Some upheld, recommendations

Summary

C was admitted to University Hospital Monklands with abdominal pain, vomiting and an inability to pass urine. C was diagnosed with possible appendicitis (inflammation of the appendix) and was operated on the next day. C was discharged after surgery but was later readmitted and underwent further surgery. C complained they should have had their first operation sooner, given the pain they were in.

We took independent advice from a consultant in general and colorectal surgery (a surgeon who specialises in conditions in the colon, rectum or anus). We found that C's first operation was carried out within an acceptable timeframe. We did not uphold this aspect of the complaint.

C complained their first operation was not carried out in a reasonable manner, as they experienced problems afterwards. C had suffered a recognised complication of the operation and we did not find failings in how C's first operation was carried out. We did not uphold this aspect of the complaint.

C also complained that they should not have been discharged home after their first operation, as they were still unwell. We found it was unreasonable that C was discharged home, as they had a raised temperature and inflammatory marker. We upheld this aspect of the complaint.

When C was readmitted to hospital for a further operation, C said that there was an unreasonable delay in carrying it out. We found there was an unreasonable delay giving C a scan, which caused a delay in carrying out their second operation. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable discharge and the delay in carrying out the CT scan. 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 CT scan should be carried out to aid diagnosis in patients with similar symptoms.
• Continuing post-operative symptoms of infection should be investigated before discharge in patients at higher risk of infective complications.

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 medical and nursing care and treatment given to their late parent (A) during their admission to Wishaw General Hospital. They also complained about the way staff behaved and communicated with the family and the way the board responded to their complaints. A was admitted to hospital suffering from breathing difficulties, after a chest infection. A was registered blind and had poor hearing and limited mobility. C was concerned about A's level of confusion, as well as a lack of personal care from nursing staff. Although C had power of attorney for A and had provided this to the board, they were not informed for a number of days that staff considered A lacked the mental capacity to make decisions about their treatment. C said that on one occasion they had overheard staff making derogatory remarks about C and A. Although C had felt that A was improving during their last visit, A was found dead early the following morning.

C complained to the board about A's care and treatment and met with medical and complaints staff twice. C was unhappy with the board's records of these meetings, as they had taken their own notes and they felt there were significant and substantial differences between the two. C felt that the board's complaint response was inaccurate and the findings inadequate. C told us they felt they had let A down and it was clear from C's submissions that the experience had been distressing for them.

We took independent advice from a consultant geriatrician and a nurse. In relation to A's medical care and treatment, we found that treatment of A's infection and the management of A's medication was appropriate. There was, however, a failure to monitor or assess A's delirium appropriately, and for this reason we found the medical care and treatment they had received fell below a reasonable standard. We upheld this aspect of C's complaint.

In relation to nursing care, we found that aspects of A's care had fallen below a reasonable standard, particularly the assessment of A's mobility and communication needs, and the response to A's repeated falls. We upheld this aspect of C's complaint. We noted that the board had already accepted there had been serious failings in nursing care and had taken steps to address these with individual staff, as well as an organisation.

Without independent witnesses, it is not possible for this office to determine what happened in relation to the alleged remarks made by staff. However, we considered that C's complaint in relation to this point was escalated and investigated appropriately. We did not uphold this aspect of C's complaint.

In relation to communication, we found that although some aspects of medical staff's communication with C was reasonable, overall there had been a failure to communicate with them about decisions relating to A's lack of capacity. Nursing staff's communication with C had also fallen below a reasonable standard. We upheld this aspect of C's complaint. However, appropriate action had been taken by the board to address those failings.

Finally, we found that the handling of C's complaint to the board had also fallen below a reasonable standard. We found that the board had not explained their approach clearly to C and although it was not unreasonable to attempt to resolve C's concerns by meeting with them, the board should have been clear with C what the process would be and they should also have provided C with a clear indication of the conclusions of those meetings, as well as when the complaints process was at an end. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should be assessed using current delirium screening tools.

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

Mrs C complained about the care and treatment she received during childbirth from the board. Mrs C's baby was born by low cavity forceps delivery which required her to have her legs in supports. She found the process painful and traumatic and complained that staff failed to explore or act upon her pain. She also said that the orthopaedic (specialists in the musculoskeletal system) care she received after the birth was unreasonable and that she was not satisfied with the way the board investigated her complaint. The board said that as a result of her complaint they had learned not to make assumptions when a woman was very vocal during labour but that she had had anaesthetic to deal with pain. They also apologised for the lack of support she had received and for poor communication.

