Some upheld, recommendations

Summary
Mrs C complained about aspects of the care and treatment provided to her late mother (Mrs A) in hospital after she fell at home in a sheltered housing complex.

Mrs C said that there was difficulty in receiving accurate information from staff about her mother's condition and whether she was going to be taken to theatre. In addition, Mrs A had gone eight days without food; and the family could not understand how Mrs A could die of pneumonia in hospital two weeks after a simple fall with no injuries.

We took advice from two medical advisers who established that Mrs A was an elderly lady in poor health. On looking at the board's care and treatment of Mrs A, we found that she had a number of pre-existing medical conditions, which meant that she did not have the physical reserves to cope with the complications that followed her fall.

Our advisers confirmed that Mrs A received appropriate care and treatment while in hospital and that it was necessary for her to be fasted in order to manage her condition, and, therefore, we did not uphold this complaint.

We did, however, find that there were failings in the way in which medical staff communicated with the family, and delays in the handling of Mrs C's complaint.

Recommendations
We recommended that the board:
• remind staff of the importance of communication with relatives about a patient's care and treatment;
• remind staff to respond to complaints in accordance with the guidance contained in the NHS complaints procedure; and
• apologise to Mrs C for the delay in responding to her complaint.

Summary
Miss C raised a number of concerns about the treatment her late father (Mr A) received in hospital.

Mr A had become unwell after surgery, complaining of abdominal pain. He was found to have several bleeding ulcers. Mr A received treatment for these, but his condition deteriorated and he died a few days after the surgery took place. Miss C felt that there had been a delay in transferring Mr A to theatre and then for surgery, and that his pain relief was inadequate. She felt that a proton pump inhibitor (PPI) (a drug that reduces acid in the stomach) should have been prescribed earlier.

Having looked at the case, our medical adviser found that Mr A had received reasonable treatment and that there were no unreasonable delays. We found that Mr A was taken to theatre for surgery when it was clinically appropriate to do so.

We did, however, find that Mr A's pain management was inadequate for a period during the admission. While recognising that Mr A's pain was difficult to manage, our adviser was concerned that someone with a history of chronic duodenal (lower intestine) ulcers did not have PPI protection throughout his recovery. We took the view that Mr A's abdominal pain should have been identified and addressed earlier and made a recommendation to the board about this.

Recommendation
We recommended that the board:
• apologise to Miss C for the failure to fully address Mr A's pain issues.

Summary
Mr C attended his GP, complaining of blurred vision. Two days later, he attended again with the same symptoms. The GP telephoned the hospital to ask for an appointment to be provided more quickly and was told Mr C would be seen as soon as possible.

Just over a month later, Mr C saw a consultant ophthalmologist who could not find anything wrong. Mr C questioned this and was told that the consultant could send him for a scan. Mr C attended for a scan three weeks later. The following week, the consultant telephoned and said that the results of the scan showed Mr C had suffered a stroke and urgently needed to attend the stroke clinic. Mr C was dissatisfied with the consultant's attitude and was unhappy that it took over nine weeks to diagnose that he had suffered a stroke.

After taking advice from one of our medical advisers, we found that Mr C's symptoms were not typical of a stroke and that the consultant had carried out an appropriate assessment. We did, however, uphold his complaint that there was a delay in the board providing him with an ophthalmology appointment after the GP asked for Mr C to be seen more urgently.
 

Recommendation
We recommended that the board:
• apologise to Mr C for the failure to act on the second GP referral.
 

Summary
Mr C complained about the treatment that his late mother (Mrs A) received in hospital.

Mrs A was admitted with shortness of breath, and was in hospital for five days. She was discharged back to her care home but when she arrived there, staff were concerned about her condition. They contacted a GP who authorised that Mrs A be redirected to the community hospital. She was admitted to the community hospital, where she died of pneumonia some five hours after admission.

We upheld most of Mr C's complaints. We noted that before we began our investigation, the board had already accepted there were failings and communication problems, and had set out an action plan to prevent a repeat occurrence. We also established that there were communication failings between staff about the facility to which Mrs A should have been discharged. Initially the consultant had deemed that Mrs A should be discharged directly to the community hospital for palliative care but they refused as Mrs A did not require rehabilitation. This information was not passed back to the consultant, and a junior doctor decided that Mrs A could then be discharged back to the care home.

We took advice from one of our medical advisers who said that the board failed in the overall management of the care of and discharge planning for Mrs A. It appeared that arrangements for her discharge were managed by junior medical and nursing staff without any involvement of more senior staff. The inadequate arrangements that resulted from this meant that Mrs A and her family were badly let down during the final hours of her life.

Recommendations
We recommended that the board:
• take into account the adviser's comments on the action plan and provide a more detailed consideration of the failings which have been identified and demonstrate how effective the suggested measures have been; and
• apologise to Mr C for the overall manner in which Mrs A's discharge from hospital was handled.

Summary
Mr and Ms C complained about the care and treatment provided to Ms C's mother (Mrs A) by her medical practice.

