Not upheld, no recommendations

Summary

C complained about the care and treatment their adult child (A) received from the board. A had a complex medical history including a diagnosis of Complex Regional Pain Syndrome (CRPS, a rare condition where persistent and severe pain occurs following an injury). A attended A&E complaining of an elevated heart rate and fatigue. A working diagnosis of sinus tachycardia (a faster than usual heart rhythm) secondary to medication was made. A was discharged home with no further treatment. A couple of months later, A was admitted to A&E following a collapse, racing heart and swelling of their hands and feet. A was admitted to hospital where their condition deteriorated overnight. A's condition continued to deteriorate and they were transferred to the Medical High Dependency Unit (HDU) and the Intensive Care Unit (ICU). Ultimately, it was decided that A should be transferred to a hospital in another health board area where cardiology and advanced cardiac (heart) support would be available. A's condition did not improve and they died a few days later.

C raised a number of complaints with the board regarding the care and treatment A received. The board investigated C's concerns and undertook a Significant Adverse Event Review (SAER). However, C remained dissatisfied with some aspects of A's care.

We took independent advice from an appropriately qualified adviser. We found that when A initially presented at A&E, the clinical staff were aware of their history of CRPS and existing medications, that a full examination was carried out along with blood tests which were normal and that there was no obvious reason to admit A to hospital at that time. We found that the treatment A received during this admission was reasonable and appropriate and that onward referral was unlikely to have changed the outcome for A.

In relation to their second attendance, we noted that A was acutely unwell. We found that appropriate investigations were carried out in a timely manner and that, as A's condition deteriorated, their care was appropriately escalated through the HDU and ICU to transfer to another hospital where specialist equipment was available. We found that where the board had identified areas for improvement in their review of matters, the action they had taken was appropriate. We considered that the board provided A with appropriate treatment and investigations in response to their presenting symptoms and that they escalated A's care appropriately in recognition of the seriousness of their deteriorating condition.

We did not uphold C's complaints.

Summary

C, a support and advocacy worker, complained on behalf of their client (A) who was unhappy with the care and treatment they received during the birth of their child (B) and whilst they were a patient on the postpartum ward.

A's labour progressed very quickly, B's heart rate dropped, and decisions were made to deviate from the birthing plan as a result. A was unhappy with decisions that were made, the care received from midwives, and the lack of communication with them about what was happening. A also had concerns about the postpartum care they received, as they required a blood transfusion and felt their concerns were ignored by staff.

The board considered appropriate guidelines were followed and appropriate action and decisions were made in the circumstances. There was a need to deliver B urgently as there was evidence of distress. In relation to the care A received after the birth of B, the board said they did not consider there were any delays in the care provided to A, or the monitoring of their condition. They did identify an issue with documentation and highlighted that there should always be a handwritten contemporaneous record. This was addressed with staff members involved.

We took independent advice from two clinical advisers: a consultant obstetrician (a specialist in pregnancy and childbirth) and a registered midwife. We found that the care and treatment provided to A during labour was reasonable in the circumstances. We also considered the care and treatment provided by midwives on the postnatal ward was reasonable. We noted that there was a debrief in this case however, given the events of the birth, further debriefing at a senior level may have been helpful. We provided the board with feedback on this point.

We found that the care and treatment provided to A during the birth of their child and postnatally was reasonable and required in the circumstances in which B's health was at significant risk. Therefore, we did not uphold C's complaints.

Summary

C complained on behalf of their adult child (A). A has received support for addiction from the partnership for a number of years. However, C complained that the partnership failed to provide evidence of a recovery plan, to explore all possible treatment options, unfairly stated A was difficult to engage with, and failed to reasonably communicate with C.

The partnership acknowledged that there had been a gap in the services provided to A due to staff absence and difficulty recruiting, however a recovery plan was in place for A.

We took independent advice from an adult psychiatry adviser. We found that the support provided to A was appropriate and reasonable and that there was a clear management plan in place. Despite the difficulties faced by the partnership in terms of staffing, we concluded that appropriate drug addiction support was provided to A and we did not uphold the complaint.

Summary

C complained about the level of supervision that their spouse (A) was provided with while they were detained in hospital under the Mental Health (Care and Treatment) (Scotland) Act 2003. A was diagnosed with bipolar affective disorder (a condition that affects a person's mood) and was noted to be disinhibited. A later told C that A had entered a patient’s room and had sexual intercourse with them. C acknowledged that this could not be corroborated by the board, but considered that the board had failed to address their concerns regarding the known issues of A’s disinhibited behaviour and them entering other patient’s rooms.

On the basis that there was no available evidence to establish the circumstances surrounding the alleged incident and whether there was any failure by ward staff to monitor A at that time, our consideration of this complaint was limited to reviewing whether the observation arrangements in place were reasonable and appropriate for minimising the risk of such an incident.

We took independent advice from a psychiatry adviser. We found that appropriate risk assessments were carried out throughout A’s admission. We were satisfied that A was given a level of supervision that was in-keeping with national guidance and their assessed risks at that time. In the circumstances, we did not uphold this complaint.

