Some upheld, recommendations

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.

Summary

C had been in contact with a number of specialists at the health board as C suspected they were symptomatic of lung cancer. C said that a tumour in their lung was visible from a number of tests carried out by hospital specialists, but that this was unreasonably missed. C also said that treatment decisions and management were not reasonable and that the failure to diagnose them with lung cancer within a reasonable time had catastrophic consequences for their prognosis. C was also concerned about the way the health board dealt with their complaint.

We took independent advice from three advisers: from 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), a respiratory physician (a doctor who specialises in treating and managing patients with conditions affecting their lungs) and from an orthopaedic specialist (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's treatment was reasonable. C was regularly reviewed and their antibiotics were changed in order to try and improve their outcome.

However, we found that there was a significant delay in the diagnosis of lung cancer resulting from an unreasonable failure of radiological interpretation which lead to significant injustice to C; this failure would shorten C's life. We also found an unreasonable failure to follow up test results or to carry out a further scan, although we concluded that in themselves this would not have changed the outcome for C.

In relation to the standard of respiratory care and treatment provided, we found that the diagnostic process and treatment decisions were reasonable.

Finally, we found significant failings in the health board's investigation of C's complaint. While the health board identified radiological errors, they did not apologise for these or explain how they occurred and what action the health board were taking to ensure they did not happen again, nor was there any consideration of the impact of these errors on C's prognosis and treatment decisions. We upheld three complaints out of four.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation and inform C of what and how actions will be taken to stop a future reoccurrence. 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:

• Carry out an audit of x-rays and scans taken between a specified time-period to ensure there is no systemic issue which may have affected other patients.
• Ensure that test results are followed up appropriately.
• Feedback the findings of our investigation in relation to the complaint handling failures to relevant staff for them to reflect on.
• Feedback the findings of our investigation in relation to the failure of radiological interpretation to relevant staff for them to reflect on.
• Review the complaint handling failures to ascertain: how and why the failures occurred; any training needs; and what actions will be taken to stop a future reoccurrence.
• Review the failure of radiological interpretation to ascertain how and why the failures occurred and what actions will be taken to stop a future reoccurrence and inform this office of the results.

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 by the Golden Jubilee National Hospital. C underwent knee arthroscopy (a type of keyhole surgery used to diagnose and treat joint problems). Around two weeks later, C developed what was considered to be a surface infection, for which they were prescribed antibiotics and given another appointment for later in the week. Two days later, C attended another hospital's emergency department with pain and swelling. They required further surgery to wash out the joint. C complained that the decision to carry out the knee arthroscopy had been unreasonable, and that the care and treatment provided when they had an infection was unreasonable.

We took independent advice from an orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the decision to carry out an arthroscopy on C's knee had been unreasonable, as C had severe arthritis and carrying out the surgery was contrary to British Medical Journal Clinical Practice Guidelines. We upheld this aspect of C's complaint.

In relation to C's treatment when they had an infection, we found that it was reasonable for the surgeon to consider this to be a superficial wound infection rather than a deep wound infection, and the care and treatment provided for this was 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 unreasonably carrying out a knee arthroscopy. 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:

• Knee arthroscopies should not be carried out in patients such as C with degenerative knee disease, in line with relevant clinical guidelines.

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 raised numerous concerns and complaints about repeated errors with the issuing of Movelat (pain relieving gel). C maintained the gel should be issued to them weekly but when submitting requests to receive the gel, they experienced difficulties. C received mixed responses as to why the gel was not issued. Some of the replies issued indicated the gel should be issued monthly. Other replies acknowledged that the gel should be issued weekly and explanations were offered for the error.

The evidence available confirmed that the gel was to be prescribed weekly to C. Despite this, C had to continually raise concerns in relation to ongoing errors with the prescribing frequency of the medication. It took some time before preventative steps were taken, by way of a note that was added to C's record confirming that the frequency of the prescription for the gel should not be changed.

