Some upheld, recommendations

Summary

C complained about the care and treatment that their spouse (A) received during two admissions to hospital. C complained that the board had failed to provide A with adequate personal care during both admissions and failed to adequately manage their medication during their first admission. C also complained that A had been unreasonably discharged following their first admission and that there had been inadequate preparation for A’s second discharge.

The board apologised for failures in A’s care and for aspects of their communication. They also apologised for a failure to adequately prepare A’s medication prior to their second discharge. They identified learning from these failures. However, C remained unhappy and asked us to investigate.

We took independent advice from a consultant in geriatric medicine and an advanced nurse practitioner. We found that A was unreasonably discharged at the end of their first admission. Therefore, we upheld this part of C’s complaint. However, the board managed A’s medication reasonably and provided adequate personal care during A’s first admission. Therefore, we did not uphold these part’s of C’s complaint.

In relation to A’s second discharge, we found that there had been a failure to provide A with adequate personal care and that they had been discharged at the end of this without adequate preparation. We upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and to A 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:

• Where a patient has a lack of bowel movements for several days, this should be highlighted and discussed with the relevant nursing, medical and allied healthcare teams.
• Where blood tests have been carried out, the patient’s results should be reviewed prior to their discharge.
• Where there is a delay in a patient being discharged, they should receive any medications they are due whilst waiting to be discharged. Patients should receive all appropriate prescribed medication when they are discharged. All relevant patient discharge documentation should be completed.
• Staff should obtain the precise details of a patient’s usual medication regime for Parkinson’s and act upon this to improve 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 complained about the care and treatment provided to their parent (A) by the practice. A was described as fit and well but had developed severe diarrhoea. Although the diarrhoea subsided, A continued to feel unwell and breathless. A was seen by an advanced nurse practitioner (ANP) and referred for an electrocardiogram (ECG) as an outpatient a few days later. A attended for these tests, but was not seen by a doctor, and returned home. A suffered a stroke that afternoon and died in hospital the following day.

C complained that although A spoke with a doctor by telephone, they were not seen in person by a doctor over a series of appointments. C believed that A should have seen a doctor much sooner and that A should have been considered for hospital admission at their appointment with the ANP. They also said that A’s ECG results were abnormal, had been misinterpreted by the practice and should have resulted in A’s admission to hospital as an emergency. C believed that had the practice provided a reasonable standard of care, A’s death could have been prevented. Although C met with the practice and received two responses to their complaint, they continued to believe the practice’s response was inadequate and brought their complaint to this office.

We took independent advice from a GP. We found that A’s care prior to their ECG was of a reasonable standard. It was noted that C disagreed with A’s medical records, but it was not possible to determine precisely what was said at A’s appointments. We did not uphold these parts of C’s complaint.

We found that A’s ECG was highly abnormal, indicating A’s heart was lacking in oxygenated blood flow. This should have resulted in a face-to-face appointment, followed by an immediate hospital referral. Therefore, we upheld this part of C’s complaint. However, it was not possible to determine whether A would have survived with an earlier admission as the cause of A’s death was a bleed on their brain. This was an unfortunate but recognised side effect of the medication given to A to treat the stroke they had suffered.

Finally, C complained about the practice’s complaint handling. We found that the practice failed to handle C’s complaint reasonably and upheld this part of their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A’s family for the failure to provide A with a reasonable standard of care on the day of their ECG. 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:

• ECG results should be accurately interpreted, taking into consideration the condition of the patient and their medical history.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure.
• The practice’s complaint investigations should ensure that failings are accurately identified.

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 them with reasonable care and treatment when they attended the emergency department with pain and swelling in their leg. C was advised that their symptoms did not indicate a pulmonary embolism (a blood clot that blocks a blood vessel in the lungs) and that they were on appropriate medication. C was also referred to the deep vein thrombosis (DVT, a blood clot in a vein, usually in the leg) clinic for further investigation.

We took independent advice from a consultant in emergency medicine. We found that the medical care and treatment provided to C in the emergency department was reasonable. Therefore, we did not uphold this part of C’s complaint.

C also complained about the care and treatment that they received when they attended the DVT clinic several days later. C was advised at the clinic that it was highly unlikely that they had a DVT. However, around two weeks later, C attended the emergency department again due to worsening symptoms. C was diagnosed with a pulmonary embolism.