Summary

C complained about the care and treatment that their spouse (A) received from the board. A was diagnosed with colorectal cancer (bowel cancer) and underwent colon cancer surgery abroad, before returning to the UK. They were reviewed by the board’s oncology team (cancer specialist team) and it was determined that the cancer had spread and that chemotherapy was required.

Although A initially responded well to chemotherapy, once the chemotherapy course ended, the cancer was found to have spread further. A was not considered fit enough to undergo further chemotherapy and died.

C complained to the board that, following the positive indications, the board failed to communicate clearly with A and their family about their prognosis, treatment and next steps. C raised particular concerns that clinicians were unwilling to give information about the nature and extent of A’s deterioration, the sizes of tumours identified and information about the treatment that could be provided.

C considered that the board failed to provide A with appropriate treatment during their time in hospital and that these failures could have resulted in A not being able to recover sufficiently to undergo further chemotherapy. C was concerned that A suffered a series of issues related to their stoma site (opening in the body) and C complained that these issues were not treated with sufficient urgency or concern.

In response to the complaint, the board provided a detailed account of the care provided to A and their communication with A's family. The board acknowledged that A responded well to chemotherapy but once the first six cycles were complete, the cancer started to grow aggressively and A never regained the fitness required to restart treatment. The board explained that following further review of A, it was established that surgery was not an option for A and gave their view as regards the progression of A's illness and recurrent infections which necessitated admittance to hospital. Additionally, the board clarified their understanding with respect to the communication with A and their family and explained why they considered this to be reasonable in the circumstances.

We took independent advice from a senior clinical oncologist. We found that the assessment and treatment of A’s cancer during the period concerned was reasonable. We considered a period of care during which A experienced difficulties with respect to their stoma site and infections and considered the care provided to be reasonable in the circumstances. We found that whilst there were clearly difficulties with respect to communication between clinicians and the family, medical professionals tried to answer questions about A’s care and there was evidence of appropriate communication with the family.

With respect to the care and treatment provided to A, we found that an appropriate diagnosis was made, with a reasonable treatment plan and follow up testing to monitor the effectiveness of treatment. Despite initial good progress, A's cancer progressed and decisions made about A's treatment, including that A was not fit for surgery, were clear with demonstrable reasoning. A suffered difficulties with infections and complications which, again, were appropriately responded to and treated. Overall, the care and treatment provided to A was reasonable and in line with good practice. As such, we did not uphold the complaint.

With respect to communication with A and their family, the records demonstrated that A and their family asked a lot of questions to help their understanding. There was evidence of frustration on both sides regarding the level and extent of communication and information requested. There may have been opportunity for clinicians to consider and better manage the family’s expectations about the level of detail which could be provided about the treatment and prognosis. However, we found that the level of detail about A’s care and treatment was in line with what would reasonably be expected in the circumstances and we did not uphold this complaint.

Summary

C complained that the council's response to their reports of anti-social behaviour had been inadequate. C said that their neighbour was subject to an anti-social behaviour order which they had repeatedly breached.

The council provided C with a noise recording application which allowed them to record noise and disturbances and send these reports to the council. However, C complained that they were not provided with sufficient information on how to use the application and on what the council would accept as evidence of anti-social behaviour. The council rejected C’s submissions as evidence of significant noise problems and refused to let C submit additional recordings.

We found that the council had responded to C’s complaints of anti-social behaviour appropriately. Their response had been affected by delays in hearing court cases, but this was outwith the council’s control. It was also noted that actions taken by the council could not always be shared with C. We considered that C was provided with adequate guidance on using the noise recording application. Therefore, we did not uphold this part of C's complaint.

C also complained that they were prevented from making further complaints by the council. We found no evidence that C was being prevented from making further complaints about noise and anti-social behaviour. The council stated explicitly as part of their submission to the investigation that if there was evidence of a material change in circumstances, then C would be allowed to complain about this. Therefore, we did not uphold this part of C's complaint.

Summary

C complained about the care and treatment a close family member (A) received from the partnership. C complained that the partnership failed to ease restrictions to family visits in line with changes to national public health guidance and had unreasonably applied restrictions on indoor visiting at A’s group home. Consequently, A had effectively remained in their home for the best part of a year without in-person family contact or social interactions, causing A’s mental and physical wellbeing to decline significantly. C also complained that during restrictions the partnership failed to take reasonable steps to help A communicate effectively with family members, investigate concerns C had raised about A’s welfare, or keep them updated regarding A’s care and treatment, including decisions as to whether A should shield.

In response, the partnership explained that group home settings were not adequately provided for in the government’s guidance but had sought advice to follow care home guidance. They acknowledged that in light of the competing and often conflicting guidance it may have been helpful to have sought clarity on the most appropriate guidance to use at an earlier stage in the pandemic but disagreed with C’s assertions that their approach to indoor visiting had been overly restrictive or detrimental to A’s health.

