Some upheld, recommendations

Summary
Mrs C complained about aspects of nursing care that her late father (Mr A) received in hospital in the two months before his death. The complaints included that Mr A was not provided with basic nursing care in relation to personal and oral hygiene or to ensure that he had adequate food and drink. Mrs C also complained about the time her father spent waiting in accident and emergency to be admitted to a ward and that the staff failed to listen when the family pointed out Mr A's inabilities to care for himself.

We took advice from one of our medical advisers, who is a senior nurse. We upheld two of Mrs C's three complaints. We found that the records showed that the level of nursing care provided was appropriate, but it was unacceptable that Mr A had to wait for more than seven hours to be admitted to hospital. Also, although Mr A was in hospital for about six weeks, there was little evidence of communication from the nursing staff to his family, even in the final days of Mr A's life. We, therefore, found that communication from the staff to the family was inadequate and that the record-keeping about this should have been better.

Recommendations
We recommended that the board:
• remind nursing staff of their responsibilities to ensure that record-keeping is maintained in accordance with the Nursing and Midwifery Council Code and Record Keeping guidelines; and
• apologise for the failure to admit Mr A to a ward within an acceptable timeframe.

Summary
Ms C has joint power of attorney for her mother (Mrs A). Mrs A has vascular dementia and can become agitated and present challenging behaviour. As she is reluctant to take her medication, her family often disguise it in fruit juice.

Mrs A had a fall and was admitted to hospital. Her daughter complained about the care and treatment her mother received when she was there. She said that the board failed to take her advice about medication and that this led to her mother receiving it intra-muscularly. She complained that this was inappropriate. She also complained that the board failed to proactively manage her mother's care and that this led to a worsening of her condition. She further alleged that her discharge failed and that Mrs A required to be readmitted to hospital.

We obtained advice from one of our medical advisers, a specialist in acute medicine for older people, who read Mrs A's clinical records. We did not uphold the complaint about administering medication as we found no evidence in the notes to suggest that the family had told staff about how they had given this to Mrs A. Our adviser said that, in his view, the notes suggested that the board acted appropriately in the circumstances. However, because the notes omitted information that could have been expected, we decided on balance that the board did not managed Mrs A's condition proactively and upheld that complaint. We also found that the board had handled Mrs A's discharge appropriately but had failed to properly address Mrs C's written complaints as they should have done.

Recommendation
We recommended that the board:
• apologise to Ms C with regard to their failure to proactively manage her mother's care.

Summary
Ms C was diagnosed for a second time with cancer in the left breast and a lumpectomy (operation to remove a lump) was carried out. Ms C complained that the board failed to carry out the consultant's agreed monitoring programme of six monthly clinic reviews and annual mammograms. She said that when attending her second six monthly clinic review she was advised by one of the doctors that her next clinic review would be in one year's time due to the volume of patients. Ms C was also dissatisfied that a mammogram appointment was supposed to have been arranged but that she had to raise it with the doctor and arrange it herself. She also complained that the board's response to her complaint contained inaccurate information, in that they said she had undergone a mastectomy (opertation to remove a breast) and reconstructive surgery, which was incorrect.

The board had advised Ms C that she was being reviewed in accordance with the agreed monitoring plan of two six monthly clinic reviews, followed by yearly reviews and yearly mammograms. The board also told her that the doctor had not said that the yearly clinic reviews were due to the volume of patients, but that they were based on patient need.

We did not uphold the complaint about the monitoring programme. Although we considered that the wording of the consultant's monitoring plan was open to interpretation, our medical adviser said that the frequency of clinic reviews was appropriate and in line with the Scottish Intercollegiate Guidelines Network for the management of breast cancer in women. We could find no objective evidence to support Ms C's concern that she had been told that her next clinic review would be in one year's time due to the volume of patients.

Our medical adviser also considered that it was not unusual or inappropriate for a mammogram appointment not to have been made prior to Ms C's last six monthly clinic review. This was because it is safer to book appointments from the clinical assessment than to have requests made many months prior to the mammogram due date.

During our investigation, the board acknowledged that a mistake had been made in their response to Ms C's complaint. The board explained that Ms C's medical records had recorded the surgical options of mastectomy and reconstruction, but that these procedures had not been carried out. We upheld this complaint, noting the importance of responses to complaints being clear and accurate to ensure confidence in the professionalism of the NHS.

Recommendation
We recommended that the board:
• apologise to Ms C for incorrectly stating in their complaint response that she had undergone a mastectomy and reconstructive surgery.

