures in line with 'Living and Dying Well' with particular reference to pain relief and communication;
• ensure that staff document in patients' medical records their communication with relatives and carers, in line with the guidelines; and
• apologise to Mrs C for the failures identified.

Summary
Mrs C complained that the board failed to inform her of a meeting which took place to discuss her and her children. The evidence showed that the meeting was arranged to discuss suspected child protection matters. It also involved people outside the children's core care team. The Scottish Government's guidance on child protection makes it clear that all service providers have a responsibility to act to make sure that a child whose safety or welfare may be at risk is protected from harm. If a child is considered to be at risk of harm, relevant information must always be shared which may prevent problems from escalating. However, the guidance also says that when involved in child protection work, authorities should ensure that, wherever possible, parents are given full information about the nature of the concerns, and the child and family are consulted on and given explanations for any actions/decisions taken. The board's own child protection guidelines are clear that if children are suspected to be at risk, these concerns should be raised without delay. When such concerns are formally raised, the parents should be informed. Only in situations where there are clear and present reasons that make informing the parents inadvisable or unsafe can it be justified not to do so. We found that the board should have told Mrs C about the meeting, and about the support services that exist to help families in these situations.

Summary
Ms C complained that a nursing assistant did not adhere to proper hygiene controls when Ms C's sister was being barrier nursed, in that she entered the room without protective clothing. Ms C also complained that no-one told the family that barrier nursing was no longer required. We upheld the complaint about hygiene control as the board accepted that the nursing assistant failed to use proper protective clothing. They explained that this was because she had understood that she was urgently needed in the room. As the board had already discussed this incident with the nursing assistant, however, we made no recommendations on this. We also upheld Ms C's complaint that staff failed to tell the family when barrier nursing was no longer required. We did not uphold complaints that the nursing assistant failed to use a side plate and gloves when serving toast and about the way the charge nurse handled the complaint.

Recommendations
We recommend that Ayrshire and Arran NHS Board:
• remind the staff involved in this complaint of the need to provide information about, and to involve relatives in, decision-making about barrier nursing; and
• remind the staff involved in this complaint about the need to keep good records both about the nursing care provided (in this case barrier nursing) and details of important communication with relatives.

Summary
Mrs C complained about the care and treatment provided to her late mother, Mrs A, by her medical practice. While under the care of the practice Mrs A received treatment for leg ulcers and symptoms relating to her underlying vascular condition. Mrs C complained that over a two month period the practice failed to refer Mrs A to hospital within a reasonable time, which meant that her vascular condition was not investigated until she was admitted to hospital. Mrs C also complained that after Mrs A was discharged from hospital the practice failed to refer her back there when the condition of her left heel deteriorated and she experienced continued leg pain. Mrs C also said that the practice failed to refer Mrs A to social work for home care assistance despite the fact that she lived alone and was incapable of self caring. Our investigation found that the delay in referring Mrs A to hospital was not reasonable, and we upheld this complaint as well as the complaint about referral to social work. However, we found that the standard of care Mrs A received from the practice after she was discharged from hospital was acceptable, as during that time she was also seen as a hospital out-patient.

Recommendations
We recommend that the medical practice:
• review the management of patients with peripheral vascular disease, seeking advice from hospital colleagues where appropriate;
• review their procedures for liaison with district nurse staff, particularly where concerns are raised by them;
• review their procedures for referral to social work;
• conduct a significant event audit into the clinical management of Mrs A and ensure lessons are learned; and
• apologise to Mrs C for the failures identified.

Summary
Ms C, who is a telephonist, suffered an acoustic shock incident at work for which she needed medical treatment. She was unhappy with the care and treatment she received from the Board and the way they handled her complaint. During a consultation with a specialist, Ms C described the pain in her ear, head and neck. She also described how noise and/or examination made her symptoms worse. The specialist told Ms C's GP that Ms C had suffered an acoustic shock and that the description of the pain sounded like muscle tension. He also said that Ms C had tinnitus and that this was difficult to tie in with acoustic shock, although it was also difficult to say what else might have caused the problem. Ms C complained that this diagnosis was not reasonable and that the Board's subsequent investigation of her complaint was inadequate. After taking advice from one of the Ombudsman's professional medical advisers, we found that the specialist's conclusions were reasonable in the circumstances. We also found that the Board's investigation of the matter was appropriate. Ms C had said she felt that certain clinical aspects of the complaint should have been subject to independent review and that this was missing from the Board's investigation. We explained to Ms C that the second stage of the NHS Complaints Procedure (investigation by our office) provides the independent and impartial examination of the clinical information that she wanted.

Recommendations
We recommended that Tayside NHS Board ensures the doctor concerned has established a tinnitus protocol for his patients.

Summary
Mr C was admitted to the Royal Edinburgh Hospital following a brain injury. He raised a number of complaints about his treatment while staying there. In particular, he raised concerns about the approaches and techniques used by staff members when dealing with incidents on his ward. He felt that he was not sufficiently involved in the planning of his treatment and did not receive adequate drug rehabilitation support. Mr C raised a number of verbal complaints with staff during his stay but he did not feel that these were listened to or followed up. The Board explained that raising frequent verbal complaints was a feature of Mr C's brain injury. They demonstrated that they had implemented a plan to set aside specific times each day for him to raise concerns with staff. However, we found no evidence that Mr C had been told about the arrangements that were in place for him. It was clear that the board recognised the need for Mr C to receive drug rehabilitation support, but based on our adviser's opinion we did not feel that the support offered to him best suited his particular requirements. We also found that the Board could have done more to involve Mr C in the planning of his care, or to record that he had chosen not to be involved. We were satisfied with the Board's approach to incident management, room searches and patient confidentiality.

Recommendations
We recommend that Lothian NHS Board - Royal Edinburgh and Associated Services Division:
• introduce a system of recording verbal complaints raised by patients and the action
taken as a result;
• review their approach to Mr C’s drug rehabilitation with the adviser's comments in mind
to ensure that patients in the brain injuries unit are given the most effective support for
their personal circumstances;
• take steps to ensure all patients' involvement in the planning of their care;
• remind staff that if patients decline to be involved in the planning of their care, this is
recorded in the records and a review date set; and
• consider taking steps to ensure that the uniform and name badge policy is adhered to by bank staff as well as permanent staff.