Some upheld, recommendations

Summary

C complained about an admission to Forth Valley Royal Hospital two weeks after undergoing emergency bowel surgery there. C was admitted with a fever and vomiting and spent many hours on a trolley in A&E in severe pain. They were diagnosed with an abdominal abscess (a painful swelling caused by a build-up of pus). C complained that the abscess was drained by a surgeon while they were still on the trolley in unsterile conditions and with no anaesthetic. C complained that they were left with the wound open and that they did not receive antibiotics until later that evening, after they were transferred to the Surgical Assessment Unit. C complained that they were left with a soaked dressing and a foul-smelling wound until the following morning. They complained that failings in their care and treatment led to development of an MRSA infection (a bacterial infection that is resistant to a number of widely used antibiotics) and a hernia at the wound site.

We took independent advice from a consultant in emergency medicine. While acknowledging the length of time C had to wait for a bed, we found that generally C’s care and treatment were reasonable. We found that C was assessed appropriately and received reasonable treatment for their condition within an acceptable timescale. However, we noted that there had been a delay in C receiving antibiotics which was unreasonable. Whilst recognising how difficult C’s experience had been, on balance, we did not uphold the complaint about the standard of care and treatment in A&E.

We also took independent advice from a general surgeon. We found that C had generally been treated appropriately and that the development of MRSA and a hernia had not occurred as a result of any failings in care and treatment. Despite there being no significant clinical failings, we acknowledged C’s extremely poor patient experience including the board’s apparent failure to ensure that C was kept clean with their wound dressing changed in a timely manner. On balance, we upheld the complaint about the standard of care and treatment in the Surgical Assessment Unit.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in providing an adequate wash and changing of their dressing, with recognition of the impact these matters have had on them. 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:

• Staff ensure that patients are kept adequately clean and dressings changed when needed.

In relation to complaints handling, we recommended:

• Complaints are responded to as comprehensively as possible, particularly in situations in which complainants have requested that specific matters are investigated.

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

Concerns were raised during C's time on community work placement. Investigations were carried out and having considered the information available, the risk management team (RMT) at Prison A took the decision to return C to closed conditions (Prison B).

C considered that Prison A failed to seek relevant evidence as part of their investigation, and dismissed relevant evidence, prior to taking the decision to return C to closed conditions. We found that the RMT at Prison A appropriately considered the circumstances of C's case, taking relevant information into account, prior to reaching the decision to return C to closed conditions. Therefore, we did not uphold this aspect of C's complaint.

C also complained about the way the Scottish Prison Service (SPS) handled their complaint. They said that no Internal Complaints Committee (ICC) hearing was convened and the recommendation put forward by them was unachievable.

We found that C escalated their complaint to the ICC around the time the Scottish Government requested everyone to stop non-essential contact and travel due to the COVID-19 pandemic. C's complaint was passed from Prison B to Prison A to respond at ICC stage because the matter related to actions taken by the RMT at Prison A. Whilst an ICC hearing was not convened because of restrictions in place, Prison A did appoint a representative to consider C's complaint. However, we found that Prison A failed to share their findings and recommendation in relation to C's complaint with Prison B to ensure the matter could be given further consideration. We considered that the ICC failed to handle C's complaint reasonably and upheld this aspect of C's complaint.

In relation to the recommendation put forward by the ICC, we found this to be reasonable. 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 failing to handle their complaint appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Provide written confirmation to C in relation to the current status of the First Grant of Temporary Release application.

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, a solicitor, complained on behalf of their client (A). A is elderly and has multiple disabilities. They live in their own flat and have care provided by the partnership. A number of support needs assessments were carried out over several years. The partnership proposed to reduce A's in-person care provision and put in place a telecare system. C complained about this and then complained to our office about a delay in receiving a response to that complaint. Our office made a discretionary decision to progress the complaint in light of significant complaint handling delays. We decided to consider the substantive matters, as well as the complaint handling process.

We took independent advice from a social work adviser. We found that the assessments of A's needs were reasonable and evidence showed that A's views and those of their carers were taken into account. The partnership were entitled to review care arrangements and consider how they use their resources. The partnership also proposed a trial period, phasing in the changes, which we found to be reasonable. Therefore, we did not uphold this aspect of C's complaint.