Summary
Mrs C is a council tenant. In 1997, she moved from one property to another in an exchange scheme. It was a condition of the scheme that Mrs C accepted her new house in its current condition and that no non-emergency/non-statutory repairs would be carried out during the first six months. Mrs C told us that when she took over the house, she reported that there was a chip in the bath tub. She said that the council refused to repair the bath and told her that she had to take the property as seen. In 2011 Mrs C transferred again. The council made a pre-transfer assessment, and assessed the bath as 'damaged'. They sent her an invoice for more than £600 to cover the cost of replacing it. Mrs C said that the damage referred to was the same chip that existed when she moved into the property.

In deciding to hold Mrs C liable for replacing the bath, the council relied on the 'Application to Exchange Houses' form and the end of tenancy document completed by the council officer who inspected the property in 1997. They also referred to a copy of the pre–transfer report prepared before Mrs C vacated the property in 2011.

Our investigation found that the 1997 forms were largely incomplete, with only the section about the décor of the property filled in. There was no record of the condition of the bath. The council took the view that because the documents did not say the bath was damaged, this meant the damage occurred after Mrs C moved in. We, however, took the view that as there was nothing in writing to show that the bath was inspected at the end of the previous tenant's tenancy, this was not evidence that it was undamaged at that date.

The council also told us that when they carried out the pre-transfer inspection in 2011 they told Mrs C that she would be charged for the bath. When we looked at the relevant report, we found that although the fact that the bath was 'chipped' was noted, there was no indication that this was rechargeable. There was no agreement by Mrs C in the declaration section to either undertake repairs herself or pay the cost of repairs, and she had not signed the report. We saw no evidence that disagreed with what Mrs C had told us, and we upheld her complaint. The council have since cancelled the invoice and re-emphasised to staff the importance of completing documents about the inspection of property at the end or start of a tenancy.

Recommendations
We recommended that the council:
• review their decision to recharge Mrs C and do so with fair cognisance of the information available and/or not available including Mrs C's version of events; and
• review their procedures in relation to the completion of documents relating to the inspection of property at the end or commencement of a tenancy, ensuring that all sections are completed as required.

Summary
Mr C complained that the council, in their capacity as landlord, did not tell him whether self-closing fire doors need to be fitted in his home or if the door that they had fitted in June 2011 met the Building Standards Regulations (Scotland) Act 2006. He also complained that the council did not respond to his complaint within a reasonable timescale and did not give him sufficient information to evidence that their actions were in line with the relevant building regulations.

We upheld some of Mr C's complaints. We found that the property had been built prior to new regulations which apply only to new buildings or existing buildings undergoing major structural change. There was, therefore, no requirement for the council to replace Mr C's door to the current building regulations. However, we found that the council did not clearly explain this to him following his enquiry. We also considered that they did not respond to the complaint according to their complaints procedure, and did not provide information (that they had agreed to give Mr C) until after the complaint had been raised with us.

We did not find any evidence to show that Mr C had asked the council whether the kitchen door that had been replaced met the relevant building standards regulations.

Recommendation
We recommended that the council:
• highlight to the housing department management team the importance of updating complainants on the progress of their complaint and ensuring clear and full responses are provided at all stages of the complaints procedure.

Summary
Mrs C received care and treatment from her GP (in a practice administered by the board) in relation to pneumonia, bunion pain and multiple sclerosis.

In 2006, Mrs C phoned her GP in the early morning, complaining of being unwell. The GP visited her at home and referred her to hospital, where she was diagnosed with pneumonia. Mrs C complained that because her GP visited after 09:00 there was a delay in admitting her to hospital. Later that month, Mrs C saw her GP about her sore bunion. In 2009, a locum GP referred Mrs C to an orthopaedic surgeon for an operation on it. Mrs C complained that the clinical picture did not alter significantly between 2006 and 2009 and that her GP should have referred her to an orthopaedic surgeon in 2006.

In November 2009, Mrs C saw a consultant neurologist (specialist in the nervous system). In February 2010, Mrs C approached her GP to follow-up on this, but said that her GP took no action. A locum GP arranged a follow-up appointment with the consultant the following month. Following investigations by the consultant, Mrs C was diagnosed with multiple sclerosis in August 2010. Mrs C complained that her GP's failure to act in February was not reasonable.

After taking advice from one of our medical advisers, we found that Mrs C's GP provided reasonable care and treatment in relation to her pneumonia and bunion. In terms of the time it took the GP to visit Mrs C after her telephone call, there were differing views about how long it was before the GP arrived. We found, however, that delay would not have affected the clinical outcome of Mrs C's condition. We did not uphold these complaints.
We did find, however, that the GP's failure to follow up on the consultation with the neurologist in February was not reasonable. Our adviser said that the GP should have been more proactive in seeking a definitive diagnosis, and that their failure to do so represented a deficiency in care. We upheld Mrs C's complaint about this.

