Some upheld, recommendations

Summary

Mrs C complained about the medical and nursing care and treatment her late mother (Mrs A) received when she was admitted to Lorn and Islands Hospital. She also complained about the communication with her family and that the board had failed to handle her complaint in a reasonable way.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) and a nursing adviser. We found that it was difficult to provide an overall view about the medical care and treatment given to Mrs A due to the length and complexity of her admission. However, we found there had been a delay in diagnosing Mrs A's delirium and that she had a urine infection. We also found that the death certificate process was handled insensitively. Therefore, we upheld this aspect of Mrs C's complaint.

In relation to the nursing care given to Mrs A, we found no failings on the part of nursing staff regarding Mrs A's dehydration, dietary intake and her personal care. Therefore, we did not uphold this aspect of Mrs C's complaint.

In relation to communication, we found that the nursing communication was reasonable. However, we found that there was a delay in medical staff communicating the results of a CT scan and the overall assessment of Mrs A's health to Mrs C. Therefore, we upheld this aspect of Mrs C's complaint.

Finally, in relation to complaint handling, we found that the board had failed to comply with their complaints handling procedure and 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 failings in clinical care, communication and 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:

• Staff should be aware of the potential for elderly patients to have delirium. Staff should be careful and sensitive with the death certification process and junior doctors should have senior supervision of this process as set out in national guidance.
• Families or carers should be involved in identifying delirium. Results of CT scans and the overall assessment of a patient's health should be communicated timeously to families.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints handling process.

Summary

Ms C complained about the care and treatment she received at the GP out-of-hours service at Gartnavel General Hospital when she attended with a rash and bruising on her legs. We took independent advice from a GP. We found that the examination carried out within the out-of-hours service was reasonable and it was reasonable that Ms C was referred to the Immediate Assessment Unit (IAU) rather than A&E. We did not uphold this aspect of Ms C's complaint.

Ms C also complained about the care and treatment she received within the IAU at Queen Elizabeth University Hospital. We took independent advice from a consultant in acute medicine. While most of the care and treatment that Ms C received was appropriate, we found that it was unreasonable that Ms C was not assessed for signs of bleeding when an initial low platelet (cells that help blood clot) result became available. 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 the failure to carry out an assessment for signs of bleeding when the initial low platelet result became 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:

• Patients with a low platelet count should be assessed for signs of bleeding.

Summary

Mr C attended the Western Infirmary Hospital a number of years ago when he was experiencing dizziness and migraines. Mr C was referred for an MRI scan to investigate his condition further. Several years later, Mr C was diagnosed with a schwannoma (a tumour on the nerve tissue). His original MRI scan images were reviewed and he was told that the tumour had been visible at that time.

Mr C complained that there was a failure to investigate the tumour when he first attended hospital as it had been visible in his MRI scan. We took independent advice from a consultant neuroradiologist (a radiologist who specialises in the use of radioactive substances, x-rays and scanning devices for the diagnosis and treatment of diseases of the nervous system). We found that in retrospect, the tumour was visible in the original MRI scan. However, as it was small and not clearly defined, we found it was reasonable that it was not identified at that time. We found that even if the tumour had been identified then, it was reasonable for it not to have been reported as it was only borderline abnormal. We also found that Mr C did not yet have any sign of a neck tumour or any symptoms relating to it. We did not uphold this aspect of the complaint.

Mr C also complained that the board failed to provide an appropriate response to his complaint. We found that their response did not accurately identify all of his concerns or provide a reasonable response to them. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not accurately identifying and providing an appropriate response to all aspects of his complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints responses should accurately identify and provide a reasonable response to all the issues of concern.

Summary

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs  A) about the medical and nursing care and treatment Mrs A received when she was admitted to Aberdeen Royal Infirmary. Ms C also complained about Mrs  A's discharge, delays in receiving a neuropsychology (the study of the relationship between behaviour, emotion, and cognition on the one hand, and brain function on the other) assessment and neurosurgery (surgery on the nervous system, especially the brain and spinal cord) follow-up and that the board had failed to respond to her complaint in a reasonable way.

We took independent advice from a consultant neurosurgeon and a nursing adviser. We found that both the medical and nursing care and treatment given to Mrs A was reasonable. We did not uphold these aspects of Ms C's complaint.

In relation to Mrs A's discharge, we found that Mrs A had been medically fit for discharge and that nursing staff had reasonably managed the discharge planning. However, the board accepted that there had been a failure to provide appropriate information and literature to Mrs A and her family on discharge and had taken action as a result of these failings. We upheld this aspect of Ms C's complaint.

In relation to Mrs A's neuropsychology assessment, we found that there had been a delay in arranging this. We also found that Mrs A was not advised of the progress of her neurosurgery follow-up appointment when the timescale was not met. Therefore, we upheld these aspect of Ms C's complaint.

Finally, we found that the board had failed to comply with their complaints handling procedure and we upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for the delay in providing a neuropsychology assessment, failing to update her on her neurosurgery review appointment and for the failings 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:

• Patients should receive a neuropsychology assessment, as part of post head injury follow-up, in a timely manner.
• Patients waiting on review appointments with the neurosurgery department should be updated on the progress of their appointments.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints process, including that all issues raised in complaints should be addressed.

Summary

Mrs C attended the emergency medicine department at Victoria Hospital with abdominal pain. She was reviewed by medical staff and it was considered that she probably had pain related to possible endometriosis (a condition where the tissue that lines the womb is found outside the womb, such as in the ovaries and fallopian tubes). She was discharged home and advised to see her GP. On the following day, Mrs C was admitted to the surgical admissions ward at the hospital under the care of a general surgery consultant. Blood tests were carried out and she was started on intravenous antibiotics. She was found to be improving and was discharged. Mrs C was readmitted to the hospital just over one month later. An ultrasound scan was carried out and an ovarian cyst was detected. Mrs C subsequently had surgery to remove the cyst.

