North East Scotland

Overview

The complainant (Mrs C) complained about the care and treatment her sister (Mrs A) received at Ninewells Hospital, Dundee (the Hospital).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in arranging an MRI scan following Mrs A's admission to the Hospital in November 2003 (upheld);
• (b) the delay caused Mrs A's condition to worsen and become irreparable leaving her in constant and severe pain (not upheld);
• (c) there was a failure by the Hospital's Pain Clinic to monitor or arrange appropriate follow-up in relation to the medication prescribed for Mrs A (not upheld); and
• (d) there was an unreasonable delay by Tayside NHS Board (the Board) in the handling of the complaint (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) issue Mrs A with a full formal apology for the failures identified in part (a) of the complaint. The apology is to be in accordance with the Ombudsman's guidance note on 'apology' which sets out what is meant by and what is required for a meaningful apology; and
• (ii) provide evidence to the Ombudsman of the steps taken to prevent a reoccurrence of the failures identified in paragraphs 21 to 23 of the report.

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

Overview

The complainant's (Mrs C) father (Mr A) died on 28 December 2004 following treatment in Gartnavel General Hospital (the Hospital).  She was concerned that there was an unreasonable delay in diagnosing his cancer and that he was not provided with adequate treatment on admission to the Hospital.  Mrs C also felt that there were unreasonable delays in the handling of her complaint by Greater Glasgow and Clyde NHS Board (the Board).

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) there was an unreasonable delay in diagnosing Mr A's cancer (not upheld);
• (b) during MrA's admission to the Hospital in November and December 2004, he was not provided with adequate treatment; in particular, there was a delay before any attempt was made to arrange a stent and radiotherapy (upheld);
• (c) Mr A had an unnecessary second bronchoscopy (upheld); and
• (d) there were undue delays in the handling of the complaint by the Board (upheld).

Redress and recommendations

The Ombudsman recommends that the Board, reflecting on this case:

• (i) review their guidelines to ensure that in cases similar to this one, staff understand the need for the appropriate multi-disciplinary team to meet at the earliest possible opportunity to discuss all options for investigation, treatment or non treatment. She also recommends that options are discussed in detail with patients and/or with their family in such circumstances;
• (ii) review the circumstances in which it may be appropriate to provide palliative treatment prior to firm diagnosis, and that they include their findings in revised clinical guidelines for staff. The Ombudsman asks that the Board inform her of the outcome of this review and the actions taken; and
• (iii) review their methods of obtaining information from internal sources with a view to ensuring that there are no resultant avoidable delays in responding to complaints.

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

Overview

Ms C raised a number of concerns on behalf of her mother (Mrs A) that she had not received proper or adequate treatment from Grampian NHS Board (the Board) whilst in Woodend Hospital (Hospital 1) for a knee operation.  She was transferred to Aberdeen Royal Infirmary (Hospital 2) on 11 December 2004.  

Specific complaints and conclusions

The complaints which have been investigated are that the Board failed to:

• (a) the Board failed to provide proper or adequate nursing and medical care to Mrs A (upheld);
• (b) the Board failed to identify a small bowel obstruction (upheld); and
• (c) the Board failed to communicate effectively with Mrs A’'s family (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) review medical and nursing documentation and advise the Ombudsman of the outcome of the review;
• (ii) introduce a system for the audit of clinical documentation, for example pulling five files on a monthly basis, and advise the Ombudsman of the proposed action; and
• (iii) consider if there are training needs for staff in relation to communication with patients and relatives/friends.

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

Overview

The complainant (Mrs C) raised a number of concerns about the way her late mother, Mrs A, had been assessed and treated on three occasions at the Accident and Emergency Department (the Department) at Ninewells Hospital in March and April 2004.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A was inadequately assessed and had been inappropriately discharged from the Department on three occasions (upheld).

Redress and recommendations

The Ombudsman recommends that, as a matter of urgency, the Board undertake an audit of all of the Departmental nursing documentation including observation charts in use in the Department and conduct a review of the chest pain protocol and advise her of the outcome.

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

Overview

Mrs C was concerned that her late husband, Mr C, was only diagnosed as suffering from non-Hodgkins Lymphoma shortly before his death.

Specific complaint and conclusion

The complaint which has been investigated is that there was a delay in the diagnosis of Mr C's non-Hodgkins Lymphoma (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant, Mrs C, said that she moved house on police and social work advice.  She complained that she had lost her Right to Buy discount, despite the fact that she was reassured after making specific enquiries on this point, that it would be unchanged.

Specific complaints and conclusion

The complaint which has been investigated is that Mrs C lost her Right to Buy discount, despite the fact that she was reassured, after making specific enquiries on this point, that it would be unchanged (upheld).

Redress and recommendations

The Ombudsman recommends that if Mrs C wishes to purchase her council house, she is able to do so on terms equivalent to those which would have applied had she retained her Right to Buy discount.  Further, that the Council take steps to ensure that a process is put in place to provide tenants with written advice, in advance of any new tenancy, of possible changes to their Right to Buy discount.

Overview

The complainant (Ms C) raised a number of concerns about her mother (Mrs A)'s care and treatment at Aberdeen Royal Infirmary (the Hospital).  In particular, she wondered whether Mrs A's cancer could have been diagnosed a few months earlier and whether this would have affected the sad outcome for her mother, who died, aged 60, in October 2005, the day after being temporarily discharged whilst waiting for the result of a biopsy.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs A's care and treatment at the Hospital from July 2005 to October 2005 were inappropriate (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.

Overview

The complainant (Miss C) raised a number of concerns about her late uncle (Mr A)'s care at Ninewells Hospital (the Hospital), to which he was admitted on 20 December 2005 and where he died on 25 December 2005, aged 62.

Specific complaint and conclusion

The complaint which has been investigated is that Mr A's care in December 2005 fell below a reasonable standard (upheld).

Redress and recommendations

The Ombudsman recommends that Tayside NHS Board (the Board):

• (i) put in place a policy, protocol or guidance in relation to infective exacerbations of chronic lung disease;
• (ii) advise urgent contact from clinical staff to carers in particularly grave situations and, more generally, encourage proactive communication from clinical staff to patients and their carers;
• (iii) provide evidence of the systems in place to monitor and audit nursing records; and
• (iv) provide evidence of the main improvements which they have made in the standard of care as part of their 'safer patient' initiatives.

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

Overview

The complainant (Mrs C) was of the view that unclear course information from Aberdeen College (the College) regarding eligibility for Individual Learning Account (ILA) funding resulted in her being £58 worse off than other students.

Specific complaint and conclusion

The complaint which has been investigated is that there was a lack of clear information from the College about eligibility for ILA funding of a computer course, PC Passport Plus (not upheld).

Redress and recommendation

While noting that the College has no role in approving or vetting material produced by partner organisations, the Ombudsman recommends that the College work with partners with a view to ensuring that information about College courses produced by partners is clear and correct at the time of publication.

The College has accepted the recommendation.

Overview

The complainant (Ms C) raised concerns about her care and treatment by a consultant (Consultant 1), information that was included in a letter and subsequent effect on her medical care as a result.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) Consultant 1's medical treatment of Ms C was inadequate (not upheld);
• (b) Consultant 1 wrote a letter to Ms C's GP containing information Ms C had advised was incorrect (upheld); and
• (c) Consultant 1's comments had a negative influence on other medical practitioners involved with Ms C's case (not upheld).

Redress and recommendations

The Ombudsman has no recommendations to make.