We took independent advice from a social worker. We found that relevant national and local guidance at that time had been constantly subject to change, making the situation extremely challenging. While there was no specific guidance for group homes, it had been reasonable for the partnership to follow guidance applicable to care homes and it had been at their own discretion to assess whether indoor visits could be reintroduced safely at A’s group home. We did not find any evidence to support the view that visiting arrangements imposed by the partnership had been unreasonable or overly restrictive. Therefore, we did not uphold this part of C’s complaint.

We also found that the partnership had made reasonable attempts to provide support to A to maintain communication with their family during restrictions. We also found that C’s concerns regarding A’s welfare had been taken seriously by the partnership, and in accordance with relevant adult support and protection practices and procedures. We did not uphold these parts of C’s complaints.

We found there was evidence of ongoing communication between C and the partnership throughout the pandemic regarding A’s wellbeing. However we identified that C, in their capacity as welfare guardian, had not always been included in discussions about A’s forthcoming medical appointments. We found no evidence to suggest this failing was in any way harmful to A and it had been reasonable for the partnership to adhere to advice they had received from A’s GP that A should shield. On balance, we did not uphold this part of C’s complaint, however we did provide feedback to the partnership, specifically that it is considered good practice in residential care setting, that welfare guardians are informed on matters involving medical appointments.

Summary

C complained about the orthopaedic care (conditions involving the musculoskeletal system) and treatment that they received from the board. C had a wrist injury and underwent an initial operation and a second operation three years later. C complained that the reason for the second operation was because the first operation carried out had been ineffective and that mistakes had been made.

C also complained that they had been allocated two community health index (CHI) numbers which had unreasonably impacted on the care and treatment that they received from orthopaedics.

We took independent advice from a consultant orthopaedic surgeon and a consultant radiologist. We found that the orthopaedic care and treatment C received was reasonable and we did not uphold this complaint.

We also found no evidence that the issue of CHI numbers had impacted on C’s care and treatment regarding their two operations. We did not uphold this complaint.

Summary

C complained about the treatment they received from the board following a knee injury. C’s injury had occurred when level 3 of the Scottish Government’s COVID-19 lockdown measures were in place, which limited travel between local authorities to essential travel only. C’s accident had occurred outwith their own local authority area. C complained that the A&E staff repeatedly asked them about their local accommodation and travel arrangements. C reported that they were only admitted to hospital for one night, and they were obliged to make their own travel arrangements for their discharge the next day despite experiencing severe pain.

The board said that C had been timeously assessed and treated at the A&E, with orthopaedics (specialists in the musculoskeletal system) taking over their care due to the diagnosis of a displaced fracture with foot drop. C’s injury had been immobilised with a knee brace and they were assessed using crutches by physiotherapy prior to discharge the next day, with the plan being for C to travel back to their own health board area to arrange further care and treatment of their injury. C was given an immediate discharge letter to pass to the receiving clinical team and a prescription for pain killers.

We took independent advice from an orthopaedic consultant. We fond that the board’s treatment of C was reasonable, both in terms of the type of injury they had sustained, and in keeping with the guidance in place at the time for management of orthopaedic injuries during the pandemic. We considered it was appropriate for A&E staff to enquire about C’s travel and accommodation arrangements to help inform their plan of care. They also commented that without lockdown measures in place, C’s injury would have required transfer to a specialist centre for surgical reconstruction. However the guidance at the time had been appropriately followed by the board for non-operative management of the injury with later reconstruction. Therefore, we did not uphold C’s complaint.

Summary

C complained about the maternity care they received from the board when they gave birth to their twins. C was suspected to have COVID-19 and this was confirmed the day after delivery.

C complained that they were placed in a room that wasn’t equipped for labour and that they were pushed towards a vaginal delivery, rather than a planned caesarean section. The board explained that the labour room was set up with equipment stored outside the room for infection control purposes. C also complained that they weren’t provided with appropriate postnatal care.

We took independent advice from a midwife. We found that the records supported reasonable decision making surrounding the delivery method and that appropriate discussions had taken place with C in this regard. We also considered that the records evidenced a reasonable standard of postnatal care and that the decision to store equipment outside the room was reasonable. Therefore, we did not uphold this part of C's complaint.

C was unable to see their babies in the neonatal intensive care unit (NICU) until after their COVID-19 isolation period ended. C complained that it wasn’t explained to them why they weren’t allowed skin to skin contact before the babies were taken away to the NICU. C also complained that there was no clear process in place for them to see their babies and that staff were initially unable to tell them when this would happen. The board acknowledged that C did not receive an explanation as to why skin to skin contact was not allowed. We noted that the board had asked staff to reflect on C’s negative experience of communication and we were satisfied they had demonstrated learning from this.

We found that the restrictions in place for visiting the NICU were reasonable, that there were clear processes and guidelines in place to support this, and that the records showed this was appropriately communicated to C. Therefore, we did not uphold this part of C's complaint. We provided complaint handling feedback to the board as we noted some inaccuracies in their responses to C.