Some upheld, recommendations

Summary

Mr C complained about the treatment his mother (Mrs A) received at Aberdeen Royal Infirmary. Mrs A was admitted to hospital to investigate heart concerns and was diagnosed with three vessel disease (a type of heart disease). An operation was carried out, but Mrs A died during the operation. Mr C was concerned about the board's response to Mrs A's reports of discomfort to nursing staff and the subsequent treatment she received. Mr C complained that the delay to take Mrs A's complaint seriously and call a doctor, contributed to her death.

We took independent medical advice from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that Mrs A was regularly assessed by both nursing and medical staff, and with the exception of the lack of ECGs on a particular date, appropriate actions were taken when she reported pain. The triple vessel bypass operation was initially successful, however, due to an uncommon complication which could not have been predicted, she died. We did not uphold this aspect of the complaint.

Mr C also complained that there were discrepancies between what he was told verbally by staff on the day after the operation and the written response to his complaint. We found that the board's response was an accurate account of events as documented in the medical records. However, while the board provided a reasonable explanation of the treatment provided to Mrs A, they did not reasonably reflect that there were two instances where ECGs were not carried out, which was out with normal process. On balance, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for inaccuracies in the complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• Share the outcome of this investigation with relevant staff to ensure complaint responses are comprehensive and accurate.

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 that his child (Child A) received for jaundice (a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels. Bilirubin is the reddish yellow pigment made during the normal breakdown of red blood cells) in the days following their birth. In particular, Mr C was concerned that Child A did not receive a blood transfusion and received UV phototherapy instead.

We took independent advice from a midwife and a consultant neonatologist (a doctor who specialises in the medical care of newborn infants, especially ill or premature newborns). We found that the care and treatment provided to Child A was reasonable and in accordance with relevant guidelines. We also found that, as Child A's bilirubin level responded well to the phototherapy treatment, it was reasonable that they did not receive a blood transfusion. We did not uphold this aspect of Mr C's complaint.

Mr C also complained about the way in which the board handled his complaint. We found that the board failed to provide a revised timescale for when Mr C could expect to receive a response to his complaint. We upheld 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 provide a revised timescale for when he could expect to receive a response to his 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:

• 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

Mrs C complained about the care and treatment her daughter (Miss A) received from the board's out-of-hours GP service on two separate occasions, and from Aberdeen Royal Infirmary during two separate admissions. Mrs C believed that the out-of-hours service had not properly assessed Miss A and should have admitted her to hospital. Miss A underwent an appendectomy (appendix removal surgery) during the first hospital admission and then required to have a further operation for a pelvic abscess which is a recognised complication of appendicitis. Miss A was also found to have Crohn's disease (an inflammatory bowel condition) which further complicated matters. Mrs C believed that it took a long time for staff to decide what to do when Miss A was readmitted to Aberdeen Royal Infirmary, that an unusual antibiotic was administered, and that the medical staff tried too many times to insert cannulas.

We took independent advice from a GP and a consultant in general and colorectal (bowel) surgery. We found that the care in relation to the out-of-hours service was of a reasonable standard, because there were clear records made by both GPs of a detailed history being taken, appropriate examination performed, observations taken and tests carried out, with advice given on what to do if Miss A's condition worsened. We also took into account that appendicitis is not always a straightforward diagnosis to make and that other conditions, such as kidney infection, can mimic this. We did not uphold this aspect of the complaint.

In relation to the first hospital admission, we found that whilst the timing of antibiotic treatment and surgery were slightly outside national guidelines, we did not consider these delays to be unreasonable. Nevertheless, although it was reasonable to discharge Miss A on antibiotic treatment and arrange for blood tests some days later, we were critical that this safety-netting measure was not appropriate. We considered that arrangements should have been made for follow-up review within 48 to 72 hours, given Miss A's c-reactive protein (a marker of inflammation) had risen again and that she had a fever. Therefore, we upheld this aspect of the complaint.

