Some upheld, recommendations

Summary

C complained that the board failed to consider their request for bariatric surgery reasonably. C also complained that the board failed to handle their complaint reasonably. C suffers from complex physical and mental health issues. They were referred for bariatric surgery by the clinicians treating their medical conditions. C attended a number of assessment appointments to determine their suitability for surgery. C was concerned by the assessment process and asked to see the report being submitted to the Multi-Disciplinary Team (MDT) meeting but this request was refused. C was not accepted for surgery.

C received a copy of the assessment report through a subject access request. C was told by the board that they would accept a complaint from C if their complaint was made within 12 months. C complained a few months later. The board delayed in acknowledging and responding to the complaint but met with C to agree how the complaint would be handled. The following month, the board wrote to C stating that they would not investigate the complaint, because it had been submitted outwith the time limit for investigation.

We took independent advice from a consultant psychologist. We found that C should have been allowed the opportunity to provide feedback on the assessment process before it was discussed at an MDT. C had been promised an appointment to do this, but the appointment was not made. However, we considered that the assessment itself had been reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to complaints handling, we found that C was not properly informed about the process that the board intended to follow and was repeatedly given the impression that the case would be investigated. The board did not demonstrate how it had determined C’s complaint was out of time. 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. 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 board should have robust administrative systems in place to ensure appointments are arranged as intended and that patients are effectively communicated with.
• In relation to complaints handling, we recommended
• The board should provide us with an update as to any procedural changes that have been made to ensure patients’ individual needs are considered when they make a complaint.
• The board should ensure timebar decisions reference the relevant board guidance.

Summary

C complained about the care and treatment provided to their parent (A) in relation to a number of hospital admissions. C complained that A was discharged without clear advice as to whether they had sepsis, and how to manage A’s condition. C also said that the board did not provide a discharge letter. C complained that when A attended hospital four days later, they should have been admitted rather than being sent home with oral antibiotics. Lastly, C said that when A was readmitted to hospital the following month, a day passed before they were seen by a consultant.

We took independent advice from a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that, while A received appropriate care during their initial admission, the board's communication around A's sepsis was unreasonable. They also did not provide an interim discharge summary.

In relation to A's second discharge, we found that A's symptoms raised the possibility of a complicated kidney infection. Therefore, we considered that discharging A with oral antibiotics was unreasonable. A should have received treatment with IV antibiotics and consideration should have been given to admission, which may potentially have prevented the need for A to be admitted the following month. We upheld these parts of C's complaint.

Finally, we found that A's condition when they were readmitted did not meet the criteria for an urgent consultant review. Therefore, we did not uphold 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 this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Decisions on admission and treatment with IV antibiotics should be in keeping with European Association of Urology (EAU) guidelines on Urological Infections and The UK Health Security Agency guidance on antimicrobial intravenous-to-oral switch (IVOS) criteria for prompt switch for adults.
• Immediate discharge letters should be issued at the time of discharge and patients and where applicable their families, should receive appropriate advice on discharge which should be documented in the patient’s medical records.
• Patients with sepsis and their family members and carers should be given opportunities to ask questions about a diagnosis, treatment options, prognosis, and complications. There should be a willingness to repeat any information as needed.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C had a bilateral total knee replacement surgery, which was carried out by another organisation. Approximately three weeks after their surgery, C was admitted to a hospital within Forth Valley NHS Board following a fall. Approximately three weeks after C’s discharge, C had surgery to repair a tendon in their right quadriceps (thigh muscle), which was carried out by another organisation.

C complained about the care and treatment that they received in hospital during their admission and the care and treatment that they received from the outpatient physiotherapy service over the next six months.

The board said that the presentation of C during their hospital admission was a common presentation following knee replacement surgery and very similar to the presentation for an injury to the quadriceps. The board said that the outpatient physiotherapy guidance was followed when treating C.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system) and a physiotherapist.

We found that the board failed to consider a right-sided quadriceps tendon injury when C was seen by a consultant in hospital, failed to reassess C during their admission and failed to escalate C when C did not progress when in hospital. On this basis, we upheld this part of C’s complaint.

In relation to the physiotherapy service, we found that the exercises C received were in line with post-operative guidance and that physiotherapists followed protocols for treating C. We did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• The Morbidity and Mortality meeting scheduled should include input from physiotherapy; discuss appropriate escalation procedures, including who to contact if a consultant is unavailable; and how patients are reviewed as inpatients, with a view to reviewing patients daily.

Summary

C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died.

We took independent advice from a nursing adviser and consultant geriatrician (specialist in medicine of the elderly). In relation to nursing care, we found failings with A's nutrition, pressure care, person centred care planning, and documentation. We upheld this part of C's complaint.

In relation to medical care and treatment, we generally found this to have been reasonable and did not uphold this part of C’s complaint. However, we provided feedback to the board regarding starting oral nutrition supplements in line with Scottish Hip Fracture Guidance.

Finally, we found that there were delays in the handling of C's complaint and the board failed to fully address of all C's concerns. The board had acknowledged these failings and taken action to address them. Therefore, we upheld this part of C's complaint but made no further recommendations in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings in nursing care provided to A, and the failings in complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Appropriate assessments should be accurately completed in a timely manner to identify patients at risk of or with existing pressure sore damage. Those patients should receive appropriate and timely pressure sore care in accordance with relevant local and national guidance.
• Malnutrition Screening should be completed in a timely manner and repeated as appropriate. Food charts should be completed accurately.
• Person-centred care planning should be completed for every patient, and documentation should support this.

Summary

C complained about the medical and nursing care they received for a spinal condition. C said the care led to avoidable complications and delayed their transfer to a specialist spinal unit.

We took independent advice from a consultant in orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and a registered nurse. We found a number of failings in the nursing care C received. This included poor record keeping and a failure to manage C’s skin care appropriately. This led to avoidable pressure injuries which were a significant factor in delaying C’s transfer. In terms of medical care, we found that the ward C was placed on lacked the necessary equipment to manage a patient in their condition. We found the medical and nursing care C received fell below a reasonable standard and upheld these parts of C’s complaint.

C also complained that the board failed to provide them with a reasonable standard of physiotherapy. We found that C’s physiotherapy care was of a reasonable standard and was well documented, showing regular review up to the point physiotherapy was stopped on medical advice. Therefore, we did not uphold this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide them with a reasonable standard of medical and nursing 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:

• Wound charts should be in place for pressure wounds and there should be subsequent weekly assessments. Care rounding should be delivered to the frequency required to prevent pressure damage. Patients should be appropriately moved position to avoid worsening pressure damage.
• Nursing staff correctly follow CPR for feet guidelines and develop person centred treatment plan for patient foot care.
• Patients should be transferred to a hospital and ward which can provide the care they need.
• That a duty of candour review is considered in light of the SPSO's findings.
• When a relevant adverse event occurs, the board should complete a SAER.

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 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.