Some upheld, recommendations

Summary

C complained about the care and treatment provided to their late parent (A) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to use it. The board said that A fell during this time and sustained injuries. C was sceptical of the account given by the board of how A sustained their injuries. A remained in hospital until their death a little over a week later.

C complained to the board that A was injured, about medical treatment and nursing care after A was injured, and about the attitude of a specific doctor. In response, the board advised C of their view of what had happened, apologised that A had fallen and assured C that work was ongoing in relation to reducing the number of patient falls at the hospital. C was dissatisfied with the board's response and raised their complaints with this office.

We found that the board had not reasonably assessed A's falls risk, had not reasonably undertaken staff handovers in respect of A, unreasonably mobilised A to the commode without their hip brace and unreasonably allowed A to use the commode alone and unsupervised. We upheld C's complaint about the care provided to A in respect of their falls risk.

There was disagreement between C and the board about the circumstances of particular parts of A's care and treatment following their injury but, notwithstanding this, we found A's care and treatment following their injury was reasonable. We did not uphold C's complaints about the care and treatment of A following their injury.

In relation to C's complaint about the attitude of a specific doctor, the recollections of C and the doctor about a specific discussion are contradictory but the evidence available of board staff's communication with C shows these were reasonable. We did not uphold C's complaint about the attitude of the doctor.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for providing A with unreasonable care in relation to their falls risk. 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:

• Relevant staff should be properly trained regarding the completion of neuro observations in line with SIGN 110, the need for accurate record-keeping in line with the Nursing and Midwifery Council code, specifically around recording all conversations with families and adding times to all records and risk assessments, and the appropriate action to take, and record, regarding the administration of pain relief following injuries.
• Relevant staff should be properly trained regarding the safe positioning of commodes, and the management of delirium and the appropriate completion of the '4AT' bundle in line with the delirium toolkit.
• Relevant staff should be properly trained in the completion of care plans to reflect need in relation to cognition, mobility and maintaining a safe environment.
• Relevant staff, including allied health professionals, should be properly trained regarding assessment of mobility and risk assessment of moving and handling (including following a fall).
• Situation, background, assessment, recommendation (SBAR) transfer handovers are recorded for relevant staff regarding falls risk and safety interventions in place.
• The board should ensure their falls risk assessment procedures are compliant with the Scottish Patient Safety Programmes (SPSP) guidelines 'Prevention of falls driver diagram and change package' (2013) and include a prompt for staff regarding bathroom safety.

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 them and their child (A) by the board during their pregnancy and after A's birth. A was diagnosed with microcephaly (a condition where the head circumference is smaller than normal) and associated issues around six weeks after their birth, and C felt that the diagnosis could have occurred at an earlier point.

During our investigation, we took independent advice from a midwife, an obstetrician (a doctor who specialises in pregnancy and childbirth) and a neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns).

In relation to the care and treatment provided to C during their pregnancy, we identified the following failings:

A lack of documentation in the care plan in relation to detail surrounding verbal discussions midwives had with medical staff during the antenatal period.

A lack of a planned schedule for obstetric reviews as per the 'Keeping Childbirth Natural and Dynamic' (KCND) pathways.

No scan carried out at 36 weeks as per the plan and no documentation to support the reasons for not adhering to this planned care pathway.

Lack of clear documentation resulting in it being difficult to accurately determine if or when an obstetric doctor saw C, and what they communicated to the midwives or C.

Lack of documentation regarding information given to C about the External Cephalic Version (ECV) procedure (a process by which a baby in the womb can sometimes be turned from buttocks or foot first to head first), delivery options, and induction.

No evidence within the files that there were discussions about risks associated with shoulder dystocia (when one or both of a baby's shoulders get stuck inside the mother's pelvis during labour) or that risk assessments in relation to previous pregnancy outcomes were undertaken.