In relation to complaint handling, we found that there were significant delays in responding to C. We noted that the partnership's information about what they would and would not consider a complaint, was unhelpful. 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 delays in responding to the complaint, giving unhelpful information about what they would and would not consider a complaint and for speculating on whether their complaint handling failings had caused detriment or injustice to the complainant. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the Model Complaints Handling Procedure. Complaints should be responded to within 20 working days or, where this is not possible, adequate explanation must be given alongside a reasonable timescale for the response.

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 actions of a consultant during an appointment to assess them for adult Attention Deficit Hyperactivity Disorder (ADHD, a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness). They also questioned the basis upon which the determination that C did not meet the criteria for ADHD had been made.

We took independent advice from a psychiatric adviser. We found that the clinical records were detailed and comprehensive and clearly showed that the consultant who assessed C had acted in accordance with relevant guidance. We found that the evidence demonstrated that the clinical records contained relevant information to provide a clear opinion as to whether or not C had ADHD which was informed by appropriate historical, clinical and questionnaire based information. We also found that the decision to discharge C back to their GP practice was appropriate and reasonable, particularly as the evidence demonstrated the consultation had been a second opinion appointment. We found no evidence that the consultant had acted unreasonably at the clinic consultation and we did not uphold this complaint.

C also complained about the response they received to their complaint. We found that the response from the partnership was unreasonable as it contained the personal views of a senior manager unrelated to the information in the case record. There was also a failure to address aspects of C's complaint regarding specific questions which had been asked during the consultation. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for including personal opinions in the complaint response which were not relevant to the outcome of the investigation and for failing to address all aspects of C's complaint in their response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Staff should be reminded of the partnership's complaints handling policy. In particular, in relation to the necessity for those dealing with complaints to remain objective, impartial and independent, and the requirement to address all the issues raised.

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 provided to their late parent (A) in A&E. We took independent advice from an accident and emergency adviser. We found that A waited an unreasonable amount of time for a clinical review on their attendance to A&E and this did not meet the triage category standards assigned to A. We also found that sepsis (blood infection) should have been considered at an earlier stage during one of A's attendances to A&E given their low blood pressure and increased respiratory rate. We upheld this aspect of C's complaint.

C complained that the board failed to provide A with reasonable care and treatment regarding a chyle leak (an accumulation of lymphatic fluid in the abdominal cavity). We took independent advice from a surgical adviser. We found that A was provided with reasonable care and treatment for the chyle leak, that their pain and discomfort was appropriately investigated and responded to and that reasonable action was taken in relation to the prevention of blood clots. As such, we did not uphold this aspect of C's complaint.

Finally, C complained that A's mobility was not fully investigated while they were in hospital. We took independent advice from a physiotherapy adviser (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise). We found that A was provided with reasonable care by physiotherapists in the assessment and management of their mobility. 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 not considering sepsis at an earlier stage during A's attendance to A&E given their low blood pressure and increased respiratory rate. 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:

• Patients should receive a clinical review within triage category timescale.
• Sepsis should be considered in A&E patients who present with low blood pressure and increased respiratory rate.

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 treatment provided to their late parent (A) by their GP practice. A had prostate cancer for a number of years which later spread to their liver.

C complained that the practice failed to reasonably monitor A's blood sugar levels (HbA1c) after prescribing medication. We took independent advice from a GP. We found that the decision to commence medication for A's raised HbA1c was reasonable and appeared to be made with the input of a specialist medical consultant. However, there was no record to indicate that the practice discussed the risks of hypoglycaemia (low blood sugar) with A or took steps to allow A to monitor their blood sugar levels. We considered that the responsibility of monitoring any risks from the medication fell to the practice. Therefore, we upheld this aspect of C's complaint.

C complained that the practice failed to reasonably respond to A's reduced haemoglobin (Hb) levels. We found that, while the actions taken after the blood test results reported two weeks prior to A's death were reasonable, there was an opportunity prior to that to act on A's falling Hb levels. We noted that given the trend of A's falling Hb levels and their overall clinical picture, there was a fair to good chance that A's condition would deteriorate prior to a scheduled admission for a blood transfusion. We considered that the decision not to admit A prior to the scheduled admission, was a doctor-led decision rather than one made in conjunction with A and their family's wishes. As such, we upheld this aspect of C's complaint.

