North East Scotland

Overview

The complainant (Mr C) raised a number of concerns about the care and treatment provided by Tayside NHS Board (the Board) to his father (Mr A) in the months before his death in October 2007. Mr C also complained about delays in diagnoses and treatment of Mr A and the handling of his complaint about these matters.

Specific complaints and conclusions

The complaints which have been investigated are that the Board:

• (a) delayed in diagnosing Mr A (upheld);
• (b) failed to provide timely treatment following diagnosis (not upheld);
• (c) did not provide adequate care to Mr A in the respiratory ward (the Ward) of Ninewells Hospital, Dundee (upheld); and
• (d) failed to handle Mr C's complaint appropriately (not upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ask the consultant responsible for Mr A's care in the Ward to apologise to Mr C for any contribution he may have made to the misunderstanding with Mr A about visiting him on 28 September 2007;
• (ii) apologise to Mr C for the failure to provide adequate care to Mr A as identified in this report; and
• (iii) review the current arrangements for selecting patients for consultant out of hours review, including processes for communication and handover between doctors.

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

Overview

The aggrieved (Mrs A) raised a concern that her husband (Mr A)'s prostate cancer was not detected in 2003/2004 when he attended a number of hospital appointments. Mrs A considered both that the cancer could have been detected at that earlier stage and that it should have been detected then.

Specific complaint and conclusion

The complaint which has been investigated is that Greater Glasgow and Clyde NHS Board (the Board) failed to provide Mr A with all appropriate care and treatment in 2003/2004 and as a consequence missed an opportunity to secure an earlier diagnosis of prostate cancer (upheld).

Redress and recommendation

The Ombudsman recommends that the Board review the Urology Department protocol for the assessment and management of men with new lower urinary tract symptoms bearing this case in mind.

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

Overview
The complainant (Mr C) raised concerns about how Glasgow City Council (the Council)'s Social Work Service handled complaints made by local residents about problems arising from a nearby children's unit (the Children's Unit), about the Social Work Service's application for planning consent for the extension of the Children's Unit, and the consideration of that application by the Council's Development and Regeneration Service.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the Council's Social Work Service failed to record and respond appropriately to complaints about the behaviour of children in the Children's Unit (partially upheld);
(b) the Council's Development and Regeneration Service arbitrarily extinguished conditions attached by the former authority to a previous consent for change of use relating to car parking and the maximum number of children to be accommodated (not upheld); and
(c) the Council's Development and Regeneration Service failed in considering the application for the extension of the Children's Unit accurately to apply a relevant City Plan policy with reference to retained landscaped area within the curtilage of the property (not upheld).

Redress and recommendations
The Ombudsman recommended that the Council review whether, in the case of complaints about the Social Work Service management response to problems emanating from children in the Council's care, which are not appropriate for being dealt with in terms of the statutory procedure, these should be considered under their corporate complaints procedure.

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

Overview
The complainant (Mrs C) raised a number of concerns regarding the treatment that her father (Mr A) received from staff at Ninewells Hospital (the Hospital). She complained that, for a five day period following admission to the Hospital, her father was neglected by nursing staff, his condition left unmonitored and incorrect assumptions made regarding his mental state. Mrs C felt that inattention and poor record-keeping by staff of Tayside NHS Board (the Board) contributed to a deterioration in Mr A's condition, and to his death.

Specific complaints and conclusions
The complaints which have been investigated are that the Board:
(a) incorrectly assumed that Mr A had dementia (not upheld);
(b) failed to treat Mr A appropriately for a five day period following his admission to the Hospital (upheld); and
(c) failed to appropriately monitor Mr A's fluid intake (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) review their progress against the action plan and provide an updated version of the document;
(ii) provide details of the steps that they have taken to implement the Scottish Government's new Food, Fluid and Nutrition programme;
(iii) provide details of the steps that they have taken to achieve the Scottish Government's new Clinical Quality Indicators for Food, Fluid and Nutrition; and
(iv) formally apologise to Mrs C and her family for the distress and anxiety caused to them and Mr A during his stay at the Hospital.