Recommendation
We recommended that the board:
• ensure that the GP reflects on the diagnosis and management of multiple sclerosis with particular reference to the discussion of the diagnosis with patients.

Summary
Mr C had several complaints about the care and treatment received by his late mother (Mrs A) in 2008 and 2010.

We upheld Mr C's complaint about the care she received in 2008. Mr C's mother had been admitted for acute pulmonary oedema (fluid in the lungs), and as part of her treatment, an arterial line (a thin tube) had been inserted into her arm so her blood pressure could be monitored. Swelling developed around the line which was then removed, and a pseudo-aneurysm (a collection of blood under the skin from a leak in an artery) developed. We found no errors in relation to the way the line had been inserted, and our medical adviser said that a pseudo-aneurysm is a recognised complication of the use of an arterial line. However, because clear records were not kept of the management of this complication and as Mrs A had moved between units during this time, the cause of the swelling was not properly identified at first. There was also a failure to conduct a prompt medical review of the event.

Mr C was also concerned that when Mrs A had a scan of her abdomen, she had to drink a large quantity of liquid. He felt that, as Mrs A had fluid retention problems, this caused her to collapse in the scanner. We found no evidence to suggest that intake of the fluid caused his mother to collapse. We also found that the scan and giving the fluid in preparation for it were appropriate clinical treatments in the circumstances. However, we were critical that fluid balance charts were not completed for Mrs A at this time, considering her complex fluid management situation. We made recommendations to address these failings.

We did not uphold Mr C's complaint that a doctor had inappropriately noted Mrs A as a 'do not resuscitate' patient without the family knowing about this. We found that a doctor can make this decision without consultation with a patient or their family, in circumstances when resuscitation is considered ineffective. We noted that it is good practice to discuss such a decision when appropriate, and found evidence that such discussions had taken place with Mr C.

We did not uphold Mr C's complaint about Mrs A's care in 2010. We found that the use of intravenous (administered into the vein) antibiotics had been appropriate, even when giving regard to Mrs A's fluid retention problems. This was because she had a severe infection, and other clinical issues indicated that intravenous antibiotics were an appropriate method of treatment. Although Mr C was also concerned that Mrs A had difficulty passing urine, which he felt was not adequately recognised or treated, we found that this was due to kidney failure, rather than because of any clinical mismanagement.

Recommendations
We recommended that the board:
• provide evidence to the Ombudsman that staff within the hospital have received training for the care of arterial lines and the complications that can occur, including the need for prompt medical review of any complication;
• undertake an audit of record-keeping within the hospital to ensure medical records are completed timeously and comprehensively, including for patients who are moved between units within the hospital; and
• provide evidence to the Ombudsman to demonstrate that staff in the hospital are aware of the importance of completing fluid balance charts for patients with complex fluid management requirements.

Summary
Ms C attended the accident and emergency department of a hospital with abdominal pain three times in two months. Clinicians diagnosed a possible urinary infection and discharged her with pain relief. Ms C complained about the care and treatment she received during these visits to hospital. She said that clinicians failed to investigate her symptoms properly and arrange appropriate referrals.

Ms C had an ultrasound scan a couple of months later, which identified fibroids (non-cancerous tumours that grow in or around the womb) and a mass near her pelvis. This was confirmed by an MRI scan which was taken shortly after. Ms C complained that the board's response to the ultrasound scan lacked urgency and that a more senior doctor should have looked at it to avoid the need for an MRI scan.

About two months later, a consultant gynaecologist reviewed Ms C and provisionally diagnosed a degenerating fibroid. Ms C underwent a full hysterectomy (removal of the womb) shortly after. During the operation, numerous fibroids were noted in addition to a large mass, and it was later confirmed that the mass was a tumour. Ms C complained that she underwent a hysterectomy that might not have been necessary and which could have been avoided if she had been referred to an oncologist and/or had a biopsy carried out beforehand. She also complained about the board's response to her complaint saying that it contained a number of inaccuracies.

We upheld two of Ms C's complaints. After taking advice from our medical adviser, we found that she should have been reviewed by a more senior doctor when she went back to the hospital with the same problem. The adviser also said that the doctor concerned should have widened the range of possible diagnoses they were considering, after the results of a dipstick test ruled out a urinary tract infection. However, we found that their response to the ultrasound scan was reasonable and that ordering an MRI scan as a result was appropriate. We also found that the decision not to involve oncology or conduct a biopsy was reasonable in light of Ms C's presenting condition at the time, as was the decision to proceed with a hysterectomy.

