Some upheld, recommendations

Summary

Ms C complained about the care and treatment provided to her late father (Mr A) at the Royal Alexandra Hospital. Mr A had dementia and was admitted with drowsiness, fever, confusion, and crackles in the lung. Ms C felt that there was not sufficient screening for sepsis when Mr A was admitted, that he was not given appropriate pain relief, and that discharge was unreasonable. Ms C also raised concerns about the nursing care provided to Mr A.

We took independent advice from a consultant in acute and general medicine, and from a nurse. We found that Mr A was appropriately assessed when he was admitted to hospital, that his pain was managed appropriately, and that his discharge was reasonable. We did not uphold this aspect of Ms C's complaint.

In relation to nursing care, we found that whilst there were some areas of nursing care which were reasonable, there were a number of failings. Namely, we found that there was limited evidence of care planning being carried out appropriately, there was no 'Getting to Know Me' document completed (this document should be completed for all patients with dementia). We also considered that a non-verbal pain assessment tool should have been used, but noted that the board had acknowledged this. We upheld this aspect of Ms C's complaint.

Ms C further complained about communication and complaints handling. We found that there was a failure to appropriately communicate with Ms C when her father was in hospital, particularly as she was his power of attorney and next of kin, and we upheld this aspect of her complaint. We also found that in relation to complaint handling, there was confusion regarding whether Ms C's complaint was in fact feedback, and this resulted in a delay in acknowledging the complaint. We also found that the response was delayed and the reasons for this were not clear. We upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to provide Mr A with reasonable nursing care and treatment; failing to communicate reasonably; and failing to handle Ms C's complaint reasonably. 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:

• Appropriate care planning should be carried out and should take into account the specific needs of patients with dementia.
• A 'Getting to Know Me' document should be completed on admission for all patients with dementia.
• Communication with relatives should be proactive, well documented, and should appropriately involve the input of power of attorneys and next of kin.

In relation to complaints handling, we recommended:

• Prompt action should be taken to determine whether someone is making a formal complaint.
• Complaint acknowledgement letters should be sent out as per the complaints handling procedure.
• Responses should be sent where possible within 20 days and without undue delay in line with the board's complaint handling procedure.

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

Summary

Mrs C complained on behalf of her daughter (Miss A) that, when Miss A attended the Queen Elizabeth University Hospital on several occasions with groin pain and leg swelling, she did not receive appropriate treatment. Miss A was eventually admitted to hospital and was later diagnosed with secondary cancer.

Mrs C said the board unreasonably misdiagnosed Miss A's condition during her initial visit to A&E at the hospital. She said that they told Miss A she had strained her groin, when in fact she had a large blood clot there.

We took independent medical advice from a consultant in emergency medicine and from a consultant in general medicine. We found that although the diagnosis given at the time was incorrect, it was consistent with Miss A's recorded history and examination findings and was not unreasonable. We did not uphold this aspect of the complaint.

Mrs C said that the board unreasonably delayed in reaching a diagnosis of Miss A's condition. Her concerns included that it took several months of visits to the hospital before Miss A was admitted. We found that the clinicians who saw Miss A at the hospital could, and should, have exercised discretion and carried out further investigations of Miss A's condition at an earlier stage. We also found that the delay in Miss A being admitted to hospital and given a diagnosis, was unreasonable. Earlier investigation would almost certainly have identified the abnormal tissue causing Miss A's problem and led to the subsequent diagnosis of an underlying secondary cancer. While further early investigation might not have resulted in a different outcome, Miss A could have been spared the pain and anxiety caused by the delay in diagnosis of secondary cancer. Therefore, we upheld this aspect of the complaint.

Mrs C also said that the board failed to deal with her complaint about Miss A's care and treatment appropriately. We found that the board had delayed in responding to Mrs C's complaint, failed to provide her with any updates and that, following repeated contact by Mrs C's MSP's office, a full response was eventually forthcoming. This was contrary to the board's complaint handling procedure and we, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Miss A for the delay in admitting Miss A to Queen Elizabeth University Hospital and investigating and diagnosing her condition at an earlier stage; and for failing to provide Mrs C with appropriate updates on her 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:

• In future cases of this type, staff should admit patients to Queen Elizabeth University Hospital and carry out further investigations at an earlier stage, in order to reach a diagnose within a reasonable timeframe.

In relation to complaints handling, we recommended:

• Where the board needs longer than the 20-day timescale to issue a full response, they must explain the reasons to the complainant, and agree with them a revised timescale whenever possible, in accordance with the board's complaints policy and procedure.

