Some upheld, recommendations

Summary

Ms C, who is a claims assessor for an insurance company, contacted us on behalf of her client (Mr A). Mr A was concerned that an operation to fix a fracture to his upper leg had failed and he was left with a shortened leg as a result. He thought that this was because a junior doctor was allowed to complete the operation unsupervised, and said that follow-up physiotherapy had only caused him additional concerns when the fracture re-opened. Mr A also believed he suffered a morphine overdose at the time of surgery which left his health additionally compromised and contributed to a post-operative problem with blood clots.

We took independent advice on this complaint from three of our medical advisers – specialists in orthopaedics, anaesthetics and physiotherapy. The orthopaedic adviser said that the surgery was not performed to an adequate standard, although not because of a lack of supervision. The adviser noted that during the operation there had been difficulty inserting screws to fix the fracture, and ultimately these had not been placed correctly. This was a recognised complication, but one he felt should have been identified at the time. He was concerned that there was no record showing that the possibility of the leg being left shortened was discussed with Mr C beforehand. The dosage of morphine was not considered to be unreasonable in the circumstances of the trauma Mr C had suffered, although it was clear that he had suffered a recognised side-effect from it. The physiotherapy problems were considered to be an inevitable consequence of the failed surgery, but not unreasonable in all the circumstances. We upheld the complaint about the standard of surgery but not those about supervision or physiotherapy.

Recommendations

We recommended that the board:

• provide evidence that their new consent form is now routinely used and includes space for noting all risks discussed; and
• remind surgical staff of the need to make a comprehensive note of operations, particularly where adverse technical problems have arisen, so that subsequent review is possible.

Summary

Miss C complained that the college had unfairly withdrawn her from her course and had failed to address her concerns about her placement. She had reported these, and when she felt they were not being addressed, tried to find an alternative placement herself. She said that the college did not allow her to take up the alternative and instead told her that she was being withdrawn from the course.

Our investigation found that the college had not allowed enough time to investigate Miss C's concerns before withdrawing her. Although some of the information Miss C gave us could not be verified, we took the view that the college should have arranged to slow things down by allowing time for proper discussion with Miss C to explore her concerns. We also saw no evidence that the college asked the placement for their views on what had happened, and we found they did not properly follow their procedures when withdrawing Miss C.

Recommendations

We recommended that the college:

• apologise for not addressing and investigating Miss C's concerns about her placement;
• apologise for not following reasonable procedures when they withdrew Miss C; and
• share our findings with relevant staff.

Summary

Mr C, who is a prisoner, had special security measures imposed upon him by the prison. These were put in place to ensure that Mr C could be managed safely. Mr C complained to us because the paperwork completed by the prison in deciding to put those measures in place was missing. Mr C also complained because the measures were applied even when the relevant paperwork was missing.

The prison agreed that the paperwork was missing and because of that, we upheld the complaint. However, we did not make any recommendations because once the prison became aware that the paperwork was missing, they took steps to replace it by completing it again. We did not uphold Mr C's complaint that the measures were applied although the relevant paperwork was not available. The prison had the authority to impose the measures, and the evidence they provided confirmed they had concerns about Mr C's safety.

Mr C also complained because the governor told him that she would respond to his complaint once her investigation was complete. The prison could not provide any evidence to show us that the governor had responded, and because of that, we upheld that complaint.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C for failing to respond appropriately to his complaint.

Summary

In January 2009, an inquiry reporter decided to uphold a council decision to refuse planning permission to build houses in a long established area of open space behind the homes of Mr and Mrs C and their neighbours. When, in March 2012, the council granted planning consent for residential development of the same site, Mr and Mrs C and their neighbours were unhappy and made nine detailed complaints to the council and then to us. Seven of these related to the report of handling of the later application that council officers presented to members of the council committee.

We upheld three of the seven complaints about the report of handling - in relation to failure to refer to a planning advice note and to fully address and consider the implications of the reporter’s dismissal of the appeal on the first application. The other two complaints, which we also upheld, related to a lack of proper evaluation of the loss of open space that implementation of the proposals would entail and unreasonable delay by the council in investigating the complaints.