We took independent advice from a midwife and consultants in orthopaedics, and obstetrics (the medical specialism for pregnancy and childbirth) and gynaecology (medicine of the female genital tract and its disorders). We found that it had been reasonable to undertake a forceps delivery as Mrs C had been pushing for an hour without her baby being delivered. To assist this, Mrs C's legs had been placed in lithotomy (leg restraints). This was associated with symphysis pubic diastasis (the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture) in up to 25% of cases and Mrs C suffered this. While Mrs C said that she was crying out in pain as a consequence, the clinical records did not support this, therefore, we could not conclude that she was ignored. However, we noted that there was no mention of a pudendal block (local anaesthesia commonly used to relieve pain during the delivery of a baby by forceps) in Mrs C's records. On this basis, we considered that the board failed to explore or act upon the causes of Mrs C's pain and upheld this aspect of her complaint.

We found that Mrs C's orthopaedic care and management after the birth had been reasonable and did not uphold this aspect of her complaint. However, the board did not investigate Mrs C's complaint well and she experienced several months delay before receiving the boards response. This was too long and, accordingly, we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in responding to her complaint and for the lack of detail in her clinical records, in particular that there was no mention of a pudendal block. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• All relevant documentation should be completed appropriately and as required. In line with Nursing and Midwifery Council/General Medical Council guidelines.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the board's formal complaints 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 complained on behalf of their partner (A). A had been suffering from debilitating shoulder problems over an extended period. A had been referred from their own NHS Board to Greater Glasgow and Clyde NHS Board for specialist surgery. Although surgery was carried out, it did not relieve A's symptoms. A underwent further surgery and received a second opinion from Greater Glasgow and Clyde NHS Board, as well as undergoing neurological tests and assessment at the pain clinic. During this period A moved house, which meant a different NHS Board became responsible for A's care.

C felt that Greater Glasgow and Clyde NHS Board had failed to properly consider A's symptoms and that they were unwilling or reluctant to investigate or perform further surgery on A. C had a lengthy correspondence with the board, during which they made several formal complaints.

Whilst this correspondence was ongoing, the board suggested that A should be referred to a specialist in England. C and A were told this referral was to be made, but they were not told what the process would be. A referral of this nature required A's own health board's agreement, but this was not provided. C made a number of attempts to contact Greater Glasgow and Clyde NHS Board to discover whether the referral was going ahead. When they did not receive a response, C took A to have further surgery on A's shoulder privately.

C said they had been forced to do this by the board's failure to provide A with adequate care and treatment and their decision to block the referral to England. C said the board should reimburse them for the expenses they had incurred and provide guarantees A would receive the treatment they would need in future. The board had declined to pay for the cost of private medical treatment, because their view was that A had chosen to take this course of action independently.

We received independent medical advice. We found that the board had provided A with reasonable care and treatment. The investigations that had been carried out were appropriate for the symptoms reported and these investigations, and the provision of a second opinion, had been carried out within a reasonable timescale. We did not uphold this aspect of C's complaint.

In relation to the referral to England, we found that the board had not made the decision to cancel A's referral to England. This decision had been made by A's own health board. Therefore, we did not uphold this aspect of C's complaint.

The board had, however, failed to acknowledge or respond to C's questions about the referral, or to respond to questions from their MSP. They had also unreasonably prevented C from accessing the complaints process. The board had told C they would be able to liaise with a named contact about A's treatment. Despite it being clear that the named contact was not responding to C and that C was not receiving answers to their questions, the board failed to take action to address this but also failed to allow C to raise a new complaint. We considered the boards communication with C to be unreasonable and upheld this aspect of their complaint. However, we noted that this did not justify reimbursing C for the cost of private treatment in England.

Recommendations

What we asked the organisation to do in this case:

• Clarify for C and A which board had responsibility for the decision not to proceed with the out of board referral, explain what the process followed was and clarify who remained responsible for A's ongoing care and treatment.

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

• The board should ensure they have a clear procedure for staff to follow, when out of board referrals are made, including communicating the outcome to the patient.

In relation to complaints handling, we recommended:

• The board should review their procedures to ensure that when communication with a patient or their representative breaks down, complaints staff are able to escalate the matter appropriately.

