North East Scotland

Overview

The complainant (Ms C) raised a number of concerns about the diagnosis and treatment given to her father (Mr A) on his admission to Aberdeen Royal Infirmary as an emergency by his General Practitioner.  In particular, she feels that had medical staff correctly diagnosed Mr A's condition, they could potentially have saved his life.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) medical staff failed to diagnose an aortic abdominal aneurysm or carry out an appropriate scan to allow them to discount this condition (no finding); and
• (b) Grampian NHS Board failed to investigate Ms C's complaint in a timely manner (upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Mr C) complained that he had received inadequate care and treatment during and after a tooth extraction at Dundee Dental Hospital (the Hospital) on 15 March 2004.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Mr C had a tooth removed at the Hospital which resulted in nerve damage, leaving him in constant and severe pain (not upheld); and
• (b) the tooth was removed in a rough manner by an unsupervised dental student (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board review their protocol, whether it is best practice that an x-ray should be taken to help identify any potential problems or infections, following the re-presenting of a post-extraction patient.

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

Overview

The complainant (Mrs C) raised concerns that her husband (Mr C), who suffered from a degenerative neurological disease (the disease), had been given inappropriate advice by a nurse working with patients with the disease.  She also complained that her complaint to Grampian NHS Board (the Board) had not been adequately investigated.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) inappropriate advice was given to Mr C about possible treatment available to him for the disease (no finding);
• (b) there was inadequate communication between members of the clinical team involved in Mr C's care (upheld); and
• (c) the Board did not appropriately investigate Mrs C's complaint (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) consider establishing a protocol for clinicians re-entering a patient's care after a period without contact;
• (ii) consider how communication can be improved in circumstances where a team of several clinicians is involved in a patient's care and when a general practice team are the only professionals involved for significant periods; and
• (iii) take steps to ensure that staff involved in the investigation or consideration of complaints are appropriately informed of the details of the complaint and that any decisions reached are properly reasoned and take into account all of the circumstances of the complaint.

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

Overview

The complainant (Ms C) raised a number of concerns regarding the care and treatment provided to her by her dentist (the Dentist).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Dentist failed to properly examine Ms C's teeth and overlooked the need for a filling (upheld);
• (b) the Dentist failed to make an accurate impression of Ms C's teeth (not upheld);
• (c) the Dentist failed to properly fit a Maryland Bridge (not upheld);
• (d) there was a delay of two months mid treatment leading to the decay of Ms C's teeth (not upheld);
• (e) a denture had been fitted improperly which induced Ms C's gag reflex and resulted in the loss of four adjacent teeth (not upheld);
• (f) appointment times were insufficient to allow for dental work of a reasonable standard (not upheld);
• (g) the Dentist improperly refitted a crown (not upheld); and
• (h) the Dentist failed to take into account the radiotherapy and chemotherapy treatment Ms C had had previously which had affected her teeth (not upheld).

Redress and recommendations

The Ombudsman recommends that the Dentist:

• (i) carries out a Clinical Audit of his own x-ray procedures to ensure that any problems with the current system can be identified and removed; and
• (ii) carries out a similar audit in respect of his record-keeping to ensure compliance with General Dental Council Standards.

The Dentist has accepted the recommendations and will act on them accordingly.

Overview

The complainant (Miss C), an advocacy worker, complained on behalf of a man (Mr A) regarding the treatment received by his late wife (Mrs A) at her GP Practice (the Practice).  Mr A complained about the Practice's failure to promptly diagnose Mrs A's secondary cancer and he considered that the overall treatment provided to her was inappropriate.  The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that the Practice:

• (a) failed to diagnose and properly treat Mrs A's illness (not upheld);
• (b) provided inaccurate information about waiting times for an ultrasound scan (upheld);
• (c) inaccurately completed an out-patient appointment form (not upheld);
• (d) delayed arranging blood tests and only did so upon Mrs A's request (no finding);
• (e) delayed admitting Mrs A to hospital (not upheld);
• (f) failed to respond to Mrs A and her family sympathetically and empathetically (not upheld);
• (g) caused distress by asking Mrs A why she needed a medical certificate (no finding); and
• (h) dealt inefficiently with a request for a repeat prescription (not upheld).

Redress and recommendation

The Ombudsman recommends that the Practice considers putting procedures in place to regularly check prevailing waiting times for relevant out-patient services/clinics and does not continue to rely on historic data which may no longer be accurate.