We took independent advice from a consultant in general medicine. We found that an advanced nurse practitioner did not give sufficient consideration to C’s significantly high D-Dimer blood test result (a test used to check for blood clotting problems) and did not seek input from medical staff. In addition, the board’s DVT protocol at the time was too simplistic to take into account all of C’s risk factors. It did not mandate the recording of those risk factors and deviated from the national guidance at the time, which recommended a repeat scan six to eight days later. Therefore, we upheld this part of C’s complaint.

C also complained about the Significant Adverse Event Review (SAER) the board had carried out. We found that the SAER fully recognised the omissions in the board’s protocol and changes were subsequently made to this. However, when carrying out the SAER, the review team did not seek input from C in line with national guidance. 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:

• All relevant staff should be aware of the board’s revised DVT protocol.

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 and their autistic child took up their tenancy, having been offered the property following assessment for priority for allocation.

C reported anti-social behaviour that they were experiencing from neighbours to the council. The behaviour ranged from communal areas being untidy and vandalised, to evidence of drug taking, loud noise and aggressive behaviour from neighbours and others entering the block.

C was dissatisfied with the action that the council took in response to numerous reports of anti-social behaviour, and they were very concerned about the impact that this was having on their child. C was also dissatisfied with the council’s handling of their application to be allocated another tenancy in a different area, and their refusal to consider sheltered housing given their child's needs.

The council responded to C’s concerns explaining that they had responded appropriately to reports of anti-social behaviour and did not uphold C's complaint. The council also explained that they considered that C’s initial allocation of housing was appropriate and in accordance with policy.

We found that the council could not evidence that they consistently responded to C’s concerns of anti-social behaviour inline with their policy and upheld this complaint on this basis. With respect to the complaints on the assessment of C’s housing application, we found that this had been assessed in accordance with policy and did not uphold the 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:

• Relevant council staff should be aware of the relevant policies including Antisocial Behaviour Neighbour Complaints Policy and Procedures , with respect to logging, investigating and responding to complaints of anti-social behaviour by tenants.

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 on behalf of their spouse (A) about the standard of care and treatment received in the months before A died. The board partially upheld the complaint, including failings in communication and a lack of privacy and dignity shown to A.

We took independent advice from a registered nurse. We found that while the board had acknowledged some failings, they had not identified other issues with person-centred care planning, care delivery and documentation. We therefore upheld this part of the complaint.

C complained that the board had failed to communicate with A and their family to a reasonable standard. The board acknowledged that despite C being A’s carer, and it having been agreed to utilise email communication, information was not always shared with the wider team, which may have contributed to C’s perception that communication was lacking. We found that the board’s position that there was no record of any upset between A and individual staff members was factually incorrect. We thereby upheld this part of the complaint.

C complained that there was no record of a care plan, and that the package of care was not adequate for A’s needs. The board acknowledged the lack of a suitable care package had an impact on discharge planning, and that they had failed to establish a more detailed person-centred care plan once A was discharged. We found that there was detailed planning and discussion around discharge involving C and A. We did not uphold this element of the complaint because, on balance, while the delivery of care did not match C and A’s expectations, this did not make the plan unreasonable in the circumstances.

C also complained that the board’s response to their complaint was unreasonable and delayed. We found that C’s complaint was complex and multi-faceted accounting to some extent for the delay. However, the response had inaccuracies and failed to identify all the failings in care. For that reason, on balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in this case. 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 ensure that person centred care planning is person specific and staff are knowledgeable on how to create a person-centred care plan; that care rounding is completed appropriately, that pain is assessed to the appropriate level and using the correct tools, that privacy and dignity is maintained by all staff for all patients and that staff are aware of how to promote continence and are competent in the use of products used to promote continence.
• Communication with patients and families should be person-centred, full, and accurate.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and identify all failings.

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 Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, C was admitted to the Orthopaedics department of Board 2’s hospital and an MRI was carried out the following day. The MRI scan results were discussed with the Board 1's neurosurgery team, following which C was discharged. C later required emergency surgery and considers the outcome would have been better if they had undergone surgery when they originally attended hospital.

When C complained to Board 2, they confirmed that they had relied on the Board 1’s specialist advice but Board 1 had failed to keep a record of the referral. C complained that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. C also complained about the neurosurgery advice provided by Board 1 to Board 2.

