Some upheld, recommendations

Summary

C complained about the care and treatment that their parent (A) received from the board. Following surgery to remove bladder lesions, A experienced severe pain and urinary problems. It was established that they had a bladder perforation. C complained that, whilst A's consultant initially accepted and apologised for the fact that A's bladder was likely perforated during surgery, the board subsequently backtracked and suggested that there could have been a number of causes. C did not consider that their family had been given a clear explanation as to how A's bladder had been perforated.

A subsequent review of A's case established that they had cancer invading their bladder muscle. The cancer could not be treated with chemotherapy or radiotherapy and staff had discussions with A regarding the difficulties associated with attempting surgery in light of their other existing medical conditions. A was readmitted to hospital via A&E the following month, due to bladder spasms and catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) pain. A CT scan was carried out and A was admitted to a ward for ongoing monitoring and treatment. A's pain worsened and further scans showed that the cancer had spread to their lungs. Surgery was no longer an option and A died shortly afterward.

C complained that the communication from the urology staff (specialists in the male and female urinary tract, and the male reproductive organs) during A's hospital admissions was poor and that there was an unreasonable delay to A and other family members being told the extent of A's condition.

We took independent advice from a consultant urologist. We considered that, when responding to C's complaint, the board sought to provide a detailed description of events and a clearly set out explanation as to the potential causes of A's bladder perforation. That said, we found that information provided by C was not taken into account and, had it been, a clearer explanation could have been provided by the board. Therefore we upheld this aspect of C's complaint.

We found that A did not require routine input from urology. Their day-to-day care in hospital was managed reasonably by gastroenterology (specialists in the diagnosis and treatment of disorders of the stomach and intestines), with input from urology as required. We were satisfied that A's urology investigations took place in good time and a reasonable management plan was put in place for their ongoing urology input. Overall, we found that the communication from the urology staff to be reasonable. We did not uphold this aspect of C's complaint.

A had a rare and aggressive form of cancer. We accepted evidence from the board that earlier scans showed evidence of changes that were visible, but not identified. We concluded that, whilst the treatment options available to A may not have been any different, had the changes been identified earlier, they may have been given details of their cancer and prognosis sooner and this may have given A more time to prepare and make arrangements. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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.

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 they received from the board. C had experienced severe nausea but initial investigations found no definitive cause for their symptoms and a presumed diagnosis of irritable bowel syndrome (IBS, a condition of the digestive system that can cause stomach cramps, bloating, diarrhoea and constipation) was made. C said that they were provided with medication but this had little effect.

C developed severe abdominal pains later the same year which required immediate surgery and initially appeared to recover well. However, their abdominal pains returned a few months later and they required a hospital admission. Further surgery was carried out, establishing and resolving the root cause of the pain.

Whilst C's pain resolved following the second surgery, they raised a number of concerns regarding the care and treatment provided by the board, delays to diagnosing the cause of their symptoms and inaccurate documentation of the procedures that they had had.

We took independent advice from a consultant gynaecologist (a doctor who specialises in the female reproductive system). We found that the initial view that C's symptoms were being caused by a bowel condition was reasonable and that IBS was a reasonable working diagnosis while tests were carried out to confirm or rule out other possible causes of their nausea. We were satisfied that the working diagnosis and the focus of investigations changed when C's symptoms escalated. We were also satisfied, following the recurrence of their abdominal pain, that the board followed a reasonable and recognised pathway to establishing the cause of C's pain. Therefore, we did not uphold these aspects of C's complaint.

We were critical, however, of a number of errors in C's medical records, including details of another patient's procedures being misfiled in C's notes. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted 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.

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 nursing staff failed to provide them with adequate personal care following an enema (an injection of fluid into the lower bowel by way of the rectum to expel its contents, to introduce drugs or to permit X-ray imaging) at University Hospital Monklands. C also complained about the provision of toilet facilities on a ward. They said that their experience had caused significant trauma. We took independent advice from a nursing adviser. We found that there was insufficient evidence to suggest that that the board provided C with inadequate personal care. We did not uphold this complaint.

