Some upheld, recommendations

Summary

C complained about the standard of surgery and post-operative care that they received when they had an elective operation for a long standing hernia (when part of an organ protrudes through your muscle wall). During the procedure the bowel was punctured resulting in an injury and transfer to another hospital.

C said that the small hernia was manageable without an operation, and complained that they had not been told about all the risks and about inadequate care post-surgery.

We took independent advice from a consultant general and colorectal surgeon. We found that it was reasonable to offer C an elective repair of the hernia and for this operation be to done by the consultant surgeon. However, more regard should have been given to whether C was at an increased risk due to their BMI. We found that the board failed to provide informed consent at an appropriate time which meant that the risks of surgery were not effectively communicated to C. We also found that the consent process for C did not meet published guidelines. Therefore we upheld this complaint.

We found that post surgery, recognition and escalation to start Patient Controlled Analgesia was appropriate, and that C responded well to this pain relief. The timing of the CT scan was reasonable. Following escalation to clinical care specialists and treatment, C was transferred for further care which was also reasonable. We therefore did not uphold this complaint.

We provided feedback that consideration should be given to the preoperative risk assessment being carried out at consultant level and that referral to specialist weight management is available for patients who require incisional hernia repairs electively.

Recommendations

What we said should change to put things right in future:

• Relevant staff should be aware of the required consent procedure and to ensure that the consent discussions are appropriately timed in advance of surgery and documented.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C raised concerns about the care and treatment provided to their sibling (A). A underwent a series of hospital admissions, suffering from bleeding from their bladder, following radiotherapy. During these admissions, the majority of communication between the board and the family was with A’s partner (B). A was initially expected to recover from the radiotherapy but was admitted and discharged repeatedly, with some readmissions happening a matter of hours after A was discharged. A continued to deteriorate and died in hospital.

C believed that A was not provided with an adequate standard of urological or nursing care. They felt that A was not provided with appropriate treatment and that they were not reviewed properly by other medical specialties, given the complexity of their case. C was also concerned that A was not provided with adequate nursing care. C believed that the board had not acknowledged systemic failings which impacted on A’s care, wellbeing and adversely affected the outcome of their treatment.

We took independent advice from a consultant urologist and a registered nurse. We found that A’s urology care fell below a reasonable standard, as did their nursing care and we upheld these aspects of the complaint.

We found that A was reviewed appropriately by other medical specialties and this aspect of C’s complaint was not upheld.

Finally, the opportunity to perform surgery on A was missed and this contributed to A’s deterioration. It was not possible, however, to determine whether A would have survived if their care had been different. The board failed to transfer A to a different consultant or offer a second opinion when this was requested and they failed to communicate reasonably with A’s family about their care. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should apologise separately to C & B for the failures in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Improved management of long-term or complex patients, with clear communication between different medical specialties. The board should review the management approach to long-term complex patients, focusing on the shared care arrangements between differing specialties.
• Patients admitted to hospital should receive appropriate nursing care including appropriate nutritional and fluid intake monitoring, when requested as part of their care plan.
• A review of whether urology patients can be provided with a dedicated ward, or part of a ward.
• Consultant care transfer and second opinion requests should be managed reasonably and transparently.
• Patients should receive adequate nutritional support to support their treatment and recovery. The board should develop an action plan, reviewing A's case and identifying learning for the staff involved in A's care.
• Patients admitted to hospital should receive reasonable medical care including being offered appropriate treatment options, nutrition, and review after transfer from HDU. Clinical correspondence should be completed to an appropriate standard.
• Patients admitted to hospital should receive appropriate nursing care including appropriate recording of their patient centred care plan.
• Patients admitted to hospital should receive appropriate nursing care including recording and management of wounds or pressure injuries.
• Decisions on surgery should be explained to the patient whenever possible, allowing the patient or their family to make informed decisions about their treatment.

In relation to complaints handling, we recommended:

• Complaint responses should be clear and written in plain English whenever possible. Where clinical terms or technical language is used, this should be clearly explained in the body of the letter.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide their parent (A) with reasonable care and treatment when they attended the A&E with symptoms including a loss of sight in one eye. C raised concerns about the delay in assessing A and failures by staff to reasonably diagnose and treat A. C also said that the board failed to reasonably communicate and provide A and C with sufficient information after A was taken to a cubicle, to provide A with appropriate personal care, to adequately record information about A’s care and treatment and to follow the relevant policies and procedures in providing care and treatment to A.