Finally, C complained that the practice failed to reasonably manage A's pain and comfort. We found that the pain management was reasonable and that the practice provided a high standard of palliative care. The medications administered, the timing of them and the increases in dosage were in keeping with the recommended standards of care, and in keeping with A's needs. 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 failing to reasonably manage A's blood sugar levels after prescribing medication and the delay in responding to A's falling Hb levels. 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:

• Decisions about admission for treatment should be made in conjunction with the patient's and family's wishes.
• The practice should discuss with patients the risk of hypoglycaemia, or the institution of finger prick monitoring when instigating medication affecting HbA1c. The patient should be counselled about the risk and this should be recorded.
• Trends towards falling Hb in a patient with cancer should be noted and acted on timeously.

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 treatment provided to their parent (A) by the board. A had prostate cancer for a number of years. A's symptoms worsened in the period complained about and it transpired that the cancer had spread to A's liver. C considered that the care and treatment provided by the board in the period prior to A's death was unreasonable, with the board failing to reasonably respond to A's worsening condition.

We took independent advice from a consultant in palliative medicine (caregiving approach aimed at optimising quality of life and reducing suffering among people with serious, complex illness), a registered general nurse and community health specialist nurse practitioner.

C's first complaint was that the board failed to reasonably respond to A's reduced haemoglobin levels. We found that A's haemoglobin levels were appropriately managed with regular review and assessment of symptoms, and the prescribing and monitoring of 'safer' medication before planning a transfusion. We noted that there was appropriate escalation of the transfusion date once doctors became aware that the haemoglobin had fallen further. Based on A's condition at the time, the initial planned date of admission for transfusion was reasonable. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably manage A's pain. We found that the levels of pain medication prescribed were reasonable. We noted that pain was not identified as a problem or symptom during A's hospital stay, therefore, discharge without regular morphine medication was reasonable. On discharge, the board appropriately handed over care to the GP, the local hospice and community palliative care. We found that when A exhibited pain, they were reviewed in line with guidance and appropriate medication was prescribed. District nurses administered pain medication through the 'just in case' medications prescribed while A was at home. As such, we did not uphold this aspect of C's complaint.

C complained that the board failed to reasonably discharge A from hospital. We found that, while the decision to discharge A was a reasonable one, and most services were appropriately notified of A's discharge, district nurses were not, impacting on the support provided by this service immediately after discharge. There was also a failing in providing a reasonable level of support for A to dress immediately prior to discharge. As such, we upheld this aspect of C's complaint. We noted that the board were sorry that more support was not offered.

C complained that the board unreasonably failed to provide a new mattress in a timely manner. We found that, while the delay in notifying the district nurses of the arrival of the mattress was unfortunate, we accepted that the board provided a mattress within 24 hours which was a reasonable response to an equipment request. We accepted that the district nurses were unaware of delivery on the day of delivery but once they became aware, a plan to transfer A was put in place. We considered that the delay in transfer was due to a holistic assessment of A's needs at that time which was appropriate in the circumstances. As such, on balance, we did not uphold this aspect of C's complaint.

Finally, C complained that the board failed to provide reasonable nursing care when transferring A to the new mattress. We found that the board had provided reasonable nursing care when transferring A onto the mattress, based on the records available. We noted that pain medication was administered prior to the transfer, which was reasonable. As such, we did not uphold this aspect of C's complaint. However, we noted that there was limited documentation of the event and fed this back to the board.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's discharge. 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:

• Referrals to the palliative care team should contain all relevant information.
• The rapid discharge algorithm for last days of life should be followed for future discharges.
• When there is the presence of confusion and/or deteriorating function in a patient, assistance should be considered to ensure a patient is dressed appropriately before leaving the ward.

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 to us on behalf of their adult child (A). A had several attendances at Victoria Hospital and admissions for further investigation following a period of illness with severe stomach pain, nausea and vomiting. C raised concerns about A's medical care and their nursing care.

