Some upheld, recommendations

Summary

C underwent surgery for removal of a complex cyst on their right ovary. C complained that during the surgical procedure the board unreasonably removed their left ovary despite their express wishes it should be retained. They said that in the absence of a fully informed pre-surgical consultation, the board had not understood their surgical choices and had unreasonably prepared them for surgery. They said that following surgery, the board had failed to provide them with adequate pain relief and had withheld their medication. C also complained that the board's handling of their complaint was inadequate and that there were delays and inaccuracies in their response.

We took independent advice from an appropriately qualified adviser with experience in obstetrics and gynaecology (pregnancy, childbirth and the female reproductive system). We found that the surgical procedure performed was in line with the recommendations of a multidisciplinary team (MDT) and that the board had acted on what they believed were C's express instructions and for which written consent had been obtained. As such, we did not uphold this part of the complaint.

We found that despite reasonable attempts to include C in the pre-surgical decision-making and consent process, the board had failed to clarify with C their understanding of the proposed surgical plan and the circumstances in which C's left ovary was to be removed. We also found that the board had not telephoned C following the MDT team meeting as had been agreed, and some of the pre-surgical discussions that had taken place between the parties were brief or had not been documented in the clinical records. Therefore, on balance, we upheld this part of the complaint.

Following C's surgical procedure we found that there were two occasions where analgesia (pain medication) had been delayed after being requested, and on one of those occasions where it appeared to have been an inadequate dose. However, we found that C's usual pain regime medications had been administered regularly and their acute pain medications administered when requested. As such, we found that C had been provided with appropriate pain relief and did not uphold this part of the complaint.

We found that the board's complaint handling in this case was poor. There was a failure by the board to update C on the progress of the investigation and there were delays in a number of their responses. The board's final response contained a number of factual inaccuracies and it had not adequately addressed all of C's concerns. As such, we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to clarify their understanding of the proposed surgical plan, the circumstances in which their left ovary was to be removed and for failing to handle their complaint reasonably. Also apologise for not sufficiently documenting the discussions that took place between the parties at the initial consultation, for failing to contact C by telephone following the MDT meeting, and for failing to document the pre-operative discussions which took place between the parties on the morning of C's surgery. 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:

• Ensure all discussions between patients and clinicians are clearly documented as part of the consent process.
• All relevant clinical staff should be reminded of the need to ensure all reasonably practical steps are taken to clarify a patient's understanding of a proposed surgical plan prior to consent being obtained and that patients are fully counselled on the nature of borderline ovarian cancer results.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. Where a response to a complaint cannot be provided within an agreed timescale, complainants should be provided within an updated timescale as to when they can expect to receive a response. The board should ensure all responses are accurate, reflect the available evidence and information, and address all points raised. Where there has been a delay in providing a response beyond the normal timescale, the board's stage 2 response should include an apology.

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 submitted a housing application to the council and complained about how this was handled. C complained that the council unreasonably suspended their application while investigating their personal circumstances, that they ignored their medical conditions, and that they did not respond to C’s concerns appropriately. The council said they considered C’s application was handled appropriately and they noted that C has since accepted an offer of permanent housing.

We found that, while C did record their medical conditions on the housing application, they did not indicate that they required any specific adaptations, therefore the council handled the application appropriately. We did not uphold this aspect of C's complaint. While we considered the council handled C’s application appropriately overall, and they gave appropriate advice in response to C’s queries, we did conclude that the council’s housing allocations policy was not clear about the circumstances that an application will be suspended. As such, we upheld the second part of C's complaint and asked the council to review their policy to ensure it is clear and transparent with regard to when housing applications will/will not be suspended.

Recommendations

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

• Housing applicants should be informed promptly if/when their housing applications have been suspended, in accordance with the council’s policy.
• The council’s policy should be clear on the circumstances where a housing application will or will not be suspended.

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 late parent (A) who died following surgery to remove cancerous tissue. C said that the care and treatment that A received in hospital was not reasonable, and that A’s cancer should have been detected earlier. C believed there were failings in the management of A’s care which caused A pain, distress and discomfort and this was worsened by the standard of nursing care.

We took independent advice from two appropriately qualified advisers. We found that the diagnosis concerning the spread of cancer was reasonable and did not uphold this aspect of C's complaint.

