Some upheld, recommendations

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.

Summary

Ms C complained that the board failed to diagnose a ruptured Achilles tendon when she attended Western General Hospital. We took independent advice from a consultant physician in acute internal medicine. We found that given the specific test for excluding a ruptured Achilles tendon was carried out, which resulted in a negative finding, it was reasonable that the ruptured Achilles tendon was not diagnosed. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received at the Edinburgh Royal Infirmary after the ruptured Achilles tendon had been diagnosed. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the care and treatment provided to Ms C was reasonable and did not uphold this aspect of her complaint.

Ms C complained that the board failed to communicate reasonably with her. We found that there was no record of any detailed discussion with Ms C prior to her surgeries about the risks or benefits of the proposed operations, the alternatives to surgery or the varying degrees of success and the possibility that her condition could be made worse. The board had a document for recording fasting and insulin instructions for diabetic patients but this was not completed in Ms C's case. Therefore, we upheld Ms C's complaint that the board's communication with her was unreasonable.

Ms C complained about the way that that the board handled her complaint. We found that Ms C's complaint was not acknowledged within three working days. There was also a delay in responding to Ms C's complaint and the board did not proactively keep her updated about the reason for the delay in responding to her complaint and provide a revised timescale for when she could expect to receive a response. 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 record a detailed discussion with her prior to her surgeries about the risk or benefits of the proposed operations, failing to acknowledge Ms C's complaint within three working days and for failing to keep her updated about the reason for the delay in responding to the complaint or providing a revised timescale for the response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients should be given full information about the risks and benefits of proposed operations, including the alternatives to surgery, and these discussions should be documented in line with relevant guidance.
• Diabetic patients should be given fasting and/or insulin instructions prior to surgery and these instructions should be recorded.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the model complaints handling procedure. The model complaints handling procedure and guidance can be found here: www.valuingcomplaints.org.uk/handling-complaints/complaints-procedures/nhs

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 about the care and treatment he received in relation to a coronary artery bypass graft (a surgical procedure used to treat coronary heart disease) at the Royal Infirmary of Edinburgh.

We took independent advice from a consultant cardiologist (a specialist in diseases and abnormalities of the heart). We found that Mr C was identified as having ostial left anterior descending artery disease (a narrowing in the blood vessels of the heart) and that the initial choice of treatment for this, bypass surgery, was reasonable. Mr C then had an uncommon but recognised complication of bypass surgery. We found that the decision to perform a second procedure to implant a stent (a small tube used to keep passageways open) was reasonable. We also noted that there was no reason to believe that performing a stent procedure earlier would have translated to any clinical benefit for Mr C. We considered that the clinical care Mr C received was reasonable and did not uphold this aspect of his complaint.

Mr C also complained about aspects of his nursing care during his hospital admission when the stent procedure was performed. We took advice from a consultant nurse in cardiology. We found that Mr C was not prescribed appropriate pain relief and that there was contradictory evidence in the records around the management of his pain. Mr C's pain should have been managed better and the failure to do so was unreasonable. We also identified failings in record-keeping, in particular, a failure to complete care documentation, around communication with Mr C and his family, and his discharge from hospital. We considered that the nursing care Mr C received was unreasonable and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing provide him with reasonable pain relief, failures in record-keeping, and failing to provide him with reasonable nursing care. 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 who are in pain should have their pain needs addressed as soon as possible. Following a surgical procedure, patients pain needs should be proactively addressed even though they are waiting to be clerked into the ward. Nursing staff should ensure the documentation of a patient's care following a surgical intervention should be completed. Nursing staff should maintain reasonable records, consistent with the Nursing and Midwifery Code of Conduct.

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 her late mother (Mrs A) received at the Royal Infirmary of Edinburgh. When Mrs A was admitted, it was recorded that she had known lung cancer and she was initially treated for pneumonia (inflammation of the lungs). It was subsequently planned that Mrs A would be discharged, but a CT scan showed that she had an accumulation of blood in her abdominal muscle. Mrs A later had a fall. She was monitored overnight, but died the following day.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the medical treatment provided to Mrs A had been reasonable. We did not uphold this aspect of the complaint.

Ms C also complained about the nursing care provided to Mrs A. We took independent advice from a nursing adviser. We found that there was no evidence of any failings that had led to Mrs A's fall in the hospital or that a specific injury sustained in the fall led directly to her death. A robust post falls assessment was also undertaken after the event, which did not indicate any specific injury.

Overall, the nursing care provided to Mrs A had been reasonable. However, there were gaps in the nursing notes provided. There was also a lack of evidence of communication with Mrs A's family. In addition, the board's response to Ms C's complaint did not address many of the points she had raised. Given these failings, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide evidence that nursing staff communicated with her appropriately. 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:

• Nursing staff should maintain records in line with the Nursing and Midwifery Council's guidance on record-keeping.

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 about the care and treatment his late wife (Mrs A) received from the practice during a number of attendances.

We took independent advice from GP adviser. We found that the care provided to Mrs A by the practice, when she presented with a swelling in her groin and a lump on her breast, to be reasonable.

Mrs A had also attended the practice with a swelling in her neck. We found that there was a failure by the practice to document a full history relating to the neck swelling, how long it was there for, and to consider further investigation of the swelling and safety netting. We considered this to be below a reasonable standard and upheld this aspect of Mr C's complaint. However, we also acknowledged that by the time Mrs A presented with the swelling in her groin, she already had incurable cancer. While earlier referral for investigation of the neck swelling could have possibly led to an earlier diagnosis, it was unlikely to have changed Mrs A's overall outcome.

Mr C also complained that Mrs A had been treated in an unsympathetic and dismissive manner by the practice, and said that he and Mrs A were unaware that she had suspected heart failure. Our investigation found no evidence of this.

Mr C also complained about the way in which the practice had responded to his complaint. We found that the practice responded to Mr C within a reasonable time, and did not identify any inaccurate information in their response. We also acknowledged that the practice had offered to meet with Mr C. 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 failure to document a full history relating to Mrs A's neck swelling; how long it was there for; or to consider further investigation of the neck swelling and safety netting. 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 review and are aware of General Medical Council Good Medical practice guidance and the Scottish cancer referral guidelines on Head and Neck Cancers.

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, an advocate, complained on behalf of her client (Mrs B) about the medical and nursing care that Mrs B's late husband (Mr A) received at Wishaw General Hospital.

Mrs B was concerned that a urine sample was not taken around the time Mr A was admitted to hospital; that sepsis may not have been treated properly; that staff did not recognise the severity of a fall Mr A sustained; and an opiate painkiller was not given at a particular time. Mrs B was also concerned that; no falls assessment was carried out and wheelchair transportation was inappropriate after Mr A's second fall; record-keeping regarding a fall was contradictory and did not capture the severity; intravenous paracetamol should have been given instead of oral paracetamol; and Mr A's blood pressure and heart rate were not properly monitored.

We took independent advice from a GP consultant and from a registered nurse. We found that there was a failure to take a urine sample which the board had accepted and apologised for. However, overall we did not identify any significant failings in Mr A's medical care and did not uphold this aspect of the complaint.

However, we found that it was unreasonable that Mr A was not transported by trolley to have his scan carried out and that there was a failure to escalate his worsening blood pressure reading to medical staff. Therefore, we upheld the complaint that Mr A's nursing care was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for failing to escalate Mr A's blood pressure reading to medical staff; and for not transporting Mr A by trolley for his 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:

• Nursing staff should comply with the board's policy on deteriorating patients and NEWS escalation.
• Nursing staff should ensure that appropriate consideration is given to a patient's transportation following falls.

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.