They complained that the practice failed to adequately investigate the decline in Mrs A's mental health; properly monitor her repeat prescription medication; fully investigate her incontinence problems; or arrange for Mrs A to have an influenza vaccination without being prompted by the family. They also complained that the practice failed to provide treatment in line with the Adults with Incapacity legislation and that there were unreasonable delays in responding to their complaints.

Turning first to the complaint that the practice failed to provide treatment in line with the Adults with Incapacity legislation, we found that they acted within their procedures, but that there were communication failures. These were contrary to the principles underpinning the legislation and also contributed to the delay in arranging the influenza vaccination. We found that there were shortcomings by the practice in the way they handled the complaint in that there were delays and that the practice failed to tell Mr and Ms C of their right to approach the SPSO at the beginning of the complaints process. We also found that the practice did not closely monitor Mrs A's repeat prescription. We made recommendations to address the failings that we found. However, we did not find any failures by the practice in the provision of care and treatment in relation to Mrs A's mental health and incontinence problems.
 

Recommendations
We recommended that the practice:
• review their systems to monitor repeat prescriptions;
• ensure effective communication takes place between practitioners and all the key people involved in a patient's care;
• review their complaints handling to ensure it complies with the NHS complaints procedure, with particular reference to timescales; and
• apologise for the failures identified.

Summary
Mrs C complained about the treatment her mother (Mrs A) received at the Victoria Infirmary. Mrs A was admitted to hospital by emergency referral from her GP with a history of recurrent falls, drowsiness and reduced mobility. Mrs A was initially treated for a presumed infection based on abnormalities in her bloods and her presenting condition. However, no clear source of infection was identified. She was identified as being at risk of blood clots and was put on anticoagulant medication.

Nursing staff observed that Mrs A's right leg was swollen. A doctor reviewed the swelling and did not consider it to be significant. Mrs A's leg was found to be swollen again eight days later. A Doppler ultrasound (a type of ultrasound for monitoring blood flow) was carried out, which showed no signs of thrombosis. A CT scan showed that Mrs A had a mass in her pelvis. Biopsies were ordered, but because of the location of the mass and the quality of the material gathered, it took some time to obtain the eventual diagnosis of cancer of the B-cells. This diagnosis was made around a month later and three days after Mrs A's death. A post-mortem was carried out which concluded that Mrs A's death was the result of a pulmonary blood clot, caused by Deep Vein Thrombosis (DVT) in the right calf, due to a large tumour.

Mrs C complained that the board failed to take prompt or effective action to investigate the cause of her mother's swollen leg. She considered that this led to a failure to identify DVT. She also complained that delays to the biopsy results meant that there was no opportunity to treat her mother's cancer. Mrs C raised further concerns about delays to providing family members with test results and poor administration of medication.

Whilst we found that the board did not regularly assess Mrs A's risk of blood clots during her admission, we were satisfied that this would not have had a detrimental impact on her treatment. We considered that there were opportunities for further Doppler ultrasounds to be carried out, but were ultimately satisfied that it was reasonable for the board not to undertake these tests in the circumstances.

There was no evidence of DVT following the Doppler ultrasound and we found that Mrs A's mass (which was likely to cause leg swelling) and the fact that she was already receiving anticoagulant medication indicated that there were alternative causes for her swelling other than DVT. We did not find that the board unduly delayed providing family members with test results.

Similarly, the evidence presented to us showed that it was difficult to obtain biopsy samples from Mrs A's mass and, once obtained, the diagnosis of cancer of the B-cells was complex, requiring specialist opinion. We were satisfied that the biopsies were ordered, and their results reported, as quickly as possible. With regard to the provision of medication, we found that cough medicine prescribed for Mrs A was taken to a different patient in error. We also established that Mrs A was prescribed the wrong dose of anticoagulant medication and that doses may have been missed on more than one occasion. Whilst we were unable to confirm that doses were definitely missed, we considered that the lower dose provided would have increased Mrs A's risk of developing blood clots.

Recommendations
We recommended that the board:
• apologise to Mrs A's family for the failure to properly prescribe and record certain anticoagulant drugs;
• remind staff of the importance of recording and signing for all administered medication; and
• draw clinical staff's attention to the guidance in the Therapeutics Handbook for Thromboprophylaxis for Medical Patients (guidance on the administration of anticoagulant drugs to patients with an increased risk of blood clots).

Summary
Mrs C was a patient of a consultant gynaecologist for about five years, during
which time she had gynaecological surgery, including a hysterectomy. At the
time of this surgery, the consultant noted signs of endometriosis (a condition in
which cells from the lining of the uterus appear outside the uterus). Five years
after the surgery, Mrs C was suffering intermittent pelvic pain and her GP
referred her to the board's gynaecology department.

Mrs C was unhappy with the care and treatment she received after the referral.
In particular, she was unhappy with the information that was provided to her
before surgery to remove her ovary. She felt that information was an
insufficient basis for her to give fully informed consent before surgery. She was
also unhappy about the removal of a stent, and complained that her ureter was
damaged during the ovary surgery. She also said that, due to failures in care
and treatment, she developed preventable infections, including MRSA.

