Some upheld, recommendations

Summary

The complainants (B & C) raised concerns about the practice following the suicide of their child (A). A and B had attended the practice two weeks prior to A’s death and B & C told us that they held concerns regarding the manner of the GP they saw, which A and B had found to be dismissive and unsupportive. While they did not consider that the doctor could have predicted the extent of A’s distress, they considered that the doctor’s demeanour may have contributed towards A feeling unsupported.

B & C also held concerns regarding the way in which the practice had cared for them following A’s death, as they had concerns about a prescription for Diazepam (a drug which belongs to a group of medicines called benzodiazepines and usually used to treat anxiety) they both received, the lack of other support offered, and the way in which the practice carried out a Significant Adverse Event Review (SAER) into what had occurred.

On investigation, we found that the doctor in question had already accepted that their body language had been inappropriate and apologised for this, when responding to B & C’s original complaint. We took independent advice from a GP on the care and treatment offered and we considered that the support provided by the doctor at the appointment was otherwise reasonable. Therefore, we did not uphold that element of the complaint.

We considered that the handling of the prescription of Diazepam and the bereavement support otherwise offered to B & C had been inappropriate. We also found that the SAER had been unreasonably delayed. Therefore, we upheld these complaints.

Recommendations

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

• Patients should be appropriately consulted before being prescribed benzodiazepines; patients should not be prescribed benzodiazepines for longer than is appropriate; the practice should consider whether prescribing benzodiazepines is appropriate for grieving families, given this may impair their grief reaction; and grieving families should be contacted with offers of support.
• Significant Event Analysis Reviews should be completed in a timely manner and identify any failings in treatment, as appropriate.

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 member of the Scottish Parliament, complained on behalf of one of their constituents (A) about the care and treatment they received from the board.

Initial investigations carried out diagnosed A with atrial fibrillation (AF, a problem of the heart characterised by irregular and often faster heartbeat). While waiting for a cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) appointment, A suffered a heart attack and was admitted to Hairmyres Hospital.

C raised concerns that the hospital’s cardiology department knew A had a problem with their heart two weeks before they suffered the heart attack and that aspects of A’s care and treatment during their admission were unreasonable. In particular, they complained that A was placed in a bed next to a disruptive patient who was suicidal while in the Acute Assessment Unit (AAU), that there was a delay in carrying out a coronary angiogram procedure (a type of x-ray used to examine blood vessels), and that communication by hospital staff was poor. C also complained that A’s follow-up rehabilitation treatment after discharge was unreasonable.

We took independent advice from a cardiology adviser. We found that while there were issues identified initially with A’s heart, there were no concerning features associated with their AF that would raise suspicion that A might have a heart attack.

While we acknowledged that being in a bed next to a disruptive patient in AAU, must have been very distressing for A at a particularly difficult and anxious time, we found that this reflected the status of AAU as a communal assessment ward and was consistent with standard practice.

Regarding C’s concerns about the delay in the carrying out of the coronary angiogram, we found that it was reasonable for staff to delay this procedure in the context of staff being required for other urgent and emergency procedures.

We acknowledged C’s concerns about staff communication and how this made A feel, in particular, surrounding the delayed angiogram procedure. While A had expected some face-to-face contact with their consultant, and although this did not occur, we did not find sufficient evidence to show that there was a failure in communication. However, we provided feedback to the board about this.

In terms of the care provided following A’s discharge, we found this was of a reasonable standard.

We found that the overall care and treatment provided to A was reasonable. As such, we did not uphold this complaint.

C also complained that the board did not respond reasonably to A’s complaint. We upheld this complaint on the basis that the board did not address all aspects of A’s complaint in their response.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to address all aspects of A's complaint in their response letter. 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 the issues raised by the complainant, in line with the Model Complaints Handling Procedure.

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 advocacy worker, complained on behalf of (B) about the care and treatment provided to B's family member (A) before their death. Around three months prior to A’s death, they attended their GP with back pain, nausea and feeling generally unwell. They subsequently attended Accident and Emergency (A&E) at Inverclyde Royal Hospital on two occasions, before being admitted to the Royal Alexandra Hospital via A&E there. A was diagnosed with a rare and aggressive type of cancer and died a short while later. C complained on behalf of the family that A was not investigated more thoroughly given their symptoms and medical history, and that the family was not included in discussions about A’s care.

