Some upheld, recommendations

Summary

C had experienced pain and numbness in their hands over a period of years and was referred to the board for treatment. C underwent some tests and was offered repeat carpal tunnel surgery. C complained that the board failed to provide reasonable care and treatment. Unhappy with the board's response to their complaint, C brought the complaint to our office.

We took independent advice about all the complaints raised with us.

C complained that the board failed to carry out reasonable tests and investigations prior to their surgery. While we considered that the rationale provided by the surgeon in relation to what tests were carried out was reasonable, we questioned whether this was reasonably explained to C. We considered that the contemporaneous records did not evidence a thorough assessment of C's condition prior to the surgery being carried out. Therefore, we upheld this aspect of C's complaint.

C complained that the board unreasonably carried out surgery to their hands. We considered that the decision to undertake the revision surgery was reasonable, albeit that further investigations could have been carried out prior to this. C had previously had carpal tunnel surgery. We noted carpal tunnel can recur and it was reasonable for a second operation to be considered. On that basis the offer of surgery was reasonable. We did not uphold this aspect of C's complaint.

C complained that the board failed to offer a reasonable treatment plan after their surgery. We considered that after it was found the surgery had been unsuccessful, the actions recommended by the surgical team were reasonable. They offered to refer C back to the pain clinic and, after this was declined, discharged C back to the care of their GP. We concluded the board's treatment plan and actions regarding pain management were 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 reasonably evidence a thorough assessment of C prior to undertaking surgery and for the administrative error regarding the nerve conduction test results. 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:

• Clinicians should ensure the assessment of a patient is accurately recorded including the rationale behind decision-making.

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

Summary

C submitted a complaint on behalf of their late sibling (A) about the treatment A had received by the board over a five-month period. A had a mass in their abdomen which led to a referral to urology (specialists in the male and female urinary tract, and the male reproductive organs) and later gynaecology (specialists in the female reproductive systems). A was initially diagnosed with pedunculated fibroids (noncancerous growths in the uterus) but it was later found by a different health board that A had cancer. C considered that the treatment provided by the board was unreasonable and led to a delay in A receiving the correct diagnosis.

C complained that the board failed to reasonably diagnose A after they were referred by their GP. We took independent advice from a specialist. We considered that the initial investigations carried out were reasonable, however, after the MRI results were received, the board failed to reasonably respond to this. The MRI result did not match with A's clinical picture and we considered that there was an unreasonable failure that this was not recognised and steps taken to investigate it further in a reasonable timescale. We considered that there was a failure in clinical judgement relating to this. Therefore, we upheld this aspect of C's complaint.

C also complained that the board failed to provide reasonable treatment when A attended A&E. We took independent advice about this complaint. We found that the investigations carried out were reasonable; we noted that further actions could have been taken, but the lack thereof was not in itself unreasonable, given the remit of A&E to only deal with emergency presentations. On balance, we did not uphold this aspect of C's complaint.

Recommendations

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

• Where radiological findings do not fit with the clinical picture a further review should be undertaken.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and respond to each main point 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 spouse (A) by the board in relation to the diagnosis, treatment, and management of A's cancer, especially regarding a delay in A receiving a Positron Emission Tomography scan (PET, a scan that produces detailed 3D images of the inside of the body). We took independent advice from a consultant gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines). We found that A's cancer pathway took 17 months, which was significantly longer than it should have taken. We found that the most significant issue for the delay in the process was the error which resulted in the PET scan not being booked, as requested by the multi-disciplinary team (MDT). Additionally, the PET scan should have been requested on a suspected cancer pathway and we were critical that this was not the case.

We found that the delay in A's diagnosis was unreasonable and on balance, due to the increase in size of A's tumour during the delay, it is likely this negatively impacted on their outcome. We considered that the care and treatment A received from the board was unreasonable and upheld this aspect of C's complaint.