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

Summary

Ms C complained about the care and treatment her late mother (Ms A) had received from the practice before Ms A completed suicide.

She complained that the practice failed to identify that her mother had a personality disorder. We took independent advice from a GP adviser. We found that it had been reasonable for the practice not to diagnose that Ms A had a personality disorder. We did not uphold this aspect of the complaint.

Ms C also complained that the practice failed to manage Ms A's anti-depressants and that they had failed to take appropriate action when she stockpiled medication. We found that the practice had acted reasonably in relation to these matters and did not uphold these aspects of the complaint.

Ms C then complained that the practice had failed to call her back, after she had contacted them to raise concerns about her mother's behaviour. We found that there was no evidence that Ms C requested or was promised a follow-up call by the practice. In view of this, we found that it was reasonable that the practice did not call her back. We did not uphold this aspect of the complaint.

Ms C complained that the practice had failed to take action when Ms A reported abuse of her children. We did not find any evidence in the practice's records that Ms A had reported physical abuse of her children. However, we considered that there was evidence of emotional abuse by Ms A to her children and that social work input should have been arranged in relation to this. We upheld this aspect of Ms C's complaint.

Finally, Ms C complained that the practice had unreasonably failed to deal with her complaint appropriately. We found that the practice had made a reasonable attempt to respond to the issues raised. It was also reasonable that one of the GPs named in the complaint carried out the investigation, given the size of the practice. That said, we found that the practice had unreasonably failed to provide updates on the investigation or information about when they expected to issue a final response. In view of 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 their failure to ensure that social work input was arranged and for failing to keep her updated on the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• GPs should be familiar with the indications of emotional abuse in children and the referral mechanisms in place for social work assessment.

In relation to complaints handling, we recommended:

• When there is a delay in responding to a complaint, the practice should tell the person making the complaint about the reasons for the delay and when they can expect a response.

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 late father (Mr A) during an admission to Glasgow Royal Infirmary. At the time, Mr A had a long standing cardiac and respiratory (heart and lung) illness and was admitted with a chest infection, shortness of breath, confusion and hallucinations.

We took independent advice from a consultant in respiratory medicine. We found that many aspects of the care provided were reasonable. However, we found no evidence that an inhaler review had been appropriately performed or planned. On balance, we upheld this aspect of Mrs C's complaint.

Mrs C also had concerns about the nursing care provided to Mr A, and the way in which his discharge was handled. We took independent advice on these matters from a registered nurse. We found that the dietary monitoring performed was reasonable and we found no failings in the way nurses interacted with Mr A. We concluded that the nursing care provided was reasonable. Similarly, we were not critical about the way Mr A's discharge was handled. We found no evidence of unreasonable failings and concluded that the handling of the discharge was reasonable. We did not uphold these complaints.

Finally, Mrs C complained about the way her complaint was investigated by the board. We did not find failings in the way the board investigated or responded to the complaints raised. However, we found that the board did not update Mrs C about the delay in responding to her, in accordance with the NHS Scotland Complaints Handling Procedure. On balance, we upheld this aspect of the complaint but noted that the board had already apologised for this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C that an inhaler review was not performed during the admission or planned. 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:

• Where a patient suffers repeat significant disabling breathlessness attributable to chronic obstructive pulmonary disease, inhaler assessment and medication review should be undertaken or planned.

In relation to complaints handling, we recommended:

• Where a complaint response cannot be provided within 20 working days, the person making the complaint should be updated on the reason for the delay and be given a revised timescale for completion. Delays in investigation should be minimised.

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 clinical and nursing care and treatment given to his late mother (Mrs A) while she was a patient at Royal Alexandra Hospital. Mr C also complained that there was a failure to notify him of Mrs A's deteriorating condition.

We took independent advice from a nurse and a consultant physician. We found that falls assessments were not undertaken as they should have been and that Mrs A had not been provided with the walking frame that she required. We also found that Mr C was alerted neither to Mrs A's deteriorating condition nor to her fall and the injuries she suffered as a result. Similarly, Mr C appeared not to have been told of Mrs A's low sodium which was likely to have contributed to her fall and agitation. Therefore, we upheld these aspects of Mr C's complaint.

In relation to clinical treatment, we found the care to be reasonable. We did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to alert him to Mrs A's deteriorating condition and to her fall and injuries, as well as the failure to advise of her poor prognosis. 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:

• Where a fall occurs, relatives should be alerted in a timely way. Similarly, they should be informed where a poor prognosis is anticipated.
• Medical staff require to communicate effectively with ward staff about the seriousness and risk of common metabolic problems.

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 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.