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.
Summary
Mr C and his family had been registered with a medical practice for several years. However, when he called for an appointment he was told that he had been removed from the list and would have to re-register. He complained to the practice about this and was told that he had been removed because correspondence sent to him had been returned unopened. We found that the practice should have checked to see if he was still at the address, but that a clerical error meant that he had instead been wrongly noted as 'no trace' on their list. We also found that they did not properly explore the reasons for this when Mr C complained and that these only became known after we investigated his concerns. Finally, following discussions with the NHS, we were able to tell Mr C that although he would have to re-register, he would be able to have a medical appointment in advance of that process. We did not uphold a complaint that the practice failed to warn him that he would be removed.
Recommendation
We recommend that the medical practice apologise to Mr C for their error.
Summary
Mr C complained about the actions of a nurse at his medical practice - for example, that she did not keep all sizes of syringe in her own room and had to keep him waiting while she collected the correct syringe from another room. He also felt that the practice's reply to his complaint did not address all his questions. Our investigation found that the nurse's actions had been reasonable. For example, she would not be expected to stock everything possible in her room and Mr C only had to wait for a few minutes. We also found that the practice had reasonably addressed Mr C's questions in their response. However, in the interests of trying to provide a practical resolution to the complaint, we did ask them for fuller information and passed that on to Mr C.
Summary
Mr C was admitted to the Western General Hospital for an operation to remove a testicular cyst and to undergo a vasectomy. Five months later, he was referred to another consultant and was told that during the operation the original planned surgery had not taken place. They said that the cyst had not been removed but instead he had had a hydrocele repair and vasectomy. (A hydrocele is an abnormal collection of fluid in a sac-like space such as the testicles.) Mr C complained that he was told nothing about the hydrocele problem and that he had to have a further operation to remove the cyst. Our investigation concluded that although Mr C's treatment was appropriate, the reasons for providing the alternative treatment were not adequately documented. Because of this we upheld his complaint about treatment. We also found that the board's handling of Mr C's complaint was inadequate. We did not uphold his complaint that the hydrocele procedure was performed without informed consent as the consent given included authorisation of any justified procedure found to be necessary during surgery. Our medical adviser confirmed that the procedure was justified.
Recommendations
We recommend that Lothian NHS Board:
• share the decision letter with the consultant and remind him of his responsibilities to maintain a standard of record-keeping which is in line with General Medical Council guidance;
• remind staff about the need to adhere to the timescales as set out in the NHS Complaints Procedure and to provide relevant updates; and
• apologise to Mr C for the failings identified in our decision letter.
Summary
Mrs C complained about the care provided to her by nursing staff during her stay at Raigmore Hospital. In particular she was concerned about the attitude of nursing staff and and about delays in attending to her needs. We did not find sufficient evidence to support her claims that the attitude of nursing staff was inappropriate and that they failed to attend to her needs within a reasonable time period. We noted, however, that although there was insufficient evidence to show what had happened the board had in any case apologised for any delays that Mrs C had experienced. We said that we would have considered this a reasonable outcome in the circumstances.