C also complained about the out-of-hours service (OOHS). A developed a postoperative wound infection, and was admitted to hospital. C complained that the OOHS, who saw A prior to admission, requested a non-life-threatening response from the Scottish Ambulance Service (SAS), rather than a life-threatening ambulance. We took independent advice from a GP. We found that the OOHS GP requested the ambulance in line with the SAS guidance, and any delays in the ambulance attending were outwith the GP's control. 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 provide A with reasonable care and treatment. 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:

• MDT requests for investigations, booking of investigations, results being shared, and follow-up MDT discussions should be actioned as soon as possible in cancer pathways.
• Patients and their family should be appropriately involved in discussions regarding their condition and management and these discussions should be recorded in the patient's notes.
• Requests from MDTs should be emailed directly to the clinicians to be actioned, rather than being sent to the gastrointestinal secretaries to be passed to the consultants.
• Where cancer is being considered as a strong possibility within the differential diagnosis, a PET scan should be requested on a suspected cancer pathway.

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

Summary

C, a support and advocacy worker, complained about the standard of medical and nursing care and treatment provided to their client (A) during A's hospital admissions at Victoria Hospital and Cameron Hospital over 11 months. The concerns raised cover numerous aspects of the care and treatment provided by clinicians at A&E and the intensive care unit at Victoria Hospital, and clinical staff at Cameron Hospital. These include unreasonable failures in relation to the response to A's deterioration, medication including dosage, communication, bedsores, rehabilitation, and discharge. C also said that the board failed to handle A's complaint in a reasonable way. C told us that as a result of the failings, A developed complications which have had a profound impact on them and their spouse's life.

We took independent advice from four advisers: consultants in emergency medicine, psychiatry and anaesthesia, and a nurse specialist in tissue viability. We found that A had not been regularly reassessed as they should have been in A&E for a number of hours during which time their condition deteriorated and their transfer to the intensive care unit was delayed, and that staff in A&E failed to communicate with A's spouse in a reasonable way. We found that clinicians failed to take reasonable action to prevent hospital-acquired pressure damage to A and then failed to investigate and treat A's pressure ulcers, which led to severe and extensive pressure damage to a degree rarely seen in today's healthcare setting. We noted that this was avoidable and that the board's failure to identify these failings in their subsequent review was very concerning. We also found that the board's response to the complaint about A's condition and its cause did not reflect the evidence from the clinical records and advice obtained from specialists. We upheld five of C's complaints.

We did not find failings in relation to medications, communication from clinical staff in intensive care, transfer, handling of A by nursing staff at Cameron Hospital, rehabilitation care and treatment and discharge. We did not uphold eight of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines onapology available at www.spso.org.uk/information-leaflets.

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

• Ensure communication by healthcare professionals is of a reasonable standard.
• Ensure patients are regularly assessed so that any deterioration is noted and respond to appropriately and within a reasonable time.
• Review the clinical failings to ascertain: how and why the failings occurred; any training needs; and what actions will be taken (or since then have been taken) to prevent a future recurrence. Before doing so, the board should consider why their previous review failed to identify the failings and ensure that the methodology of this review is robust and that whoever undertakes it is appropriately qualified, objective and impartial.

In relation to complaints handling, we recommended:

• Ensure all complaint responses are accurate and reflect the available evidence and information.

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

Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity).

Mr C complained that the service refused to offer him bariatric surgery after he attended a weight management programme. We found that the board provided an inadequate reason for not progressing Mr C to the next stage of the pathway, where patients are considered for surgery, and considered that this decision was unreasonable. We found that the board did not give appropriate consideration to Mr C's individual circumstances in making their decision and had failed to offer a second opinion or appeal process. We upheld Mr C's complaint and made a number of recommendations.

Mr C also complained that the board had informed him of their decision not to progress in a public setting, where other patients could overhear. We carefully considered Mr C's account and the board's account of what happened. We were unable to reconcile the differences, and we did not find evidence to conclude that clinicians had failed in their duty to maintain patient confidentiality. Therefore, we did not uphold this complaint.

Finally, Mr C was also unhappy with the way the board handled his complaint. We found that there were short delays in the board informing Mr C about the timescales for responding to the complaint. We also found that the board had not communicated accurately with Mr C about a case conference that was initially offered to him. We noted that the board had apologised for the confusion in relation to this. We upheld this complaint and provided feedback to the board about complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for deciding that he could not progress to Tier 4 of the Bariatric Surgery Pathway solely because he had not lost 5% of his body weight and for not giving reasonable consideration to his other conditions and his weight loss prior to commencing the programme. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• Provide Mr C with an opportunity to seek a second opinion or appeal the decision in respect of his progression to Tier 4 in light of SPSO's findings and taking into account his current circumstances.

