Some upheld, recommendations

Summary

C complained on behalf of their partner (A) following A's admission to University Hospital Hairmyres with drowsiness. There was an indication that A may have taken too much of their prescribed medication at home. C raised concerns that a period of deterioration during A's admission was due to poor care.

We took independent advice from an appropriately qualified adviser. We considered that A's deterioration was related to infection, and were unable to identify anything to suggest that their deterioration was due to poor care. We did not uphold this aspect of the complaint.

C complained that their concerns about A's deterioration were ignored, and that when they asked to speak to medical staff, this was not arranged. The board noted that C had been given the telephone number of the consultant's secretary, and that two doctors were on the ward during the day on weekdays and were available to speak to patients and relatives. We considered that nursing staff should have arranged for the ward doctors to speak to C, rather than providing a number to make an appointment with the consultant. We considered that this would have been simpler, quicker and more effective. We upheld this aspect of the complaint.

C also expressed concern about the arrangements in place for A's medication on discharge, including that they were not given a dosette box to assist them in managing the medication at home. We noted that there was concern that A's medication may have caused the symptoms which led to their admission, and as such they considered that the discharge medication should have received more care and attention. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for not giving more care and attention to A's discharge medication. 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:

• Care and attention should be given to arrangements for discharge medication, especially where there is evidence of a patient having had previous problems taking (or relatives having had problems administering) the correct 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

Ms C complained to us about the care and treatment provided to her late partner (Mr A) by Raigmore Hospital during an admission. Mr A was assessed and a crisis plan was agreed; Mr A was then discharged home, but soon after he died. Ms C complained that the board unreasonably discharged her partner home. She also raised concerns about the significant adverse event review (SAER) carried out by the board into Mr A's care and treatment.

We took independent advice from a mental health nurse and from a consultant psychiatrist (a medical practitioner who specialises in the diagnosis and treatment of mental illness). We found that the board carried out an appropriate and systemic risk assessment. We found that a coherent short-term crisis plan was agreed with Mr A, until he could engage with his local mental health services. We found that the decision to discharge Mr A home was reasonable. We did not uphold this aspect of Ms C's complaint.

We found that the board's SAER process and report was reasonable; and it identified appropriate learning. However, we noted that when Ms C complained to the board, they said that they would address her concerns through the SAER. In the circumstances and given the time it took to complete the SAER, we considered that the board should have kept Ms C updated more regularly on its progress. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to keep her appropriately updated. 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:

• If the board decides to address a complaint through their SAER, they should then keep the complainant appropriately and regularly updated on its progress.

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

Miss C complained about the care and treatment her late mother (Mrs A) received at Raigmore Hospital after she was admitted with symptoms of bleeding from her stoma (an artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut or trachea). Mrs A died around three weeks later following surgery to revise the stoma (resected ileostomy). Miss C raised concerns that the surgery was unnecessary and Mrs A had not properly consented to it; that the nursing care was poor (in terms of wound management, personal care, repositioning Mrs A and cables that had tied down her hands); and that the board did not handle Miss C's concerns through the NHS Model Complaints Handling Procedure (MCHP) appropriately.

We took independent advice from a consultant general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus). We considered that the decision to operate was reasonable on the basis that Mrs A had multiple admissions in the period immediately prior to this admission and required blood transfusion. In addition, Mrs A had undergone appropriate investigation to identify the source of gastrointestinal blood loss and that the pathology report of the resected ileostomy had confirmed that it was the source of bleeding. In addition, we were of the view that although Mrs A had experienced a rare complication of the surgery, there was no evidence that it had fallen below a reasonable standard. However, we found that there was insufficient evidence to show that any of the recognised risks of the surgery had been discussed with Mrs A. We considered this unreasonable and not in accordance with guidance. Therefore, we upheld this aspect of Miss C's complaint. We noted that the board's investigation had accepted that the documentation regarding communication was of an unreasonable standard and that the staff involved had reflected on their practice for learning and improvement. The board also took steps to amend the surgery consent form to ensure that the recognised risks of surgery are clearly captured.

In terms of nursing care, we found this to be reasonable and appropriate. We did not uphold this aspect of Miss C's complaint.

In relation to complaint handling, we found that the board should have summarised the issues for investigation and checked whether Miss C wanted to provide any further information before they issued their response to the complaint. Therefore, we upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the failings identified in terms of the documentation of communication; the surgery consent process; and the handling of her complaint. 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:

• Ensure surgical staff understand their responsibilities in ensuring important events and communications with the patient or supporter is recorded; and involving patient supporters in decisions about treatment in accordance with the Good Surgical Practice guidance.
• Ensure the current standards of consent are followed as outlined by the Royal College of Surgeons.

In relation to complaints handling, we recommended:

• Ensure complaints are handled in line with the NHS MCHP: www.spso.org.uk/the-model-complaints-handling-procedures

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 to the board about the decision to move them to another ward and the manner in which they were discharged while they were a patient at Royal Edinburgh Hospital. The board explained that beds are allocated according to clinical need and, due to extreme pressures on hospitals at that particular time, it was felt appropriate to move C to another ward as they were clinically stable. The board said appropriate referrals were made following C's discharge, however, as C did not return to the ward following an overnight pass, they were unable to complete their assessment for home treatment.

We took independent advice from a mental health nurse. We found that it was unavoidable that a patient had to be transferred to another ward due to the pressures on the wards at the time, and that the board followed a reasonable process in selecting C as a suitable candidate. We did not uphold this aspect of the complaint.

However, we found that while appropriate assessment was carried out, the board failed to appropriately manage C's discharge as they did not ensure that Intensive Home Treatment Team supports commenced when C left the hospital. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to ensure that the planned post-discharge inputs by the Intensive Home Treatment Team commenced at the point of discharge. 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 that planned post-discharge inputs by community-based services are followed through at the point of discharge and that said community-based services are timeously notified that discharge has taken place. This is especially important in circumstances where discharge has occurred in irregular circumstances which elevate the risk of the person becoming lost to follow-up.

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 that he was unreasonably removed from the boards waiting list when he did not attend an appointment. We took independent advice from a dental adviser. We found that it was reasonable to remove Mr C from the waiting list without offering him another appointment in the clinical circumstances. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the board did not communicate reasonably with him. We found that the board's letter to Mr C did not inform him that, if he contacted the service within four weeks, he may be offered another appointment. This was contrary to the NHS Lothian Standard Operating Procedures for Waiting Times Management. We also found that there was no written record of Mr C's call to the board. We upheld this aspect of Mr C's complaint.

Lastly, Mr C complained about the way the board handled his complaint. We did not find evidence that the board had handled Mr C's complaint unreasonably. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to inform him that if he contacted the service within four weeks he may have been offered another appointment and for failing to record Mr C's call to the board. 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 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.