Some upheld, recommendations

Summary

Mrs C complained about a decision that was taken by the board to refuse out-of-area funding for a paediatric consultant for her child's (Child A) care. Mrs C said that the process leading up to the decision, how the decision was communicated to her and how the board handled her complaint was unreasonable.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine) and found that the board followed the correct process in reaching a decision regarding the referral and, therefore, did not uphold this part of the complaint.

However, we identified that the board had failed to provide Mrs C with a clear explanation of the process that they followed and the rationale for their decision; to give correct information to Mrs C regarding a third doctor's involvement; to correct their error when communicating with Mrs C; and to provide relevant information to SPSO in this regard in response to our enquiries. We upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide clear explanations, for providing her with erroneous information; failing to correct this error; and for the complaint handling failings. The apology should acknowledge the impact this has had on Mrs C. 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:

• Notifying clinicians and families should receive a full explanation of the outcome of funding requests, including information on the evidence used to reach that decision.
• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: http://www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by Queen Elizabeth University Hospital and by Gartnavel General Hospital. After Mrs A died, amyloidosis disease (a condition caused by the accumulation and deposition of amyloid protein in the body in various organisations) was diagnosed. Mrs C complained that, had this condition been diagnosed earlier, Mrs A would not have suffered as she did and that she would not have been subjected to unnecessary physiotherapy or to a one-night hospital transfer which she believes exacerbated Mrs A's condition. Mrs C also complained that the board wrongly discharged her mother on one occasion and failed to admit her to a high dependency unit, but sent her to a rehabilitation unit instead.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly). We found that the medical investigations, treatment, physiotherapy and nursing care provided to Mrs A were reasonable. We did not uphold these aspects of the complaint.

However, we concluded that the decision to discharge Mrs A home from hospital on one occasion was unreasonable; the decision to admit Mrs A for rehabilitation was not appropriate due to her frailty; and the decision to transfer her to a general hospital was not reasonable. Therefore, we upheld these aspects of the complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to discuss other possible options for Mrs A’s discharge and for transferring her inappropriately. 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:

• Before transferring or discharging frail patients consideration should be given to all the options for discharge/ transfer; whether a patient’s condition is stable enough for any transfer and whether a patient’s condition is such that they will benefit from rehabilitation if appropriate.

Summary

Mr C’s father (Mr A) was referred by his GP to the Royal Alexandra Hospital for investigation of breathlessness. Two chest x-rays and a CT scan were performed over the following months. Mr A attended A&E seven months after his initial referral with severe pain in his side and back and a further x-ray was carried out. Mr A was admitted to hospital later that month following a fall, and a further x-ray and CT scan were carried out. Further to a biopsy (tissue sample) of an identified mass, Mr A was told he had incurable cancer. He died the following month.

Mr C complained about a failure to diagnose the cancer from the first CT scan. We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques). We found that an abnormality on the CT scan was not reported. This resulted in an avoidable delay of approximately three months in the diagnosis of Mr A’s cancer. Therefore, we upheld this aspect of the complaint. The board have already apologised to Mr C for not picking up the cancer on the CT scan, and have undertook to discuss this at a learning meeting.

Mr C also complained about a delay in notifying Mr A of the results of this CT scan. We took independent advice from a consultant physician. We found that the scan result had been left on a consultant’s desk awaiting dictation, and the consultant had retired. It took Mr A’s prompting before a secretary arranged for another consultant to review and share the result. Mr A received the result ten weeks after it had been reported. We considered this delay was unreasonable and that a more robust system was required. We also noted that the board had not addressed this aspect of Mr C's complaint. Therefore, we upheld this aspect of the complaint.

Mr C also complained that there was a failure to diagnose Mr A's cancer from the x-ray taken during his admission to A&E. We found that the x-ray raised the possibility of an abnormality and suggested a repeat CT scan which was later carried out. We considered that this was appropriate and there was no unreasonable failure to diagnose the cancer directly from the x-ray. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in informing Mr A of the result of his CT scan, and for failing to address Mr C's complaint about this. 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:

• There needs to be a robust system in place for reviewing and communicating imaging results. The board should review their system and provide this office with an assurance that mechanisms are in place to avoid a repeat of the circumstances which contributed to the delay in this case.
• The board should reflect on the adviser's comments in relation to minimising any systems deficiencies which might contribute to perceptual errors when reporting imaging studies, unless such reflection occurred as part of the Learning from Discrepancies me

In relation to complaints handling, we recommended:

• The board should adhere to their Complaints Policy and Procedure, and aim ‘to establish all the facts relevant to the points made in the complaint and to give the person making the complaint a full, objective and proportionate response’.

