North East Scotland

Overview

The complainants (Mr B and Mrs C) raised a number of concerns about the care and treatment of their late mother (Mrs A) during her final admission through Accident and Emergency at Inverclyde Royal Infirmary in February 2006.  They were also concerned about the manner in which their complaints had been dealt with by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) failed to provide appropriate care to Mrs A on 14 and 15 February 2006 (upheld); and
• (b) failed to respond promptly and appropriately to Mr B and Mrs C's complaints (upheld).

Redress and recommendations

The Ombudsman recommends that the Board apologise in writing to Mr B and Mrs C for the failure to provide appropriate care to Mrs A and her family on the 14 and 15 February 2006 and the failure to respond to their complaints in a timely and effective manner.

The Ombudsman recognises that a number of other changes introduced by the Board and NHS Scotland avoid the need for further recommendation, although she notes with concern the time taken to introduce some of the changes and the negative impact several structural reorganisations had on this complaint.

The Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Ms C), who is a solicitor, complained that the University of Glasgow (the University) failed to support or communicate with her client (Ms A) adequately during teacher training placements in secondary schools, did not challenge secondary schools when placements were terminated or find alternative placements quickly enough and, in relation to one specific school placement (Placement 4), her tutor (Academic 1) did not inform Ms A that an informal visit would result in a formal report.  In addition, Ms C claimed that the University should have suggested practical remedies to placement problems that had been identified between the part of the University in which Ms A was studying (the Faculty) and secondary schools.

Specific complaints and conclusions

The complaints which have been investigated are:

• (a) the alleged failure of the Faculty to support Ms A during her placements (not upheld);
• (b) the alleged failure of the Faculty to challenge schools' behaviour and decisions to terminate Ms A's placements (not upheld);
• (c) the Faculty's actions and communication with Ms A during and after placements were terminated (not upheld);
• (d) the alleged failure of the Faculty to find alternative placements in a timeous manner (not upheld);
• (e) Academic 1's alleged inappropriate recording of a visit to Placement 4 (not upheld); and
• (f) the alleged failure of the University to suggest practical remedies to the problems they appeared to accept there were between the Faculty and the schools upon which the Faculty relied for student experience (not upheld).

Redress and recommendations

The Ombudsman recommends that the University:

• (i) reflect on this complaint and consider how best to deal with termination of placements. Although it may be a rare occurrence, it is clear that termination of placements is a distressing time for schools, students and Faculty staff; and
• (ii) reflect on this complaint and consider how best to deal with the need to arrange an alternative placement at short notice.

The University have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mrs C) was a disabled tenant of Dundee City Council (the Council).  Following a number of falls and the alteration of her front steps, Mrs C had difficulties entering and leaving her house.  She approached the Council to ask that her entrance be suitably modified to assist her access.

Specific complaint and conclusion

The complaint which has been investigated is that the Council did not respond reasonably to Mrs C’s request for suitable adaptations to the front entrance of her house to assist her access (not upheld).

Redress and recommendation

The Ombudsman recommends that the Council give full consideration to the reinstatement of the original layout of Mrs C’s steps and any other measures that may assist Mrs C in accessing her property.

The Council have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mr C)'s GP referred him to a Consultant Urological Surgeon at the Southern General Hospital (the Hospital).  After tests, however, Mr C was referred on to a clinic for the treatment of sexual and reproductive health problems (the Clinic).  Mr C's complaints concern his treatment at the Hospital and the confusion surrounding his referral to the Clinic.

Specific complaints and conclusions

The complaints which have been investigated are that Mr C's treatment:

• (a) at the Hospital was unreasonable (partially upheld); and
• (b) at the Clinic was unreasonable (upheld).

Redress and recommendations

The Ombudsman recommends that Greater Glasgow and Clyde NHS Board (the Board):

• (i) apologise to Mr C for the shortcomings identified in this report;
• (ii) offer Mr C an appointment to have a full assessment with the new consultant at the Hospital;
• (iii) audit the Clinic's system of dealing with referrals to ensure it is now working properly and advise her of the outcome; and
• (iv) offer Mr C an appointment to begin therapy with a named counsellor and a further follow-up appointment with the Clinic Consultant.

The Board have accepted the recommendations and will act on them accordingly.