In relation to nursing care, we found that there was a lack of accurate and appropriate pressure assessments, and a lack of timely interventions led to the development of severe pressure damage. There was inappropriate wound management causing deterioration to wounds and poor observation of urinary output. We also found that the standard of record-keeping was unreasonable, that national pressure ulcer prevention standards and relevant policy were not followed and there was delay in referring to specialists. 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 standard of nursing care provide to A, for failing to carry out appropriate assessments to prevent severe pressure damage, failing to provide appropriate wound management, failing to appropriately monitor urine output, delaying referrals and failing to follow relevant standards and policy. 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 wound chart should be completed for each wound detailing size, tissue type present, treatment and treatment objectives.
• Fluid balance charts should be completed to acceptable standard for early recognition of fluid balance issues.
• Pressure ulcer risk assessments should be calculated properly on admission and reassessments recorded at least weekly and when clinical condition changes.
• Sufficient information should be given to a patient and or their family to allow them to make an informed choice when deciding to decline pressure relieving interventions. This should be recorded in the case notes.
• Tissue viability referrals should be made in line with the relevant national guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement with the family.

We reviewed the relevant medical records and took independent advice from a consultant paediatrician and registered mental health nurse. We concluded that the assessments by both paediatricians were reasonable and appropriate tests and follow-up were arranged. We did not uphold this aspect of C's complaint.

However, we considered that it was unreasonable for CAMHS to reject the referrals on the basis that they failed to risk assess A in accordance with the board’s guidance. On that basis, we upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for failing to accept the initial referrals to CAMHS and for the subsequent delay in treatment and the distress caused. 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:

• Ensure staff have reflected and learned from the findings of this investigation.
• The CAMHS service correctly follows the board’s suicide prevention guidance and pathway.

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 spouse (B) complained about events during two periods of hospital treatment for their child (A). A has complex medical needs. They are cared for by C and B at home, however they have required multiple and prolonged spells in hospital. C and B complained about the care and treatment A received, communication by the board, communication within the board and how their complaint was handled.

In response to C and B’s complaints, the board acknowledged a number of failings in A’s care and treatment and the way in which they had communicated with C and B. They also said that consideration should have been given to earlier involvement of social work and the community children’s nurse.

We took independent advice from a consultant paediatrician and a social work adviser. We found that the care and treatment A received on their first admission were unreasonable. We considered that there was inadequate dietetic support, an unreasonable reliance on C and B's assessment as to whether intake was sufficient, and a lack of information and help for the family when A required emergency care after a gastro-jejunal tube (G-J tube, a tube used to vent the stomach and small intestine) procedure. We upheld this aspect of the complaint.

In relation to A's second hospital treatment, we considered the care and treatment to be reasonable. We did not uphold this aspect of the complaint.

We also found a lack of reasonable communication with C and B about A's care and treatment and a lack of reasonable communication between the board’s staff during A's second admission. We upheld these aspects of the complaint.

Finally, we found that the board failed to handle C and B's complaint reasonably. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and B for the lack of information on what to do if they had concerns following the procedure, for wrongly informing them that the child concern form (CCF) would be removed from A’s medical records (and explain the reasons why this cannot be done) and for the failings identified in complaint handling. 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 local guidance for the management of fabricated or induced illness (FII) for multi-agency use, of the guidance for the completion of CCFs, of their roles and responsibilities in such cases; and of the GMC guidance: Protecting children and young people 2012 (in particular Sections 56 and 57).
• Children with feeding tubes should have a de-escalation plan individualised for each child advising of the feeding regimen if the tube dislodges. This should be shared with parents, tertiary and local centres. There should be clear documentation of advice regarding fasting for procedures and a checklist to identify those who may be at risk of fasting. Consideration should be given to carrying out such procedures on an in-patient basis if the patient is considered at increased risk.

In relation to complaints handling, we recommended:

• Complaint investigations and responses, including acknowledgement of receipt, should be in accordance with the board’s Complaints Handling Procedure. The board should keep a complainant regularly updated about their complaint including when they should expect to receive a response to their communication and if there is going to be a delay in providing this.

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 treatment A received in hospital after they fell at home and injured their back. A had previously suffered a stroke and, as a result, a computerised tomography (CT) scan of their brain was carried out. This showed no change from the previous CT scan that was carried out. Following an assessment in A&E, it was concluded that A’s back pain was muscular and that they were also suffering from an infection. A remained in hospital for treatment and observation. Twelve days after being admitted to hospital, MRI scans of A’s brain and lumbar spine were arranged. These scans showed that A had suffered a new stroke and had spinal compression fractures. C felt that A should have had an MRI scan when they were admitted to hospital or soon after. In C’s view, this would have confirmed the issues earlier and resulted in more appropriate care being delivered.