Summary

Ms C complained that the board failed to provide reasonable care and treatment to her friend (Mr A) at the Queen Elizabeth University Hospital, before his death. Mr A had been admitted to the hospital due to exacerbation of his asthma and flu. After a few days, his condition deteriorated. He died six days after being admitted to hospital.

We took independent advice from a consultant in acute medicine. We found that:

• more information about Mr A’s alcohol intake should have been obtained;

• if the alcohol liaison nurse’s entry had been read or actioned, his diazepam (a tranquillizingmuscle-relaxant drug used to relieve anxiety) prescription would probably have been cancelled;

• there was a failure to respond promptly to his deterioration;

• it was unreasonable that he was seen by a junior grade doctor when he was clearly very unwell;

• prescribing sedation and planning to review him four hours later was not an appropriate response to a patient who was deteriorating and showing evidence of lower oxygen levels than normal;

• he should have been seen more promptly after his initial deterioration by a more senior doctor;

• he should have had important investigations such as X-rays and blood tests as soon as he was settled enough to comply with them;

• it was unreasonable that he was not on a fluid balance chart daily from admission;

• he should have been assessed more thoroughly for potential sepsis (blood infection) when he deteriorated; and

• what was written down in the notes did not seem to be have been read by other members of the team.

Therefore, we upheld this aspect of Ms C's complaint.

Ms C also complained about the lack of communication from staff about Mr A’s deterioration. We found that staff should have contacted her earlier than they did. The failure to do so substantiated the concern that staff did not recognise or respond to Mr A’s deterioration appropriately and that they did not recognise how unwell he was. We upheld this aspect of the complaint.

Finally, Ms C complained that the board failed to accept that Mr A had sepsis. She considered that sepsis should have been recorded on his death certificate. We found that the tests that were carried out at that time showed serious infection but did not indicate sepsis. Based on the information available, it was reasonable that sepsis was not recorded on Mr A’s death certificate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

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

• Clinical entries in medical notes should be read and acted on. If a decision is taken not to act on the entry, this should be noted. Caution needs to be exercised when sedating patients with respiratory failure.
• Patients who have an elevated Early Warning score should be reviewed regularly, particularly if no definitive management plan has been established. The appropriate tests and investigations should also be carried out, including the tests for sepsis.
• Medical and nursing staff responsible for the care and treatment of a patient should ensure that they read the relevant notes.

Summary

Mr C complained about the clinical and nursing care and treatment his late wife (Mrs A) received during two admissions to Vale of Leven Hospital (VOLH) and the clinical care and treatment she received during her admission to Royal Alexandra Hospital (RAH) when she was transferred there from VOLH.

We took independent advice from a consultant in acute medicine and a nursing adviser. We considered that the overall clinical care and treatment Mrs A received during her first admission to VOLH was reasonable and that appropriate assessments and investigations were carried out. However, we found that during her second admission there was a failure to carry out a medical review following an increase in Mrs A's National Early Warning Score (NEWS). NEWS is a tool used to determine the severity of a patient's condition and to highlight any deterioration. We also found that there was a failure to recheck Mrs A's NEWS within six hours. We found that, had this been done, it may have alerted staff to how unwell Mrs A was and allowed staff to speak to Mr C. We considered that the failure to respond appropriately to the elevated NEWS and the failure in relation to the communication with Mr C was unreasonable and we upheld this aspect of the complaint.

In relation to the clinical care and treatment given to Mrs A during her admission to the RAH, we found that this was reasonable and we did not uphold this aspect of the complaint.

In terms of the nursing care that Mrs A received at VOLH, we found that overall the nursing care and treatment had been reasonable. All reasonable assessments were carried out, including a falls assessmenta and the medical records were comprehensive and of a standard that met the National Midwifery Council guidance. However, we also found that there was no documentation within the medical records of the rationale for nursing staff not following NEWS guidance. In these circumstances we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to provide Mrs A withreasonable clinical and nursing care and treatment at VOLH. 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 staff should ensure they are able to recognise and respond to elevated NEWS in line with NEWS guidance.
• Relevant staff should be mindful of NEWS guidance and ensure that they document the rationale for not following the guidance.