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

Ms C complained about the care and treatment provided to her by the board at Queen Elizabeth University Hospital when she was admitted with cellulitis (a bacterial skin infection) and with sepsis (blood infection). She complained about nursing and medical care in A&E and the acute receiving unit (ARU).

We took independent medical advice from a senior nurse, a consultant in emergency medicine, and a consultant in acute medicine. In relation to nursing and medical care in the A&E, we found that this was reasonable and we did not uphold these aspects of Ms C's complaint. However, we identified failings in the monitoring of Ms C's condition by nursing staff in the ARU. We upheld this aspect of Ms C's complaint, however, we noted that the board had previously acknowledged this and had taken action to address these failings.

In relation to medical treatment in the ARU, we found that the fluids prescribed to Ms C were unreasonable as they were not a recommended fluid for patients with sepsis, and they were not provided at a fast enough rate. We also noted that there was a failure to recheck Ms C's national early warning score (NEWS - an aggregate of weighted physiological parameters that gives an indication of how unwell a patient is, or if they are deteriorating) prior to transferring her to another ward. We therefore upheld this aspect of Ms C's complaint.

Ms C also complained about the board's handling of her complaint. We found that the board did not respond to the complaint within the required timescale and for this reason we upheld this aspect of Ms C's complaint. However, as the board had apologised and learnt from this matter already, we did not make any further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to prescribe intravenous fluids reasonably based on the relevant guidance; and the failure to recheck her NEWS score prior to transferring her to another ward. 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:

• Intravenous fluids should be prescribed in line with relevant guidance.
• NEWS scores should be rechecked appropriately prior to transfer.

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 their parent (A) received at Forth Valley Royal Hospital and Falkirk Community Hospital.

We took independent advice from a nursing adviser. We did not identify any failings regarding the care provided to A at Forth Valley Royal Hospital and so did not uphold this aspect of the complaint. However, regarding the care provided to A at Falkirk Community Hospital we found that:

A was unreasonably transferred to a four-bedded room rather than a single room;

there was an unreasonable delay in A having their dietary/fluid requirements assessed by nursing staff following their admission to Falkirk Community Hospital; and

A was not given prescribed medication while awaiting discharge from hospital.

We upheld this aspect of the complaint.

C also complained about the board's handling of their complaint. We found that the board did not consider whether C had authorised their sibling to raise a complaint on C's behalf. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for transferring A to a four-bedded room at Falkirk Community Hospital rather than a single room; the delay in assessing A's dietary/fluid requirements on their admission to Falkirk Community Hospital; not giving A their prescribed medication while they were awaiting discharge from hospital; and not confirming whether C had authorised their sibling to make a complaint on their behalf about the out-of-hours GP. 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 receiving palliative/end of life care should be transferred to a single room. In the event that this is not possible, where appropriate, they and/or their family/carer should be consulted prior to the transfer going ahead.
• Patients should receive prescribed medications while awaiting discharge from hospital.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the board's complaints handling procedure including consideration being given to checking whether individuals have authorised a person to make a complaint on their behalf, particularly where multiple complaints are received from members of the same family.

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 parent (A), who has a diagnosis of Alzheimer's disease (the most common type of dementia), was a patient in Falkirk Community Hospital. On discharge, A was moved to a nursing home, as they required greater care. C questioned the board's care of A while they were a patient in the hospital; in particular about the prolonged use of Risperidone (an antipsychotic drug). C was also unhappy about the delay in issuing a discharge letter and the fact that it was sent to the nursing home. C complained that the letter contained incorrect information.

The board's view was that A had been prescribed Risperidone before they were admitted to hospital and that as they remained agitated and confused at times, in the absence of any clinical indication that they were experiencing side effects, there was no reason to alter the dose that had already been prescribed. Furthermore, they said that the medication was regularly monitored. The board agreed that there had been a delay in issuing a discharge letter and apologised that the letter contained incorrect information.

We took independent advice from an appropriately qualified adviser. We found that Risperidone had been prescribed reasonably and appropriately to A and that its use had been regularly monitored. We did not uphold this aspect of the complaint. However, we found that with regard to the discharge letter, the level of care given to A (with regard to delay and release of sensitive information) fell below the standard they could have expected. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay and failing to discuss/obtain consent for the sensitive content of a discharge letter prior to releasing it to the care home.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets

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

• Discharge letters should be issued in a timely way. Sensitive information included in a discharge letter should be discussed with and consent obtained from the patient/guardian prior to its inclusion.