As a result of an external Significant Clinical Incident Review (SCIR) carried out by the board, some improvement actions had been taken to address the issues identified with the lack of documentation of discussions between midwives and medical staff, and the failure to discuss induction of labour. However, we upheld this aspect of C's complaint and made further recommendations to the board.

We did not identify any failings in relation to the care and treatment provided to C during labour; C and A's discharge from hospital; or the care and treatment provided to A after discharge. We did not uphold these aspects of C's complaint.

However, we found that there was an unreasonable failure to identify A's tongue tie when still in hospital after being born. Therefore we upheld C's complaint that the board failed to provide reasonable care and treatment to A whilst in hospital after being born.

C also complained about the board's involvement in the external SCIR, and the board's handling of their complaint. We found that the board's involvement in the SCIR was reasonable and did not uphold this aspect of C's complaint. However, we considered that their complaint handling was unreasonable, as C was not informed of their right to bring their complaint to us in a timely manner, and the board did not reasonably manage the multiple streams of communication during the complaint process. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment during C's pregnancy in relation to documentation, schedules for obstetric reviews and scans, communication, and risk assessments; the failure to identify a tongue tie; and the failure to handle C's complaint reasonably. 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:

• Clear documentation should be made when care plans change, which reflects the rationale for change and the new plan to be followed.
• Discussions between midwives and medical staff, and medical staff and patients, should be clearly documented.
• ECV procedure and delivery options should be discussed and documented as appropriate.
• Obstetric reviews should be scheduled in line with the KCND pathways.
• Risks associated with previous shoulder dystocia should be discussed, and risk assessments in relation to previous pregnancy outcomes undertaken.
• The names and roles of all providers of clinical care should be identified within the records, and discussions.
• Tongue ties should be identified as promptly as possible.
• Where meetings are held between patients and clinicians, the discussions should be documented.

In relation to complaints handling, we recommended:

• Complainants should be informed of their right to take their complaints to the SPSO in a timely manner.
• Efforts should be made to manage communication when there are multiple streams of communication during the complaint process.

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 admitted to New Craigs Hospital following an overdose. They complained about the care provided, specifically the assessment of their condition, the suggestion to take part in a group class and a lack of access to pain medication for their migraines. C also complained about the boards response to their complaint.

We took independent advice from a consultant psychiatrist. We found that appropriate assessments were carried out and the working diagnosis was supported by the notes. The suggestion of a class was not unreasonable and C was able to decline to participate in that option. There was limited evidence about the prescription/requests for pain medication. We found the care provided to be reasonable and did not uphold this complaint.

In relation to complaint handling, we found the board did not proactively update C as often as they should have. We also found that the complaint was not fully responded to and the information given about bringing pain medication from home was not accurate. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to handle their complaint reasonably. 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 ensure complaints are fully responded to and the information given is accurate.

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 underwent treatment for abnormal cervical changes. Around nine years later, a cervical smear test showed borderline changes and they were scheduled for follow-up six months later. Their next smear showed changes requiring investigation and C was seen for a gynaecology (relating to the female reproductive system) scan, at which the consultant also carried out a colposcopy (a simple procedure used to look at the cervix). Everything appeared normal but taking C's history into account they were followed up six months later. The follow-up smear showed severe dyskaryosis (change of appearance in cells that cover the surface of the cervix), prompting an urgent referral to colposcopy. C was seen six weeks later and was later informed that they had adenocarcinoma (a type of cancer), and required a radical hysterectomy (surgery to remove the uterus) and adjuvant chemoradiation (additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back).

C complained that their history of three abnormal smears in the ten preceding years should have led to a referral to colposcopy after their first abnormal smear. C believes that if they had been referred to colposcopy and had a biopsy taken earlier, the need for adjuvant chemoradiation could have been avoided. They complained that the board failed to take account their medical history when considering whether to refer to colposcopy or take a biopsy. C also complained about the board dropping them from cancer tracking, and about the delay between biopsy and treatment.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in pregnancy, childbirth and the female reproductive system). We found that referral to colposcopy was not indicated earlier, explaining that the first smear was the first abnormal smear in a new episode and the recommendation for repeat in six months was in keeping with the cervical screening programme. We also found that C's examination following the second smear was satisfactory and it was reasonable not to carry out a biopsy at that time. We did not uphold these aspects of C's complaint.

