Some upheld, recommendations

Summary

Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the healthcare team, and between staff and Mr A and the family.

In November 2012 Mr A was admitted to hospital for treatment of blood clots in his wrist and arm which were surgically removed. After five days in hospital Mr A was discharged. Mrs C came to collect him but, as they were leaving the ward, Mr A fainted. He was re-admitted and discharged again four days later. Two weeks after the second discharge Mr A was admitted again to treat an infection in his arm where he had had the surgery. This time he was in hospital for five days before being discharged.

Our investigation, which included taking independent advice from our medical and nursing advisers, found that both discharge decisions had been reasonable, in that Mr A was clinically stable and the various investigations and observation results were within the normal range. Both advisers commented that Mr A's collapse on leaving the ward following the first discharge could not have been predicted, as it was due to his existing heart condition, which could cause sudden and unpredictable symptoms.

On the matter of communication, however, we did find some failings. Both advisers expressed concern at some of the verbal and written communication, and in particular about an event when Mr A was taken alone by ambulance to the hospital's emergency department. Ambulance staff had noted that he was confused and unsteady on his feet. When he arrived at the hospital Mr A was reviewed by a triage nurse (who assesses a patient's condition and the urgency of treatment required) who noted that he had dementia. Despite this, he was moved several times during the 80 minutes he spent in the emergency department, and our medical adviser said that this would have added to Mr A's confusion. In addition, when he was moved there was no evidence that information about him was shared between members of the healthcare team. Mr A later left the department unaccompanied and arrived home as Mrs C was preparing to go to hospital to see him. Although a staff member had seen Mr A leaving alone in a taxi, no one had contacted Mrs C to alert her to this.

Recommendations

We recommended that the board:

• apologise for the failings identified in our investigation;
• consider putting in place a protocol for the monitoring and supervision of dementia patients within the accident and emergency department; and
• feed back to the staff involved in this complaint the importance of effective communication between staff and patients' families / carers.

Summary

Mrs C complained that when she was in labour in the Royal Infirmary of Edinburgh, a doctor conducted an intimate examination without introducing herself or obtaining Mrs C's consent for the examination. Mrs C also complained that the examination was very painful, and that although she asked the doctor to stop, she did not do so right away. The doctor told Mrs C that she needed a forceps delivery (where a specially designed instrument is used to assist with the delivery of the baby) and would need to go to theatre. The baby was successfully delivered but Mrs C had been hoping for a natural birth and complained that she was not offered any alternative options.

Mrs C wrote to the board three months after the birth to complain about her care and treatment. Although the letter of complaint was acknowledged promptly, she then waited almost three months for the response. Before she received the response, Mrs C brought her complaint to us. She also complained that, while she was still waiting for the board to respond, she had to attend an out-patient appointment. She was upset to be met there by the doctor about whom she had complained. We also investigated this additional complaint.

Our investigation included taking independent advice from a consultant in obstetrics and gynaecology. We upheld Mrs C's complaints about her care and treatment during the delivery. The adviser was of the view that Mrs C had been unable to give informed consent for the examination or the forceps delivery, due to her level of pain and distress and the lack of information about alternative options. The adviser was also critical that, when asked to do so, the doctor did not immediately stop examining Mrs C. The adviser considered that there was no immediate danger to Mrs C or her baby at the time of the decision about forceps delivery, and said that she should have been given time to have additional pain relief and then consider all the options, including no treatment or intervention.

On the matter of the out-patient appointment, the NHS guidance on complaints handling says that information about complaints should not normally be kept in a patient's clinical records. Because of this, neither the board nor the doctor concerned could have anticipated that Mrs C would been seen at the clinic by the doctor about whom she had complained. When the doctor realised who Mrs C was, she arranged for her to be seen by the consultant instead. That was appropriate and we did not uphold this complaint.

In regard to the delays in complaints handling, the board acknowledged the delay and that Mrs C had not been kept informed about this or about the reasons for it. We upheld this complaint, but noted that the board have since made changes within the complaints department.

Recommendations

We recommended that the board:

• ensure that all relevant staff are reminded of the guidance on taking consent from women in labour (in particular the need to record oral consent) and, where necessary, provide refresher training;
• provide a copy of our decision to the doctor involved to allow her to reflect on her practice in relation to the complaints and discuss any learning points at her next appraisal;
• provide the Ombudsman with evidence to demonstrate that the changes put in place within the complaints department have improved response timescales; and
• issue a written apology for the failings identified during this investigation.

