Some upheld, recommendations

Summary

C complained on behalf of their parent (A) who suffered from dementia and was admitted to hospital with multiple medical issues including a chest infection, delirium, kidney failure and poor mobility including recent falls.

C raised a number of complaints, including that there were failures in the medical care provided to A with respect to falls and post falls care and seizures. C also complained of failings in nursing care relating to diet and nutrition, hygiene and cleanliness, and the general monitoring and awareness of A’s condition. Lastly, C complained regarding restrictions on visitation and poor communication.

We took independent advice from a consultant specialising in the care of the elderly and a second experienced nursing adviser. We found that the medical care provided appeared to have been reasonable. We therefore did not uphold this complaint, however, we were critical of the standard of medical record keeping and we provided feedback to the board about this.

We found that there were failures to complete the necessary risk assessments and care documentation including the risk assessment tool for malnutrition, monitoring fluid balance and applying appropriate wound care and a failure to identify and respond to a deterioration in A’s condition. We therefore upheld this complaint.

We found that general communication with the family appeared reasonable, and that pandemic restrictions were an unfortunate reality for many patients and families. However, it appeared that there had been a failure to notify the family that A had significantly deteriorated. This resulted in the family not being present when A passed away and on this basis we upheld the complaint regarding communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. 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 appropriately assessed by nursing staff in particular in relation to malnutrition, fluid balance, wound care and nursing care provided in line with the assessments carried out. Any significant deterioration should be appropriately recognised and acted on as required. Records about a patient’s care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines. Patient’s records should include clear details explaining why a decision about care and treatment has been made.

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 board in the lead up to the delivery of their twin babies. One of the twins (A) was stillborn.

C complained that the board failed to provide reasonable care and treatment during C’s pregnancy. We took independent advice from a consultant obstetrician and gynaecologist (specialist in pregnancy, childbirth and the female reproductive system). We found that while many aspects of the care and treatment were reasonable, the omission of some key measurements and tests was unreasonable and did not accord with guidelines. This impacted on clinicians being able to reach a fully evidenced position on what care was appropriate. Therefore, we upheld this part of C's complaint.

C complained that the board failed to reasonably communicate the risks and options available to them. We found that the records indicated that the board reasonably communicated with C in relation to the risks and options available to them. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to reasonably investigate C’s concerns. We found that many aspects of the reviews which were carried out were reasonable. However, we found that the reviews failed to identify that the significance of the lack of the measurements being taken was unreasonable, leading to a delay in identifying learning that could be taken forward. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Where adverse event(s) occur the review should be thorough and identify all relevant learning from the event.
• Where it is considered that there are growth issues in relation to a fetus, appropriate investigations and tests, including measuring the pulsatility index as required, should be carried out in line with relevant national guidance.

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

Summary

C complained about the care and treatment that their late parent (A) received whilst in hospital. A was admitted to hospital with light headedness, dizziness, and pain in the hip and leg. C had concerns about the board’s failure to consider A’s previous medical history, decisions made during surgery, communication, care provided, and what was recorded on the death certificate.

The board said that investigations into A's blood loss found no issues and that they planned to discharge A. However, due to further bleeding A was not discharged and required emergency surgery. A was made aware of the risks associated with the surgery. This operation was successful, however, a further procedure was required to remove a section of A's bowel. Due to further changes in A’s condition, the board moved A to palliative care.

We took independent advice from a consultant in intensive care and acute medicine, a general surgery consultant and a registered nurse. We found that A's care and treatment was reasonable. However, A's medical history was recorded incorrectly by medical staff, affecting the treatment plan, investigations, and diagnosis. We found that A's operations were carried out reasonably. However, the surgical team failed to examine A in person when consulted which was unreasonable. Overall, we considered that the care and treatment provided to A was unreasonable and upheld this part of C's complaint.

In relation to nursing care, we found that the care and treatment provided to A was reasonable. We also found that A's death certificate was not completed incorrectly. Therefore, we did not uphold these part's of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to take an accurate medical history on admission, there was a missed opportunity for the vascular team to identify the correct diagnosis during their review of A, the failure to consider a diagnosis of aorto-enteric fistula earlier, and particularly, once the CT scan findings were available, and the failure of the surgery team to review A in-person. 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:

• Accurate medical history should be established by clinicians and investigations, including CT scans, that are carried out should be critically reviewed when considering diagnosis alongside the history. Medical records should be viewed to establish/confirm the correct medical history.
• When asked, the surgical team should fully review the presentation and history of the patient. Where necessary the patient should be seen in-person.
• When a specialist review is requested such as vascular, the specialist team should fully review the presentation and history of the patient.

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 relative (A) and A’s child (B) about the health and social care partnership, of which the counil administered the complaint investigation. B was removed from A’s care. Following a short period of kinship care by B’s grandparent, they were placed with foster carers. C and their partner applied to be B’s kinship carers as soon as B was taken into care. However, they were not made B’s kinship carers until several years later.