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

• Patients should be considered for Tier 4 of Bariatric Surgery Pathway in accordance with the Scottish best practice guidelines and individual circumstances should be taken into account.
• Patients should receive a letter detailing the reasons for failure to progress to Tier 4 which should be in line with Best Practice Guidelines. A second opinion or appeals process should be available to the patient if required.

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

Mr C was concerned about the care and treatment that his late wife (Ms A) received at Dumfries and Galloway Royal Infirmary.

Mr C complained that his wife was misdiagnosed with pneumonia when she initially attended the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that the investigations carried out during this attendance were reasonable. We also found it was reasonable to treat Ms A for a suspected infection based on the history, examination and investigations, while arranging a CT scan on an out-patient basis to investigate Ms A's symptoms further. We did not uphold Mr C's complaint regarding this point.

Mr C complained about the delay in reporting an x-ray carried out during this attendance at the Clinical Assessment Unit. We took independent advice from a radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found an unreasonable delay in reporting a chest x-ray and we upheld Mr C's complaint in this regard.

Ms A was subsequently diagnosed with lung cancer and a few months later was admitted to the hospital with worsening shortness of breath. Mr C complained about the care and treatment that his wife received during this third attendance at the Clinical Assessment Unit. We received independent advice from a consultant in acute medicine. We found that there should have been earlier consideration to administering IV fluids and IV antibiotics to Ms A given that her low blood pressure and high heart rate were indicative of sepsis (blood infection). We upheld Mr C's complaint about the care and treatment provided in the Clinical Assessment Unit on Ms A's third attendance.

Mr C also complained about the care and treatment that Ms A received on the respiratory ward at Dumfries and Galloway Royal Infirmary. We took independent advice from a consultant physician in respiratory and general medicine We found that the medical care and treatment was reasonable and did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained about the nursing care provided to Ms A. We took independent advice from a nursing adviser. We found that Ms A's catheter bag was not emptied regularly, there was a delay in Ms A receiving a pressure mattress and the syringe driver was not checked every four hours which was contrary to the guidance that a minimum of four-hourly checks should be carried out within in-patient settings. We upheld Mr C's complaint about the nursing care that Ms A received.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the delay in reporting the chest x-ray and for not giving earlier consideration to administering IV fluids and IV antibiotics to Ms A given that her low blood pressure and high heart rate were indicative of sepsis. 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:

• Checks on syringe drivers should be carried out four hourly as a minimum within in-patient settings in accordance with the relevant guidelines.
• Consideration should be given to administering IV fluids and IV antibiotics to patients who have low blood pressure and high heart rates.
• X-rays should be reported without undue delay.

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 that their late parent (A) received. A had Muir-Torre Syndrome (individuals with this diagnosis are more likely to develop certain types of cancers).

We took independent advice from a consultant colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), a consultant dermatologist (a doctor specialising in the disease and treatment of the skin, hair and nails) and from a consultant haematologist (a doctor specialising in the disease and treatment of the blood and bone marrow). We found that A received appropriate monitoring and treatment in respect of their Muir-Torre Syndrome. We did not uphold this aspect of C's complaint.

C also complained about the care and treatment that A received for arm pain. We took independent advice from an orthopaedic surgeon (a surgeon specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that a clinic letter was typed two weeks after an urgent appointment and that the time between a scan being performed and potentially receiving the results was unreasonable because it fell outside of the 18 weeks referral-to-treatment standard. We upheld this aspect of C's complaint.

Lastly, C complained about the care and treatment A received for cancer. We found that it was reasonable that no further investigations were arranged to try and identify the primary source of A's cancer, given that A was too unwell for treatment. It was reasonable that A did not receive chemotherapy in the circumstances, and the communication with A and A's family about the possibility of chemotherapy was also reasonable. We did not uphold this aspect of C's complaint.

