Some upheld, recommendations

Summary

Mrs C complained about a number of issues with the care and treatment she received from the board. Mrs C had a complex medical history and had accessed a number of different services provided by the board.

Firstly, Mrs C raised concern that the board had not provided her with timely and appropriate maxillofacial (relating to the jaws and face) care and treatment. Mrs C was referred to the maxillofacial service for extraction of a tooth. After an initial consultation, Mrs C was listed to have the tooth extracted. At the subsequent consultation, a different doctor found that the tooth was vital and could be restored with further treatment. Mrs C was discharged from the service. Mrs C's general dental practitioner made a further referral to the service and after further consultations Mrs C's tooth was extracted. She felt that the board's actions had prolonged her pain. We took independent advice from a speciality doctor in oral and maxillofacial surgery. We considered that the care provided to Mrs C was reasonable. We did not uphold this complaint. However, we found evidence of issues with record-keeping in the service and we made a recommendation in relation to this.

Mrs C also raised concern that the board had not provided her with timely and appropriate orthopaedic (the branch of medicine involving the musculoskeletal system) care and treatment. Mrs C had a number of consultations in the orthopaedic service and was unhappy with the way clinicians investigated her orthopaedic condition and managed her care. In response to Mrs C's complaint, the board acknowledged that she had experienced delays and they described that they were reviewing the referral process to reduce delays. We took independent advice from a consultant orthopaedic surgeon. We found no medical failings in Mrs C's orthopaedic care, however, we noted that there was evidence of a significant delay in Mrs C being offered an appointment following a referral from her GP. We upheld this aspect of Mrs C's complaint.

Mrs C further complained that the board had not provided her with timely and appropriate physiotherapy treatment. She said that the self-management exercises recommended to her by the board were not helpful and she wanted to receive additional treatment, including hands-on therapy. In response to this complaint, the board said that the treatment provided had been appropriate. We took independent advice from a musculoskeletal outpatient physiotherapist. They said that it was standard practice to provide exercises to a patient to

self-manage chronic musculoskeletal pain, and hands-on treatment was of little long-term benefit in this situation. We considered that Mrs C received a reasonable standard of physiotherapy care and treatment and found no evidence of a delay in providing this. We did not uphold this aspect of Mrs C's complaint.

Mrs C was unhappy that the board failed to carry out timely and appropriate investigations into her facial/head pain symptoms. Mrs C had been reviewed by clinicians in a number of departments over a number of years in relation to this issue and she was unhappy with the investigations carried out and the lack of liaison between various specialties. We took independent advice from an oral surgeon with expertise in facial pain. We found that a number of appropriate investigations had been performed, yet there was limited evidence that appropriate haematology (related to blood disorders) investigations and investigation into temporomandibular disorder (a problem affecting the muscles and joints in the jaw area) were performed. We were also critical about the coordination of investigations between different disciplines and found that tests had not been carried out to exclude a specific type of headache. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, Mrs C was dissatisfied with the way the board handled her complaints. While we acknowledged that Mrs C's complaint was exceptionally complex, we did not find evidence that the board provided a clear timescale within which they aimed to respond to Mrs C. We considered that the delays in complaint handling were unreasonable and also noted that in once instance, the board did not appropriately acknowledge one of Mrs C's complaints or inform her of her right to complain to us. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the unreasonable delay in providing an appointment to her, not investigating her orofacial pain reasonably, failures in record-keeping, and the delays in complaint handling. 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:

• Where multiple specialties are involved in investigating a clinical issue, the care should be well coordinated with effective communication between disciplines.
• Neurology staff should be mindful of the possibility of neurovascular and migrainous causes in patient's presenting with complex orofacial pain.
• Patient care should be documented in line with the requirements within the General Medical Council and General Dental Council standards. Temporomandibular joint disorder should be managed in line with contemporary clinical guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in accordance with the NHS Complaints Handling Procedure.

