Health

Overview
The complainant (Mr C) raised a number of concerns that his General Practitioners (GPs) failed to take timely action to fully investigate the symptoms he was reporting during five visits to his GP Surgery (the Practice) between August and November 2012.  He complained that this led to a delay in the diagnosis of his testicular cancer.

Specific complaint and conclusion
The complaint which has been investigated is that the GPs failed to take the appropriate steps to diagnose Mr C's testicular cancer promptly (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• issues a written apology for the failings identified in this report; and
• ensures that GPs 1 and 3 reflect on their practice in relation to these events and discuss any learning points at their next appraisal.

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

Overview
The complainant (Mrs C) raised a number of concerns that treatment decisions, communication and level of support by healthcare professionals were not of a reasonable standard following her husband (Mr C)'s cancer diagnosis.

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

• (a) failed to provide a reasonable standard of care and treatment to Mr C following his cancer diagnosis (upheld); and
• (b) failed to clearly communicate with Mrs C regarding Mr C's prognosis and provide an adequate level of support to help Mrs C cope with his illness (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• provide a plan detailing the changes they have made to:  prevent a recurrence of failing to store medical records securely; and meet Scottish government emergency department targets;
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
• provide a plan detailing the changes they have made to prevent a recurrence of failings in their communication with Mr and Mrs C regarding chemotherapy treatment;
• ensure their responses to complaints are meaningful and appropriate in tone, use of language etc; and
• further apologise to Mrs C for the failures identified and offer to meet her to discuss in more detail the response she received to her complaint.

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

Overview
The complainant (Miss C) raised a number of concerns that her sister (Ms A) had been provided with inadequate care and treatment in that the symptoms with which she was presenting between October and November 2011 were not appropriately investigated and treated. 

A Critical Incident Review (CIR) of the events surrounding Ms A's care and treatment was held in May 2012 by Tayside NHS Board (the Board) following Ms A's death in April 2012.  Miss C complained that the Board failed to provide the family with a copy of the CIR report despite repeated requests and failed to arrange a meeting with the family.

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

• (a) between October and November 2011, staff at Ninewells Hospital failed to provide Ms A with appropriate medical treatment in view of the symptoms with which she presented (upheld); and
• (b) staff at the Board failed to provide the family with a copy of the CIR report despite them making repeated requests and failed to take steps to arrange a meeting with the family (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• (i)  provide evidence that appropriate action was taken to address the mis-reporting of the Magnetic  Resonance Imaging scan of 10 October 2011;
• (ii)  ensure that future Radiology Discrepancy and Complications Meetings are minuted and the minutes appropriately circulated;
• (iii)  review the application of the 'three day guidance' to ensure that staff appropriately assess patients before referring back to their GP and where necessary provide refresher training;
• (iv)  ensure that staff on the Acute Medical Unit are reminded of the need to be proactive in addressing patients pain;
• (v)  continue to work towards producing a care pathway to improve the treatment of patients who present with un-resolving and/ or deteriorating symptoms, including improved communication with primary care providers (GPs);
• (vi)  remind staff dealing with complaints about the usefulness of meetings at an early stage of the complaints process as per their Complaints Management Procedure; and
• (vii)  issue a written apology to Ms A's family for the failings identified in this report.

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

Overview
The complainant (Mrs C) raised a number of concerns about her husband (Mr C)'s care and treatment when he was admitted to the Emergency Department of Aberdeen Royal Infirmary on 19 November 2012. 

She said that despite being assessed at 09:20 for transfer to the Acute Medical Assessment Unit he was not transferred there until 20:18.  In the meantime, he had been lying on a trolley.  Once transferred, Mrs C said that there was a delay in him seeing a doctor and that his condition continued to decline.  Regrettably, Mr C died at noon the next day and Mrs C further complained about Mr C's appearance when she arrived in hospital after his death.

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

• (a) the care and treatment given to Mr C on his admission to hospital in November 2012 were unreasonable (upheld);
• (b) Grampian NHS Board (the Board) unreasonably asked Mrs C to sign Mr C's death certificate before she had been given a chance to see him (upheld); and
• (c) the Board unreasonably failed to properly lay out Mr C before Mrs C saw him (upheld).

Redress and recommendations

The Ombudsman recommends that the Board:

• apologise to Mrs C for the fact that Mr C was not examined further by the medical team whilst he was still in the Emergency Department;
• provide a plan detailing the changes they have made to prevent such a recurrence (that is, missing target times and a failure to assess and treat in a timely manner);
• confirm the learning gained as a consequence of this complaint and provide details of how this has been passed to and considered by relevant staff;
• emphasise to all staff in the Emergency Department the importance of keeping accurate and timely clinical records;
• advise me of the steps they have taken to ensure that staff are aware of their responsibilities in similar circumstances and to be alert to the sensitivities of family members;
• take steps to ensure that this does not happen again and emphasise to all appropriate staff the necessity of preserving a patient's dignity in death; and
• be sensitive to the needs of close family members in such matters and advise appropriate staff accordingly.

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

Overview
The complainant (Mrs C) complained on behalf of her husband, Mr C.  She said that after Mr C fell down the stairs at home and an ambulance was called, staff failed to ensure that he was properly cared for.  She believed that the actions of the paramedics contributed to his resultant paraplegia (complete paralysis of the lower half of the body including both legs, usually caused by damage to the spinal cord).