C also complained that the board had failed to communicate effectively with them after they had a laparoscopy (an examination of the abdominal organs using surgical methods to determine the reason of pain or other complications of the pelvic region or abdomen) at a private hospital under a waiting list initiative. They said that this had caused delay to their treatment. We found that there had been a delay in communicating the results of the laparoscopy to C and this caused delay to C's treatment. The board were wrong to consider that C's GP should have discussed the results of the laparoscopy with them. The board requested the laparoscopy and it was their responsibility to discuss this with C. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately communicate the results and/or findings of the laparoscopy with C. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Staff should be aware of their responsibility to directly discuss the outcomes and/or findings of tests or procedures they have requested with their patients.
• They will ensure that mistakes are rectified.

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) during two admissions to Aberdeen Royal Infirmary where they had been admitted for investigation and treatment of persistent vomiting and weight loss. We took independent advice from a nurse and asked for their comments on A's care and treatment during both admissions.

During the first admission, C complained about A being given incorrect medication, comfort and observation charts being completed inaccurately, and of the poor level of cleanliness in the ward's bathroom. We found that there were failings in these areas, which the board had acknowledged in their own complaint investigation and had identified actions for improvement and learning. Therefore, we upheld this aspect of C's complaint and asked the board to provide evidence of the actions that they had said they planned to take.

During the second admission, C complained that A was given the wrong nasogastric feed and failed to take proper action when A self-harmed; was provided with the wrong type of feeding tube; staff failed to communicate properly with C or A during the admission; and A was not given medication on discharge.

We found that the care of A's enteral feed (feeding tube leading into the stomach) to be reasonable, however we found that the planning and documentation of A's care after they had self-harmed was unreasonable. We also found that A had been given the wrong length of feeding tube and that the procedure went ahead despite this being known. Therefore, we upheld these aspects of C's complaint.

We found that communication with A had been reasonable and we did not uphold this aspect of C's complaint. In relation to communication with C, we found this to be mostly reasonable, however there had been a serious oversight in communicating with C when A had self-harmed. Therefore, on balance, we upheld this aspect of C's complaint.

In relation to A's discharge, we found this to be reasonable and we did not uphold this aspect of C' complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failings we have 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 ensure staff are aware of how to report and respond to incidents of self-harm when they occur within acute care settings.
• The board should ensure the correct type of feeding tube is used according to the planned 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 about the care and treatment that they received from the board during an in-patient stay at Forth Valley Royal Hospital. C was admitted to the hospital while in the early stages of labour. C gave birth a few days later and was discharged to their home the following day. After discharge, C's health began to deteriorate and were later admitted to a different hospital, where they received a blood transfusion and treatment for an infection.

C complained that the board had failed to inform them that they had a yeast infection and failed to provide them with any treatment for this. C also complained that a clinician knowingly recorded an inaccurate pulse rate on their records and that the board failed to appropriately treat their post-natal high blood pressure and/or blood loss.

We took independent advice from an obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the board had failed to inform C that they had a yeast infection. Therefore, we upheld this aspect of their complaint.

We found insufficient evidence to establish that an inaccurate pulse rate had been recorded on C's records. We also found that C's blood pressure and/or blood loss were within normal limits when they were discharged from hospital. Therefore, we did not uphold these aspects of C's complaints.

However, we did find that clinicians failed to reasonably respond to C's high pulse rates at one point during their admission. While this issue was not raised by C in their complaint, we considered that it was reasonable to make recommendations to the board in relation to this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to adequately monitor and respond to their condition. 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 closely monitor Modified Early Warning Scores (MEWS) and appropriate action should be taken in light of them.
• When a candida (yeast) infection is identified, patients on the ward should be informed.

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 they received from the board after they were diagnosed as having a tumour in their bowel.

C underwent surgery to remove their tumour. Following the procedure, they experienced a number of complications that led to extended hospital treatment and the need to be fitted with a stoma (a surgically made pouch on the outside of the body). It was ultimately established that their surgery failed to heal properly, possibly due to a fault with an item of equipment used to staple their bowel. C complained that the issues resulting from their surgery had life-changing consequences.