We accepted that any delay in issuing the gel will not have had serious consequence for C, and we recognised the actions taken to minimise errors with the prescribing frequency of the gel. However, we found the administrative handling of the matter was poor. C had to unnecessarily submit repeated feedback and complaints only to receive mixed replies and for the problem with the prescribing frequency to continue longer than it needed to. As such, we upheld this aspect of the complaint.

C also complained about the decision taken by the healthcare team to discontinue a prescription for Difflam spray (an anti-inflammatory spray used to treat many painful conditions of the mouth or throat). It was explained to C that the throat spray was a short-term treatment for symptomatic relief of painful conditions of the mouth. It was noted that C had been taking the spray for several months, but there was no record to confirm the reason for that. C was reviewed by the dentist, who found no evidence of ulcers. The dentist had initially agreed to reinstate the spray but it was discontinued following a further discussion with an advanced nurse practitioner due to lack of mouth ulcers.

We took independent advice from an appropriately qualified clinical adviser, We found that the decision to stop the mouth spray had been taken in line with good practice as set out by the General Medical Council. As such, 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 issue the pain relieving gel weekly, as per their prescription. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the unnecessary time and trouble they had to go to in an effort to get clear explanations and replies in relation to the prescribing errors with the pain relieving gel, and to get the issue resolved.

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 spouse (A) received from the practice. C had arranged a same-day appointment at the practice as A had been sick over the weekend. When the time approached; A was too ill to attend, therefore, C called the practice to request a house visit. A triage phone call took place that morning. A's symptoms were noted, advice provided and medication prescribed for sickness and diarrhoea. The following day, C requested a house visit as they felt that A's condition had worsened. Arrangements were made for a house visit to take place. C was concerned that A's condition was further deteriorating, so they contacted the practice to check when the doctor would arrive. The practice subsequently arranged for an emergency ambulance. A was taken to hospital but died shortly thereafter. The primary cause of death was found to be diabetic ketoacidosis (a complication of diabetes mellitus) and respiratory tract infection.

In responding to the complaint, the practice said that they could not always judge the severity of the symptoms over the phone; however, from the symptoms provided to the doctor, the appropriate action was taken in A's case. C remained dissatisfied with the care and treatment A had received and raised the matter with us. C was also unhappy that the practice's response to the complaint did not adequately cover all of their concerns.

We took independent advice from a GP. We found that, at the time of the triage phone call, there was an unreasonable failure to take an adequate history and further assess A (by way of an examination either by a house visit or hospital admission). We, therefore, upheld this aspect of the complaint. During our investigation, the practice provided us with some evidence of reflection and learning that had taken place.

In terms of C's concerns about the practice's response to their complaint, we found that they had appropriately contacted C in a timely manner in an attempt to obtain clearer information about C's specific concerns. Whilst it was not clear whether the practice attempted to get a better understanding of the complaint over the phone when C declined the offer of a meeting to discuss their complaint, we did not consider that they had failed unreasonably to respond to the complaint. We, therefore, did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable failure to gather sufficient information, including history, examination and testing, in order to make an informed diagnosis. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 way the council had handled their reports of noise nuisance about a local village hall. The hall was leased by the council to an independent association that was responsible for managing bookings. C felt the noise caused by activities taking place at the hall breached the terms of the lease and believed the council should enforce this. C also reported the matter to the council’s Environmental Health service.

We found that the council handled C’s noise complaints satisfactorily, taking into account the status of the village hall, its lease and the powers available to the council to take enforcement action. We noted that although Environmental Health deemed that the noise was not a statutory nuisance, they continued to engage with the association to work towards an agreeable outcome. We did not uphold this aspect of the complaint.

C also complained about the way that the council handled their complaint about the service they received. We found that a number of aspects of the council’s complaint investigation were appropriate. However, we noted that the council failed to update C about the delay in the investigation and provide a revised timescale for the response. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to update them about the delay in the investigation and provide a revised timescale for the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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.