In relation to the second hospital admission, we found that the choice of antibiotic treatment was reasonable. In addition, we considered that the problems with cannulation, whilst distressing for Miss A, was not because of sub-standard care, and that the time taken to perform another operation was reasonable given the fact that re-operating is a major undertaking; and there had been an outbreak of flu at Aberdeen Royal Infirmary, which resulted in Miss A being transferred to another hospital. Therefore, we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Miss A for failing to put in place an appropriate safety netting measure at the time of the first discharge from hospital. 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:

• Surgical staff should arrange appropriate follow-up review post-discharge where relevant to ensure robust safety measures are in place.

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 underwent a hip replacement at Victoria Hospital. Mr C complained that the board failed to ensure they had obtained informed consent from him and that they failed to provide him with a reasonable standard of care and treatment.

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 consent process was reasonably documented and that Mr C did provide informed consent. Therefore, we did not uphold this aspect of Mr C's complaint.

We found, however, that Mr C had not received proper post-operative care, with delays in his review appointments There was a failure to discuss in full the nature of the nerve injury he had suffered, as well as the possible treatment options. We upheld 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 provide a reasonable standard of care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Review the x-rays taken and document their findings in detail, as well as providing Mr C the opportunity to discuss the findings should he wish to.

In relation to complaints handling, we recommended:

• The surgeon should reflect on the case as part of their appraisal process, in particular the delays in post-operative contact and the failure to review Mr C's x-rays 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

Mrs C complained about the care of her child (Child A) in Ayrshire Central Hospital. In particular, she complained that Child A was prescribed antihistamine medication as a sleep aid, without proper instruction or explanation of potential side effects. A meeting was held but Mrs C did not consider that the board's subsequent written response reflected the detail of what was discussed. The full findings and decision outcome were not detailed or explained in the response. Neither was the action plan that the board had put in place. The response did not comply with the requirements of the NHS Complaint Handling Procedure and we referred the matter back to the board for further work.

Following the board's further response we investigated whether the actions in prescribing medication were reasonable and whether the board's handling of the complaint was unreasonable or not.

We took independent advice from a consultant paediatrician (consultant specialising in the medical care of children) and concluded that clinicians acted reasonably in assessing Child A for prescription medication. We did not uphold this aspect of the complaint, however, we provided feedback to the board that medical records should reflect all discussions regarding a patient's care and that those records should be legible.

With respect to the handling of the complaint, we found that the board unreasonably failed to respond to Mrs C's initial complaint, and also failed to provide adequate detail in their response following the involvement of our office. We identified that the board had failed to produce a report of their investigations, communicate whether the complaint was upheld or not, and did not keep Mrs C adequately updated as to their progress. We upheld the complaint and made recommendations with respect to ensuring that the board take actions to implement recommendations from a previous case we investigated.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adequately respond to the points of complaint originally raised, or those outlined in the complaint to our office, and for not updating Mrs C regarding the delays in responding. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets .

In relation to complaints handling, we recommended:

• The board should ensure the recommendations with respect to a previous complaint to our office, have been properly implemented and complaints handling is now compliant with their statutory responsibilities.

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 primary school her child (Child A) attended. She complained that she was not updated about Child A's academic progress; that Child A was unreasonably given access to scissors; that there was an unreasonable failure to record incidents with other pupils; and that there was a failure to communicate reasonably with her regarding her concerns.

In relation to Child A's academic progress, we found that there were appropriate pupil progress reports and that these had been discussed with Ms C at parents' evenings. We considered that this was reasonable and that although there was no record of other discussions about Child A's academic progress, this was appropriate as it was not something which appeared to have been raised. We did not uphold this aspect of Ms C's complaint.

With regard to Child A having access to scissors, we were not able to establish that this had occurred and we did not uphold this aspect of Ms C's complaint. However, we noted that there appeared to have been some inconsistencies in the way an incident was recorded, and we suggested that the council may wish to reflect upon this.

We found that the council's recording of incidents with other pupils was reasonable and in line with policy, and therefore we did not uphold this aspect of Ms C's complaint.

