North East Scotland

Overview
The complainant (Mr C) raised concerns about the failure by the medical practice (the Practice) to diagnose that he had Crohn's disease. He said that the Practice failed to carry out appropriate investigations, despite his regular visits complaining about stomach problems.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) over a five-year period from April 2005, the Practice unreasonably failed to diagnose that Mr C had Crohn's disease (upheld); and
• (b) the Practice failed to respond properly to Mr C's letter of complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i) issue a written apology to Mr C for the failure to carry out further investigations and/or make a referral when he attended with ongoing bowel symptoms in March and April 2009;
• (ii) apologise to Mr C for the failure to take steps to try to obtain his full medical records in order that they could respond to his complaint in full; and
• (iii) make relevant staff aware of our finding on this matter.

Overview
The complainant (Mrs C) complained about the care, treatment and diagnosis her daughter (Ms A) received at an out-of-hours service at Peterhead Hospital (Hospital 1) in May 2011. Mrs C also complained about the responses she received from NHS Grampian (the Board) in relation to her complaints.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) the out-of-hours doctor (the Doctor) incorrectly explained that Ms A had not presented with photophobia despite her complaining of this to a nurse, and shielding her eyes with her hood (not upheld);
• (b) the Doctor inappropriately failed to mention in his letter of response to Mrs C's complaint that Ms A had presented with a headache (upheld);
• (c) the Doctor unreasonably reached an incorrect diagnosis (not upheld); and
• (d) the Chief Executive issued a dismissive response to Mrs C's complaint which reflected the lack of investigation into her concerns (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman that they have reviewed their complaints handling procedure in relation to complaints about its out-of-hours service, to ensure a proactive approach is taken; and
• (ii) issue a full apology to Mrs C for the failures identified within this report.

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

Overview
The complainant (Ms C) raised a number of concerns on behalf of Mr A's family that Mr A was not admitted to an in-patient facility for mental health and that there were failures in communication between the medical and mental health teams treating Mr A.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) Greater Glasgow and Clyde NHS Board (the Board) failed unreasonably to admit Mr A to hospital (not upheld); and
• (b) there was no reasonable communication between the teams to whom Mr A was or should have been referred, including the Royal Alexandra Hospital, the intensive home treatment team, the community mental health team and the alcohol problems clinic (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) review the coordination of the relevant services to ensure the failures identified in this report are addressed; and
• (ii) apologise to the family.

Overview
The complainant (Mrs C) raised a number of concerns regarding the nursing care provided to her late mother (Mrs A) during an admission to the Royal Alexandra Hospital in Paisley (the Hospital) from 12 October 2010 until her death on 16 October 2010.

Specific complaint and conclusion
The complaint which has been investigated is that there were several unacceptable shortcomings in care during Mrs A's admission to the Hospital in October 2010 (upheld).

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

• (i) provide him with an update regarding their implementation of the introduction of the Liverpool Care Pathway;
• (ii) consider the Adviser's comments on the several failings in Mrs A's end of life nursing care and draw up and implement an action plan to address these failings;
• (iii) conduct a significant events review of this case; and
• (iv) apologise to Mrs C for the failures identified in this report.

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

Overview
The complainant (Mrs C) underwent reconstructive breast surgery following treatment for breast cancer. She complained to Grampian NHS Board (the Board) that the surgeon and the surgical procedure were both changed at short notice. She had had a different procedure explained to her by a different surgeon at a consultation prior to the surgery. Mrs C said she had not had sufficient time to consider the changes prior to undergoing the surgery. She also complained that the outcome of the surgery was unacceptable.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) it was unreasonable to change the surgeon and the surgical procedure Mrs C was to undergo at short notice, without giving her sufficient time to consider the changes or make a fully informed decision (upheld); and
• (b) the outcome of Mrs C's surgery was unacceptable (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) ensure this case is discussed with the Registrar at his next appraisal;
• (ii) consider the issue of consent, and provide evidence to the Ombudsman that the General Medical Council's guidelines are being followed in relation to obtaining informed consent from patients for surgical procedures;
• (iii) take steps to ensure that a similar situation does not occur in the Plastic Surgery Department when cases are re-assigned to cover consultant leave;
• (iv) bring this report to the attention of all staff involved in Mrs C's care, to prevent a recurrence of similar issues; and
• (v) provide a full apology to Mrs C for the failures identified within this report.

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

Overview
The complainant (Mr C) complained about the care his late father (Mr A) received at the Southern General Hospital (the Hospital) in February 2011. Mr C was concerned that the staff involved in Mr A's care had failed to consider and assess his cognitive function, or communicate with Mr C in relation to the plans for discharge, resulting in Mr A being inappropriately discharged. Mr A fell and was injured two days after being discharged home, and was re-admitted to the Hospital.

