Some upheld, recommendations

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.

Summary

C complained about the care and treatment they received at Ninewells Hospital. C was diagnosed with a small renal (kidney) cyst a number of years ago. This was treated at the time, but C complained that it was not subsequently monitored. They later developed a mass in their abdomen that weighed nearly three kilogrammes when it was removed several years later. C considered that the board delayed in operating when C was referred to the urology team (specialists in the male and female urinary tract, and the male reproductive organs) and that there were further delays in providing treatment when they were later diagnosed with cancer.

We took independent advice from a consultant urological surgeon and a consultant 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 that C's renal cyst was incorrectly categorised as simple, when in fact it had the features of a complex cyst with a risk of malignancy. This should have required a referral to urology for active surveillance or surgical resection at that time. Therefore, we upheld this complaint.

In relation to the delay in operating following a referral to urology, we found that a discussion at a renal multi-disciplinary team meeting and then clinic review and a consent discussion were appropriate when C was subsequently diagnosed with a large left renal mass. We did not uphold C's complaint that the board's urology team had delayed in operating at that time.

Finally, we found that C had a very rare form of renal cancer and that the matter was complex because the final diagnosis was not clear. We did not identify any unreasonable delay in C's diagnosis and treatment of cancer. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to correctly categorise the cyst. 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:

• Cysts of this nature should be categorised correctly.

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 child (A) by the dermatology service at University Hospital Hairmyres regarding skin lesions. In particular, C was concerned about the length of time taken to refer their child to paediatric dermatology at a children's hospital, that this referral was not marked as urgent and antibiotics or a steroid cream were not prescribed earlier. We took independent advice from a consultant dermatologist. We found that the length of time taken to refer A to paediatric dermatology was not unreasonable in the circumstances. It was reasonable that the referral to paediatric dermatology was routine rather than urgent given A's clinical presentation, that antibiotics were not prescribed earlier as there was no indication of increased swelling, pain and increasing size or progression of the lesions, and that topical steroids were not prescribed in the absence of a definite clinical diagnosis. We did not uphold C's complaint about the care and treatment provided to A.

C also complained about the way the board handled their complaint. We found that one of the board's complaint responses did not address all the points raised by C. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to address all the points they raised in the complaint 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:

• Complaint responses should address all the points 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 a family member (A) received in Monklands Hospital prior to their death. C raised particular concerns that nursing care was not delivered proactively and that the family had to continually ask for care to be provided, including catheter care, oral care, nutrition and pain management. A suffered a fall while in hospital and C also raised concerns about the adequacy of the medical assessment which was carried out following this.

We took independent advice from a nursing adviser. We found that the nursing care was reasonable overall, with appropriate care rounding evidenced in the records. This covered catheter care, pain management and general care. However, we identified an unreasonable two-hour delay in commencing appropriate medication for pain and agitation due to medical staff being unavailable to prescribe. We also identified that prescribed oral care was not administered as prescribed, and that person-centred care planning did not reflect A's needs with regards to oral hygiene and end of life needs. We considered that this contributed to A's noted discomfort in the final days of their life and, on balance, we upheld this complaint.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) regarding the medical assessment which followed A's fall. We noted that a thorough and well-documented assessment was carried out which concluded that A had sustained minor injuries only and that no scans or further investigations were required. We did not consider there was a clear connection between the fall and its follow-up and A's subsequent deterioration. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in commencing appropriate medication for A's pain and agitation; the failure to administer oral care as prescribed; and for the failure to update the person-centred care plan to reflect A's needs. 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:

• Person-centred care plans should be updated at every shift change to capture person-centred needs. The board should carry out a review of person-centred care planning in the relevant ward.
• The board should investigate why medical staff were unavailable to prescribe timely medication for pain and agitation. Measures should be put in place to prevent this happening again; and the board should demonstrate compliance with the Scottish Palliative Care Guidelines 2013.
• Treatment should be administered as prescribed, or a code entered in the medicine kardex to indicate why this has not been administered. Ward staff should be reminded, in a supportive manner, of their responsibilities and the policy for the administration of prescribed medication.

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 taken into Queen Elizabeth University Hospital for a kidney removal after the discovery of a cancerous cyst. A few days after the operation they were detained under the Mental Health Act and transferred to Stobhill Hospital. C believed they were not physically fit for discharge at that stage, and that there was insufficient evidence of risk to justify detaining them. In addition, they considered that their medication was mishandled throughout their time in both hospitals and that staff failed to treat them with respect and dignity. C is also blind and felt that the board had failed to reasonably take account of this in the way they interacted with and cared for them.

We took independent advice from a nephrologist (a doctor who specialises in kidney care and treating diseases of the kidney), a psychiatrist and a nurse. We found that C's care and treatment was generally reasonable, with the exception of the handover between the two hospitals, which was insufficient and led to problems with the dosage of C's medication. On this basis, we upheld C's complaint that the board failed to provide reasonable clinical treatment, but did not uphold their other complaints.

Recommendations

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

• Reasonable handover notes should be provided when patients are transferred between hospitals, to ensure continuity of 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.

Summary

Mr C complained to us about the care and treatment that his late mother (Mrs A) received at Glasgow Royal Infirmary. Mrs A had vascular dementia (a common type of dementia caused by reduced blood flow to the brain, which can cause problems with mental abilities and the physical activities of daily life). Mrs A was admitted to hospital with a fractured collarbone, following a fall at home. During her hospital admission, Mrs A had difficulties swallowing and eating. Her condition worsened and she was diagnosed with aspiration pneumonia (an infection caused by food, saliva or stomach acid being inhaled into the lungs). After Mrs A was discharged home, she was readmitted to the hospital around a week later. Her condition failed to improve and she died in hospital.

Mr C complained that the board had failed to provide Mrs A with reasonable medical care and treatment. In particular, Mr C felt that Mrs A's swallowing difficulties were wrongly attributed to her having advanced dementia. Mr C felt that Mrs A was not given appropriate treatment for her pneumonia because of this. We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that it was reasonable that Mrs A's swallowing difficulties were attributed to her having advanced dementia. We also found that overall, Mrs A's pneumonia was treated appropriately; and there was no evidence that it was left untreated because of her having advanced dementia. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide Mrs A with reasonable nursing care; in particular, that she was not given appropriate nutritional care in light of her difficulties swallowing and eating. We took independent advice from a nurse. We found that the nursing staff took reasonable action to try to address Mrs A's nutritional needs. However, we found that on one occasion, Mrs A was given the wrong meal for her diet. We also found that when Mrs A's condition worsened during her first admission, nursing staff failed to escalate this to medical staff. These failings had been identified and acknowledged by the board.

In light of these failings, we upheld this aspect of Mr C's complaint.

Recommendations

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

• Patients on a restricted diet should receive the appropriate meal.

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.