Finally, in relation to communication, we found that on one occasion, there was a failure to pass a letter that Ms C had handed in to the school to the appropriate person. We considered that this was likely to be a one-off failure, however, we upheld the complaint about communication on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to pass on Ms C's letter to the class teacher. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-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

Mrs C complained about the care and treatment provided to her father (Mr A) during two admissions to Ninewells Hospital. Mrs C complained about nursing care, medical treatment, surgical treatment, communication, and complaint handling.

During our investigation we took advice from a nurse, a consultant in acute medicine, a dermatologist (a specialist in diseases of the skin, hair and nails), a plastic surgeon, and a vascular surgeon (a clinician who treats disorders of the circulatory system).

In relation to nursing care, we found that there had been failings in relation to wound assessment and management; pressure ulcer prevention and management; mouth care; medication administration; adhering to fluid balance; and involving palliative care specialists. We were also concerned that the board's own investigation had not identified these failings. We upheld Mrs C's complaint about nursing care.

In relation to medical treatment, we found that many aspects of this were reasonable and that dermatology care was of a very good standard. However, we identified that there was a delay of around 12 hours in Mr A receiving antibiotics at one point and on this basis, we upheld this aspect of Mrs C's complaint.

We found that the surgical treatment provided to Mr A by both plastic and vascular surgery was reasonable and did not uphold this aspect of Mrs C's complaint.

With regard to communication, we found that the communication between the different teams and clinicians had been of a good standard. We also found that in general, there was good communication with Mr A and his family. However, at a point when Mr A's condition was deteriorating and it was unclear how much information he could understand and retain, there was a gap in communication with his family and we considered this to be unreasonable. We therefore upheld this aspect of Mrs C's complaint.

We considered the board's handling of Mrs C's complaint. We found that there were significant and unacceptable delays throughout the complaints process, and that communication from the board was reactive rather than proactive. We also found that there were a number of failures or delays in answering Mrs C and her family's questions. We considered the handling of Mrs C's complaints to have been unreasonable and we upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable nursing care to Mr A; failing to provide reasonable medical treatment to Mr A; failing to reasonably communicate in relation to Mr A's care and treatment; and failing to handle Mrs C's complaint in a reasonable and timely manner. 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:

• Wounds should be assessed and managed appropriately and timeously, and in line with relevant guidance.
• Pressure ulcer prevention and management should meet the Healthcare Improvement Standards for Pressure Ulcer Prevention 2016.
• Mouth care should be carried out frequently, especially in patients who are not eating or drinking well, and if problems develop they should be addressed in a timely manner.
• Medication should be administered in accordance with the Nursing and Midwifery Code and the board's own local policy on prescribing and administration of medication. Where medications are not administered reasons for this should be documented.
• Accurate fluid balance and adherence to fluid restriction should be a priority in patients who have renal failure.
• Patients such as Mr A should be reviewed by palliative care staff in a timely manner, and efforts should be made to make patients comfortable during the end of life period.
• Action should be taken in a timely manner when a patient develops a new fever, and antibiotics should be commenced promptly.
• It should be documented if a patient is able to understand and retain information, and if not, communication with relevant family members should take place and be documented.

In relation to complaints handling, we recommended:

• Complaints should be handled in a reasonable and timely manner, and in line with complaint handling guidance.
• The board's complaints handling system should ensure that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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 that her late mother-in-law (Mrs A) received when she attended the emergency department at University Hospital Monklands on two separate occasions. Mrs A was also under the care of a consultant surgeon at the time.

We took independent advice from a consultant in emergency medicine and a general surgeon. We found that the majority of the care and treatment provided in the emergency department was reasonable. However, we also found that the on-call surgical doctors did not make Mrs A's consultant surgeon aware of her attendances to the emergency department. Therefore, we upheld this aspect of Mrs C's complaint. The board said that they had already taken action to address this issue so we asked them to provide evidence of this.