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

Overview
The complainant Mr C , was unhappy with the care provided to his late mother, Mrs A. Mrs A had been admitted to the Victoria Infirmary (the Hospital) following a fall. Shortly after her admission, the Hospital identified an outbreak of the winter vomiting virus in the ward to which Mrs A had been admitted (Ward A). While there, Mrs A was diagnosed with an infection and her condition deteriorated. Sadly, Mrs A died a few days after moving from Ward A to Ward B. Mr C said he was concerned about the care and treatment provided to Mrs A and that he and his family had been distressed by the way Mrs A had been cared for after it became clear she was unlikely to recover. He said Mrs A had been moved into an open ward (Ward B) and the curtains around her bed left open. Mr C also raised complaints about matters relating to the closure of Ward A and stated that the Hospital had failed to ensure the public was aware there was an outbreak of infection. He also said he had been concerned about the general level of hygiene in and around Ward A.

Specific complaints and conclusions
The complaints which have been investigated are that:
(a) the care and treatment provided to Mrs A was inadequate (upheld);
(b) there was insufficient care taken by staff handling an outbreak of infection in Ward A (upheld);
(c) the level of hygiene in and around the ward was inadequate (no finding);
(d) there were significant failures in communication about the effect on Mrs A of the infection and the serious nature of Mrs A's condition (upheld);
(e) there was a failure to ensure Mrs A's dignity (upheld); and
(f) the Board did not respond appropriately to the complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:
(i) use a root cause analysis or similar tool to examine the reasons for the clinical failures identified in treating Mrs A’s diarrhoea and managing her fluid intake;
(ii) provide clear evidence over the next 12 months that the new policy on professional standards of record-keeping is having significant improvements on the quality of documentation;
(iii) provide the Ombudsman with evidence that the initiatives underway on infection control should prevent a recurrence of the failings identified in this report;
(iv) use this complaint as part of their own ongoing programmes to improve cleanliness and, in particular, consider how hygiene standards can be tracked and monitored and how visitors and patients can be encouraged to feel they can approach staff about any concerns they have;
(v) share with the Ombudsman the results of patient and staff surveys on communication over the next 12 months and the audit of communication following report 200600345 and any action taken as a result;
(vi) keep the Ombudsman informed of the progress of implementation of the Liverpool Care Pathway over the next 12 months;
(vii) provide evidence of the actions being taken to ensure individual patient dignity until the Hospital is closed;
(viii) ensure that guidance to complaint handling staff emphasises the need for full disclosure of relevant information; and
(ix) make a full, detailed apology to Mr C and his family for the failings identified in this report.

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

Overview
The complainant (Ms C) raised a number of concerns about the care and treatment, which she had received from Greater Glasgow and Clyde NHS Board (the Board) during the period April 2003 to October 2005.

Specific complaint and conclusion
The complaint which has been investigated is that the Board failed to provide reasonable care following Ms C's operation on 18 April 2003 (upheld).

Redress and recommendation
The Ombudsman has no recommendations to make on these issues because he is satisfied that the Board have made changes that address the concerns raised in this report.

Overview

The complainant, Mr C , was concerned that his late father (Mr A) had suffered serious pressure sores while in the Southern General Hospital (Hospital 1) following an operation on both his knees. Mr C felt that the decision to operate had not been taken appropriately and that the care provided while Mr A was in Hospital 1 was inadequate. Mr C was also unhappy about the way the Board had responded to concerns raised by him and his family.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the decision to operate was not appropriate, in that further tests should have been taken prior to the operation (upheld);
• (b) the post-operative care provided to Mr A was inadequate (upheld);
• (c) communication with Mr A and his family, concerning Mr A's care and treatment, was not adequate (upheld); and
• (d) the Board did not respond appropriately to the complaint raised by Mr C (partially upheld, to the extent that there was a delay in responding with no reasonable explanation given for this).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) undertake a root cause analysis or similar tool to examine the reason why the pressure ulcers developed and why there was no proactive treatment once this occurred;
• (ii) provide the policy/guidance for the assessment and treatment of pressure ulcers, with particular reference to the referral to the specialist teams in tissue viability, pain and nutrition; undertake an audit to review the processes; and provide an action plan to address any shortcomings;
• (iii) undertake an audit of documentation to include nursing assessment, pain assessment and nursing care of Wards A and B;
• (iv) provide evidence of the education and training programme provided to nursing staff in relation to the assessment and care of pressure ulcers;
• (v) undertake an external peer review of the nursing care in Ward A, to include an examination of the clinical leadership and management, patient experience and quality of care. In undertaking the review, consideration should be given to Improvement Methodology and the Scottish Government initiatives outlined in Leading Better Care;
• (vi) provide details of the action plan created as a result of the above recommendations and provide updates where relevant. Action plans should be specific, measurable, achievable, realistic and timely (SMART) and include robust quality indicators such as the Clinical Quality Indicator for Pressure Ulcer Prevention;
• (vii) as a priority, review the documentation provided to patients and provide the Ombudsman with the results of this;
• (viii) provide details of the audit made in response to report 200600345 and any action taken as a result;
• (ix) if not covered by that audit, undertake a specific audit of communication within Hospital 1, to include communication with families, and between staff;
• (x) reinforce to clinical staff the importance of responding to requests from complaint handling staff timeously; and
• (xi) make a full apology to Mr C and his family for the failings identified in this report.

