Health

Summary
Miss C complained that her medical practice failed to take her seriously. She said she had requested referral to a Community Psychiatric Nurse (CPN) and that this was refused. She explained she had depression and thoughts of taking her own life and that she was struggling to cope with everyday tasks. Our investigation showed, however, that Miss C's request for referral to a CPN had not been refused. It was in fact sent the day after the GP consultation and had been replied to. Our medical adviser was very clear that Miss C's medical records show that the practice has taken Miss C's concerns seriously over a long period of time. Indeed, there is considerable evidence that they went to considerable lengths to try to contact Miss C on occasions when they had concerns about her well-being. Our adviser was also clear that the practice had at times appropriately sought the involvement of other services, such as psychiatric and social work services.

Summary
Mrs C complained about the service that she received when attending her local out-of-hours medical service. She felt that the information that she was given delayed her treatment. She had been unwell for a number of days and called NHS 24 for an appointment at the out-of-hours centre. Before the appointment was arranged, she took a turn for the worse and made her way to the centre. She was met by an unidentified individual (understood to be the doctor's driver). She was told that she could wait for the doctor but that this could take several hours. Alrternatively she could return home and call NHS 24. Mrs C returned home. When NHS 24 called with her appointment, she cancelled it as she was too unwell to return to the out-of-hours centre. Mrs C saw her GP the following morning and was immediately referred to hospital. We found that the service provided was poor as a result of the Board's policy for out-of-hours walk-in patients, which required a medical assessment to be made by non-medical staff. Information provided to patients in the absence of a doctor was also found to be poor.

Recommendations
We recommend that Highland NHS Board:
• review their policy with specific attention given to which members of staff should assess patients' medical records;
• apologise to Mrs C; and
• review the information provided to patients when the reception is unmanned.

Summary
Mr C was unhappy because when he tried to register with a new medical practice, they declined his application. He said he had not been given a true and satisfactory explanation of why this happened. The National Health Service (General Medical Service Contracts) (Scotland) Regulations 2004 say that 'a contractor which refuses an application ... shall, within 14 days of its decision, notify the applicant in writing of the refusal and the reasons for it'. We spoke with the practice and found that they had written to him within the required timescales to explain their reasons for refusing his application. In doing this, they fulfilled the requirements of the Regulations. The practice is entitled to refuse an application, and it was not for us to question their reasons for doing so.
 

Summary
Mr C raised concerns on behalf of his son, Mr A, about the care and treatment that Mr A received from the local community addiction team. He complained that Mr A had been given inconsistent information and contradictory advice about methadone prescriptions. He was also concerned about what he considered to be inconsistent attitudes from members of staff, which had caused Mr A distress and anxiety. In addition Mr C complained about the tone and content of the Board's funding application letter, written for the purpose of referring Mr A to a full time residential placement. We found that overall the treatment options were reasonable and consistent with good practice. However, we upheld Mr C's complaint about methadone prescriptions, in that the explanations provided for prescription changes were not always adequate. We also found that the Board's letter setting out the funding application provided an unjustified negative clinical opinion and failed to set out details of the criteria for funding.

Recommendations
We recommend that Borders NHS Board:
• apologise to Mr A and his family for their failure to adequately communicate the reasons for their prescribing decisions to him and for the distress this caused him and his family;
• apologise to Mr A and his family for the negative comments contained in the funding referral letter dated 20 October 2009; and
• review the procedure for funding applications to ensure staff and applicants are aware of a) the process and b) the criteria used in reaching decisions.

Summary
Mrs C had felt unwell for several days. One night she telephoned NHS 24 about her symptoms. They agreed to arrange an appointment for her with the GP out-of-hours service and told her to wait for a call telling her an appointment time. Mrs C, however, felt faint and short of breath before NHS 24 called back with this and went to the out-of-hours service with no appointment. She was told she could not be seen immediately, but could wait. Because she did not feel well enough to wait, she decided to go home. Mrs C was admitted to hospital the next day and was found to have internal bleeding. She later made a number of complaints about how NHS 24 handled her call. These included that they failed to note all her symptoms or to contact her with an appointment in good time. She was concerned that this had delayed her admission to hospital.