In relation to the cancer tracking, the board accepted that C should not have been dropped as, given C's pathology results, they clearly required further treatment. Tracking is carried out to ensure patients are followed up timeously and within national targets. We considered that it was unreasonable to drop C from tracking, and we therefore upheld this aspect of C's complaint.

Finally, we considered that the delay in seeing C for colposcopy following their severely dyskaryotic smear, and further delay between diagnosis and treatment, was unreasonable. 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 delay in commencing treatment, recognising the impact this matter 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:

• The board should meet national targets for the first appointment following referral with an abnormal smear, and following a positive cancer diagnosis.

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 the board's significant clinical incident investigation and complaint investigation unreasonably failed to identify all the failings regarding the care and treatment provided to their spouse (A). We took independent advice from a general surgeon. We found that the Significant Clinical Incident Review did not identify that:

it was unreasonable that no clinical observations or clinical review took place when A developed an acute onset of pain on the surgical ward;

it was unreasonable that A's case was not discussed earlier with a consultant on the surgical ward; and

it was unreasonable that a request for an urgent CT scan was not made earlier.

We upheld C's complaint in this regard and made recommendations to the board.

C also complained that the board failed to take reasonable action to address the failings identified following the significant clinical incident investigation and complaint investigation. We took independent advice from a nursing adviser with experience of working in and managing an Intensive Care Unit. We found that the board had taken reasonable action to address these failings. While we fully appreciated that actions taken by the board will not change A and C's experience, we were satisfied that learning and improvement had taken place which should prevent the same situations from arising again. We did not uphold C's complaint in this area.

We also considered how the board had handled C's complaint. We found that the board did not provide a revised timescale for when C could expect to receive the response to their complaint and made recommendations to the board in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out a clinical observations or a clinical review when A developed an acute onset of pain on the surgical ward, failing to discuss A's case with a consultant earlier on the surgical ward, failing to request an urgent CT scan at the relevant time, and not providing a revised timescale for when they could expect to receive a response to their complaint. 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:

• Deteriorating patients should be escalated to a senior clinician especially in those with ongoing low blood pressure. Where appropriate in these cases, a senior doctor should carry out a physical examination.
• Patients who have an acute onset of severe pain should be reviewed by a clinician and the findings should be documented.
• Significant Clinical Incident Reviews should be robust and, so far as is possible, identify all failings in clinical care to ensure there is appropriate learning and improvement.
• Urgent CT scans should be requested where a diagnosis of ischaemic bowel is being considered.

In relation to complaints handling, we recommended:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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 parent (A). A was diagnosed with oesophageal cancer (tumour in the tube which connects from throat to the stomach) and later underwent chemotherapy and radiotherapy. Over a year later, A had a CT scan but the results were not reported for around three weeks. The CT scan found evidence that the cancer had spread to the liver. It was no longer possible to cure the cancer and A's care became palliative (managing pain or related symptoms, but not treating the underlying disease or condition). A was admitted to the Queen Elizabeth University Hospital where they later died.

C complained that there was an unreasonable delay in reporting and communicating the results of A's scan. We took independent advice from a consultant oncologist (a doctor who specialises in the diagnosis and treatment of cancer). The board had accepted there was a delay in formally reporting the CT scan and acknowledged it was a significant failure to report a life changing progression of disease. We upheld the complaint but as the board had already apologised for this error, we did not make any further recommendations. We also noted that the delay in issuing the report did not change the situation for A as the disease was already advanced.

C complained that the board failed to communicate reasonably with A's family during their admission to hospital. We found that there were annotations about discussions with the family in the records and it was routinely noted when family were present. However, there was little in the notes to show what was said or what individuals' concerns were. Therefore, we upheld this complaint.