Recommendations

We recommended that the council:

• consider and set out a timetable for the preparation of an open space audit and strategy to comply with Scottish Planning Policy on Open Space and Physical Activity; and
• consider the preparation of internal guidance that reports of handling should assess all relevant aspects of planning history, particularly where a previous decision might be seen to be contradicted by the proposed recommendation; and clearly distinguish between the analysis of the provisions of the development plan in force and those of any emerging plans as material considerations.

Summary

Mr C complained to us on behalf of his elderly parents, who he said found it expensive to heat their home because of old draughty windows. Two windows had been replaced but the council had decided not to replace the remaining windows, although they had resealed some. Mr C said this had not made any appreciable difference. He said that a clerk of works from the council had said that the windows would last another eight years and if they were replaced, everyone else would want this. Mr C believed that the council had replaced windows in newer houses than that of his parents, and felt that the criterion for replacement should be based on the condition of the windows, not their age.

When we investigated this, the council told us that their programme of replacement was based on need. They told us also that there had been a robust assessment into the condition of the windows in Mr C’s parents’ house. However, there was no record of the assessment, as reports were usually provided verbally and dealt with at the time. We considered that it was unreasonable not to hold records of assessments or their outcome. We upheld Mr C's complaint about this, and made recommendations. We did not uphold his complaint about newer houses having windows replaced as the council clarified that it is not age but condition which dictates this decision, but we made a related recommendation.

Recommendations

We recommended that the council:

• undertake a further inspection within 10 working days of the issue of our decision and ensure a report is produced;
• review their current procedures where a request for repair or replacement works is requested, and put in place improvements to record keeping, especially where assessment has found that limited or no works are required; and
• review their decision not to replace the windows in Mr C's parents' house, based on a fresh reassessment of the windows, and notify Mr C of the outcome of the reassessment and whether this has changed the decision about replacement.

Summary

The council were due to replace the kitchen and bathroom of Mr C's council house as part of a planned modernisation programme. Some years earlier, Mr C had, with the council’s permission, installed an electric shower at the foot of the bath above the taps. Two months before the work began he was visited by a council housing officer and a representative of the contractor. His recollection was that at the visit he was given two choices - a shower worked from a mixer tap at the foot of the bath, or a new electric shower that he would have to pay for. He says he chose the mixer tap arrangement. When the work was carried out, however, an electric shower was installed at the other end (the head) of the bath. Mr C complained that the council did not install the type of shower he had chosen; failed to install the electric shower in the correct position; and failed to respond to his letters to the chief executive.

Our investigation found that the council had a contract plan for all bathroom works. This clearly indicates that existing sanitary ware would be replaced in white and that an electric shower and curtain rail would be put in place at the head of the bath. The council confirmed that this would be at no cost to the tenant, and were adamant that no alternatives were offered. From the information provided, it appeared that the council’s intentions may not have been explicitly communicated during the visit, but we did not uphold the first two complaints as there was no evidence that the council failed to comply with Mr C’s choice or that they had installed the shower in the wrong place. We did find, however, that they had taken too long to deal with his complaint and made recommendations.

Recommendations

We recommended that the council:

• ensure that in future pre-works visits in respect of bathroom and kitchen modernisation, they fully explain any works that alter an existing tenant's preference and record this discussion; and
• ensure that the chief executive writes to Mr C to apologise for the delays in dealing with his complaint.

Summary

Mrs C complained about the standard of care and treatment her elderly mother (Mrs A) received in hospital. Mrs C felt that Mrs A was handled roughly by nursing staff and had been left on an incontinence mat with her pyjama bottoms removed and the curtain drawn around her bed in the event that she needed to go to the toilet during the night. Mrs C also raised concerns that: the number of ward moves Mrs A had during her stay in hospital caused her to be unsettled; the television facilities were inadequate; there was a delay in restarting Mrs A's statin medication (a drug used to reduce cholesterol and the likelihood of further cardiac disease); and that the standard of discharge planning was poor.

Although we did not find sufficient evidence to support that Mrs A had been handled inappropriately, we were dissatisfied with the board's explanation of why her pyjama bottoms were removed. They had said that, as Mrs A had been admitted with back pain, removal of her pyjama bottoms would prevent further painful movement during the night in the event that Mrs A needed the toilet and would also prevent them from becoming soiled. We did not consider the board's reasons were justified because the staff did not appear to have given thought to providing Mrs A with a hospital gown or arranging for her to wear a nightdress in order to maintain her dignity.