Mrs C also complained that the board failed to handle her complaint reasonably and in particular that the board did not respond to all the points of her complaint. We found that the board provided a response to the majority of the concerns Mrs C raised and, therefore, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to make Mrs A's consultant surgeon aware of her attendances to the emergency department. 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

Ms C complained about the care and treatment her late sister (Ms A) received in Dr Gray's Hospital before her death. Ms A attended the emergency department in the hospital after striking her head. She had suffered a laceration (cut in the skin), which was glued shut, and she was then discharged. On the following day, she was admitted to the hospital with a high heart rate and shortness of breath. It was subsequently noted that Ms A was suffering from acute chronic kidney injury and chronic atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). She became unresponsive and was taken for a CT scan to check if her head injury was contributing to her loss of consciousness. Ms A died in the radiology department.

We took independent advice from an emergency medicine adviser and a consultant in acute medicine. We found that the standard of documentation for Ms A's presentation to the emergency department was poor. It was also unreasonable that she was not scanned in the emergency department before she was discharged, given her reduced level of consciousness and confusion; her headache; and the fact that she was on anticoagulant medication (medication to prevent blood clots). Further tests should have been carried out and her discharge from the emergency department was contrary to guidance. In addition, the advice given to her when she was discharged from the emergency department would have been challenging for Ms A to understand and retain. It was also surprising that, when she was admitted to hospital, Ms A was given increasing doses of beta-blockers given that she had an allergy to. Therefore, we upheld this aspect of the complaint. The board said that they have taken action to address these failings and we have asked them to provide evidence of this.

Ms C also complained that the board had failed to provide an accurate account of Ms A's death. We found that the board's response on this matter had been accurate. We did not uphold this aspect of the complaint.

Ms C complained that the board failed to communicate appropriately with her family. We found that it had been unreasonable for the board not to contact the next of kin when Ms A deteriorated. We upheld this aspect of the complaint. However, we noted that the board had acknowledged and apologised for this failure and we made no further recommendations in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to provide reasonable care and treatment to Ms A in the hospital's emergency department. 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

Mr and Mrs C complained about the treatment Mrs C received both during and after her pregnancy. Mrs C felt unwell throughout her pregnancy with nausea, heartburn and abdominal pain. Mr and Mrs C reported her symptoms during phone calls to the midwife unit. Mrs C was advised to take pain relief and get back in touch if the pain worsened. When Mr and Mrs C attended the Victoria Hospital for their 20 week scan they were told there was no foetal heartbeat.

After delivery of the baby Mrs C had bloods taken, and tests from the placenta, but waited more than ten weeks to see a doctor to discuss the test results. After chasing up the results Mr and Mrs C were told that bloods had been lost, requiring Mrs C to return to the ante-natal clinic for further testing. She was subsequently told she tested positive for lupus (an autoimmune condition that affects the body's defences against illnesses and infections) and required further blood testing. Errors in the testing meant that Mrs C had to return to the clinic again. Each time she had to wait with pregnant couples and found this distressing. Mr and Mrs C felt the miscarriage could have been avoided if Mrs C had received better treatment. They complained that Mrs C's lupus should have been diagnosed sooner, and that the loss of their baby might have been avoided.

We took independent advice from a midwife and a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the advice given to Mrs C each time she contacted midwives regarding her symptoms was reasonable. We did note, however, that Mr and Mrs C's account of the reported symptoms was not reflected in the records and we were unable to reconcile the two. We found that testing for lupus during pregnancy is unreliable because results may be falsely positive and that there were no clinical indicators for Mrs C to be screened prior to her miscarriage. We considered that the treatment Mrs C received during her pregnancy was reasonable and did not uphold this aspect of the complaint.

In relation to treatment after the miscarriage, we found that errors in the blood sampling were unreasonable. We noted that Mrs C had experienced a traumatic loss and that having to return to the ante-natal clinic several times to have bloods taken added significant stress to her situation. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C for these failings in their care, with an acknowledgement of the impact this had on them. 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 consider whether alternative arrangements could be offered for future patients who have experienced stillbirth or miscarriage, particularly if the procedure could be carried out elsewhere.

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.