We took independent advice from an appropriately qualified adviser. In respect of whether the board unreasonably delayed in diagnosing and treating A’s stroke, we found that there was not sufficient evidence of a fresh stroke to justify an MRI scan at the time of admission. Based on A’s presentation at the time and the need to prioritise their treatment, there was not an unreasonable delay in the board diagnosing and treating A’s fresh stroke. As such, we did not uphold this complaint.

In respect of whether the board unreasonably delayed in diagnosing and treating A’s spinal compression fractures, we found that, given A’s symptoms, an earlier MRI scan of the spine was not indicated. However, we highlighted one clinician’s entry in the medical records that indicated a need for further investigation of A’s back injury that was identified on the date of admission. This entry also suggested that an x-ray was to be arranged. However, this specific entry in the medical records did not appear to have been followed up or acted on, with no narrative in the records to explain why. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for unreasonably delaying in carrying out further investigation into A’s back injury despite a clinician recording this as being indicated. 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 review the circumstances surrounding this with the aim of establishing why the clinician’s findings do not appear to have been followed up and why an x-ray was not carried out when the medical records suggest that it was to be.
• The possibility of osteoporotic fractures should be considered in all older patients presenting with new-onset back pain (particularly where trauma could be involved), unless a clear alternative diagnosis is evident. Under these circumstances, imaging should be undertaken to investigate the possibility further.

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 dissatisfied with the treatment received from the board following an urgent referral to the gastroenterology department (specialists in the diagnosis and treatment of disorders of the stomach and intestines) from their GP after experiencing back pain and rectal bleeding. The referral was triaged by the board and a colonoscopy (examination of the bowel with a camera on a flexible tube) was arranged.

Following the colonoscopy, C was advised there was a probable tumour in their lower bowel. C’s treatment was discussed at a multi-disciplinary team meeting (MDT) and C was advised that a referral to a hospital within another board had been made for a Transanal Endoscopic Mucosal Surgery (TEMS, a minimally invasive surgery) procedure.

C was examined by a colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus) at the other board and the TEMS procedure was scheduled. Further MDTs took place where the question of an anterior resection (a surgical procedure to remove the diseased portion of the bowel and rectum) being a more appropriate treatment was considered. C had a meeting with a consultant surgeon at Borders General Hospital and their understanding following this meeting was that clinicians would further consider and reach a decision on what the most appropriate treatment for C was. The consultant surgeon’s letter to C’s GP indicated that their understanding of the outcome of the meeting was that C had expressed a preference for TEMS with further steps, such as an anterior resection, afterwards if needs be, and had made arrangements for C to be seen by the TEMS team.

C attended an appointment at the other board where the colorectal surgeon said that C had refused an anterior resection. C denied this. It was also decided that a further biopsy would be undertaken. Whilst awaiting the results of the biopsy, C complained to the board and had further correspondence with them whilst also approaching this office about their concerns.

We took independent advice from an oncologist (a doctor who specialises in the diagnosis and treatment of cancer). We found that it was reasonable that C was not referred to an oncologist and that investigations of a tumour reported following their colonoscopy were reasonable. However, we found that the board had unreasonably downgraded C’s referral and that the board’s failure to treat C’s condition as cancer was unreasonable. We noted that the board did not meet the treatment time guarantee and that there were significant delays in decisions on C’s treatment that were reached jointly with another board. We considered that the likelihood of delays should have been made clear to C to allow them the opportunity to properly consider all of the options available. We upheld C’s complaint about the treatment they had received.

C also complained about the board’s response to a complaint they submitted. We found that it was unreasonable that the board did not directly address some matters that C raised and upheld this aspect of C’s complaint. However, we considered it was reasonable that the board took a different position to C about what had been said at a particular consultation.

C also complained about a subsequent response the board provided to them. We found that the board’s response was generally reasonable. Therefore, we did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified. The apology should make clear mention of each of the failings identified and 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:

• In similar cases, referrals and test results should be assessed reasonably and patients should receive treatment within 62 days of the referral and within 31 days from the decision to treat, as per Scottish Government treatment time targets. Our findings should be brought to the attention of relevant clinicians in a supportive manner and they should consider identifying these as learning point for their annual appraisals.
• A mechanism should be in place to ensure patients are informed when delays to treatment are likely.
• The pathway for the treatment of patients from Borders NHS board to another board area should be appropriate and efficient; including that clinician availability does not delay treatment decisions and that it is clear where responsibility for ongoing management and treatment lies at all times.