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

Overview

The complainant (Ms C) complained about some aspects of care and treatment and communication with the family in respect of her mother, aged 80, who had been admitted to Aberdeen Royal Infirmary (the Hospital), a hospital in the area of Grampian NHS Board (the Board) in October 2007. She had been badly injured in a road traffic accident and, most sadly, never properly recovered full consciousness, dying in the Hospital about a fortnight later.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) some aspects of the care and treatment were inadequate (upheld); and
• (b) communication with the family was inadequate (no finding).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) apologise direct to Ms C for the shortcomings identified in this report;
• (ii) reflect on the medical lessons to be learnt from this case and consider appropriate action;
• (iii) ensure that, in future, they are able to evidence patients fluid levels, by retaining, for example, a record of daily fluid totals for a year after the event, in case needed;
• (iv) consider how to improve the record-keeping, including notes of discussions with patients and families, of medical staff in the ward in question, and take action accordingly;
• (v) consider any need for a wider audit of medical record-keeping; and
• (vi) reflect on the criticisms about complaint handling and consider appropriate action.

Overview

The complainant raised a number of concerns about the care and treatment of an 80-year-old woman (Mrs A), on behalf of Mrs A's son. Mrs A was admitted to the Royal Alexandra Hospital (the Hospital), in the area of Greater Glasgow and Clyde NHS Board (the Board), in September 2006 with stomach pain and constipation. The complainant said the admission should have been made several days earlier and that the inadequate treatment received in the Hospital might have contributed to Mrs A's death later that month in the Hospital.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) out-of-hours doctors should have admitted Mrs A to the Hospital earlier (not upheld);
• (b) Mrs A's care and treatment in the Hospital were inadequate (upheld); and
• (c) the Board lost some of Mrs A's medical records (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• (i) ensure that all appropriate healthcare professionals in the Board's hospitals are made aware of the appropriate management of constipation in older people; and
• (ii) reflect on the lessons learnt from this complaint and take appropriate action to help avoid a recurrence.

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

Overview

The complainant (Mr C) raised concerns regarding the Scottish Executive Inquiry Reporters Unit (SEIRU)'s handling of his appeal in respect of a proposed Alteration or Removal of Buildings or Works Order (the Order). In particular, Mr C was unhappy with the actions of the appointed reporter (the Reporter) and the conduct of the corresponding hearing (the Hearing). The specific points of complaint are listed below.

Specific complaints and conclusions

The complaints which have been investigated are that:

• (a) the Hearing and corresponding site visit were not conducted in a proper and fair manner (not upheld);
• (b) SEIRU mismanaged the documentation relating to the Hearing (not upheld); and
• (c) SEIRU did not fully consider Mr C's subsequent complaints (upheld).

Redress and recommendation

The Ombudsman recommends that the DPEA issue an apology to Mr C for the lack of clarity in their responses to his complaints. More generally, she would remind them of the importance of outlining their role and remit to complainants and of providing a clear explanation of what they can and cannot consider. Where they are not able to fully respond to any specific points raised, they should provide details as to why this is the case.

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