Finally, although we found that much of the board's response was accurate, it did contain two inaccuracies. More seriously, the board did not respond appropriately to Ms C's complaint about her hysterectomy.

Recommendations
We recommended that the board:
• forward a copy of the decision letter and Ms C's letters of complaint to the relevant clinician to reflect on;
• draw up a written policy clearly stating the need for senior review when a patient presents to accident and emergency complaining of the same problem; and
• apologise to Ms C for the inaccuracies contained in their response and their failure to provide a substantive response to her concerns about her hysterectomy.

Summary
Mr C complained about cataract surgery carried out by a trainee surgeon. During the operation the iris of his eye was damaged. Mr C's concerns were that he had not been advised that a trainee surgeon was to carry out the surgery and that it was not appropriate for a trainee to have done so.

We took advice from one of our medical advisers who is a consultant ophthalmologist. We did not uphold the complaint that it was inappropriate for the trainee, an experienced cataract surgeon who had nearly completed their training, to have carried out the operation. This is normal practice and there was adequate supervision. However, before the surgery took place, Mr C should have been told of the possibility that the surgeon might be a trainee. As he was only told that the doctor who operated might be a different doctor from the consultant he had been seeing, we upheld this complaint.

Recommendation
We recommended that the board:
• take steps to make patients aware that procedures could be carried out by trainee staff under supervision. This advice could be incorporated in a patient information leaflet, consent form, or documented in the patient's records.

Summary
Mr C complained on behalf of his partner (Ms A) who was a hospital in-patient receiving treatment for schizoaffective disorder (a mental disorder affecting thinking processes and mood). Ms A was prescribed unilateral electroconvulsive therapy (ECT – a treatment that involves sending an electric current through the brain). This was to be provided at another hospital, as there was renovation work taking place in the ECT unit at the first hospital. After three sessions of ECT Ms A complained of gaps in her memory as well as a general feeling of her mind being blank. It was found that she had received bilateral ECT (electrical current passed through the whole brain) instead of the prescribed unilateral ECT (electrical current passed through only one side of the brain).

Mr C complained that Ms A was not reasonably administered her prescribed medication in the first hospital, as she was asleep when medication rounds took place and she was not woken. He also complained that the second hospital provided bilateral ECT without Ms A's consent and that the information provided before the treatment was not reasonably relevant to his partner's circumstances.

We did not uphold the complaints about medication and information. We were satisfied that the information provided prior to the treatment was appropriate. We found that Ms A missed medication doses on around 20 occasions, mainly of ibuprofen. However, we accepted the advice of our medical adviser that patients would not be woken for such pain medication. Ms A also missed two doses of depakote (a mood stabilising anti-epileptic drug). We found that this drug should be maintained at a certain level in the blood stream and, as such, patients should not miss their dose. However, recommended practice is for the dose to be provided as soon as possible after the patient wakes up. If they wake closer to the time when the next dose is due, then a dose can be missed rather than a double-dose being provided.

There was insufficient evidence for us to determine exactly when Ms A woke up on the occasions in question or how close this was to the planned delivery of her next dose of medicine. We also found that such episodes were rare, and our medical adviser said that they did not happen close enough together to have had a significant impact on Ms A's overall wellbeing.

The board accepted and apologised unreservedly for the fact that bilateral rather than unilateral ECT was performed. This was due to different practices in the two hospitals. The board pointed out that Ms A signed a consent form allowing staff to decide what type of ECT was provided. We found that the consent form did allow bilateral ECT, but that any decision about this should be linked to clinical need and the patient's preference. We found that unilateral ECT is recommended in most cases and that by providing bilateral ECT the board increased the likelihood that Ms A would experience side effects. There was no clinical indication for bilateral ECT. The board failed to record any reasons for deviating from the prescribed treatment, and communication between the prescribing team and the team providing the treatment was poor.

In this respect, the board failed to comply with standards set out by the Scottish ECT Accreditation Network (SEAN). So although Ms A's signed consent allowed the board to carry out this treatment, we did not consider that they went about deciding to do so in the way that the consent form suggests, and we upheld this complaint.

Recommendation
We recommended that the board:
• provide us with evidence of their standardised procedure for prescribing and recording treatment within their ECT departments including specific detail as to how specific SEAN standards (10.2 and 11.8) are being complied with.