We took independent advice from a consultant orthopaedic surgeon in relation to the complaint about maintaining accurate records. We found that Board 1 unreasonably failed to maintain records of the specialist advice provided to Board 2. We upheld the complaint.

We took independent advice from a consultant neurosurgeon in relation to the complaint about neurosurgery advice. We found that C had been appropriately assessed with a thorough examination. As such, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing 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 system is in place which ensures when advice is provided by the board for tertiary patients there is a record of this as a permanent part of that patient’s electronic record.

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 parent (A). A had presented with foot pain and initially had been thought to have Plantar Fasciitis (an inflammation of the tissue along the bottom of the foot). A later returned to the practice with an infected toe, which failed to respond to antibiotics. A was referred to vascular medicine and later underwent surgery in hospital, but died a few months later. C believed that A should have been referred to vascular medicine sooner, as A was at high risk and displayed symptoms of vascular disease. C was also unhappy with the language used in the complaint response that the family received.

We took independent advice from a general practitioner. We found that A was given a reasonable standard of treatment and care. There was no evidence that symptoms of vascular disease were dismissed or overlooked. We did not uphold this aspect of the complaint. In relation to the language used in the complaint response, we found that the complaint response was inappropriately informal and contained some errors, which added to the family’s distress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the inappropriate language and incorrect dates in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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 council had failed to address excessive noise from a recreational area near their home. We found that the council had taken appropriate action in relation to C’s complaints of noise nuisance and did not uphold C’s complaint. However, we did provide the council with feedback on ensuring they carry out visits within a reasonable timeframe where they have agreed to do so, or contact the customer to explain why they are unable to do so.

C also complained about the council’s handling of their complaint. C raised a complaint with the council about the high levels of noise from the recreational area. The council responded on the same day saying that they could not consider noise nuisance under their complaints procedure as the nuisance was not being caused by the council or by any maladministration on behalf of the council. C was advised to engage with the appropriate council service regarding monitoring and establishing the noise nuisance and was signposted to the SPSO if C felt they were not responding to what they considered to be complaints.

We found that the council unreasonably failed to act in line with the Model Complaints Handling Procedure by refusing to further respond to C’s complaint. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the Local Authority 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 complained on behalf of a relative (A) who had a learning disability and had been prescribed a special adjusted diet according to the International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. A had choked on their food and required emergency care. C complained that A’s food, a takeaway meal, had not been suitable for them and had not been prepared in line with their adjusted diet. They considered that this and other failings caused the near fatal choking incident.

We took independent advice from a speech and language therapist. We found that it was reasonable for staff to have obtained a takeaway meal for A and did not uphold this part of C’s complaint. However, we found that staff had failed to follow guidance and ensure that an assessment had been carried out as to whether this meal was safe for A, and that they failed to prepare the meal for A in line with their adjusted diet. Therefore, we upheld these complaints. In addition, we upheld complaints that the partnership had failed to provide A with the correct cutlery and that they failed to appropriately investigate the incident.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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/information-leaflets.

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

• Relevant staff should ensure that for any patient on the International Dysphagia Diet Standardisation Initiative (1) recommendations made by the multidisciplinary professionals are adhered to, (2) that recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to a patient’s diet and (3) recommendations/guidance issued by the multidisciplinary professionals are clearly understood and followed in relation to any adaptations that may be needed for the patient when eating.

In relation to complaints handling, we recommended:

• The partnership’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement.

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 post-operative care and treatment that they received from the board after they suffered a leg and ankle fracture. C said that unreasonable post-operative care led to a poor recovery and the requirement for an additional operation.

We took independent advice from a consultant orthopaedic surgeon (specialists in the treatment of diseases and injuries of the musculoskeletal system). We found that the board failed to report some x-rays and to reasonably explain why further x-rays were taken and who had reviewed them. We also found that there had been an unreasonable delay in carrying out a CT scan and in discussing C’s case at a Morbidity and Mortality meeting. Therefore, we upheld this part of C’s complaint.

C also complained about the board’s handling of their complaint. We found that the board handled C’s complaint reasonably and 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. 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 patient’s medical records should document the reasons why a scan(s) has been taken and who has reviewed them. The results should be recorded on the hospital’s clinical portal system.
• There should be processes and guidance in place to ensure when it is appropriate to carry out a CT scan.
• Where a patient’s case is appropriate for discussion at a Morbidity and Mortality meeting, this should take place as soon as possible.

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.