C also raised a number of concerns about care provided to A during their admission. We found that there were elements of the care provided to A which were not best practice, some of which the board had already acknowledged in the complaints process. However, there were also many elements of A's treatment which were reasonable. On balance, we did not uphold this complaint.

Recommendations

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

• For staff to have the opportunity to reflect on the findings of this investigation.

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, an advocate, complained on behalf of their client (B). B's partner (A) was diagnosed and treated for a frozen shoulder (a condition affecting the shoulder, making it painful and stiff with loss of mobility) by the board after attending the emergency department. A's pain and symptoms did not improve so they continued to attend health services. B considered it was unreasonable for A to have been diagnosed with a frozen shoulder based on their level of pain and the board failed to provide reasonable treatment. A's health deteriorated and they were diagnosed with cancer. B said this diagnosis and A's prognosis were not appropriately communicated.

We took independent advice in relation to the complaints.

C complained that the board unreasonably administered a steroid injection to A. We found that A's symptoms were atypical for a frozen shoulder and there were red flag symptoms present. Therefore, the case should have been discussed with the responsible consultant at the clinic and further investigations carried out, prior to a decision on whether the injection should be administered. Therefore, we upheld the complaint.

C also complained that the board failed to diagnose A's cancer in a reasonable timescale. We found that there was a short but unreasonable delay in diagnosing A's cancer. We considered that the actions during most of A's attendances were reasonable. However, they raised concerns regarding no consultant opinion being sought when A attended the emergency department and that there was a missed opportunity to investigate A's atypical symptoms during one of the appointments. We found that there was a lack of clinical ownership for A's case. Therefore, we upheld the complaint.

C also complained the board failed to communicate A's cancer diagnosis in a reasonable manner. There was limited information to consider as the records were not a verbatim account of conversations. We found that there was no evidence to suggest the doctor communicated with A and B in a cold or uncaring manner. Therefore, we did not uphold the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for administering the steroid injection to A and for the delay in diagnosing A with cancer. 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:

• Cases involving multiple specialties should be appropriately managed and atypical signs of frozen shoulder appropriately investigated.
• Registrars should consult with senior clinicians prior to administering steroid injections where there are atypical signs for frozen shoulder.
• Relevant records should be available to clinicians.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all key points raised by the complainant.

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 the board in respect of their late parent (A). After being examined by their GP due to stomach pains and an irregular heartbeat, A was admitted to hospital. A was initially admitted to the hospital's Initial Assessment Unit (IAU). C stated that, when A was examined in the IAU, the family informed the doctor about A's history of having an abdominal aortic aneurysm (AAA, a bulge or swelling in the aorta, which is the main blood vessel that runs from the heart down through the chest and stomach).

A was transferred to a ward for further investigation. During this time, A's stomach pain increased. Clinical staff initially considered this as the result of constipation. On speaking with C, a doctor stated they were not aware of A's history of AAA. After further investigation, the doctor told the family that complications with the AAA could be ruled out. Shortly afterwards, A's condition deteriorated and a CT scan showed a leaking AAA. It was decided that it was not appropriate to operate and A died later that day.

C complained about the treatment A received and, in particular, that clinical staff unreasonably delayed diagnosing a leaking or ruptured AAA despite being informed of A's history. In addition to this, C complained that the doctor they spoke with after A's death did not report the matter to the Procurator Fiscal despite giving the impression they had done so. Finally, C complained about the fact that the same doctor did not write to them following A's death, after telling them this would happen.

In respect of the first complaint, we took independent advice from a specialist in acute medicine. We found that, given A's presentation at the time, the actions and decision-making of clinical staff was reasonable. The records showed that the possibility of a ruptured AAA was considered after A was transferred to the ward. However, given the outcomes of examinations and investigations carried out, this diagnosis was considered unlikely. Instead, an alternative diagnosis of pneumonia was initially pursued, with a secondary complaint of abdominal pain attributed to known constipation. We found that these conclusions were reasonable and justified by the recorded evidence. We also found that there was not sufficient evidence to reach a conclusive view on whether the IAU doctor was aware of A's history of AAA. We, therefore, did not uphold this complaint.