Specific complaints and conclusions
The complaints which have been investigated are that Greater Glasgow and Clyde NHS Board (the Board):

• (a) did not provide reasonable care and treatment to Mr A during his admission to the Hospital between 10 and 24 February 2011 (upheld);
• (b) did not reasonably consider whether Mr A was fit for discharge on 24 February 2011 (upheld);
• (c) did not dress Mr A in the outdoor clothes that had been provided for his journey home on 24 February 2011 (upheld); and
• (d) did not provide a reasonable response to Mr C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence to the Ombudsman of the implementation of a policy for the assessment of cognitive function of elderly patients, which should include documenting whether or not clinical staff find a patient has capacity to participate in decision making;
• (ii) provide the Ombudsman with a copy of the new discharge policy to demonstrate it states that relatives and carers must be engaged with during the planning for discharge process;
• (iii) ensure that their discharge policy and checklist contains a reminder that patients are dressed appropriately upon discharge;
• (iv) provide a full apology to Mr C for all of the failings identified within this report; and
• (v) review and clarify their policy in relation to the review of hip fracture patients by the DOME.

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

Overview
The complainants (Mr and Mrs C) raised a number of concerns about the treatment that Mrs C's mother (Mrs A) received when staying in the Southern General Hospital (the Hospital) between 6 October 2009 and 4 February 2010. They complained that staff of Greater Glasgow and Clyde NHS Board (the Board) failed to monitor Mrs A's condition properly or provide her with effective treatment. Mr and Mrs C raised further concerns about staff communication, record-keeping, a lack of patient dignity and a failure to provide stimulation for patients with dementia.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) there was a failure to provide the appropriate care and treatment to Mrs A between 6 October 2009 and 4 February 2010 (upheld);
• (b) the nursing notes contained inaccurate and inconsistent information along with unprofessional language (upheld);
• (c) there was poor communication between ward team members and the family (upheld); and
• (d) the handling of the complaint was poor (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs A's family for the issues highlighted in this report; and
• (ii) provide the Ombudsman with a report on the improvements made within the older people's unit as a result of their action plan, including details of how the National Dementia Strategy is being implemented by the Hospital.

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

Overview
The complainant (Mrs C) raised concerns that there was a delay by clinicians at Royal Aberdeen Children's Hospital (the Hospital) in diagnosing that her daughter, (Miss A), who had pneumococcal meningitis in August 2007, was profoundly deaf. Miss A had been reviewed at the Child Hearing Assessment Clinic on a regular basis but it took until January 2010 for the diagnosis to be made.

Specific complaint and conclusion
The complaint which has been investigated is that there was an unreasonable delay in the diagnosis of Miss A's hearing loss (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) share the contents of this report with the various clinicians involved in Miss A's care and treatment and consider carrying out Evoked Response Audiometry hearing tests at an earlier stage in children who have suffered meningococcal disease; and
• (ii) apologise to Mrs C for the delay in reaching a definitive diagnosis on Miss A's hearing loss.

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

Overview
The complainant (Miss C) raised a number of concerns that in August 2010, the Board failed to properly identify her late father (Mr A)'s health complications, provide adequate post-operative nursing care and failed to communicate with her about his care.

Specific complaints and conclusions
The complaints which have been investigated are that:

• (a) medical staff failed to properly identify health complications leading to Mr A's death (upheld);
• (b) Mr A did not receive adequate nursing care post-operatively on 18 and 19 August 2010 (upheld); and
• (c) nursing staff failed to communicate adequately with Miss C regarding Mr A's care (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) provide evidence of the measures in place to address the failures identified within this report in the MEWS system;
• (ii) confirm to the Ombudsman that they will raise this report with the junior doctor in their annual appraisal;
• (iii) bring this report to the attention of the relevant staff; and
• (iv) apologise to Miss C for the failures identified.

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

Overview
The complainant (Mrs C) was unhappy with the support given to her son (Master A) by a District Nursing Team (DNT), from January to June 2010. She was also unhappy with Grampian NHS Board (the Board)'s handling of her complaint. Master A, who was five years old at the time of the events complained about, was diagnosed with Type 1 diabetes in August 2006. He had a history of asthma, allergies and eczema.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:

• (a) gave Master A instructions on self-administering insulin without Mrs C's consent or knowledge, or that of Master A's Paediatric Diabetes Care Team (upheld); and
• (b) failed to handle Mrs C's complaint properly (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i) apologise to Mrs C for the misunderstanding and confusion caused by the DNT's poor record-keeping;
• (ii) obtain signed consent from parents/carers where healthcare staff want a child to self-administer insulin;
• (iii) look into having a single named point of contact for parents/carers in relation to all of a child's diabetes care and treatment; and
• (iv) review how complaints are dealt with by the Moray Community Health and Social Care Partnership, to ensure that the Complaints Handling Procedures are followed.

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