Summary

Mr C complained about the care and treatment provided by the board to his child (Child A) at Royal Hospital for Children, Glasgow. Mr C also complained there was a lack of reasonable communication about Child A and that the board did not respond reasonably to his complaints. Child A had been transferred from another hospital with a history of focal seizure and decreased conscious level. They were admitted to the paediatric intensive care unit (PICU) and after a period of time transferred to a another ward. Child A was initially diagnosed with a type of encephalitis (an acute inflammation of the brain).

We took advice from a senior consultant paediatric neurologist and a senior paediatric nurse. We found that the care and treatment Child A received during their admission to the PICU was appropriate and there was no delay in considering, diagnosing and treating Child A’s condition while they were in the PICU. Child A was subsequently transferred from the PICU to another ward where they developed another type of encephalitis. While Child A received appropriate medical treatment, we raised concern that Child A was not re-admitted to PICU for closer nursing observation given their respiratory difficulties and low Glasgow Coma Scale (GCS) scores (a scoring system used to describe the level of consciousness of a patient). While this did not have an adverse effect on Child A’s short or long-term clinical outcome, we considered that their re-admission to the PICU would have allowed for closer and more appropriate nursing care and observation, and would have reduced significantly or avoided much of Child A’s family’s distress. Therefore, we upheld this aspect of the complaint.

In relation to the nursing care, we found that the nursing care including specialist nursing care which Child A received while he was in the PICU and in the ward, was reasonable. Accordingly, we did not uphold this aspect of Mr C’s complaint.

In relation to Mr C’s complaint about communication, we did not find evidence to conclude that staff failed to communicate reasonably with each other about Child A’s care and treatment or that Mr C was given conflicting advice concerning this. Overall, we found that there appeared to have been reasonable communication with Mr C and his family. However, we highlighted areas where communication with Mr C could have been improved. The board also acknowledged in their complaint response that communication with Mr C’s family could have been better when Child A was transferred to another ward for which they had apologised and taken action to address. Given the shortcomings identified in communication, on balance, we upheld this aspect of the complaint.

Mr C also complained about the board’s handling of his complaint. We considered the length of time that Mr C waited for a formal response to his original complaint to the board was excessive and that, on occasion, the board had failed to communicate reasonably with Mr C about his complaint which added to his distress. Given this, we upheld the complaint. We noted that the board had acknowledged that there were delays and had appropriately apologised to Mr C for this. The board also told us that their complaints department had put in place an agreed process of cover for staff who were on planned or unplanned leave. Taking account of this, we considered the action the board had taken was reasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and his family for not re-admitting Child A to PICU given their clinical condition and that communication with Mr C's family about Child A's care and treatment could have been better. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Relevant staff should review their approach to admitting patients with low GCS scores and respiratory difficulties to PICU.
• Where a patient’s case is complex, consideration should be given to appointing senior named members of the clinical and nursing staff to communicate principally with the patient and/or their family

Summary

Mrs C complained about the care and treatment provided to her father (Mr A) at Borders General Hospital. Mr A had a long history of health problems including arthritis (a disease causing painfulinflammation and stiffness of the joints) and chronic obstructive pulmonary disease (COPD, a disease of the lungs in which the airways become narrowed) and he was admitted to hospital due to the severity of his tremors. Mr A had been taking regular doses of dihydrocodeine (DHC, an opioid painkiller) for several years for his arthritic pain. When he was admitted to hospital, Mr A's DHC was stopped and he suffered withdrawal symptoms. Mrs C complained that Mr A's medication was stopped for no reason. The board explained that there was no signature on the drug chart so they could not identify who stopped the medication and why but they had taken steps to address this failing.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the decision to stop the DHC was likely an error and we were satisfied the board had taken the appropriate steps to remind all junior doctors of the importance of documenting their decisions in the clinical notes. We upheld the complaint on the basis that it could not be identified why the medication was stopped and made a further recommendation in relation to complaint handling.

Mrs C also complained that Mr A was discharged from hospital when he was still very ill and that there was little consultation with the family and consideration of how they would manage at home. The board confirmed that Mr A was clinically well enough to be discharged home and that they delayed the discharge appropriately when Mr A's wife expressed concerns about how she would cope at home. We found that Mr A was medically fit for discharge and the process was appropriately managed. We did not uphold the complaint.