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

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment which he had received from Greater Glasgow and Clyde NHS Board (the Board) since 1996 for his erectile dysfunction.  Mr C was particularly concerned that he had been asking for a penile implant operation for a number of years and only in 2005 had the Board agreed to consider him for the procedure.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) it was unreasonable for the Board to have taken nine years to agree to Mr C's request to be considered for a penile implant operation (partially upheld);
• (b) the Board failed to correctly perform a Nesbit's operation, to correct the bend in Mr C's penis, which resulted in the bend moving from the base to half way up Mr C's penis (no finding);
• (c) Mr C did not have his follow-up appointment three months after his operation, as planned, and had to contact the hospital to ask for the appointment to be arranged (partially upheld);
• (d) the Board failed to provide Mr C with appropriate care and treatment for his erectile dysfunction (not upheld); and
• (e) the Board failed in their handling of Mr C's case from the point at which he was advised that he would be considered for the penile implant operation, ie July 2005, onwards, including that Mr C was later advised by the Board that the operation was not available within the NHS in Glasgow (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise to Mr C for the delay in providing his penile implant operation, for adding his name to the waiting list prematurely and not advising him of the conditions and restrictions which applied and for the delay in his follow-up appointment for the Nesbit's operation;
• (ii) take steps to ensure that, early, well documented psychiatric reports are produced in future cases of this type when requested or required; and
• (iii) take appropriate steps to ensure that, in future cases of this type, patients' names are not added to waiting lists prematurely and that they are advised of any conditions or restrictions which apply.

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

Overview

The complainants, Mr and Mrs C, complained about the care and treatment provided by two GPs (referred to in this report as GP 1 and GP 2) to their son, Mr A, who died on 12 September 2004, aged 15.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) GP 1 and GP 2 failed to investigate Mr A's symptoms and should have done so, even while waiting for referral elsewhere (upheld);
• (b) GP 1 and GP 2 failed to progress a diagnosis of Mr A's condition (upheld);
• (c) GP 1 failed to note the symptom of breathlessness in the records (no finding); and
• (d) GP 1 did not take Mr A's pulse (upheld).

Redress and Recommendations

The Ombudsman recommends that:

• (i) GP 1 and GP 2 apologise to Mr and Mrs C for the shortcomings identified in the report; and
• (ii) GP 1 raises complaints (a), (b) and (d) and GP 2 raises complaints (a) and (b) as issues at their annual appraisal and take them into account in their Continuing Professional Development.

GP1 and GP 2 have accepted the recommendations and will act on them accordingly.

Overview

The complainant Mr C raised a complaint on behalf of his mother (Mrs A) about Dundee City Council (the Council)'s handling of refurbishment work carried out to her Council home. In particular, he was aggrieved at Mrs A being expected to return to her home when it was uninhabitable, the delay in carrying out the redecoration work and the inadequate compensation for both the period of absence and damage to carpets. He also complained that the Council did not take the particular circumstances relating to Mrs A into account in relation to her decant arrangements and that they failed to respond adequately to all issues when he raised his complaint.
Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the extenuating circumstances relating to Mrs A should have resulted in consideration outwith the Council's Decant Policy and the Council failed to provide adequate compensation for the period of absence from the property (partially upheld);
• (b) the cost of replacing damaged carpets exceeded the level of compensation provided by the Council (not upheld);
• (c) the property was uninhabitable on completion of the works (upheld); and
• (d) the Council failed to respond adequately to issues raised in correspondence by Mr C (upheld).

Redress and recommendations

The Ombudsman recommends that the Council:

• (i) apologises to Mr C for their failure to provide a copy of the relevant Policy on request;
• (ii) gives consideration to the individual and particular circumstances relating to Mrs A and her decant situation;
• (iii) provides Mrs A with a decision in writing in relation to her individual and particular decant situation;
• (iv) apologises to Mr C for their failure to respond fully and appropriately to his letter of 21 December 2004; and
• (v) provides a written response to Mr C that either addresses the questions raised in his 21 December 2004 letter or explains why such a response will not be forthcoming.

Overview

The complainant (Mrs C) said that her GP Practice (the Practice) inappropriately removed her and her husband (Mr C) from their list.

Specific complaint and conclusion

The complaint which has been investigated is that Mr and Mrs C were inappropriately removed from the Practice's list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) ensure that the relevant regulations and guidance are adhered to before they ask for a patient to be removed from their list; and
• (ii) apologise to Mr and Mrs C for not adhering to the relevant regulations and guidance before asking for them to be removed from their list.

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

Overview

The complainant (Ms C) raised concerns that a GP Practice (the Practice) had failed to diagnose her brother (Mr A) with deep vein thrombosis (DVT) or subsequent pulmonary embolism.

Specific complaint and conclusion

The complaint which has been investigated is that the Practice failed to diagnose Mr A with DVT or subsequent pulmonary embolism (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) review the circumstances of this case and consider whether any lessons can be learned for the future management of young adults with chest symptoms;
• (ii) apologise to Mr A's family for the poor management of Mr A's pulmonary embolism; and
• (iii) review their clinical record-keeping practice.

The Practice has accepted the recommendations and will act on them accordingly.