In respect of the second complaint, we noted that The Crown Office & Procurator Fiscal Service has produced guidance called Reporting Deaths to the Procurator Fiscal: Information and Guidance for Medical Practitioners. One situation where deaths should be reported is where the nearest relatives of the deceased raise concerns that the medical treatment given to the deceased may have contributed to their death. Given the evidence available about the conversation between C and the doctor following A's death, we could not reach a conclusive view on whether the Procurator Fiscal should have been informed at this point. However, another situation where deaths should be reported to the Procurator Fiscal is where a death certificate has already been issued and a complaint is later received which suggests an act or omission by medical staff caused or contributed to the death. This did not happen in this case and, therefore, we upheld this complaint.

The final complaint related to the doctor who spoke with C following A's death and their failing to contact C about the outcome of a meeting that was to take place. We noted that the doctor had acknowledged there was an unacceptable delay in writing to C. However, we did not consider the board's stage 2 response to contain an explanation for such a delay or indicate that any reflection had taken place about what went wrong. We reviewed the statement provided by the doctor as part of the board's complaint investigation and considered this to provide far more context about what happened. If the board had provided a fuller response that reflected the doctor's statement, C may have had a better understanding of what happened and considered this aspect of the complaint closed. We upheld this complaint because there was a clear failing, which had already been acknowledged by the board. We also provided feedback to the board about the importance of providing open and transparent explanations when acknowledging failings in complaint responses.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to inform the Procurator Fiscal of A's death, following the complaint made by C. 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:

• In line with the guidance issued by the Procurator Fiscal, deaths should be reported where, at any time, a death certificate has been issued and a complaint is later received by a doctor or by the health board, which suggests that an act or omission by medical staff caused or contributed to the death.

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 parent (A). A had a fall at home and was admitted to hospital due to a fractured hip. C was concerned that A was discharged from hospital only a few days after they had surgery. We took independent advice from an orthopaedic surgeon (specialist in diagnosing and treating conditions involving the musculoskeletal system) and an occupational therapist. We found that a comprehensive occupational therapy assessment was carried out prior to A's discharge which fully considered A's home environment and that the decision to discharge A four days after surgery was reasonable and met the targets set out in the Scottish Standards of Care for Hip Fracture Patients. We also found that the discharge and medications were discussed with A.

We, therefore, did not uphold C's complaint about A's discharge from hospital.

C also complained about the way the board handled their complaint. We found that the board did not always proactively update C or provide a revised timescale when they could expect to receive the response to their complaint. Therefore, we upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not always proactively updating them or providing a revised timescale for when they could expect to receive a response to their complaint. 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:

• Where the 20 working day timescale for a response cannot be met, the complainant must be kept updated on the reason for the delay and given a revised timescale for completion.

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 late parent (A). A was admitted to Forth Valley Royal Hospital after falling at home. A few days into their admission, A was diagnosed with pneumonia (a chest infection) and then later developed sepsis (a severe complication of infection). A's condition deteriorated and they died.

C complained about A's medical treatment; in particular, that there was a delay in recognising and treating A's sepsis. We took independent advice from a geriatric (medicine of the elderly) adviser. We found that A's medical care and treatment was reasonable. We did not uphold this complaint.

C also complained about A's nursing care. C said that A was not given enough help with personal care and that their conversations with nursing staff had not been recorded adequately. We took independent advice from an acute nursing adviser. We found that the standard and frequency of the communication recorded appeared reasonable. However, we found that there was a lack of evidence of regular and appropriate care rounding to meet A's personal care needs. We upheld this 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:

• Patients should be given timely and appropriate nursing care.

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.