Summary

Mrs C complained to us that nursing staff failed to document her concerns appropriately at a pre-operative assessment before she had a wisdom tooth surgically removed. She said that she told them that she was extremely anxious and that it was agreed that she would be taken first on the list for surgery. However, when she attended hospital to have the surgery, she was not first on the list and this made her extremely distressed.

We took independent advice from a nursing adviser. We found that there had been a failure to document the concerns Mrs C raised at the pre-operative assessment and that this had made her extremely anxious on the day of the surgery. We upheld this complaint.

Mrs C also complained that nursing staff had been rude and dismissive about her concerns when she attended the hospital for the surgery. We did not find any evidence to support this aspect of her complaint and we did not uphold the complaint.

Mrs C complained that she had not been given adequate pain relief after the surgery. We found that the board had not documented Mrs C's request for stronger pain relief at the pre-operative assessment and upheld this complaint.

Finally, Mrs C complained that she had been discharged from hospital without antibiotics. We took independent advice from a dental adviser. We found that it had been standard practice and reasonable to discharge her without antibiotics. We did not uphold this complaint.

Recommendations

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

• The documentation that is completed at a pre-operative assessment should include a section for any concerns raised at that assessment.
• Pain relief medication prescribed should be appropriately recorded. All medicines on discharge should be clearly and accurately recorded on discharge documentation.

Summary

Mr C owned a flat in a block of properties. The council also owned flats in the same block of properties. Mr C complained that the council unreasonably charged him for a share of the repair costs to a communal path.

We found that all owners have duties and responsibilities in respect of repairs and maintenance of shared parts of property, normally set out in title deeds. As owners, both Mr C and the council shared responsibility for communal areas. Given this, it was reasonable for the council to conclude that private owners, such as Mr C, should bear a proportion of the repair costs and be invoiced accordingly. We saw no evidence that Mr C was not responsible for paying a share of common repairs. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the council failed to communicate reasonably with him about the communal path repairs. We found that the majority of the council's communication was reasonable. However, we found that the council's communication with Mr C about the availability of an inspection report should have been clearer. We upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not making it clear that an inspection report was not available. 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:

• The council should communicate clearly with owner-occupiers regarding the availability of inspection reports for assessed communal repairs.

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 secondary school his child (Child A) attended. He said that after his family had told the school of an incident which Child A had witnessed, the school failed to communicate reasonably with him regarding their progress and wellbeing. We found that the evidence showed that following the school being informed of the incident, this was appropriately discussed with Child A, and teachers were reasonably alert to any change in their behaviour or wellbeing. We determined that as there did not appear to be any cause for concern, there was no need for the school to communicate with Mr C. We also noted that Mr C and his family could have discussed any concerns they had with the school and they had appropriate opportunity to do so. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that following Child A's exam results, there was an unreasonable failure to communicate with him. We found that whilst the majority of communication was reasonable and timely, there was a failure to alert Mr C of the exam board's position on the potential to apply in retrospect for 'exceptional circumstances'. On this basis, 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 alert him to the Scottish Qualification Authority's position on exceptional circumstances in a 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:

• Communication regarding post-results matters should be timely, open, and transparent.

Summary

Mr C complained about the nursing care and treatment his father (Mr A), who had dementia, received when he was admitted to University Hospital Monklands. He also complained that Mr A had been unfit for discharge on the day of his planned discharge. In addition, Mr C complained about the level of communication with Mr A's family from the board.

We took independent advice from a nursing adviser and a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that the nursing care Mr A received had been reasonable and we did not uphold this aspect of Mr C's complaint.

Mr A's planned date for discharge was modified due to his deteriorating health. We found that there had been a failure to assess Mr A's mental health and the possible presence for delirium prior to the original date for discharge, and as a result, the consultant geriatrician advised that staff could not be confident, or show, that Mr A had improved to a level where it was safe to consider discharge. We were particulary concerned that a dementia test was not carried out. We found that the board had unreasonably considered Mr A fit for discharge on the date of the planned discharge and upheld this aspect of Mr C's complaint.