We took independent advice from a consultant in emergency medicine. With regards to care and treatment, we found that appropriate investigations were carried out during A’s hospital attendances and reasonable management plans were put in place. While we considered that there could have been closer attention to pain measurement recording, and a referral to an out-patient clinic could have been made by A&E staff directly (rather than relying on A to re-attend their GP for this purpose), we accepted that improvements in these aspects of care would not have altered the outcome for A. On balance, we did not uphold this aspect of C's complaint.

Regarding communication with A’s family, we noted that A was a competent adult and it is not expected practice to involve family members in treatment decisions when the patient has capacity. The records indicated that medical staff did speak with A’s family on occasion and we were satisfied that they were not deliberately excluded from discussions. As we found no significant omissions in communication, we did not uphold this aspect of C's complaint.

C also complained about the board’s handling of the complaint. We found that the complaint was not responded to in a timely and robust manner. An initial meeting was held with A’s family but the board did not follow this up in writing. Additional questions and concerns developed during A’s family’s wait for a written response. Delays were not proactively explained and revised timescales were not communicated to C. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the identified failures in the handling of 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:

• The board should ensure complaint investigations conform to the NHS Model Complaints Handling Procedure, particularly in terms of the requirement to respond in writing and in a timely manner. They should review their handling of this complaint with a view to identifying areas for learning and improvement.

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’s sibling (A) received care and treatment from the board in response to symptoms of pain and urinary issues. A was later diagnosed with bladder cancer and died. C complained that the treatment provided to A prior to their diagnosis was unreasonable. Dissatisfied with the board’s response to their complaint, C brought their complaint to our office.

We took independent advice from a consultant urological surgeon (a doctor who specialises in the male and female urinary tract, and the male reproductive organs). We found that the board failed to carry out a general anaesthetic cystoscopy (passing a thin viewing tube called a cystoscope along the urethra (the tube that carries urine out of the body) and into the bladder) in a reasonable timescale. This was accepted in the board’s own complaint investigation. However, we considered that there were opportunities to pick up and correct the delay which were missed. As such, we upheld the complaint.

In relation to a complaint about pain management, we found that while there were elements which could have been improved, overall the board reasonably managed A’s pain. We considered that the board could have enquired about pain with A and did not do so, however, there was also no record that A had reported pain which had not been responded to. As such, we did not uphold this complaint.

We considered that the board had failed to diagnose A in a reasonable timescale. We found, which the board had previously acknowledged, that due to the delay in carrying out the general anaesthetic cystoscopy there was an unreasonable delay in diagnosing A with cancer. We also considered that the lack of follow-up for one of A’s symptoms following a botox injection was a failing. As such, we upheld this complaint.

Finally, C complained that the board had failed to reasonably respond to their complaint. We found that, overall, the board’s responses to C’s complaint were accurate and the board took action to discuss C’s concerns at a meeting and provide explanations as to what happened during A’s care. While there were delays in responding to C’s contact, the board reasonably responded to the complaint. As such, we did not uphold the complaint.

Recommendations

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

• Patients with a potential malignancy should be kept moving through the pathway, even where staffing and capacity issues exist.
• Procedure-specific patient information leaflets should be provided.

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 relative (A). A was admitted to hospital with an ongoing Clostridium difficile infection (bacteria that can infect the bowel and cause diarrhoea). A remained in hospital until their death.

C raised concerns with the board about the level of clinical and nursing care provided to A. The family were particularly concerned that staff took the decision to implement the nil by mouth protocol, meaning A would not be given any foods or fluids. The board acknowledged failings and agreed to review relevant practice.

We took independent advice from appropriately qualified advisers. In relation to the clinical care provided, we found that clinical staff took detailed consideration of A’s health and were aware how frail they were when admitted to hospital. The records indicated that a good level of investigation took place along with frequent blood tests and x-rays, when appropriate. We considered that the clinical care A received was reasonable. We did not uphold this aspect of C's complaint.