C complained that the partnership had unreasonably delayed in assessing their kinship care application. C also complained that there had been failures to facilitate B’s contact with their family, to address concerns about B’s foster carers, to provide them with support following B’s kinship care placement and to provide specified information. The partnership accepted that there had been delay in assessing B’s kinship care and identified learning from this. They did not identify any other service failures.

We took independent advice from a social work adviser. We found that there had been a failure to progress the kinship care placement timeously and to take reasonable steps to facilitate B’s family contacts. We also found that there had been a failure to provide specified information. We upheld these complaints. However, we found that there had not been a failure to address concerns about B’s foster carers or to provide C with support following B’s kinship care placement. We did not uphold these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.
• Provide C with an explanation on why there had been undue delays in completing B’s kinship care assessment and/or information about the findings/recommendations and actions taken from the CSWO review.

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 various aspects of the board’s care and treatment of their partner (A) and their communication with C and A during an inpatient admission covering the end of A’s pregnancy and the birth of their child (B) by caesarean section. The board accepted that a number of areas of communication had not been reasonable and apologised for this. The board explained what action would be taken to address these areas for improvement. The board also accepted that in a few specific cases, A had not received reasonable care but indicated that they considered A’s care and treatment had been reasonable overall. In response to a specific complaint from C, the board stated that A had not had sepsis (blood infection) or been treated for it during their admission. A few months later, however, the board wrote to C and stated that their labour had been complicated by sepsis.

We took independent advice from an appropriately qualified midwife. We found that, overall, A and B received good care and appropriate standards of treatment that were in line with relevant professional standards. Given this, and that reasonable actions to minimise recurrence were taken in relation to areas where the board had accepted care was not of an acceptable standard, and where communication could have been improved, we did not uphold the complaint that the board had not provided reasonable care and treatment to A.

We found that A had had sepsis during their admission and receive prompt and appropriate care. However, we considered that the board’s repeated altering of their position on whether A had sepsis, both minimised A’s experience and, potentially risked inadequate care and treatment responses being provided to patients with suspected sepsis in the future. We upheld the complaint that the board’s response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that their response inaccurately stated that A did not have sepsis and was not treated for sepsis during their admission. 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:

• Relevant board staff have a clear understanding of the symptoms and diagnosis of sepsis and the actions to take in treating sepsis and suspected sepsis.

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 concerned about a number of issues regarding their care and treatment, and that of their child (A), during their pregnancy, A’s birth and afterwards. C raised complaints with the board and were dissatisfied by their response. The board’s response accepted that there had been issues with aspects of the boards complaint handling and a number of issues with their communication, but did not indicate that the board considered that there had been any issues with C or A’s care or treatment.

We took independent advice from qualified advisers with experience of obstetrics, neonatology and midwifery (the medical specialisms for pregnancy, childbirth etc.). We found that, overall, C and A had received reasonable care and treatment from the board and that, where areas for improvement around communication had been identified, reasonable actions had been taken to address these. We did not uphold these part's of C's complaint. We noted that the board had accepted that C had been assigned to an incorrect consultant’s waiting list for a post-birth debrief and upheld this complaint. We also noted that the board had appropriately apologised to C for this. However, we considered that the board should have taken steps to minimise the possibility of a similar situation recurring in the future.

In considering the board’s response to C’s complaints, we found that there were specific areas where the board’s response and actions could have been improved. However, taking into account those areas for improvement in complaints handling the board had identified, the apologies provided to C and the specific circumstances of the time C raised their complaints, overall the board responded reasonably to C’s complaint. We did not uphold this part of C's complaint.

Recommendations

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

• Steps are taken to minimise the possibility of patients being assigned to incorrect consultant’s waiting lists for post-birth debriefs.

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 university’s handling of an investigation into allegations made against them and their subsequent complaint about the matter. The allegation against C was investigated by the university’s sports association and upheld. The matter was then passed to the university’s student conduct team for consideration as to whether any further sanctions should be applied. C complained about the processes followed by the sports association. C also complained about the processes followed and the delays incurred during the university’s conduct investigation.

We considered C’s complaint that the university’s investigation into the allegations made against C were unreasonable. During our investigation, we found that C had not requested an appeal of the university’s decision. In order for this office to investigate a complaint about an appeal, the student or their representative must first have completed the organisation’s appeals procedure before bringing their complaint to us. As C had not done this, our investigation was limited to considering whether the university had informed C of their right to appeal and provided them with information on how to do so. We found that the university had reasonably informed C of their right to appeal. Therefore, we did not uphold this part of C’s complaint.

We also considered whether the university’s investigation of C’s complaint was unreasonable. We found that it was reasonable for the university not to consider C’s complaint about the sports association. As an autonomous external body, it is not covered by the complaints procedure. In relation to the university’s handling of C’s complaint about the university’s code of student conduct investigation, we found that there were significant delays to the completion of the complaint investigation. We also found that the university did not reasonably provide C with updates regarding the progress of the complaint investigation, with this only being forthcoming in response to the enquiries made by C. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delays by the university to investigate the 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:

• Complainants should be advised prior to the response deadline if the 20 working day target cannot be met. Information should be given about the reason for the delay and revised anticipated date of completion 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 their housing. C had moved into the property because they were downsizing from their previous home. The property they moved into had been purchased by the council from its owner as part of a ‘buy back’ scheme for council properties. C complained of persistent damp and mould within the property that was causing them significant health problems. C was offered alternative properties by the council but C rejected them on the basis that they were unsuitable.