C raised a number of concerns regarding the care and treatment that they received from the board at the time of their surgery and once they had been discharged. They also did not consider that the board adequately took responsibility for the issues that affected them.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). It was evident from C's complaint that they went into surgery expecting a straightforward procedure. The procedure was complicated by C's high body mass index (BMI, a measure for estimating human body fat) and took several hours longer than they had anticipated. Whilst we were critical of the board for not explaining to C that their BMI was a potentially complicating factor, overall we were satisfied that the surgery was carried out reasonably. During the procedure, the surgeon made reasonable adaptations when issues arose and there was no indication at the time of the issues that would later affect C. We were also satisfied that there was no indication at that time that there was a fault with the equipment being used during the procedure. Therefore, we did not uphold this aspect of C's complaint.

Following their surgery, C experienced a significant amount of pain. We were largely satisfied that the board's staff took this seriously and took appropriate action when it became apparent that the pain was not resolving as expected. C was ultimately found to have a leak from the site of their bowel surgery. We found that this was treated appropriately with further surgery once it was identified. That said, we found that C's symptoms should have led staff to suspect a potential leak sooner than they did. Whilst we found nothing to suggest that the outcome would have been any different for C, had staff considered a leak earlier, an earlier diagnosis could have been made and C's pain may have been relieved sooner. We upheld this aspect of C's complaint.

We found that, four months after C's surgery, the board proactively identified and investigated a cluster of patients (including C) that had experienced bowel leaks following surgery. The board concluded that there was no common factor linking these cases. Two months later, the board were advised by a medical equipment manufacturer that an item of equipment that was used during C's surgery was faulty and should be withdrawn from use. We found that there was no clear link between the faulty device and the leak that C subsequently experienced. However, we were critical of the board for not going back and reviewing the cluster of cases in the presence of the new information regarding the faulty medical device. We also found that the board could have done more to address C's questions about the situation. Therefore, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in diagnosing the leak. 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 share this decision with the staff involved in C's care with a view to identifying any aspects of their care and treatment that could have been improved.
• The clinical team should review C's case with a view to ensuring their protocols for considering and diagnosing anastomotic leaks take account of all relevant risk factors.

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 was concerned about the care and treatment that their late spouse (A) received at Inverclyde Royal Hospital following a surgery for a hip fracture. C complained that A did not receive appropriate post-operative rehabilitation and physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery). We took independent advice from a physiotherapy adviser. We found that the physiotherapy assessments and treatment were appropriate. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the nursing care that A received. In particular, C was concerned that proactive steps were not taken to prevent A falling and that A was not supervised to take their medication. We took independent advice from a nursing adviser. We found that the board acted reasonably by implementing appropriate and proportionate actions to mitigate the risk of A falling. However, there was no record that A was supervised to take their medication and this was unreasonable given A's cognitive impairment and physical frailty.

In light of the above, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not supervising A taking their medication. The apology should meet the standards set out in the SPSO guidelines on apology available at 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 about the care provided to a family member (A) at Woodend Hospital and Aberdeen Royal Infirmary. Immediately prior to the episode of care we considered, medical investigations had been performed which indicated that A had metastatic cancer (cancer which has spread from one part of the body to another). A was then referred to the urology department (specialists in the male and female urinary tract, and the male reproductive organs).

We took independent advice from a urology adviser. In response to C's complaint, the board acknowledged that there had been a failure to request a CT scan as planned and apologised for this. We found that there was a failure to expedite a flexible cystoscopy (bladder examination using a narrow tube-like telescopic camera) and keep A informed about their care. In addition, we found that A should have been referred to oncology (specialists in the diagnosis and treatment of cancer). In view of these findings, we concluded that the care and treatment was unreasonable and we upheld C's complaint.

C also complained about the board's actions leading up to the decision whether or not to carry out a full post-mortem examination following A's death. C considered that the board had failed to follow the procedure that applied in the circumstances that the nearest family members did not agree about a post-mortem. C was also unhappy with the lack of communication about this matter. We considered a number of pieces of relevant legislation and guidance and took into account comments from the adviser. The circumstances leading to the decision about post-mortem were complex. On balance, we found that the board acted reasonably in this instance and we did not uphold the complaint. We provided feedback about good practice for the board to consider.