We took independent advice from a consultant neurologist and a nurse. We found that there was an unreasonable delay in A being assessed by a doctor. We also found that there was poor record keeping in A’s medical and nursing records, which showed the level of care and observation A had received was unreasonable. We found that, had A’s observations been recorded as required, it was possible that a deterioration in A’s condition would have been picked up sooner. Consequently, we found that the care and treatment provided to A in the A&E was unreasonable. We, therefore, upheld this part of C’s complaint.

C also complained that, after A was transferred to the high dependency unit, a consultant neurologist failed to sensitively explain to them about A’s diagnosis and prognosis. We found that adequate and appropriate information was conveyed to C by the consultant neurologist and the communication between them had been clinically appropriate and satisfactory. It was not possible to determine whether or not the consultant neurologist had failed to explain this sensitively. We did not, therefore, uphold this part of C’s complaint.

C further complained that a senior research nurse failed to take reasonable steps to contact them regarding a stroke research study. We found that there was a failure to take reasonable steps to contact C regarding the stroke research study. We, therefore, upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• A significant adverse event review should be carried out.
• Basic observations should be carried out to the frequency required for the presenting condition of the patient to allow any deterioration in the patient to be identified timely and acted on as soon as possible. Records should be accurate and reflect the care and interventions carried out to the standard required by the Nursing and Midwifery Council.
• Where a patient safety incident occurs, a datix should be completed. There should also be evidence of reflection and learning for the staff involved in relation to such incidents.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late parent (A) who was diagnosed with lung cancer. C considered that there had been missed opportunities to diagnose A earlier, and that as a result A was denied appropriate care which may have affected their outcome. C also complained that the cause of death determined by the board was inconsistent with A’s diagnosis. Additionally, C complained that the cause of death was amended at a later date, which caused them to doubt the accuracy of the board’s conclusions.

In their complaints response, the board stated that X-rays conducted earlier in the year had been reviewed and that radiologists were in agreement that A’s disease could not have been identified earlier. The board had also apologised that the cause of death had initially been determined to be hospital acquired pneumonia, and that this had now been corrected to community acquired pneumonia with lung cancer as the major contributing cause.

We took independent advice from an experienced respiratory consultant. We found that it was not unreasonable that A’s cancer had not been detected on earlier X-rays. However, a decision to downgrade a GP’s referral from ‘urgent suspicion of lung cancer’ to ‘new urgent’ created delays in investigations of approximately four weeks, and likely longer had A not been admitted to hospital unrelated to the referral. Further delays of around three weeks were also apparent between the final investigation and the final multidisciplinary team (MDT) discussion. We also found that it was unlikely that there would have been a different outcome for A due to the nature of A’s illness. As such. we upheld C’s complaint.

Regarding the cause of death, we found that the cause of death had been correctly identified in line with the available information and that whether the pneumonia had been hospital or community acquired was a technicality that was less significant than the overall conclusions. Based on this, on balance, we did not uphold this aspect of the complaint that there had been inaccurate or misleading information provided.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• There should be a robust system in place for triaging respiratory referrals, which should only be downgraded when there is a clear clinical reason to do so. All patients with suspected cancer undergoing investigations should be appropriately tracked to prevent delays.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that their adult child (A) received from the board during three admissions to hospital with non-epileptic seizures.

A is a prisoner and has a learning disability and autism. C is A’s welfare guardian. In terms of the guardianship order in place at the time relevant to the complaint, C was granted the power ‘‘to consent or withhold consent to medical or dental treatment and to require the Adult to comply with such treatment and to administer such medications as may be prescribed for the Adult’ and ‘To decide and approve the appropriate level of health and social care for the Adult".

C complained that they had not been appropriately involved in A’s care, despite holding the guardianship order. C complained that the board gave non-emergency treatment to A knowing that they were deemed to lack capacity to make that kind of decision.

We took independent clinical advice from a neurology adviser, who referred to the Adults With Incapacity (Scotland) Act 2000 (AWI), the code of practice for practitioners and relevant guidance.

We noted that A’s presentation was complex. We found that the board carried out appropriate investigations and provided reasonable care and treatment during each of A’s admissions. We did not uphold this aspect of C’s complaint.