We took independent advice from a consultant gastroenterologist (a specialist in diagnosing and treating disorders of the stomach and intestines). We found that A was given appropriate medical care and treatment and we did not uphold that aspect of C's complaint.

We also took independent advice from an acute nursing specialist. We found that there were delays or issues in getting some of A's prescribed medications. Also, on one occasion, A was given a dose of a medication that was higher than recommended. We found that as A developed a staph aureus bacteraemia (SAB, where a bacteria commonly found on the skin enters the body) infection during their admission, the board appropriately carried out a significant adverse event review and took steps to improve this aspect of care. However, we found that the specific concerns that A's family raised about what caused A's SAB infection should have been addressed in their significant adverse event review. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care. 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:

• Adverse event reviews should address questions or concerns raised by the patient/their family, in line with relevant guidance.
• Medication should be administered to patients safely, appropriately and in line with their prescription.
• The board should have an appropriate system in place for accessing and administering less common medications.

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 that their adult child (A)'s dyslexia was not taken into account when the board provided them with care and treatment, and that the care and treatment was not of a reasonable standard. C believed that if A's treatment had been better, then they would have had a better chance of surviving their cancer diagnosis. C felt that A's condition had been misdiagnosed because of A's age, as they were much younger than most people who suffered from this type of cancer.

We took independent advice from an appropriately qualified adviser. We found that the board accepted that they had not been aware of A's dyslexia. We also found that there was no evidence that A lacked the capacity to make decisions about their care and treatment and that at the majority of their appointments, they had been accompanied by their other parent. Therefore, we did not uphold this aspect of C's complaint.

In terms of their care and treatment, we found that A had been difficult to diagnose because the options were limited for medical staff, due to A's unwillingness to agree to treatment. However, it would have been appropriate for A's case to have been discussed earlier at a multidisciplinary team meeting. This might have resulted in A's cancer being identified sooner. We upheld this aspect of C's complaint. However, this did not mean that the outcome for A would have been different, as the cancer was very aggressive, and it was unlikely that its progression could have been slowed or halted.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not having held a multidisciplinary team meeting to discuss A's case at the earliest opportunity. 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 ensure clinicians have time to access multidisciplinary team meetings including all appropriate specialties to discuss unusual cases.

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 a failure to accurately diagnose and treat their parent (A)'s pancreatic cancer. A was being investigated by Raigmore Hospital in the months prior to their death. C complained that too many invasive tests were carried out and an accurate diagnosis was not established.

We took independent medical advice from a consultant surgeon, who noted that A had an advanced pancreatic cancer which can be difficult to diagnose. We considered that repetition of invasive tests was reasonably required in order to pursue a diagnosis. We noted, however, that A's lung abnormalities were discussed by a lung multidisciplinary team (MDT), but an upper gastrointestinal MDT was not involved despite the fact the suspicion of pancreatic cancer could not be ruled out. We fed this back to the board. However, overall, we considered that there was a comprehensive attempt to obtain a diagnosis. On balance, we did not uphold this complaint.

C also complained about a failure to communicate clearly with A and the family regarding the diagnosis. They said that they were never made aware of the suspected cancer diagnosis, despite this having been documented throughout the records. We found no evidence to support that timely and meaningful discussions took place with A and their family. A consented to multiple invasive tests without being made aware that suspected cancer was being investigated. We considered that the risks and benefits of these tests should have been clearly discussed with A, in order for them to have made a fully informed decision as to whether to proceed with them. In the circumstances, we upheld this complaint. We also noted that the board's response to C's complaint did not provide a sufficient explanation of the extent of the tests carried out.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that timely and meaningful discussions did not take place with A and the family to inform them of the suspected cancer diagnosis and make them aware of the purpose, potential benefits and risks of invasive investigations; and that the complaint response did not comprehensively address the specific concerns raised. The apology should meet the standards set out in the SPSO guidelines on apology: www.spso.org.uk/information-leaflets.

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

• Patients should be provided with all the information they need to be able to make informed decisions about their care. This should include information about their diagnosis; any uncertainties in this regard; and a clear explanation of the purpose of any proposed investigations or treatment, including potential benefits and material risks. This should be adequately recorded in the case notes to evidence that meaningful dialogue has taken place.

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.