Specific complaint and conclusions
The complaint which has been investigated is that the Scottish Ambulance Service (the Service) failed to ensure that their staff used a stretcher and neck brace when transferring Mr C to hospital (upheld).

Redress and recommendations
The Ombudsman recommends that the Service:

• (i)  make a formal apology to Mr and Mrs C for their failure to properly immobilise Mr C after the incident on 24 March 2012 and for the inadequacies of their internal investigation; and
• (ii)  externally audit their complaints handling processes to ensure that they are sufficiently robust and fit for purpose.

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

Overview
The complainant (Mrs C) raised a number of concerns about the care and treatment her son (Master A), then six and a half years old, received from the GPs at Master A’s medical practice (the Practice) from May to August 2011.  Master A subsequently attended Ninewells Hospital in Dundee and then the Royal Hospital for Sick Children in Edinburgh, where he was diagnosed with cancer (Burkitt's Lymphoma stage IV).  He received treatment but, sadly, died.

Specific complaints and conclusions
The complaints which have been investigated are that from May 2011 GPs at the Practice:

• (a) failed to provide Master A with appropriate clinical treatment in view of his reported symptoms (upheld); and
• (b) unreasonably delayed referring Master A for a specialist hospital opinion (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• (i)  provide Mrs C and her husband with a written apology for the failings identified in this report; and
• (ii)  provide my office with evidence that this case has been discussed with all GPs involved as a learning tool and that all learning points are taken forward as part of their continuous professional development.

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

Overview

The complainant (Mrs C) said that she and four of her family members were inappropriately removed from their GPs'' list.  Mrs C said that she had not received a warning that they were to be removed from the list.

Specific complaint and conclusion

The complaint which has been investigated is that Mrs C considers that she and four of her family members were inappropriately removed from their GPs'' list (upheld).

Redress and recommendations

The Ombudsman recommends that the Practice:

• (i) put a process in place to 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 Mrs C for not adhering to the relevant regulations and guidance before asking for her and her family members to be removed from their list.

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

Overview
The complainant (Miss C) raised a number of concerns about her late father's (Mr A) prostate cancer diagnosis.  This included Mr A's concerns at being advised that he did not have prostate cancer resulting in his treatment being stopped.  Miss C was also dissatisfied with the lack of information and support given to Mr A and the family about the diagnosis, prognosis and side effects of the treatment.

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

• (a) did not provide reasonable care and treatment to Mr A from May 2011 onwards (upheld);
• (b) unreasonably withheld information about his condition from Mr A and his family (upheld); and
• (c) did not reasonably handle Miss C's complaint (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• review their prostate cancer guidance to ensure it is consistent with national guidelines for the management of patients with widespread prostate cancer when a biopsy is not indicated;
• ensure timely involvement by a specialist cancer nurse shortly after diagnosis of prostate cancer;
• ensure Doctor 4 discusses the failings identified in this report at his next appraisal;
• ensure clinical staff clearly record any verbal responses they provide to patient correspondence;
• apologise to Miss C and the family for the failings identified in this report; and
• ensure that complaint responses are consistent, accurate and set out in a structured manner.

Overview
The complainant (Mr C) raised a number of concerns that his mother (Mrs A) had received inadequate care and treatment in October 2011 resulting in a failure to diagnosis kidney failure or admit Mrs A to hospital.  Mrs A subsequently died on 2 November 2011.

Specific complaint and conclusion
The complaint which has been investigated is that between September 2011 and October 2011, doctors at Mrs A’s medical practice (the Practice) failed to take into account Mrs A's symptoms, previous medical history and family concerns and that they did not arrange an emergency hospital admission (upheld).

Redress and recommendations
The Ombudsman recommends that the Practice:

• review the GMC Guidance on record-keeping and evaluate a sample of their case notes to see if they are fulfilling the required standards;
• review with the doctors involved in Mrs A's care the SIGN guidance on chronic kidney disease and its management and identify this as a learning need within their appraisals;
• discuss this complaint and its evaluation with the doctors involved in Mrs A's care in their yearly appraisal;
• carry out a significant event analysis of this incident and discuss the results within the practice team; and
• apologise sincerely to Mr C and his family for the failures in the care and treatment provided to Mrs A.

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

Overview
The complainant (Mrs C) complained on behalf of her mother (Mrs A) to Grampian NHS Board (the Board) about the care and treatment her father (Mr A) received while a patient in Aberdeen Royal Infirmary (the Hospital) from 5 August to 23 September 2012.  Mr A had been admitted to the Hospital's Acute Stroke Unit after suffering a stroke at home.  Mr A died in the Hospital on 23 September 2012.

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

• Mr A's medical care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld); and
• Mr A's nursing care in the Hospital from 5 August to 23 September 2012 fell below a reasonable standard (upheld).

Redress and recommendations
The Ombudsman recommends that the Board:

• draw this report to the attention of all senior medical staff involved in Mr A's care;
• take steps to put in place an action plan to address the failings identified in this report;
• ensure that staff document relevant discussions they have with a patient's family or their carer;
• act upon the comments of Adviser 1 in relation to the introduction of a policy on the certification of a patient's death;
• draw to the attention of relevant staff, the importance of providing evidenced based complaints responses;
• share with relevant nursing staff the comments of Adviser 2 with regard to maintaining a patient's dignity;
• draw to the attention of relevant staff, Adviser 2's concerns about the Board's rationale for removing Mr A's pyjama bottoms; and
• apologise to Mrs A and her family for the failings identified in complaints (a) and (b).

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