Summary

Miss C complained that the medical and nursing care and treatment provided to her late mother (Mrs A) was inadequate. She also complained about inadequate communication between staff and her late mother and the family. Mrs A was admitted to hospital suffering from a blood clot in the intestine which then caused problems with her bowel. She had surgery several times while in hospital and was transferred to the intensive care unit (ICU), where she died some three weeks after being admitted.

In relation to the medical treatment, Miss C complained that when Mrs A was taken into hospital with sudden abdominal pain, there were delays in obtaining a diagnosis; in undertaking investigations; and in addressing her level of pain. Miss C also complained that it was unreasonable to have transferred Mrs A from the Accident and Emergency department to the Surgical Observation Unit before transferring her to an in-patient ward. During our investigation we took independent advice from one of our medical advisers, an experienced surgeon, who was of the view that Mrs A's medical care and treatment had been reasonable. The blood clot had caused tissue in Mrs A's intestine and bowel to die, and the adviser said that diagnosis of this condition is largely one of elimination of possible causes and that there had been no unreasonable delays in investigating and treating Mrs A's condition. The adviser said that the condition can be very painful but that strong painkillers can mask physical symptoms and so it was not unreasonable that it took some time to get Mrs A's pain under control. We did not, therefore, uphold Miss C's complaints about her late mother's medical treatment.

In relation to the nursing care and treatment, we also took independent advice from our nursing adviser, who had concerns over some of the issues Miss C had raised. In particular she was concerned about monitoring and observations, record-keeping, pain scoring, and communication by nursing staff. There were also problems with the communication of a decision to reverse a Do Not Attempt Resuscitation decision (DNAR - a decision taken that means a doctor is not required to resuscitate the patient if their heart stops) from medical staff. While the medical adviser was satisfied that both the original DNAR decision and the reversal decision were appropriately taken, only the original decision was discussed with the family. While such decisions are clinical ones and do not require approval or consent from the patient or family, it is good practice to discuss these issues where possible. Overall, we upheld Miss C's complaints about nursing care and communication.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the failings identified during this investigation;
• provide evidence that the standards of record-keeping meet the required professional standards across the wards/units involved in this complaint and, where necessary, provide training to meet these standards;
• ensure that there are robust systems for handover between the clinical departments identified when patients are transferred;
• ensure that the knowledge and skills of the nurses involved in this complaint when performing clinical observations, including pain assessments, meet the relevant local guidance;
• ensure that staff on the ICU ensure that alternative support strategies are in place for families/carers when visiting arrangements are reviewed; and
• remind all staff involved in this complaint of the importance of good communication between staff and patients and their families/carers.

Summary

Ms C, who is an advice worker, complained on behalf of her client, Ms B. Ms B's late fiancé (Mr A) had died a few days after being admitted to Glasgow Royal Infirmary with severe jaundice. Ms B had told Ms C that the board provided inadequate nursing care, and that hospital staff failed to communicate adequately with Mr A's family, including about the severity of his condition, which she said caused Mr A and his family unnecessary distress and suffering. Ms C also complained about the board's complaints handling.

During our investigation, we reviewed Mr A's clinical records and took independent advice on his care from our nursing adviser. We found that at the heart of the complaint was Ms B's view that nursing staff acted insensitively towards Mr A. In cases where people are unhappy with the attitude of staff, it is often difficult to find evidence to support the complaint. This is not to say that we do not believe the accounts given; rather we find there are differing recollections, and often no independent evidence of behaviour or attitude. In Mr A's case, we could not reach a finding on whether nursing staff were insensitive.

Based on the evidence in the clinical records, we did not uphold the complaints about nursing care and communication. The records showed that Mr A was attended to regularly, and our adviser did not have any concerns about nursing care, noting that the board had since taken steps to support a person-centred care approach. The adviser also said the records showed that staff had tried to communicate the seriousness of Mr A's condition. The board had, however, acknowledged that some aspects of communication should have been better and had put improvement measures in place. In terms of how the complaints were handled, however, we upheld Ms C's complaint, as we found gaps in the records, and unreasonable delays in resolving the complaints.

Recommendations

We recommended that the board:

• reflect on staff's practice of introducing phone calls by saying 'do not worry', to determine whether they think it is appropriate as routine wording in all cases; and report back to the Ombudsman;
• ensure that, wherever possible, complaints (whether informal or not) are progressed in the absence of staff on sick leave;
• remind staff of the need to make records of informal complaints, in line with guidance; and
• ensure staff record when they tell complainants about the formal complaints process.

