Ms C complained about the care and treatment her late father (Mr A) received at Raigmore Hospital after he died unexpectedly following elective knee surgery. Ms C also complained about Highland NHS Board's investigation of her complaint.

The Board's investigation of Ms C's complaint did not identify any failings in Mr A's care. We took independent advice from a consultant trauma and orthopaedic surgeon. We found that Mr A's symptoms prior to discharge were not appropriately acted on. Had they been, there is a possibility that other specialities could have been called in to assess and assist. However, we could not say whether this would have affected Mr A's outcome. We concluded that Mr A's postoperative care and treatment was of an unreasonable standard and upheld the complaint.

In terms of the consent process for Mr A's surgery, we were also critical that there was no record to demonstrate that all the specific recognised risks of a total knee replacement surgery were covered sufficiently during a clinic consultation. We concluded that this is contrary to national guidance on consent and was unreasonable.

We also found that the Board's investigation and response to Ms C's complaint contained inaccurate information; did not reasonably address all the concerns Ms C raised; and did not reasonably identify and address the failings in Mr A's care. The letter concentrated mainly on the opinion as to the cause of Mr A's death rather than systematically addressing the points Ms C had written in her complaints form. We concluded that the response to Ms C's complaint was not compliant with the NHS Complaints Handling Procedure (NHS CHP) because the investigation and response should have been more comprehensive, clearer and easier to understand. We upheld the complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Ms C:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

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Points to note 

As well as the recommendation above to ensure there is a standard operating procedure for the management of acute kidney injury and to include this in junior doctor induction, the Board may wish to consider the placement of ward posters informing others about the issue.

Mr C complained about the care and treatment that he received from Greater Glasgow & Clyde NHS - Acute Services Division (the Board) after he sustained a navicular fracture to his left foot (a fracture of the navicular bone on the top of the midfoot). Mr C also complained that the Board failed to respond reasonably to his complaint.

In March 2017, Mr C attended the Emergency Department (ED) of the Queen Elizabeth University Hospital, Glasgow (the Hospital). Mr C was assessed by a junior doctor and found to have pain on touching some of the bones in his foot. An xray was ordered, which the junior doctor interpreted as showing an un-displaced fracture (a fracture where the bone fragments do not separate) of one of the metatarsal bones (the 'forefoot' bones linking the toes to the middle part of the foot). Mr C was given a walking boot, advice and discharged. Two days later, the x-ray was reported by a radiologist as showing no acute joint or bony injury.

At the start of May 2017, Mr C attended again at the ED following a referral from the GP out-of-hours service as his foot was swollen and he was still in pain. Further xrays were taken. Mr C was reviewed by the on call orthopaedic doctor. The doctor's diagnosis was that there was possibly a hairline fracture (a very fine fracture) of the fourth metatarsal. Mr C said he was advised nothing further could be done and was sent home. The following day, Mr C attended the orthopaedic out-patients department at the Hospital following a call asking him to attend. He was advised by an orthopaedic doctor that the third and fourth metatarsal were broken, in addition, the navicular bone was broken in three parts with a 5mm gap.

Subsequently, Mr C underwent surgery to address the fracture. However, he continued to experience problems with his foot. Mr C had a major limb amputation of the lower part of his left leg in October 2019.

We took independent advice from a consultant in emergency medicine, a consultant orthopaedic surgeon and a consultant radiologist.

We found that it was not unreasonable that the ED junior doctor did not identify Mr C's fracture in March 2017 as it was uncommon to see a patient present at the ED with a navicular fracture and a junior doctor will rarely see a patient present with this type of fracture and often not at all. In addition, the fracture was subtle on the x-ray. On account of this, the junior doctor who saw Mr C made an understandable, reasonable, mistake in not diagnosing that he had sustained a navicular fracture.

Notwithstanding this, Mr C's fracture should have been identified in the radiology report of the x-ray taken in March 2017 and although the fracture of the navicular on the x-ray was subtle; it was unreasonable that the radiologist did not report this fracture.

Mr C was diabetic. We found that the clinical history supplied on the request for the radiograph did not include this information. While we did not consider the failure to identify and include this information in Mr C's clinical history amounted to an unreasonable standard of treatment, had the information about Mr C's diabetes been supplied it may have further alerted the reporting radiologist to the possibility of a stress fracture.

We found that when Mr C re-attended the Hospital in May 2017 after being referred by the out-of-hours service, a further opportunity to identify the navicular fracture was missed.