During the course of our investigation we identified aspects of the board's complaint handling which could have been better; in particular that C was not provided with a written record of the complaint meeting with the board, contrary to the NHS Scotland Complaints Handling Procedure. Also, the board's complaint response did not address all of the concerns that C raised. We made recommendations to the board in respect of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the length of time taken to type the clinic letter following A's appointment with the Trauma and Orthopaedics service; for the length of time A had to wait for a follow-up appointment with the Trauma and Orthopaedics service; for not providing a written record of the complaint meeting; and for not addressing all the concerns that C raised. The apology should meet the standards set out in the SPSO guidelines on apology available at or www.spso.org.uk/information-leaflets.

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

• In line with Scottish Government standards, where possible, no patient should wait longer than 18 weeks from referral to treatment.
• When a clinic appointment has taken place following an urgent GP referral, a letter setting out the clinic findings and the plan for any diagnostic investigations should be sent promptly to the patient's GP.

In relation to complaints handling, we recommended:

• Responses to complaints must address all areas that the board are responsible for.
• Written records of complaint meetings should be completed and provided to the person making the complaint.

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 relative (A) during two hospital admissions with the board. C considered that the care that was given to A under the Adults with Incapacity (AWI) Act without consultation with C and their partner was unreasonable, given they were A's guardians. C also complained that the nursing and medical treatments provided to A were unreasonable. C raised concerns about A's arm during their admission and considered that these were not reasonably investigated or responded to.

We took advice from appropriately qualified advisers. We found the board failed to keep reasonable records of the AWI. The board acknowledged that a key piece of paperwork was missing, which suggested that while the assessment had been undertaken, it could not be evidenced. We, therefore, upheld this complaint.

We also found that the board failed to reasonably assess A's capacity. We noted that there were records of some discussion, however there was no evidence that the key paperwork for this was completed. We, therefore, upheld the complaint.

We found that the board provided reasonable treatment to A during their admission. This particularly related to how a cannula (a thin tube inserted into a vein or body cavity to administer medication, drain off fluid, or insert a surgical instrument) was utilised. The adviser considered the use of this was reasonable. It was acknowledged that the cannula shifted, however, this was a known risk and it could not be determined what caused it. Therefore, we did not uphold this complaint.

We found that while there were a number of areas of nursing care which were reasonable, the board failed to provide reasonable nursing care, in particular in relation to the recording and management of A's pressure ulcers. We upheld this complaint.

We found that the board provided a reasonable explanation to C regarding the deterioration of A's arm during their admission. While they could not definitively determine what had occurred, it was reasonable based on the information available. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to keep reasonable records regarding the AWI. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• A patient's assessment of capacity should be clearly documented, along with the wishes of any guardian/POA.
• Nurses should follow the tissue viability nurse's documented plan of care.
• Nurses should follow tissue viability advice or escalate the issue to senior management where there is dispute between a family member and a clinical expert.
• Use of the AWI legislation should be appropriately recorded in patient records.
• Wound charts should have tissue type recorded by percentage.

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 treatment provided by the board's community eating disorder service. They complained about the length of time it took the board to diagnose them and about the various referrals among clinicians involved in their care. C said that their mental health had deteriorated during the treatment period; their eating disorder was exacerbated and they had suicidal thoughts.

We took independent advice from a consultant psychiatrist. We found that C presented with a number of mental health issues and had been managed at times by different teams within the mental health service. Although there was a period during which there was a lack of clarity regarding the overall management of C's care, generally we considered C's treatment to be reasonable and consistent with good practice. We found that the assessment of complex psychiatric presentations, where there is a history of multiple mental health issues, can be prolonged, with diagnosis and treatment modified or refined over time. Therefore, we did not uphold this aspect of C's complaint. We did, however, provide feedback to the board on short-comings identified: failure to obtain permission for a student to attend an assessment, which caused C distress and anxiety, and poor communication in relation to treatment aims during the initial phase of treatment.