Summary

Mrs A had a brain tumour. Two years after she was diagnosed with this, and after three epileptic seizures and a possible stroke, she was admitted to hospital. Mrs A's family were unhappy with her care and treatment while she was there and discharged her home early the next month. Mrs A died just under three weeks later. Mrs A's son (Mr C) complained about her care and treatment and the level of communication with her family while she was in hospital. He also complained about the way the board dealt with his subsequent complaint.

During our investigation, we gave careful consideration to all the relevant information, including all correspondence, meeting notes, Mrs A's clinical records and the board's complaints policy. We obtained independent advice from our nursing adviser and this too was taken into account.

Our investigation found that Mrs A's fluid and food intake was poor, but that the nursing notes showed that she was offered food and drinks. Our adviser said that while staff had clearly tried to improve her intake, it was often the case that very unwell patients were reluctant to eat or drink. Mrs A also had a thrush infection in her mouth, and this must have been difficult for her. We found that Mrs A's medication and pain relief were appropriate for her condition and she had been referred to the palliative care (care to prevent or relieve suffering) team. We also found that before Mrs A was discharged, a plan was put in place to support her at home. The records showed that staff had tried to keep the family regularly updated, but it was accepted that their efforts had not perhaps met the family's expectations and could be improved. Overall, we found that Mrs A's care and treatment was acceptable. However, we upheld Mr C's complaint about complaints handling, as after he complained there was clear evidence of delay.

Recommendations

We recommended that the board:

• offer a formal apology for the delay in dealing with the complaint.

Summary

Mr C complained that his wife (Mrs C) was not provided with reasonable care and treatment after an operation to remove her womb, ovaries and fallopian tubes at Glasgow Royal Infirmary. He said that Mrs C had received an incorrect amount of morphine (pain relief) after surgery and as a result she stopped breathing and nearly died. Mr C and his son witnessed this and it had caused them both considerable upset. Mr C also said that the board unreasonably handled his complaint about this.

We took independent advice on this complaint from one of our medical advisers, who is a consultant anaesthetist. Our investigation found that Mrs C did not receive excessive morphine. Our adviser said that Mrs C exhibited a recognised but rare complication of a standard analgesic (pain relief) technique, which resulted in her breathing being impaired. We found that hospital staff and clinicians provided the correct care and treatment to Mrs C throughout her stay in hospital and so we did not uphold this complaint. However, we found that staff communication at the time of the incident could have been better, and made a recommendation to improve this.

During our examination of the complaints handling we found a period where the board delayed in contacting Mr C, which they had acknowledged. For this reason we upheld that complaint and made a recommendation.

Recommendations

We recommended that the board:

• advise the Ombudsman on the steps taken to ensure that the communication failures (after the incident, and a misleading entry on the discharge letter) do not recur;
• issue Mr C with a full and sincere apology for the failings identified; and
• advise the Ombudsman of the steps they take to ensure that the complaints handling failures identified in this complaint do not recur.

Summary

Mr C complained about the care and treatment that a medical practice provided to his late mother (Mrs A) before her death. He said that GPs had not taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. He also said that they had unreasonably put Mrs A on the Liverpool Care Pathway (a framework used by healthcare professionals in the last hours or days of life when a death is expected).

We obtained independent advice on this complaint from our GP adviser. We found that in general, the practice had taken reasonable steps to assess and monitor Mrs A's pain when making changes to her medication. However, we upheld this complaint as they should have ensured that arrangements were in place to review Mrs A and that this was noted in the medical records, after her medication was increased on one occasion and it was identified that she had a chest infection. At the very least, they should have phoned to find out if the medication was effective or was causing problems. There was no evidence that they did so.

Our investigation also found that the practice had considered admitting Mrs A to hospital or to a hospice when her condition deteriorated. They discussed this with the family and with the nursing staff caring for Mrs A. They decided that she should not be admitted and that they would start the Liverpool Care Pathway. We did not uphold this complaint as, although we considered that the GP should have recorded more detail about the decision we found that, based on the information available at the time, the decisions not to admit Mrs A to hospital and to start the Liverpool Care Pathway were, on balance, reasonable. That said, we found that the practice's responses to Mr C about the matter had not been satisfactory and that they had failed to respond in detail and we made a recommendation to address this.