Overview

The complainant (Mrs C) raised a number of concerns relating to her husband (Mr C)'s admission to Ninewells Hospital, Dundee (the Hospital), his treatment during his stay and the way in which her complaint was handled by Tayside NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C's belongings were never recorded on his admission to the Hospital (upheld);
• (a) no response was made to Mr C's cardiac monitor sounding an alarm at various points during his stay in the ward and it was entirely ignored during the night (no finding);
• (b) Mr C was given contradictory information about how he could get his cardiac monitor reset (no finding);
• (c) Mr C's pressing of the call button was not answered for one hour (no finding);
• (d) staff on duty in the ward were not appropriately qualified (not upheld); and
• (e) there were inadequacies in the handling of Mrs C's complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) remind staff of the need to comply with the 'Patients' Funds and Property Procedure' when admitting patients to the ward;
• (ii) ensure that all staff, especially bank nurses, are reminded of the importance of accurate record-keeping; and
• (iii) take action to remind appropriate staff of the need to comply with the relevant procedures, in relation to investigating and responding to complaints within the required timescales.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Miss C) raised a number of concerns about the care and treatment received by her mother (Mrs A) in Stobhill Hospital (the Hospital) prior to her death on 11 July 2007.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) despite having suffered Transient Ischaemic Attacks (TIA), Mrs A was discharged without having had a scan to determine the exact cause of her symptoms; in particular, she should not have been discharged after her second TIA (not upheld);
(b) Mrs A was prescribed aspirin, which Miss C said was unsafe (not upheld); and
(c) there was a delay in the Greater Glasgow and Clyde NHS Board (the Board) informing the family that Mrs A had contracted MRSA (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) stress to nursing staff the importance of comprehensive note taking;
(ii) formally apologise to Miss C for the delay in advising that Mrs A had contracted MRSA; and
(iii) emphasise to staff the importance of good communication in keeping family members advised of a patient's changing condition and of recording such conversations in the appropriate clinical notes.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mr C) was referred to an orthopaedic consultant (Consultant 1) at Ninewells Hospital for treatment to his knee and foot.  Before a date for surgery could be arranged, personal circumstances meant that Consultant 1 had to take an extended period of absence from work, at short notice.  Mr C complained that his surgery was unacceptably delayed, as Tayside NHS Board (the Board) did not make adequate arrangements to progress the treatment of Consultant 1’s patients during his absence.

Specific complaint and conclusion
The complaint which has been investigated is that Mr C was subjected to an unacceptably long wait for operations on his foot and knee (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board considers Mr C’s overall treatment plan, and the time taken up by administration, when reviewing their procedures in line with the Scottish Government’s revised waiting time targets.

The Board have accepted the recommendation and will act on it accordingly.

Overview
The complainant (Ms C) raised a number of complaints against Tayside NHS Board (the Board) about the care and treatment of her late brother (Mr A) in Ninewells Hospital (the Hospital).

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Mr A was administered laxatives inappropriately and at the incorrect dose (not upheld);
(b) Mr A developed gastroenteritis which was not treated appropriately (not upheld);
(c) the Board failed to properly monitor Mr A's fluid levels and administer his intravenous drip on 25 and 26 April 2006 (upheld);
(d) the result of the post-mortem examination of Mr A's heart is at odds with his previous cardiac examinations at the Hospital (not upheld);
(e) the Board used insensitive language to describe the events leading to Mr A's death (not upheld);
(f) Mr A was inappropriately taken for an x-ray shortly before his death (not upheld); and
(g) nursing staff failed to appropriately monitor Mr A (not upheld).

Redress and recommendation
The Ombudsman recommends that the Board apologise to Ms C for their failure to properly monitor Mr A's fluid levels on 25 April 2006 and to properly administer his intravenous drip on 26 April 2006.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant (Mrs C) claimed that staff within Tayside NHS Board (the Board), in particular, a Diabetic Specialist Nurse (Nurse 1), failed to provide adequate advice and support in relation to her husband (Mr C)'s condition.

Specific complaint and conclusion
The complaint which has been investigated is that there was a lack of information, and misleading information, about Type 1 diabetes provided to Mr and Mrs C at the time of, and following, Mr C's diagnosis (partially upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) apologise in writing to Mr and Mrs C for the deficiencies in record-keeping and the lack of clarity of communication; and
(ii) consider introducing a protocol for post-discharge care of patients with diabetes to reduce the potential for confusion as illustrated by this complaint, in particular, in instances where more than one Board is involved in patient care.

The Board have accepted the recommendations and will act on them accordingly.

Overview
The complainant, Ms C, raised a number of concerns about the Head Teacher (Head Teacher 1) of the primary school (the School) her daughter (Ms A) attended up to 20 December 2005.  These regarded the manner in which Head Teacher 1 dealt with her complaint and her alleged failure in the duty of care the School had demonstrated towards Ms A.  Ms C also raised concerns about Glasgow City Council, (the Council) in that they had not adequately followed their complaints procedures after Ms C and her partner (Mr B) complained to them about their dissatisfaction with the outcome and manner the School dealt with their complaint.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) Head Teacher 1, when Ms A was a pupil at the School, had not dealt adequately with Ms C's complaint that the School had failed in their duty of care towards her daughter (not upheld); and
(b) the Council failed to follow satisfactorily their complaints procedure after Ms C complained to them about the way her complaint was handled by the School (not upheld).

Redress and recommendations
The Ombudsman recommends that the Council:
(i) take action to ensure that, during the course of a formal complaints investigation, statements made as part of the investigation are dated and include, wherever possible, dates of the events recounted within the statements;
(ii) that written records which form part of an investigation are retained for an agreed period of time; and
(iii) give consideration to the inclusion of this within the procedures outlined in the relevant section of the School's Pastoral Care Policy.

The Council have accepted the recommendations and will act on them accordingly.