In relation to the nursing care, we found that important information from A’s family with regards to the requirement to provide thickened fluids was handled poorly by nursing staff. We found that it was unreasonable to carry out the appropriate swallow test with A using water instead of thickened fluid. In addition to this, risk assessments and person-centred documentation were never completed throughout A’s time in hospital. Had this documentation been completed, then failings might have been avoided in A’s case, meaning medications and fluids would have been provided. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for failing to provide a reasonable level of 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:

• National guidance and standards of care for older people in hospital should be implemented appropriately by the board by demonstrating that appropriate guidance is available for staff when undertaking compromised swallow tests; measures are in place to maximise patients receive their medications; and important documentation is completed on admission and from that, an appropriate person-centred plan of care will be devised.

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

Summary

C complained about a consultation with a consultant psychiatrist. During the consultation, C discussed a previous incident where their GP prescribed medication without carrying out a review of C's medical records. Following the consultation, the consultant psychiatrist recommended C be prescribed Mirtazapine (antidepressant medicine). C experienced side effects from the medication and subsequently discovered that their GP's records showed they had been prescribed this medication a number of years previously and had experienced adverse side effects. In light of this, C complained as they did not feel the consultant psychiatrist carried out an appropriate check of C's medication history before recommending that Mirtazapine was prescribed. C also complained about the time taken by the board to investigate their complaint and the thoroughness of their investigation.

In respect of C's first complaint, we took advice from an appropriately qualified independent adviser with a background as a consultant psychiatrist. We found that the course of action taken by the consultant psychiatrist was appropriate and reasonable. We recognised that the decision to recommend Mirtazapine ultimately had a negative outcome for C, but we concluded that the decision-making and process leading to this recommendation was reasonable. We considered the consultant psychiatrist took appropriate action to ensure they had enough information to make an informed decision. In light of this, we did not uphold this complaint.

In respect of the C's second complaint, we concluded that the board had carried out an appropriately thorough investigation, but their responses could have been clearer and more detailed. We also considered the time taken for the board to provide both a stage 1 and stage 2 response was unreasonable. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not handling their complaint in a reasonable or appropriate manner. 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:

• The board should reflect on how the complaint was handled from when it was received to when the stage 2 response was issued. Consider what failings took place during the process and what learning and improvement can be put in place.

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

Summary

C complained about the care and treatment their late partner (A) received during two consecutive admissions to Dumfries and Galloway Royal Infirmary. A had a number of existing medical problems and spent around four weeks in hospital, including 18 days in critical care, before being discharged. C complained that A was inappropriately discharged with pneumonia, and required readmission 12 hours later. A spent almost a further three weeks in hospital before being discharged again, and died two months later. Whilst in hospital, A developed a severe pressure ulcer. C complained that nursing staff failed to take reasonable measures to prevent the pressure ulcer from developing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that A’s suitability for the first discharge was assessed over a number of days and blood tests and basic observations did not indicate an underlying pneumonia at that time. We considered that it was reasonable for A to be discharged and we did not uphold this aspect of C's complaint.

We also took advice from a tissue viability nursing specialist (a nurse who provides advice and care to patients with, or at risk of, developing wounds). We found that, while the risk of pressure damage was identified and care prescribed to mitigate this, this was not adhered to. Risk assessment, skin inspections and repositioning were not carried out as often as required, and the pressure ulcer was initially graded incorrectly. Inappropriate dressings were also used and there was a delay in providing a pressure relieving mattress. 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 pressure area care to A. 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 take steps to ensure staff are competent in pressure area care, with particular focus on the deficiencies identified in A’s care, and that they are aware of current best practice/adhere to the board’s own guidance (Active Care Prescribing Sheet & Wound Assessment Chart) as well as Healthcare Improvement Scotland’s Prevention and Management of Pressure Ulcer Standards (2016).
• The board should take steps to review why pressure relieving equipment was not readily available in this case and address any system failure which contributed to this 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 their relative (A) received from the board; in particular, about the mental health care they received at Borders General Hospital following an impulsive overdose and their subsequent community health care.