Recommendations

In relation to complaints handling, we recommended:

• Reasonable steps should be taken in future to identify relevant parties involved in complaint issues, to allow the issues to be thoroughly investigated, responded to in specific terms, and focussed learning to take place. This should be highlighted to all complaints handling staff.

Summary

Ms C complained on behalf of her father (Mr A) that it was unreasonable for the practice to refuse Mr A a home visit. Mr A had been seen by the practice the day before and the next day a home visit was requested for him. The practice did not consider that a home visit was required and asked Mr A to attend, which he agreed to. Ms C said that Mr A required urgent medical attention and should have been seen at home.

We took independent medical advice and found that whilst there were differing accounts of what was discussed during the call requesting a home visit, there was no evidence in the medical records of clinical symptoms which were described during the call, nor in the notes from Mr A's appointment the previous day, which would have suggested a house call was required. We found that the practice's policy on home visits was reasonable and was applied appropriately in the circumstances. Therefore, we did not uphold this aspect of the complaint.

Ms C also complained that the practice's response to her complaint was unreasonable. We found that the practice failed to communicate with Ms C in line with their complaints handling procedure. Therefore, we upheld this aspect of the complaint. We noted that the practice had apologised for this but made a further recommendation for learning and improvement.

Recommendations

In relation to complaints handling, we recommended:

• All staff who handle complaints should be made aware of the findings of our investigation and reminded of the requirements of the complaints handling procedure.

Summary

Miss C complained about the university's communication with her regarding the visa she required to obtain to enter the UK to take up her place on a taught research degree. Miss C complained that the university unreasonably delayed in identifying the fact that Miss C required a Certificate of Acceptance of Study for a visa and delayed in advising her of this. We considered that the university had two opportunities to clarify Miss C's status with her and did not do so. However, we considered that it was Miss C's responsibility, prior to accepting the place on the course, to establish which visa she required and what documentation she needed to produce in order to obtain the visa. The fact she required a Certificate of Acceptance of Study from the university in order to obtain the visa was set out on the UK government's website. We noted that Miss C had accepted a place at the university in the knowledge she could not study in the UK without a visa but she delayed in providing this information to the university. Therefore, we did not uphold this aspect of the complaint.

Miss C also complained that there was a delay in advising her that she required to demonstrate her ability in English by sitting a Secure English Language Test (SELTs) before she would be issued with a Certificate of Acceptance of Study. For this type of course, the UK government allows the university sponsor to determine how they evidence English language ability and it is the university's decision regarding whether or not they require a SELTS. However, we found that the university's website and correspondence did not make it clear that it requires students on this course who require a Tier 4 visa to sit an International English Language Test System (IELTS) test to prove English language ability. 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 an unreasonable delay in advising her that she required to demonstrate a CEFR B2 ability in English by sitting a SELTS before she would be issued with a Certificate of Acceptance (on the basis it was not clear they only accepted IELTS (Academic) and she had other qualifications). 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:

• Information regarding what language tests are acceptable, and when they are required, is clear and non-contradictory.

In relation to complaints handling, we recommended:

• To ensure there is awareness of the higher institution's role in determining how they choose to assess English language ability for this type of course.

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, who was away from her property at the time of a fire on its roof terrace, complained about the action taken by the Sanctuary (Scotland) Housing Association (SH) following the fire. In particular, Mrs C complained that SH had failed to make reasonable attempts to inform her of the fire which had affected her home; and also, that they had failed to take reasonable action to mitigate the damage to her flat and possessions. Mrs C also complained that SH had unreasonably delayed making effective repairs to her home and that they had failed to reasonably manage the roof terrace.

We found that SH had made reasonable attempts to contact Mrs C when they discovered she was away from her property and we did not uphold this aspect of her complaint. We also found that SH had dealt with the matter under their emergency repairs procedure and had secured Mrs C's flat and made it safe. We did not consider that they had failed to take reasonable action to mitigate the damage to her flat and possessions, and we did not uphold this aspect of the complaint.

In relation to Mrs C's concerns that there were delays in making effective repairs, SH accepted that there had been a failure to deal with this matter in a timely way, and while Mrs C's home had remained in a habitable condition, they recognised the difficulties Mrs C had experienced and had made a compensation payment prior to our investigation. We upheld this aspect of the complaint. SH also accepted that they had failed to deal with Mrs C's complaint properly.

Finally, we found no evidence that SH had failed to manage the roof terrace correctly and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to follow the complaints handling policy. 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:

• Relevant staff require to be aware of and follow SH's complaints handling policy.

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.