We found that when C raised the matter of guardianship with the board during a telephone call, the board ought to have done more to explore this further. Guardianship paperwork should have been included in A’s records, with AWI paperwork completed appropriately for each admission. Whilst it was appropriate for the board to carry out emergency treatment without consulting the guardian, C ought to have been consulted in relation to all non-emergency treatment. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinical and nursing staff are familiar with Adults with Incapacity legislation and guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their family member (A) during their admission to hospital, following a fall at their home. A was admitted to hospital after falling unwell, and for management of their underlying heath issues.

A was discharged but had to be re-admitted to hospital two days later. C raised concerns that A did not receive appropriate care and treatment during their admission, that they should not have been discharged and that medical staff did not properly communicate A’s care plan during the admission.

In response to the complaint, the board explained that staff were aware of, and managed, A’s pre-existing health conditions and that appropriate investigations were undertaken to investigate their symptoms. A’s weight loss during admission was noted and the board explained monitoring of this aspect of their care could have been better. The board explained that A was assessed as being medically fit for discharge and this was discussed with family.

We took independent advice from a consultant in the care of the elderly and from a registered nurse. We found that whilst the general management of A’s underlying health conditions and symptoms was reasonable, in the initial days of their admission A was administered within correct medication and there was a missed opportunity to perform an x-ray to investigate A’s symptoms. For these reasons, we found that A’s care and treatment was unreasonable.

We also found that medical staff failed to recognise the status of A’s family members as Power of Attorney, and did not appropriately communicate with A or their Power of Attorney with respect to their care. The communication with A and their family was unreasonable. We upheld this complaint.

Finally, we found that appropriate assessments were carried out to determine A was fit for discharge and we did not uphold this complaint

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinicians should be aware of the importance of ensuring patients are prescribed appropriate medication for pre-existing medical conditions. Clinicians should ensure that appropriate investigations and assessments are carried out for patients on admission to hospital.
• The board should be aware of, and follow Assessment, Planning, Implementation and Evaluation processes. As such the Board should keep appropriate documentation to evidence basic care provided to patients.
• Clinicians should be aware of the legislation with respect to the AWI process and the importance of ensuring POA’s are identified and included in communications and decision making around relevant patient care.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board.

We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that the medical care after A’s falls was reasonable. We found that the board had taken reasonable and proportionate actions to acknowledge, apologise for and support learning and improvement regarding the provision of pain relief and a delay in reviewing an x-ray after A’s first fall. We found that the board did not reasonably handle A’s prescriptions for haloperidol (a sedating medication) or codeine (a type of painkiller). On balance, we upheld this part of C’s complaint.

We took independent advice from a registered nurse. We found that the care and treatment regarding A’s falls was unreasonable, as a mechanical aid should have been used to assist A from the floor, and risk assessments and care plans should have been updated. We found that A should have been more closely supervised prior to their second fall. We also found that the board’s post-fall protocol was not reasonable in its current form. Finally, we found that A’s hygiene needs were not reasonably met in hospital. The board had taken some action to support learning and improvement regarding the management of falls. On balance, we upheld this part of C’s complaint.

We took independent advice from a physiotherapist. We found that the care and treatment provided to A was reasonable, and physiotherapy sessions were appropriate, timely and sufficient, considering A’s clinical presentation. We did not uphold this part of C’s complaint.

Additionally, we found that some points of the board’s complaint response were incomplete and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified by this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Patients with dementia should receive regular assessments of the benefits of medication, with consideration given to stopping or reducing medication when possible, and patients' families/carers should be informed appropriately.
• Nursing staff should handle falls using safe handling techniques in order to reduce risk to patients and staff. Nursing staff should have access to a reasonable and up-to-date post-falls protocol.
• Nursing staff should ensure patients' physical needs are appropriately assessed and responded to.

In relation to complaints handling, we recommended:

• The quality of the complaint response is very important and should address all the issues raised and demonstrate that each element has been fully and fairly investigated.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their adult child (A). A had addiction issues and was admitted to intensive care with a head injury after a fall. They were later transferred to a different hospital and onto a ward after their condition improved. A received treatment from the addiction team while in hospital and following further scans and reviews, was deemed fit for discharge. A died at home shortly after discharge.

C complained that the board failed to provide A with a reasonable standard of medical or nursing care. They also said that the board failed to communicate appropriately with social services or community addiction services prior to A’s discharge.