We found that extensive works had been carried out to the property prior to C moving in. We also found that, whilst C disputed the suitability of the alternative properties they were offered, the council had followed the correct procedure in assessing C’s medical needs and the properties offered to C. Therefore, we did not uphold these parts of C’s complaint.

In relation to C’s reports of damp and mould, we found that these issues were investigated. However, the council took an unreasonable length of time to respond, given that they were aware of the health issues being experienced by the family. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to respond timeously to their concerns. 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 council should have effective systems in place to ensure that problems with mould and damp are responded to timeously.

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 adult child (A) in relation to A’s pregnancy. A attended hospital on two occasions over a weekend with no fetal movement. The baby (B)’s heartbeat was considered normal on both occasions and A left the hospital with a plan to return on the Monday. On A’s return to hospital, an intrauterine death (when a child dies in the womb) was diagnosed. A requested to have their waters broken to relieve the pressure that they were experiencing. A ‘s labour was very quick and they delivered B in the toilet of the labour suite at the hospital. They called for a midwife to attend and assist them.

C complained that the hospital did not listen to their concerns for B to be delivered as an emergency. C and A believed that there was too much focus on B’s heartrate and that further investigations, including ultrasound, should have been undertaken. C also complained about the difficult circumstances of B being born in the toilet, and the care provided in the run up to, and following, labour.

In response to the complaint, and following the completion of a Significant Adverse Event Review (SAER), the board found no specific failings of care which led to B’s death. Monitoring of A and B was appropriate, and ultrasound scanning was not available over the weekend. The board noted that A had chosen to return home, rather than be admitted over the weekend which was against medical advice. The board explained that early delivery by caesarean section was not indicated given the clinical picture was reassuring. C and A met with representatives from the board following the complaints response where issues relating to the delivery of B were discussed. The board acknowledged that a midwife should have responded to A’s calls that they were delivering B in the toilet, and acknowledged that A should not have been in a labour ward where they could hear other mothers and healthy babies.

C was dissatisfied with this response and brought their complaint to us. They disputed the accounts of doctors that A was advised about the risks of going home during the weekend and remained of the view that more should have been done for A and B over the weekend.

We took independent advice from a GP who worked as an obstetric and gynaecology registrar (a specialist in pregnancy, childbirth and the female reproductive system) and a registered midwife. We found that appropriate advice was offered to A about the risks of returning home over the weekend, that the level of monitoring and assessment was reasonable and that the assessments were reassuring with respect to the health of A and B. Therefore, we did not uphold this part of C’s complaint.

In relation to the treatment provided to A during labour, we found that care in preparation for delivery of B was reasonable, with appropriate monitoring and pain relief provided. When A rushed to the toilet, given the recent examinations checking the progress of A’s labour, it was reasonable for midwifery staff not to consider A was about to give birth. However, there was a lack of documentation and records at the time of delivery and the immediate period before and after this which prevented our office from drawing conclusions about the level of care provided. Given the board’s acknowledgements that a midwife should have attended immediately to A when they called for help, together with the lack of appropriate record keeping during labour, and the accommodation in the labour suite being inadequately soundproofed, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failures identified. 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:

• Clinical and midwifery staff should keep clear and accurate records, relevant to their practice, in line with the Nursing and Midwifery Council code.

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 living in a residential unit for young people who are looked after by the council. C complained that the council failed to take appropriate action when they raised safeguarding concerns about the unit manager and failed to investigate a breach of confidentiality when C received abusive messages from a former member of staff. C also complained that the council had failed to keep them informed about decisions made about the future of the residential unit and their complaints had not been handled in accordance with the council’s complaints procedures.

We took independent advice from a children and families social worker. We were satisfied that C had been kept reasonably informed about the position of the future of the unit. Therefore, we did not uphold this part of C’s complaint. However, there were some failings in relation to communication and record-keeping in response to the safeguarding concerns raised. There were also failings in the investigation into abusive messages from a former member of staff and in the complaints handling. Therefore, we upheld these parts of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints. 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:

• Safeguarding concerns should be communicated appropriately and in line with safeguarding guidance and clear and accurate records should be maintained.
• Staff in the unit should be aware of the issues regarding the use of social media highlighted by this case.
• The council should maintain clear and accurate records of discussions and meetings that take place, in line with required standards.

In relation to complaints handling, we recommended:

• Complaint responses should comply with the Model Complaints Handling Procedure and council staff should be familiar with the complaints handling procedure. Complaint investigations should be clearly recorded at each stage and responses provided within 20 working days. If this is not possible, the complainant must be updated on the reason for the delay and provided with a revised timescale.

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.