We could not say with certainty what was said to Mrs C in advance of the two
procedures. From looking at the evidence, we found that Mrs C signed consent
forms for each procedure. Both forms stated that the nature and purpose of the
procedures had been explained to her, and that she consented to further
alternative operative measures that might be found necessary during the course
of the operation. In addition, the consent form for the ovary surgery had been
annotated and showed that the potential for bowel and bladder damage were
discussed. We were satisfied from the evidence that consent was properly
obtained and Mrs C was provided with sufficient information, and therefore, we
did not uphold this complaint.

We took advice from three of our medical advisers. One adviser said it was not
possible to say exactly how, or at what stage of, the ovary surgery Mrs C's left
ureter was damaged. The adviser was critical of the sparse record of the
operation and was also of the view, based on the available information, that the
damage to Mrs C's ureter could have been avoided. Given the deficiency in
record-keeping, and taking into account the views of the adviser, we upheld this
complaint.

In terms of Mrs C's treatment in hospital, two of our advisers found no evidence
of failures in care and treatment leading to Mrs C developing preventable
infections. However, based on the medical notes provided by the board, one
adviser was of the view that Mrs C should have been seen by a consultant
gynaecologist more urgently in another hospital, especially when she was still
unwell on the two days following her readmission after ovary surgery. In
addition, the adviser was critical of the wait for a CT urogram (a scan of the
urinary tract) before her move to another hospital. Given these failings in care
and treatment, we upheld this complaint.

Recommendations
We recommended that the board:
• apologise to Mrs C for the damage to her ureter during surgery;
• ensure operation notes include appropriate details, taking account of
Royal College of Obstetrics and Gynaecology guidelines and the
comments made in our decision; and
• draw the failings in care and treatment to the attention of medical staff in
the gynaecology department.

Summary
Mrs C is an owner/occupier in a tenement building which is partially private but in which the council still has an interest. She was dissatisfied with the cost of mutual repairs (stair entry door) which the council arranged and she claimed that all the works she was billed for had not been undertaken. When Mrs C received a reduced bill, she claimed that the council failed to explain the reason for the reduction.

Mrs C complained that the council's handling of the matter, particularly that they took an excessively long time to investigate. Our investigation established that the council had arranged for the repairs to be undertaken without consulting with the other owners because it was deemed to be emergency work, necessitating immediate action in the interests of residents' safety.

The council informed us that visits were undertaken but it was clear that there had been a delay in responding to Mrs C's complaint, and it was not handled appropriately under the terms of their complaints procedure. We upheld the complaint about failings in the council's complaints handling. We did not uphold Mrs C's complaint that the council had not explained the reason for the reduction in the repairs bill because the evidence confirmed that a satisfactory explanation was given.

Recommendation
We recommended that the council:
• issue a formal apology from the Chief Executive to the complainant in recognition of the council's shortcomings in the handling of her complaint under their complaints procedure.
 

Summary
Mr C complained that the council had breached National Care Standards by amending their policy in relation to foster carers’ ability to claim for travel expenses, and in relation to providing child care at training and consultation days. He also complained about the way the council had handled his complaints.

Mr C stated he was disadvantaged by the amendment to the foster carer’s allowance, which meant he could no longer claim for journeys of less than 50 miles. He felt that this expenditure should not come out of an allowance for an individual child, and that he was discriminated against as an individual who lived in a more remote location than other foster carers receiving the same allowance. He also explained the council had failed to provide child care at some training events, which made it more difficult for foster carers such as him to attend.

We did not uphold this complaint, although we criticised the council’s consultation process in relation to changing its policy about foster carers’ allowances. We found that the change did not breach the Standards and were within the council’s discretion. We also found that the council had apologised for failing to provide child care at training events, and did so at subsequent events.

We upheld Mr C’s complaint about the complaints handling process. We found there were lengthy delays in him receiving responses at some stages of the process, and that at one stage the complaint went back to someone who had dealt with it at an earlier stage. Mr C also had to request twice that his complaint be responded to by the Chief Executive as per the council’s procedure.

Recommendations
We recommend that the council:
• provide an apology to Mr C for failing to follow its complaints procedure adequately in relation to your complaints; and
• provide evidence of the new complaints handling process, and of staff training in relation to complaints handling.
 

Summary
Mr C's 86-year-old mother (Mrs A) was admitted to The Golden Jubilee National Hospital for hip surgery. Following surgery, she was returned to the ward for bed rest and was noted to be a little confused. The hospital said that they explained to Mrs A that she should not mobilise and to use her call bell if she needed assistance. They said that she seemed to understand this advice.

During the night, Mrs A fell out of bed and dislocated her hip which then required further surgery. Within half an hour, she fell out of bed again and was then placed in an alarmed bed. Since her falls and surgeries, Mrs A’s recovery has been protracted and her long term prognosis is poor.

Mr C complained that his mother was not properly monitored following her surgery. Our investigation confirmed that although Mrs A's first fall could not have been anticipated, the hospital did not take appropriate action after a second fall. We found that the hospital also failed to send Mr C a copy of the appropriate incident report after he requested it.

Recommendation
We recommended that the hospital:
• apologise for failing to send Mr C a copy of the appropriate incident report and that they provide one.