We obtained the recording of the call, which lasted 17 minutes. During the call, Mrs C spoke to a call handler, then a nurse practitioner. The recording showed that they asked clear and appropriate questions about Mrs C’s symptoms, that Mrs C confirmed them and that she agreed the proposed action. We noted that a particular symptom, which Mrs C felt NHS 24 had ignored, was not in fact mentioned during the call. We, therefore, did not uphold her complaint that they failed to take a full history, or properly note her symptoms. They also appropriately arranged an appointment for her with the out-of-hours service. Although Mrs C felt they had asked her to attend there when she was too unwell to go, the recording showed that she did not say this to them at the time and had agreed to attend an appointment that night. She also said that she was not offered transport or a home visit, or an alternative appointment the next morning, but having investigated this we found that NHS 24 were not required to do any of these as a result of the telephone call.

The outcome on this summary page is different to the outcome that appears on the PDF below and the report laid before Parliament due to a typographical error. The outcome code on the report laid before Parliament  was 'not upheld'; it should have read 'not upheld, no recommendations'.

Summary
Mrs A was an elderly resident of a nursing home. She suffered from severe
Alzheimer’s disease and a range of other health problems. She was admitted to
hospital for assessment as she was becoming increasingly agitated. At the time of admission, Mrs A had a wound on her left leg. She was in the hospital for just over two weeks, and was discharged back into the care of the nursing home, where she died about a month later.

Mrs A’s son, Mr C, complained to the board about the care and treatment of his mother in hospital. He said that staff did not communicate with him adequately and that record-keeping was poor. The board upheld his complaint. They acknowledged gaps in record-keeping, that the scales used to weigh Mrs A were inaccurate and that communication was not good. They said they had taken steps to resolve these problems. After complaining to the board, Mr C remained dissatisfied. In his complaint to the Ombudsman he said that he was particularly concerned that Mrs A suffered unacceptable weight loss and inadequate wound care. He also complained of inadequate communication with Mrs A’s family and poor record-keeping, in that the records contained conflicting information about where the wound on Mrs A’s leg actually was.

We took advice on Mr C’s complaint from one of our clinical advisers. Having seen Mrs A’s nursing records, our adviser said that the care and treatment was reasonable. There was evidence that the board carried out appropriate nursing care. This included attending to hygiene needs, action, although initially minimal, to improve nutrition, eating and drinking, wound care and referral to a dietician and a speech and language therapist. In addition, the adviser said it was not unexpected that Mrs A may have lost weight as her condition deteriorated. Dementia sufferers have to be reminded to eat and drink, and in some cases they refuse to eat due to a loss in cognitive ability. It is common for older, frail people to lose weight in hospital but there are, of course, national nutrition standards in place. Having said this, our adviser was critical of the initial nutritional assessment. This noted that Mrs A was at low risk of malnutrition, so
minimal action was taken at that time to improve her nutritional status. However, after considering all the evidence about this complaint, on balance we did not uphold it although we did make a recommendation on nutritional care. The adviser said that, based on the available evidence, the assessment, care and treatment of Mrs A's leg wound was reasonable.

We did, however, uphold Mr C’s complaints about communication and record-keeping.  Hospital staff have a duty to keep the next of kin well informed. The records show that communication with Mr C appeared to have been poor. There were only two references to communicating with him during Mrs A's stay in hospital and there was no record of how Mr C wanted to be told about any change in his mother’s condition. Given that Mrs A was incapable of making decisions Mr C should, for example, have been consulted about any treatment changes. On the complaint about record-keeping, we noted that on admission to the hospital, the initial nursing notes were completed by a student nurse. It appears that this was when the wound was noted to be on the right side rather than the left. The initial notes were countersigned by a charge nurse, but they continued to record the ulcer as being on the right side, and there was not enough cross-referencing to the wound chart. Our clinical adviser therefore said that aspects of the record-keeping were below an acceptable standard.

Recommendations
We recommended that the board:
• provide the Ombudsman with a copy of their nutritional care strategy as outlined in the NHS Quality Improvement Scotland Clinical Standards for Food, Fluid and
Nutritional Care in hospitals. They should also provide details of the action plan
appropriate for the hospital;
• ensure that sufficient communication tools are in place to ensure families and
carers of patients at the hospital are informed of care and treatment issues. The
board should also inform us of how, in practice, they will ensure families and carers will be better informed; and
• put in place a plan to monitor the quality of record-keeping at the hospital, to ensure records are kept in line with the principles outlined in the Nursing and Midwifery Council’s record keeping guidance for nurses and midwives, and inform us of this plan and its results.