Recommendations

We recommended that the practice:

• make the staff involved in Mrs A's care and treatment aware of our findings;
• issue a written apology to Mr C for the failure to satisfactorily respond to his complaints;
• take steps to ensure that in the future complaints are investigated and responded to appropriately; and
• remind the GPs of the need to maintain clear and thorough medical notes.

Summary

Mrs C complained that nursing staff failed to provide support to her daughter (Ms A) after she was discharged from hospital. She said that they had failed to act appropriately in relation to two visits made to the local housing office to try to secure accommodation for Ms A. Mrs C also complained about the handling of her complaints.

To investigate the complaint, we took all relevant documentation into account, including Ms A's clinical notes and the complaints correspondence. We also obtained independent advice from two of our medical advisers.

The investigation showed that there were differing accounts of what happened after the first visit to the housing office, which we could not reconcile. Based on the available evidence and our advisers' comments, we found that Ms A's discharge was planned and that the support provided by the nursing staff was reasonable. We were, however, concerned about a lack of detail in the nursing notes, and made a recommendation about this. We also found that, while the board had provided a reasonable response to the issues Mrs C raised, they failed to respond within the timescale set out in the NHS complaints procedure.

Recommendations

We recommended that the board:

• ensure that, when nursing staff on the ward record clinical events, they do so in sufficient detail that it is clear to colleagues precisely what occurred, what risks there were (if any), and how matters were dealt with and by whom; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary

Mr and Mrs C complained to Scottish Water about a blocked drain, but were told that the problem was theirs to resolve as the blockage was on their property. Mr and Mrs C instructed contractors, who established that the problem lay under the public footpath and was for Scottish Water to address. Scottish Water later confirmed this as correct. Mr and Mrs C requested that Scottish Water reimburse their costs, and complained about delay in completing the work. Scottish Water refused, however, to refund the costs on the grounds that they had no legal liability. They did, however, apologise for and explain the delay. Mr and Mrs C continued to pursue their complaint both with us and Scottish Water, who reviewed the circumstances and offered Mr and Mrs C 50 percent of their costs.

During our investigation we took into account all the relevant documentation and made further enquiries of Scottish Water. Our investigation found that the blockage causing problems was indeed under the public footpath and was for Scottish Water to resolve. However, accessibility to the drain from Mr and Mrs C's' side was complicated by an existing shaft. In the circumstances, Scottish Water said that they had no alternative but to ask Mr and Mrs C to address this, at their own cost, to allow access. However, we found that Scottish Water could have asked to do this work themselves or installed an access chamber from the public side of the blockage which, while it would have increased the time taken, would have been at Scottish Water's cost. While Scottish Water ultimately offered to reimburse 50 percent of costs, they were entirely responsible for the blockage under the public footpath. We upheld Mr and Mrs C's complaints about the costs and the handling of the complaint, but not about delay, for which we found the explanation reasonable.

Recommendations

We recommended that Scottish Water:

• repay the costs incurred;
• make a formal apology for the way in which the complaint was handled; and
• consider formulating a policy to cover circumstances where an ex-gratia payment may be required.

Summary

Mrs C's business occupies small premises next door to her domestic property. Her business does not have running water, sink or toilet and the water she uses for her business is obtained from her domestic property. Business Stream told Mrs C that because her business had access to water and waste water facilities in her property she was liable to pay for water services for business use. Mrs C questioned whether she was liable for charges as she did not have a direct water supply and only used a small amount of water for her business. She also said that she was previously told that in her circumstances she would not be charged.

During our investigation, Business Stream told us that they had no record of Mrs C previously being told that in the circumstances there would be no charge for the water she used for her business. They said they had reviewed her situation as a result of the complaint, but that her business did have access to water services in her domestic property. Although she was paying for the domestic element of these services, she was not paying for the services she used in connection with her business. We noted that her liability to pay for water for business use had been confirmed and did not uphold this complaint.

Mrs C also complained about the delay in an invoice being sent to her and said that, as a result, she received an invoice in 2013 backdated to 2010. We found that there had been a delay in the SPID (unique supply identification number) being created and her premises being set up on Business Stream's account. We also saw evidence that from 2011 Business Stream had sent Mrs C letters at her business premises, asking her to contact them. We could not, therefore, conclude that Business Stream were wholly responsible for the delay in the invoice but, on balance, we upheld the complaint as we were concerned that there was a delay of almost a year before the property was set up on Business Stream's billing system.

Recommendations

We recommended that Business Stream:

• apologise for the initial delay in setting up Mrs C's business property on their billing system; and
• contact Mrs C to discuss the repayment options available.