In relation to Mrs A's discharge from hospital, we upheld the complaint as we considered that care fell below a reasonable standard because Mrs A had not been reviewed by a doctor 17 days prior to her discharge and no consideration was given to either transferring her to a specialist geriatric unit in the hospital or referring her to a local geriatrician for inpatient review. We also found that Mrs A's statin medication was appropriately stopped when she was noted to have impaired kidney function, as statins can affect this. However, when Mrs A's kidney function returned to an acceptable level, no consideration appeared to have been given to re-starting it until Mrs C raised the matter at the time of discharge, so we upheld this complaint.

We did not uphold Mrs C's other complaints. Although the various moves Mrs A had between wards within the hospital were not ideal, we were of the view that these were necessary for specific reasons and to improve her clinical care. In addition, we did not consider the television facilities to be unreasonable and noted that the board had already taken steps to remind staff to ensure that patients were aware of the available facilities.

Recommendations

We recommended that the board:

• share with relevant nursing staff our comments with regard to maintaining a patient's dignity in relation to continence issues;
• ensure that Mrs A's consultant reflects on our comments regarding her discharge;
• review the hospital's discharge planning process with a view to ensuring that, where relevant, patients under the care of an orthopaedic consultant should be reviewed by geriatric services;
• remind relevant nursing staff that when patients are being transferred between wards, they should ensure the patient and their family are fully informed where appropriate;
• undertake an audit of the medicines reconciliation process for patients discharged from orthopaedic wards; and
• apologise to Mrs C for all the failures identified.

Summary

Ms C contacted us on behalf of her client (Mr A) who was unhappy with treatment he received during a hospital consultation. She said that Mr A was not provided with the correct treatment and procedures were not properly explained to him beforehand.

After taking independent advice from one of our medical advisers, we did not uphold the complaint about treatment as we found that it was reasonable given the symptoms he reported. We did, however, uphold the complaint about the explanations provided. The board told us that patients are fully informed verbally before the consultation, that they are sent a leaflet in advance by post and that Mr A had given verbal consent to the procedure. Mr A disagrees, and there was insufficient evidence for us to reach a decision on whether reasonable verbal information was in fact provided beforehand. We found that the board had no written record or evidence that the procedure was explained to Mr A, or whether he had been sent a leaflet or given verbal consent. Because of the lack of clear evidence that the board had adequately explained this to him, we upheld the complaint.

Recommendations

We recommended that the board:

• carry out a review of the patient's pathway when attending the relevant clinic, with a view to improving documentation and record-keeping to incorporate a record of all advice given, acknowledgement that the patient understands the advice and that consent had been given; and
• consider revising the appointment letter to either incorporate the information leaflet or clarify that a leaflet is enclosed.

Summary

Mr C had been diagnosed with a retroperitoneal liposarcoma (a malignant soft-tissue tumour) which was removed. Two years later, a CT scan (a special scan using a computer to produce an image of the body) showed that the tumour had grown back, and it was decided that scans should be carried out to monitor its growth. The scans showed that the affected area had grown and so it was decided to surgically remove the tumour. When the operation was carried out, it was not possible to remove the tumour completely. The right ureter (the tube that carries urine from the kidney to the bladder) was also involved in the tumour and it was divided and closed off.

Mr C complained that the surgeon failed to obtain an up to date CT scan of the affected area before he carried out the operation. After taking independent advice from one of our medical advisers, we found that such a scan was not needed as it would not have changed the need for or prevented the surgery on Mr C's ureter. We also found that all the required investigations were performed and documented before Mr C had the operation.

We did, however, uphold his other complaints. Mr C complained that the surgeon had failed to obtain informed consent from him for the operation. He said that he thought that only the tumour would be removed and had never been told that surgery on other tissue or organs might be required. The board's consent policy clearly says that it is essential for health professionals to clearly document both a patient's agreement to treatment and the discussions that led to that agreement. The policy says that this will be done either using a consent form that the patient signs, or by documenting in the patient's case record that they have given verbal consent. We found that the clinical decisions and surgical treatment were correct and in line with the accepted standard of practice for this operation. However, there was no documented evidence that Mr C was given sufficient information before the surgery about possible loss of kidney function. Consequently, we found that that there was no evidence that the board had communicated with Mr C effectively during the consent process.