Summary
Mr C went to his GP about problems he was having with his knee. His GP referred him to a knee clinic, from where Mr C was sent for physiotherapy sessions. Mr C felt that he was not properly examined or treated at the clinic and that treatment was delayed.  He felt that they should have referred him for a scan. He had had a scan on his knee (outside the UK) and was told then that the problem might require surgery. However, after seeing Mr C’s medical records and taking advice from one of the Ombudsman’s professional medical advisers we did not uphold his complaint. Our adviser took the view that diagnosis and treatment with physiotherapy was correct, although he pointed out that no clinical review was carried out after the physiotherapy, which would have been desirable. Despite this, he said that Mr C’s overall care and treatment was reasonable. We pointed out the issue of the clinical review to the health board, although we did not make any recommendations on the complaint.

Summary
Ms A injured her back in 2007 and went to the Accident and Emergency Department at Raigmore Hospital. They diagnosed a soft tissue injury in her lower back. They told her GP that she was able to move about and they had allowed her home with some advice about how to deal with the injury. In 2010, Ms A had an x-ray and a scan that showed she had three fractures in her back. This caused her concern that she might have been mis-diagnosed in 2007. An MSP complained on Ms A’s behalf that the hospital failed to carry out a comprehensive and appropriate assessment of her injury.

After taking and accepting advice from one of the Ombudsman’s professional medical advisers we found that that the hospital’s assessment of Ms A had in fact been entirely reasonable, and of a good standard. Our adviser said that medical records showed that the doctor made a good assessment of the possible presence of neurological damage. The symptoms recorded at the time would not normally support a diagnosis of a fracture, but would support a muscular or arthritic cause for the pain. He said that there was a possibility that a fracture first occurred then but, given the assessment that was made, it was unlikely that it had. As the hospital had diagnosed a muscular injury, it was reasonable and in accordance with relevant guidelines for them not to have
x-rayed Ms A’s spine. He pointed out that the guidelines generally advise against
x-rays in such circumstances. The board had also pointed out that x-rays of the lumbar region involve large doses of radiation.

Our adviser also said that the fractures seen on the x-ray in 2010 could have happened before or after Ms A attended the hospital in 2007, and that the x-ray could not be used to establish when they occurred. He had reviewed the films with an experienced consultant radiologist who agreed with this conclusion. Ms A also now had other underlying medical conditions that may have had a bearing on the discovery of the fractures in 2010.

We recognised that Ms A had experienced considerable health difficulties over the last few years, but found that the care and treatment she received in 2007 was entirely reasonable in the circumstances at the time.

Summary
Mr and Mrs C complained that the board unreasonably delayed in performing a sperm retrieval operation to find out if in vitro fertilisation was likely to be a successful route for them to have a child. Mr C said that in August 2010 he was told that he would receive an appointment for this soon. In October of that year, however, he discovered that his consultant had moved to another hospital that did not have the specialist equipment or insurance for transporting the sample for testing. When investigating the complaint, we asked the board for the medical records and their comments and they told us that they had already acted to resolve the complaint. There has been a meeting between the departments concerned and the board have ordered equipment to enable transportation of sperm samples to testing facilities. They are also considering how they can reduce waiting times for this procedure for other patients. Mr C has a revised date for his operation and can come back to us if this does not happen when expected.

Summary
Ms C made a GP appointment for her daughter, who was unwell. When, however, her daughter became more unwell Ms C phoned to request a GP home visit on an earlier date. She did not specifically cancel the booked appointment. As their records showed that she had not kept an appointment on an earlier occasion, the practice wrote to her saying that if she continued to miss appointments, they would remove her from their register. She complained that it was unreasonable for them to have done this, and said that she was also unhappy with the practice's attitude when she phoned them about the letter.  We explained that although we could look at the first part of her complaint, we would be unable to prove what happened during the phone call.  Although she was disappointed that we would not be looking at this, she withdrew her complaint.