C also complained about the board's handling of their complaint. When the board first responded to C's complaint they failed to address most of C's questions. C's MSP became involved and the board then responded in full around eight months after C complained. We were critical of the board's complaints handling, noting that the matters C complained about were of a serious and sensitive nature and the delays in responding added to their distress. Although much of the delay in preparing the response was outwith the complaints team's control, we found that they could have kept C more regularly updated. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable handling of their complaint, with a recognition of the impact the delays had on 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:

• Complaints should be handled in line with the Model Complaints Handling Procedure. In the event that designated timescales cannot be met, complainants should be kept updated. Complaints should be responded to fully.

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

Mr C's child's nursery raised child protection concerns with social work. Mr C complained about the conduct of the social work investigation. He considered that social work were prejudiced in their actions and manipulated facts to justify their decision to investigate the child protection concerns.

We took independent social work advice, which confirmed that the concerns raised warranted investigation. We concluded that the decision to start a child protection investigation was reasonable and we did not uphold this aspect of the complaint. However, the council might have considered whether there were grounds for the nursery to have acted on the information they had sooner. We fed this back to the council.

Mr C also complained that the communication with him and his wife (Mrs C) during the investigation was inadequate. We were advised that it is normal practice for social work not to communicate with the accused parent in case this jeopardises the investigation. We concluded that the communication with Mr C during the investigation was not inadequate. However, we considered that the communication with Mrs C was inadequate. We noted that she did not appear to have a full understanding of the situation and that social work should have taken earlier steps to pursue the use of an interpreter. Also, when she was told that their child was going to be interviewed by the police and social work at a Joint Investigative Interview (JII), she was told of this over the telephone rather than in person, and she (or someone else familiar to her child) was not given the opportunity to accompany her child to the police station for support. We upheld this aspect of the complaint.

Mr C also complained that they did not receive a clear explanation of the specific nature of the child protection concerns. We noted that Mrs C's lack of understanding of the situation appeared to include the nature of the allegations. When social workers visited to share the details at the conclusion of the investigation, Mr C was not included in this discussion and it was not clear why this was the case given that no further investigation was planned. Mr and Mrs C were informed the next day of the decision to take no further action. This was not followed up with a written explanation of the decision. Mr C requested written confirmation of the decision but the letter sent merely confirmed the social work case had been closed. Mr C was required to submit a formal complaint to the council before he received an explanation, and even then we considered things could have been explained more clearly. We upheld this aspect of the complaint.

Finally, Mr C complained about the time it took to complete the investigation. We were advised that there were departures from expected process which resulted in avoidable delays in progressing the investigation. There were delays in opening a record following the initial contact from the nursery; in checking the child protection register; and in contacting the police. Also the JII was unusually held before an Initial Referral Discussion took place. The time taken to decide to take no further action exceeded the target timeframe by 16 calendar days. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for not clearly explaining to them the specific nature of the child protection concerns and for the avoidable delays caused by the departures from expected process in the child protection investigation, and the consequent distress caused.
• Apologise to Mrs C for not explaining the Joint Investigative Interview process to her in person, and for not giving her or someone else familiar to her child the opportunity to accompany the child to the police station for support. The apologies should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• In line with the National Guidelines for Child Protection in Scotland, parents/carers should, wherever possible, be given full information about the nature of the concerns. A written record of decisions taken about the outcome of an investigation should be given to parents/carers unless this is likely to impede any criminal investigation; and where necessary explanations should be given more than once and/or in writing.
• In line with the West of Scotland Child Protection Consortium Inter-Agency Child Protection Procedures Manual: the Initial Referral Discussion should take place promptly and more appropriately before a decision is taken to proceed to a Joint Investigative Interview, the child protection register should be checked as part of the initial inquiries and this should happen almost immediately, and certainly before the decision to undertake a Joint Investigative Interview, a record should be opened within 24 hours of the initial contact in which child protection concerns are raised, the Police should be contacted early in the process to discuss whether a joint or single agency response is required and, a decision to proceed to a Child Protection Conference, or to take no further action, should be reached within 21 calendar days of the notification of concern, unless there are clear reasons why the investigation requires a longer time to conclude.
• Staff should ensure the non-accused parent or carer is involved as much as possible. In line with the council's Child Protection Procedures, staff must give careful consideration to providing support and security to the child when carrying out interviews, including whether to ask someone who knows the child well to sit with the child during interviews.

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.