In relation to communication, we found that the nursing communication was reasonable but the board had identified some failings. We also found failings in the medical communication in the initial part of Mr A's admission to the hospital. We upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family for the failings this investigation has identified. 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:

• Ensure older people in hospital have their cognitive status assessed and documented. Older people in hospital experiencing an episode of delirium should be assessed, treated, and managed appropriately.

Summary

Miss C complained about the care and treatment she received from the Princess Royal Maternity Hospital. She raised concerns about the general anaesthetic she was given during her emergency caesarean section, which she said was given the wrong way round and jeopardised her ability to breathe, risking both her and her baby's lives.

We took independent advice from a consultant anaesthetist who covers obstetric (medical specialism for pregnancy and childbirth) theatres as part of their elective and emergency work. We found that the sequence of drug administration in Miss C's case was wrong and could have caused Miss C difficulty breathing, but the awareness of this would have lasted for only a few seconds at most. There was no risk to Miss C's baby from this drug error and the risk to Miss C was limited to the unpleasant experience she suffered, but there would not have been any risk to her life. Given the failing in the administration of the drugs, we upheld this part of Miss C's complaint.

The board acknowledged their failing in this case and took appropriate remedial action on this matter. However, we made one recommendation for further action by the board.

Miss C also complained that she developed a chest infection and contracted Clostridium Difficile (bacteria that can infect the bowel and cause diarrhoea) whilst in hospital. We did not identify any failings by the board in these areas. We did not uphold this part of Miss C's complaint.

Recommendations

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

• Consideration should be given to the supply of pre-filled syringes of suxamethonium, as raised by the board's departmental morbidity and mortality meeting.

Summary

Mr C complained about the overall care and treatment given to his late father (Mr A) while he was a patient in Borders General Hospital.

Mr A was elderly and had a history of acute kidney injury and fluid overload. He was admitted to hospital with gastroenteritis (inflammation of the lining of the stomach). During his stay, clinicians experienced difficulty in getting his fluid balance right between heart failure and fluid overload, and his poor kidney function and fluid intake. When he was considered fit, Mr A was discharged home; however, he was admitted to hospital again the next day. After his second admission he was discharged home, and while the high risks of this were discussed, Mr A was keen to go home. He returned home but again required to be hospitalised the next day with increasing confusion and shortage of breath. Mr A's condition continued to deteriorate and a few days later he died. Mr C was unhappy with the medical and nursing care. He said that Mr A's condition was often unkempt and he had pressure ulcers.

We found that Mr A's medical care and treatment had been reasonable and given appropriately in response to his presenting symptoms. Both times he had been discharged, he was fit. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to nursing care, we found that Mr A's nursing notes were not of the required standard. Similarly, relevant standards in relation to the prevention and management of pressure ulcers were not followed by nursing staff. Therefore, 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 the failure to deliver Healthcare Improvement Scotland standards appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for care of older people in hospital 2015.
• Nursing staff should be fully aware of, and apply, Healthcare Improvement Scotland standards for the prevention and management of pressure ulcers 2016.

When it was originally published on 19 June 2019, this case wrongly referred to Health Improvement Scotland. The correct name is Healthcare Improvement Scotland.

Summary

Mrs C complained about the board's handling of two extra contract referrals for out-of-area treatment for her ongoing health problems. Mrs C said that after her first referral to the extra contract referrals panel was granted, the board failed to offer any practical or financial assistance to make the trip to a hospital in England for treatment.

We found that there was no information on how the panel reached their decision on Mrs C's first extra contract referral, and key sections of the panel decision form were left blank or appeared to contain incorrect information. It was unclear what the panel took or did not take into account when making their decision not to support Mrs C with travel/accommodation costs, and there was some uncertainty in relation to the conditions of funding and whether the panel were approving an overnight stay as part of the request. We also found that there was no mention in the panel's decision letter of a patient's right of appeal regarding the extra contractual referral panel decision process. Therefore, we upheld this part of the complaint.

Mrs C also complained that the board unreasonably failed to deal with her complaint about the handling of the two extra contract referrals in accordance with their complaints procedure. We found that the board's handling of Mrs C's complaint was appropriate and we did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to handle her first Extra Contractual Referral appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
• The board should consider any application received from Mrs C now for travel and an overnight stay, taking into account any relevant policies such as their Travel Expenses Protocol.