In relation to complaints handling, we recommended:

• Staff should handle complaints in line with the Model Complaints Handling Procedure, which includes responding to all aspects of complaints.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the standard of medical care and treatment provided to their parent (A). A received a likely diagnosis of metastatic lung and liver cancer. They were placed on palliative care, however, after approximately a year, A remained in good health. C sought a further review, A received subsequent scans, and it was ultimately established that they did not have cancer (approximately two years after the original diagnosis).

C raised concerns about the basis for the initial diagnosis that A had cancer. They also complained about the subsequent management of A. C said there was no appropriate follow-up or subsequent communication after the diagnosis. Ultimately, C requested a review, but said it took significant time for the board to establish there was no cancer.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the diagnosis that A likely had cancer was reasonable. It was based on a reasonable radiological opinion given the findings on A’s CT scan. We did not uphold C’s complaint in that regard.

In relation to A’s subsequent management, we found that there were unreasonable failings. The standard of care and attention the board provided to A following discharge was not reasonable, and we found evidence that follow-up was proposed for A and then not acted on. We also found that there was a failure to respond within a reasonable time to the referral for an oncology review. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified in this investigation and include recognition of the impact the failings have had on them. The apology should meet the standards set out in the SPSO guidelines on apology at www.spso.org.uk/information-leaflets.

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

• Ensure effective systems are in place for review on hospital discharge and communication is effective especially where there is diagnostic uncertainty.

In relation to complaints handling, we recommended:

• Ensure board investigations identify and address incidents covered by the Duty of Candour with the relevant Scottish Government guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment their late parent (A) received at Queen Elizabeth University Hospital. A was admitted to hospital with a diagnosis of pancreatitis (inflammation of the pancreas). They were treated with fluids and antibiotics and their fluid balance was measured. They recovered and were discharged later that month. A was readmitted with various symptoms including abdominal pain, vomiting, loose stools and not eating or drinking on two further occasions and was discharged both times. A was later readmitted to the hospital in cardiac arrest and died shortly after arrival at the hospital.

We took independent advice from an appropriately qualified adviser. We found that the board failed to provide A with a reasonable standard of care and treatment. During one admission, there was a lack of comment on A’s hernia, a lack of investigation of low blood pressure and no evidence of a cardiology (specialists in diseases and abnormalities of the heart) input. On another admission, we found that the care and the management plan concerning A’s hernia was below standard and that there appeared to be a delay in the involvement of other specialists. We also found issues relating to the planning of surgery for A. Therefore, we upheld this aspect of C's complaint.

C also complained that A's final discharge from hospital was unreasonable. We found A's discharge to be reasonable and did not uphold this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not making a timely assessment of risk for surgery, the failure to address A’s low blood pressure, the standard of monitoring and examination of A’s hernia, the delay in the involvement of clinical specialists, the standard of the management plan for A's hernia repair, the standard of planning of A's urgent surgery and for delays in surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should have a policy in place on the management of emergency cases and prioritisation to ensure delays and recurrent cancellations of cases are minimised.
• The board should review how deteriorating patients are managed to ensure timely involvement of relevant specialties in care when there are complex patients.
• Ward round documentation needs to reflect concerns and management plans clearly.

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 had enrolled on two short courses run by Queen Margaret University. They made a number of complaints to us about the action taken by the university in relation to adjustments that they requested for disabilities that affected the way they worked.

C complained that the university did not initially provide them with reasonable support for the courses. We were satisfied that the university sought to make reasonable adjustments for C and that they demonstrably took account of C’s input when preparing an Individual Learning Plan (ILP). We did not uphold this complaint.

C also complained that the university then unreasonably failed to provide the support that was agreed. We found that there had been a delay in providing C with a USB stick that the university had committed to provide them with and we upheld this complaint.

We also found that there was no evidence of communication with C when their disability adviser was absent and that the Head of Student Services had failed to respond to C’s contact. We upheld C’s complaints about these matters.

We also upheld C’s complaint that the university had failed to provide a note taker for a course. Although the equality legislation recognises that there can be more than one way to address an assessed need, in this case, the alternative arrangements did not run smoothly and did not address the matter within a reasonable timescale. We also upheld a complaint that the university had failed to provide a transcript of the course as previously agreed with C.

We did not uphold C’s complaint that a lecturer had failed to respond to their contact about the course or their complaint that the university failed to deal with their complaint effectively.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for these failings. 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 university should ensure that any agreed adjustments are provided within reasonable timescales.
• The university should ensure that staff reasonably communicate with students who contact them.

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.