The board’s investigation found that A’s care and treatment was appropriate and timely. However, the board suggested exploring possible improvements in information sharing between public and private sector professionals.

We took independent advice from a consultant psychiatrist and a mental health adviser. We found that the hospital care and treatment, including changes to A’s medication were reasonable and appropriate. We considered that there was a shortcoming in care as there was no follow-up out-patient hospital appointment after the discharge from hospital to assess A, despite a significant change in their medication and a new diagnosis. However, we did not consider this was an unreasonable failing given there was a plan for care by community psychiatric nursing who would have had access to psychiatric advice as and when required. We did not uphold this complaint.

In terms of the community mental health care, we were critical that A did not receive a face-to-face assessment even though multiple concerns were raised by various individuals about A’s deteriorating behaviour; and particularly given A had not made themselves available to be seen. For this reason, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to carry out a face-to-face assessment following concerns that were raised by multiple individuals. 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 with Community Mental Health Team follow-up who show evidence of a significant deterioration in mental state or social circumstances, or where a significant deterioration in mental state is indicated by the expressed concerns of family or significant others, consideration should be given to having a face-to-face review and screening for presenting clinical risks/vulnerabilities.

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’s property was flooded from an attic above where both they and the council had water storage tanks. The complaint concerned the council’s response to C’s concerns that they had been responsible for the damage to their home and about how the council responded to their associated compensation claim and complaint.

We found that, after C’s insurance claim was made, it took the council seven weeks to provide information to allow the insurers to consider the matter. It took a further six weeks to provide information after being approached by the insurers for comments on their reasons for repudiating the claim. Furthermore, the council failed to comment on an apparent contradiction in those reasons. Therefore, we upheld this aspect of C's complaint.

However, we found no grounds to show that the council behaved unreasonably to C during and after the flood was reported. In addition, although C’s councillor raised the complaint on their behalf, there were no specific details or date logged in relation to this. Accordingly, it was not possible for us to determine whether or not the complaint had been appropriately addressed in a timely manner. We did not uphold these aspects of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The council should now comment appropriately on the information provided by the insurers and they should apologise to C for their delay in dealing with this matter.

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 had taken steps to obtain a Welfare Guardianship Order in respect of their adult child (A). Part of this process involved C's solicitor requesting the production of a suitability report from the local council. Due to a variety of reasons, the production of a suitability report took a significant length of time. As part of the application process, C's solicitor sought an Adults with Incapacity report from A's new GP. Following this request, A's GP submitted an Adult Support and Protection (ASP) concern referral in respect of A. This referral was received by the board's Social Work Adult Services.

In response to this referral, the social worker who was allocated to A carried out a number of inquiries. This included contacting the mental health officer (MHO) at the council, who was tasked with producing the suitability report. C complained about the social worker's involvement in the guardianship application process. In C's view, the social worker inserted themselves into the application process in a manner that was beyond their remit and sought to delay or hinder the application. C also complained that the board and the social worker did not act in line with the relevant procedures in respect of the ASP process after receiving the concern referral.

We took independent advice from a social worker. In respect of the guardianship application process, the social worker did not act beyond their remit. Under the circumstances, it was appropriate for the social worker to make contact with the MHO after receiving the ASP concern referral. It was also appropriate for the social worker to provide their professional opinion in respect of the guardianship application. As such, we did not uphold this aspect of the complaint.

In respect of the ASP process, the board carried out their duties in line with their obligations and their inquiries were appropriate. However, the board failed to provide a reasonable level of clarity about whether their actions were taken under ASP legislation and guidance. We did not consider there to be evidence to indicate that the social worker acted in bad faith. However, in our view, the evidence showed a lack of clarity around why specific actions were being carried out and a lack of accuracy in the language used by the social worker in their correspondence. Therefore, although we were satisfied that the board's actions were in line with their obligations, we did not consider them to have been carried out reasonably. As a result, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to act reasonably after receiving an Adult Support and Protection concern referral in respect of A. 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:

• Adult services staff should ensure that actions taken after receiving an Adult Support and Protection referral are clearly and accurately communicated to relevant parties.

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.