Several weeks after Mr C was discharged from hospital, he was admitted to another hospital with hydronephrosis in his right kidney (a condition where one or both kidneys become stretched and swollen because of a build-up of urine). Mr C said that he and the staff in the other hospital were initially unaware that his right ureter had been intentionally closed off. Because of this he was initially diagnosed with a possible kidney stone, before it was identified that the problem was related to the surgery on his ureter.

We found that it was not possible to say whether Mr C was given sufficient information after the operation, as there was no written documentation of the discussions on ward rounds. The board said that he was told what had been done. However, it was clear that after the operation Mr C was not fully aware of the extent of the surgery he had. We could not say whether this was because he was told, but did not retain the information, or because this information was not given to him. However, important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes and there was no evidence in Mr C's notes that staff had effectively communicated details of the operation to him.

Recommendations

We recommended that the board:

• consider if their consent form should be reviewed in order that there is a section to record possible risks and complications; and
• remind the relevant staff involved in Mr C's care and treatment that important information shared with the patient on ward rounds should be clearly documented in writing in the clinical notes.

Summary

Mrs C's late husband (Mr C) was admitted to hospital, having been referred there by his GP for rectal bleeding and diarrhoea. His symptoms were attributed to his known history of diverticulitis (a common disease of the digestive system), but he was also found to have an abdominal aortic aneurysm (ballooning of part of the aorta, the body's largest artery). His symptoms settled and he was discharged after three days. However, a CT scan (a special scan using a computer to produce an image of the body) carried out during his admission showed that his aneurysm required urgent treatment and he was readmitted within two weeks for surgery, in which a graft was used to repair the aneurysm.

Mr C recovered well and was discharged six days later with arrangements for him to be reviewed in another six weeks. Around five weeks after his surgery, however, Mr C began coughing up blood. He attended the accident and emergency department, and was readmitted to hospital. Tests were carried out to check for a blood clot in his lungs or a chest infection, and he was treated for a presumed chest infection. Mr C's kidney function was also impaired and he became septic (with infection in the bloodstream), but the cause of the sepsis was unclear. He was referred for review by a surgeon who arranged another CT scan. This showed evidence of air pockets around the graft that had been used during his aneurysm repair. Mr C was treated with antibiotics, then had further surgery to remove and replace his infected graft. After the operation,

Mr C was taken to the intensive care unit (ICU) and high dependency unit (HDU), but was transferred back to the main ward three days after his operation. He developed oedema (swelling) and kidney failure. He was transferred back to the ICU, but suffered two heart attacks and died three weeks after the surgery.

Mrs C complained that the board discharged Mr C too soon after his initial operation. She also felt they failed to identify the source of his infection, despite his recent operation wound being a likely site and that the vascular surgeon who carried out his operation was not informed of his re-admission soon enough. Mrs C also complained that Mr C was transferred out of the ICU/HDU too soon.

After taking independent advice from our medical advisers, we upheld Mrs C's complaints about her husband's first discharge from hospital, and the move out of ICU/HDU, but not her other complaints. We found that the board failed to follow their own discharge planning policy properly and, although there was no clear evidence to suggest that Mr C was not fit for discharge after the first operation, a lack of records meant we were unable to be certain of this. We noted that the board took appropriate action when Mr C developed a rash over his entire body, but we criticised the decision to transfer him back to the main ward after his last operation. Our adviser said that his fluid balance was poorly managed and that staff on the main ward would not have been qualified to provide the close monitoring and treatment that he required. We were, however, satisfied that the board took reasonable steps to identify the source of Mr C's infection. As he initially presented with respiratory symptoms, there was no cause to involve the vascular surgeon or to investigate his operation site as the source of infection. However, as potential sources were ruled out, the vascular surgeon was contacted for his view.

Recommendations

We recommended that the board:

• audit their performance in relation to their discharge from acute care policy with particular emphasis on record-keeping and ensuring patients are reviewed daily;
• apologise to Mr C's family for the additional discomfort caused by his premature discharge to the main ward; and
• arrange for their ICU and HDU staff to review Mr C's case with specific reference to fluid balance management to identify any points of learning.