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 Child and Adolescent Mental Health Service (CAMHS) care and treatment provided to their child (A). A had an assessment with CAMHS, and following this, the board felt that further CAMHS input was not necessary as they considered the information suggested attachment related difficulties as opposed to a neuro-developmental disorder. C complained that the board had not carried out an in-depth assessment or obtained relevant information from A's school.

We took independent advice from a CAMHS mental health nurse. We found that the assessment of A carried out by CAMHS was reasonable and gathered the appropriate information in order to make a decision that no further input or support from CAMHS was required. We did not uphold this aspect of C's complaint.

C also complained that following A's appointment, the board's communication was unreasonable as they were not told of follow-up appointments in a timely manner and had not fully discussed A's case with C. We found that in all but one case, appointment letters were sent to C in a timely manner. However, we found that the board had failed to explain to C that the school assessments were no longer required and the reasons for this. On this basis, we upheld this aspect of C's complaint.

We also identified that the board had failed to follow up on an action agreed in their complaint response and made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to explain that school assessments were no longer required and the reasons for this; and for failing to follow up the referral. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets
• The board should consider whether it would still be appropriate to follow up the referral to the area inclusion team at this point. They may wish to contact C to discuss whether this is something A would still benefit from.

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

• If decisions are made not to proceed with assessments, this should be explained to the patient/their family.

In relation to complaints handling, we recommended:

• Actions agreed in complaint responses should be followed up and there should be evidence of the actions being taken.

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

Ms C's adult son (Mr A) has complex care needs and lives at home with her. Ms C complained that the council's care budget unreasonably relied on her being the second person providing him with care. We took independent advice from a social worker. We found that the council had allocated Mr A a care budget, which was equal to the cost of commissioning him support, such as a placement at a residential home. We found that this approach was reasonable and it complied with the relevant statutory guidance. We found that if Ms C was unable to provide Mr A with care, it would have been necessary to consider changing how his care hours were spread during the week or consider a residential placement. We did not uphold this aspect of the complaint.

Ms C also complained about how the council responded to her enquiry about getting a different type of shower chair for Mr A. The council refused her request, as they said his current shower chair was meeting his clinical need. We took independent advice from an occupational therapist. We found that there was insufficient evidence that Mr A's current shower chair was meeting his clinical need and that Ms C was not clearly told the reasons for refusing her request. We considered that the council had not responded reasonably to Ms C's enquiry. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the issues we have identified in how the council responded to her enquiry about a shower chair for Mr 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:

• Service users should be appropriately assessed to ensure their current equipment is meeting their clinical need. Service users and/or their carers should be clearly told why any requests for equipment have been refused; and they should be given appropriate advice and follow-up. This should then be appropriately documented.

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, who is homeless, applied to view properties advertised as being immediately available to let. Mr C considered that the properties were not in a condition to be advertised as being immediately available to let.. In relation to the first property, we found that the electric meter had been read during the void period and therefore it was reasonable for the association to expect that it was working when the property was advertised as being immediately available to let. In relation to the second property, the association offered a paint pack as an incentive to rent this property, and we found that this was in accordance with their policy for properties where décor affected the ability to let the property. We did not uphold these complaints.

Mr C also complained that he was advised that he could obtain immediate entry after viewing the properties and signing the tenancy agreement. We found that in relation to the first property this information was not clear on the website and it would have been reasonable to expect that this would be explained at the outset, given that prospective tenants looking to rent a property immediately may be living in stressful circumstances. We therefore upheld this complaint.

Mr C also complained that he was suspended from the property register because he refused two properties. We found that whilst Mr C understood that he had been suspended, the records did not show that he had and this should have been explained to him. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to make it clear that he may not be able to move into the property on the day of viewing as the tenancy agreement required to be signed and any gas uncapped prior to a tenant. The association should also pay Mr C the sum of £50 as a goodwill gesture, for travel expenses in respect of his journey to view the first property.

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

• Ensure the website contains information under immediately available properties which states the applicant may not be able to move in on the day of viewing and why. Ensure housing officers state, when arranging viewings of immediately available properties, that the applicant may not be able to move in on the day of viewing and why.

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.