We took independent advice from a consultant neurosurgeon (specialist in surgery of the nervous system, especially the brain and spinal cord) and a nurse. We found that both the medical and nursing care A received was appropriate. Therefore, we did not uphold this aspect of C's complaint. However, we found that A's discharge did not adequately consider their vulnerability and whether A would be safe in the community. We considered that the board did not communicate appropriately with social services and addiction services. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in the report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

What we said should change to put things right in future:

• When discharging vulnerable individuals, particularly when they live alone, the board should ensure that the level of support being provided in the community is recorded. Where appropriate, this should be discussed with the patient and /or their family as well as social services.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C suffered with lower back and right hip pain. C complained about the care and treatment provided by the practice in relation to their diagnosis of Hip Osteoarthritis. C said that despite raising concerns with the practice, they failed to take appropriate action to ensure C’s symptoms were further investigated.

We took independent advice from a qualified GP. We found that the management of C’s symptoms was reasonable and appropriate steps were taken to investigate C’s symptoms. We did not uphold this aspect of the complaint.

With respect to the handling of C’s complaints, we found that the practice’s complaints handling procedure was not compliant with current requirements. We also found that, whilst their complaints response demonstrated that they had investigated the complaint, the practice unreasonably failed to provide further response to C’s subsequent communications or the communications from our office. We therefore upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonably failing to provide an appropriate response to C’s concerns and to the communications of our office requesting a further response to C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The practice should provide complete responses to complaints raised. Those handling and responding to complaints should be aware of the complaints handling procedure and the importance of providing full responses both to complainants and the SPSO.
• The practice's complaints handling procedure is consistent with and reflects the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C’s parent (A) was admitted to the hospital's A&E three days after a fall. A had a complex medical history including chronic pain. On admission, A reported lower right-sided chest pain, associated with gradually increasing shortness of breath. A chest X-ray showed no evidence of r ib fractures but a subsequent CT scan showed multiple right-sided rib fractures (from ribs 3-10), a flail segment (when three or more consecutive ribs are fractured in two or more places, causing a segment of the rib cage to become detached from the rest of the chest wall), an intercostal haematoma (solid pooling of blood between the ribs) and a right sided pleural effusion/haemothorax (build-up of fluid/blood between the ribs). A was treated in the Intensive Care Unit (ICU) for one week before being stepped down to the Medical High Dependency Unit (MHDU). A was reviewed by the ICU team as and when required and after becoming acutely unwell they were transferred to ICU again, where they died a few days later.

In relation to A’s admissions to MHDU, C complained about problems with A’s medication, concerns around pain management and the nursing care A received, in particular issues around fluid and nutrition, and not responding to alarms or adhering to observational guidelines. C also complained that staff in the MHDU failed to provide appropriate care and treatment in response to A's deterioration.

We took independent advice from a consultant in critical care and a senior critical care nurse. We noted that management of A’s condition was complex given their history of chronic pain together with a severe acute injury. We found a number of failings in A’s pain management, including doses of sustained release oxycodone being administered outwith the appropriate dose interval, an increase in dose of oxycodone which was not clearly justified, and lack of involvement of the acute pain service for ongoing support after A returned to the MDHU from ICU. Taking all of this into account, we found that the board failed to provide a reasonable standard of pain management and upheld this aspect of C’s complaint.

We found that NEWS (National Early Warning Score, a tool for identifying deterioration of patients in acute settings) observations were irregular and that there was evidence that nursing staff failed to escalate appropriately when NEWS scores were 5 and above. Nursing records were lacking in detail and there was no evidence of A receiving oral care. On balance, we upheld C’s complaint about the standard of nursing care.

We found that overall the response to A’s deterioration was reasonable. A was regularly reviewed by consultants, with escalation as appropriate. We did not uphold this aspect of C’s complaint. However, we were critical of the board’s complaint handling, noting long delays in compiling the complaint response and a failure to keep C updated, and that the board’s own investigation did not identify failings picked up by our own investigation.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified as a result of our investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Observations are undertaken in accordance with the board’s observations policy and National NEWS Scoring and Guidance, with appropriate escalation. Nursing staff have an understanding of Person Centred Care Plans. Documentation is sufficiently detailed.
• Opioids are administered strictly in accordance with relevant dose periods. Decisions to increase medication doses are clinically justified.
• The board should review how patients with severe chest trauma are managed by the acute pain service after regional analgesia has been removed, and the patient has been stepped down from critical care. Their consideration should include triggers for referral and consideration of policies to ensure that access to the acute pain service for this group of patients is not determined by the choice of step-down environment or nominated parent team, but rather by the extent of the patient’s injuries and likely complexity of their ongoing analgesia management.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Additionally, learning from complaints should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.