Finally, we found that the board's response to C's complaints could have been clearer in one respect. We also found that the board did not respond to a related complaint (about A's treatment a number of years prior) and inform C whether they would extend the timescale for accepting a complaint or not. We made a recommendation to address this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delay in performing an urgent CT scan; the failure to ensure that A was adequately informed about the plans for a CT scan; and the lack of referral to oncology. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Inform C of their decision whether or not they are extending the timescale (in relation to their complaint about A's historical treatment), and provide a reason for this.

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

• Care plans agreed at multi-disciplinary meetings should be implemented and followed up to ensure appropriate communication takes place with the patient/patient's representative and that timely investigations and referrals take place where relevant.

In relation to complaints handling, we recommended:

• Complaint responses should be comprehensive and transparent. In line with the NHS Model Complaints Handling Procedure, the timescale for acceptance of a complaint may be extended if the Feedback and Complaints Officer considers it would be reasonable in the circumstances. Where a decision is taken not to extend the timescales a clear explanation of the basis for the decision should be provided to the person making the complaint, and the person should be advised that they may ask this office to consider the decision.

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 way that the Crown Office and Procurator Fiscal Service (COPFS) dealt with their communications with them following their adult child (A)'s death by suicide. C said that the COPFS failed to deal with C's request for the return of A's property appropriately; failed to provide C with the final post-mortem report on A's death within a reasonable time; and failed to investigate C's complaint about these two matters appropriately.

It is not for this office to question decisions by the COPFS regarding the release of A's belongings, as the COPFS's decisions regarding prosecutions/whether or not to investigate Fatal Accident Inquiries are outwith the remit of this office. We therefore considered whether or not the COPFS did what they advised C that they would do in relation to the release of A's belongings and whether they acted in line with their guidance.

The records showed that the COPFS considered C's request for the return of A's property, made during a telephone call, and authorised release of some of A's belongings and that this was then communicated to the police and the belongings were released. It would appear that after receipt of an email from C in which they complained and requested the release of the remainder of A's belongings, the COPFS then authorised their release. The COPFS acknowledged that they should have responded to C's email, advised that they fed back this failing to staff and provided documentary evidence to verify that this took place at the time. We considered the remedial action by the COPFS to be reasonable and did not uphold this part of the complaint.

On the matter of the provision of the final post-mortem on A's death, the COPFS explained the difficulties they experienced with their toxicology report service provider and how this in turn impacted on the timescale for receipt of post-mortem reports by the COPFS and notification of the outcome to the next of kin. In this case, notification of the outcome of the post-mortem to C and issuing of the report on request did not take place until more than four months after the timescale stated in the COPFS's procedures. We were critical of this delay and upheld this part of the complaint. We noted that COPFS indicated that they had taken a number of steps to address the delay which was positive.

On the issue of the investigation of C's complaint, while a number of aspects of the COPFS's investigation into C's complaint and complaint response were reasonable, we found that the complaint response failed to address C's expression of dissatisfaction regarding the delay in completing A's post-mortem. We, therefore, upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the unreasonable delay in notifying C of the outcome of the post-mortem on A's death and providing them with a copy of the report on request and for failing to address C's concerns about the delay in providing A's post-mortem report in their complaint response. 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:

• For COPFS complaint responses to address all issues raised as part of the complaint that the COPFS are responsible for, in accordance with their complaint 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 to the council about the school their child (A) attends. A was transitioning from early years to primary school. As A had additional needs, a transition plan was required. C complained to the council that the school failed to put in place the appropriate transition arrangements in line with their obligations under the Additional Support for Learning (ASL) (Scotland) Act 2004; that they did not communicate appropriately with them about A's support and education and that they did not carry out an appropriate investigation of their complaint about the handling of a staged intervention meeting.

We found that the council failed to meet the required timescales when putting in place the appropriate transition arrangements for A and as such we upheld this aspect of the complaint.

We noted that there was reasonable mechanisms in place to keep C updated about A on a daily basis. While the council recognised that there were times that C's email correspondence was not responded to, we are satisfied with their overall communication with C and as such, we did not uphold the complaint. We also noted that the council carried out an appropriate investigation of C's complaint about the school's handling of a staged intervention meeting. The council consulted with all attendees and have demonstrated that they have reflected appropriately on the school's handling of the meeting. We did not uphold this aspect of C's complaint.

Recommendations

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

• The council should have appropriate measures in place to ensure that statutory timescales for putting in place an appropriate transition are met.

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.