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

• Decisions by the Extra Contractual Referral panel should be appropriately documented and relevant sections of the Panel Decision Form completed, making it clear what was taken into account when reaching their decision, including any consideration of their Travel Protocol, where appropriate.
• Notification of the Extra Contractual Referral panel's decision should include the right of appeal regarding the panel's decision process, in accordance with the Protocol.

Summary

Mrs C's mother (Mrs A) was transferred to hospital by ambulance with low oxygen levels. Mrs C had a power of attorney (POA) in place, enabling her to make decisions on Mrs A's behalf. Mrs A was admitted to hospital and the following day medical professionals spoke with her regarding a 'do not attempt cardiopulmonary resuscitation' (DNACPR) agreement, without first consulting Mrs C. Mrs C complained to the board that it was inappropriate for medical professionals to speak with Mrs A regarding the DNACPR as she had dementia and did not understand what was being said. Mrs C also complained about the lack of knowledge of the POA that was in place. In their response, the board explained that it was a priority to complete a DNACPR given Mrs A's deteriorating condition, and it was appropriate in the circumstances to discuss this with her. The board said that they were aware of the POA and this was appropriately recorded in Mrs A's medical records.

Mrs C complained that the board's actions in implementing a DNACPR were unreasonable, that they unreasonably failed to clearly record in Mrs A's records that a POA was in place and that the handling of the complaint was unreasonable.

We took advice from an independent medical adviser. With respect to the actions in implementing the DNACPR, we found that given Mrs A's state of health on admission to hospital, it was appropriate for medical professionals to consider a DNACPR and discuss this with Mrs A. Whilst there were concerns about Mrs A's capacity, the records indicated that this was considered by medical professionals. It was reasonable for medical staff to decide DNACPR was required and that Mrs A had capacity at the time to be involved in the discussions. We did not uphold this complaint.

With respect to the complaint that the POA was not clearly recorded in the file, we found that at the time of Mrs C's complaint, the board were unable to locate a copy of the POA on file. Whilst the medical notes showed the medical professionals were aware of the POA in place, there was not a record kept on file at all times. On this basis, we concluded that the board failed to clearly record in the file that an active POA was in place. We upheld this complaint.

In relation to Mrs C's complaint, we found that the board failed to respond to the complaint within the 20 working day time-frame and failed to provide any explanation for the delay. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to keep her updated on the progress of her complaint, the delay in completing the investigation or to provide a revised timescale for response. 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:

• Where the board have been provided with a physical copy of a POA document, a copy should be kept in the relevant patient's medical records, in a prominent position, at all times.

In relation to complaints handling, we recommended:

• Complaints handling staff should be aware of the requirements of the Complaints Handling Procedure with respect to timescales for response and keeping complainants informed about their complaint.

Summary

Ms C complained about the treatment she received from the practice in response to her symptoms of oedema (swollen tissue from retained fluid). Ms C said that she had reported symptoms to the practice on numerous occasions. Ms C said there was an unreasonable delay in responding to her symptoms. During an appointment with a GP Ms C was told to stop a certain medication. Ms C said that during the appointment she was not given proper instructions or after care, i.e. to get her blood pressure checked. A few weeks later, after a severe headache, it was found that Ms C's blood pressure was too high and she required hospital admission.

We took independent medical advice from a GP. We found that Ms C's treatment by the practice was reasonable and found no failings in the treatment offered. The practice considered Ms C's symptoms, taking into account her overall medical hisotry and chronic illnesses when considering appropriate action to respond to Ms C's reports of oedema. Therefore, we did not uphold this part of Ms C's complaint.

Ms C also complained that the board failed to provide reasonable after care, specifically that her blood pressure should be checked. There was no written record or evidence to support the practice's view that appropriate information was provided to Ms C regarding having her blood pressure checked. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified by the investigation. The apology should meet the standards set out inthe SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance

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

• The GP meets the standard of good record-keeping.