In conclusion, we found that overall the Board failed to provide Mr C with a reasonable standard of care and treatment and that it was likely that the failure to identify Mr C's fracture in March 2017 had a detrimental impact on his outcome. In light of the failings identified, we upheld this aspect of Mr C's complaint. 

Finally, we found that the Board failed to handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Board to do for Mr C:

We are asking the Board to improve the way they do things:

We are asking the Board to improve their complaints handling:

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Points to note 

• While it was not unreasonable that the junior doctor did not identify the navicular fracture when Mr C first attended the ED in March 2017, the Board may wish to consider raising awareness of a navicular fracture with junior doctors joining the ED on placement.
• When a patient attends with a fracture at the ED, the Board may wish to give consideration to recording past clinical history as this can provide a potential alert for subsequent care and treatment.
• Adviser 2 commented that the subsequent management of Mr C's case by the Board's consultant orthopaedic surgeon after the navicular fracture had been identified should be commended.

Summary

Ms C complained on behalf of Mrs A, about Moray Council (the Council) Children and Families social work department. Mrs A's two children, Child Y and Child Z, were removed from Mrs A's care in September 2016 as a result of a Child Protection Order (an emergency legal order granted by a Sheriff which allows the local authority to remove a child from their parent's care). Ms C complained that the Council unreasonably failed to gather and take into account relevant information when making decisions regarding the children's care and education, both before and after the children were removed from Mrs A's care and placed into accommodation.

During our investigation, we took independent advice from a social worker (the Adviser). We identified the following failings: 

• Prior to the children being accommodated:
  • little or no evidence of exploring parenting style, family or other supports; or questioning and challenging what was observed;
  • little or no evidence of clear assessments of risk and need;
  • little evidence of the Getting It Right For Every Child practice model (GIRFEC; the Scottish Government's approach to supporting children and young people) being utilised, including a robust, multi-agency assessment; and
  • failure to make attempts to engage the family in supporting the prevention of a breakdown in the family or to provide kinship care as a means of preventing statutory care.
• Following the children being accommodated:
  • failure to consider and arrange independent advocacy for the children in a timely manner; 
  • in the absence of independent advocacy, failure to explore ways of communicating with the children to elicit their views and feelings;
  • failure to include the views and feelings of the children in many reports;
  • failure to facilitate Child Y attending their hearings when Child Y voiced their wish to attend;
  • when Child Y changed their story about allegations made, it appeared that the allegations were given less weight and there was not enough understanding of the way in which children and young people may retract their stories. Rehabilitation with the children's father (Mr A) went ahead without this being resolved or there being more clarity on the risks and safeguards in place;
  • failure to reasonably consider and assess potential kinship placements and follow national guidance and legislation in relation to kinship care assessments;
  • failure to communicate in a reasonable and timely way with extended family in relation to kinship care;
  • no evidence that Child Z's views were obtained in relation to moving school; or that Child Z or the new school were prepared for the transition;
  • failure to promote or encourage extended family relationships;
  • failure to inform Mr & Mrs A of Child Z's admission to hospital shortly after they were accommodated; and
  • failure to complete a number of Looked After Child forms which should have been completed at the point of the children being accommodated, in a timely manner.

Given these numerous and significant failings, we upheld the complaint and made a number of recommendations to address these failings.

Ms C also complained that the Council failed to handle complaints raised by herself and Mrs A in a reasonable and timely manner. We acknowledged that the complaint was complex, involved correspondence from a number of different people, some of which had overlapping issues, and that there were concurrent information requests. The Council had taken some action to address their complaint handling failings. However, we considered that it remained that much of the handling of Ms C and Mrs A's complaints was unreasonable and we did not consider the action previously taken by the Council to address all of the complaint handling failings. We therefore upheld this aspect of Ms C's complaint.

Redress and Recommendations

The Ombudsman's recommendations are set out below:

What we are asking the Council to do for Ms C and Mrs A:

We are asking the Council to improve the way they do things:

We are asking the Council to improve their complaints handling:

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Points to note

The Adviser noted that there was a regular programme of supervised contact with both parents, but commented that, in their view, the timetable of contact placed a heavy burden on the children as on occasion they were having two contact visits a day, one with each parent and some that included extended family. The Adviser acknowledged that it is always a difficult balance to ensure there is sufficient contact but also that it is relaxed and comfortable to promote a good experience and build relationships. However, they considered the contact plan, while demonstrating a regular arrangement, was a demanding one for everyone, not least the children. The Council may wish to reflect on this matter.