Mrs C complained that she had not received a reasonable standard of care and treatment when she attended the emergency department. We took independent advice from an emergency medicine consultant. We found that the standard of assessment and treatment she received there had been reasonable. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained about the surgical care and treatment she received when she was admitted to the hospital. We took independent advice from a general surgery consultant. We found that Mrs C should have had a magnetic resonance imaging (MRI) scan or computerised tomography (CT) scan during or shortly after her initial admission. The delay in carrying this out delayed her subsequent surgery. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained about the medical care and treatment she had received during her admissions. We found that she should have had early medical investigation to establish an underlying cause for her symptoms during or shortly after the initial admission. In addition, although antibiotics were prescribed and given, there was no evidence that the sepsis pathway plan was implemented. Although it had been reasonable to discharge Mrs C from hospital after her first admission, additional investigations should had been carried out whilst she was an in-patient or shortly after her discharge. In particular, she should have had a repeat test to ensure her blood tests were returning to normal. We also 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 delay in carrying out a scan and in diagnosing that she had an ovarian cyst and for the failure to carry out repeat blood tests during or shortly after her first admission to hospital. 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 board should ensure that patients receive the appropriate tests.

Summary

Mr C complained about the care and treatment provided to him in relation to surgery he underwent at Dumfries and Galloway Royal Infirmary. Mr C felt that the board had failed to provide reasonable care and treatment to him leading up to the surgery and action was not taken to prevent the deterioration which led to surgery. Mr C also felt that when he was in hospital he was not provided with reasonable nursing care and treatment, and that the care and treatment provided to him after surgery in relation to occupational therapy (a method of helping people who have been ill or injured to develop skills or get skills back by giving them certain activities to do) was unreasonable.

We took independent advice from a diabetologist (a doctor who specialises in the treatment of diabetes), a nurse, and an occupational therapist. We found that the care and treatment leading up to Mr C's surgery was reasonable as all appropriate investigations were undertaken and he was provided with treatment in line with the relevant national guidance. We did not uphold this aspect of Mr  C's complaint.

In relation to the nursing care provided to Mr C, we found that Mr C had been provided with the wrong dose of medication for four days during an admission, which we considered unreasonable. We also found that the communication from nursing staff to Mr C was unreasonable as they did not appear to have taken into account his mood or mental wellbeing. We upheld this aspect of Mr C's complaint.

Finally, in relation to the occupational therapy input for Mr C after his surgery, we found that there was no evidence that Mr C's ability to use his wheelchair in restricted spaces was explored, there was little evidence that Mr C was given sufficient opportunity to practice functional tasks prior to discharge and there was no evidence that Mr C's mental health and wellbeing was considered by the occupational therapy team. 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 failing to provide reasonable nursing care, and failing to provide reasonable care and treatment to Mr C after his amputation. 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:

• Staff should perform medicines reconciliation appropriately to avoid incorrect dosages being given.
• Occupational therapy assessments should be full and thorough, and in particular take into account the mental health needs of patients.

Summary

Ms C complained about a number of aspects of the Scottish Prison Service (SPS)' management of her. She complained that the SPS:

held her in an unsuitable cell when she was on Act 2 Care (the suicide risk management policy)

acted unreasonably in relation to an incident when she was attempting suicide

unreasonably removed her from Act 2 Care

failed to acknowledge and manage her risk when she raised concerns about her wellbeing on one occasion

unreasonably left her unsupervised with a sharp object

We found that, in relation to acknowledging and managing Ms C's risk when she raised concerns about her wellbeing on one occasion, the SPS had failed to assess Ms C's risk reasonably at this point and failed to follow their own 'Talk to Me' policy (which replaced Act 2 Care). Therefore, we upheld this aspect of Ms  C's complaint. However, in relation to Ms C's other four complaints, we found that the SPS had acted reasonably and we did not uphold these aspects.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to appropriately acknowledge and manage her risk after she raised concerns about her wellbeing. 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 'Talk to Me' strategy should be adhered to in relation to assessments.

Summary

Mrs C was granted planning permission to create an extension to her home for her father (Mr A) after he was diagnosed with Alzheimers disease. Mr A sold his own house and the money raised was transferred to Mrs C to fund the extension works. Mr A's illness later worsened and he experienced an emergency detention in hospital and was later discharged to a care home.

The council said that the value of the capital from the sale of Mr A's house should be treated as notional capital in his financial assessment which meant that he was to be regarded as self funding for his care home accommodation. Mrs C disputed the decision but the council's original decision was upheld. Mrs C complained that not all relevant facts had been taken into account by the council and as a result Mr A was considered to have deliberately deprived himself of capital. She also complained that the council had not provided her with a clear reasoned explanation of their decision in terms of the Scottish Government Charging for Residential Accommodation Guidance (CRAG).

It is not within our power to review the decision or overturn it. We can only look to see whether the decision taken was on reasonable grounds, taking all the relevant facts into account, in line with relevant guidance. We found that the council had considered all the information Mrs C provided, made reference to CRAG and obtained legal advice. We found no evidence of failures in the council's decision making and, therefore, did not uphold this aspect of Mrs C's complaint. However, we did find that the council had not provided a reasonable explanation to Mrs C for how they reached their decision. We upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to provide a reasoned decision in relation to Mr A's CRAG assessment. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• In accordance with CRAG, reasoned decisions should be provided after an assessment has been made.

Summary

Mr C complained about the health care and treatment he received for his leg ulcers in prison, in particular that there was a delay of over a year in starting his recommended treatment plan (using compression bandages).

We took independent advice from a nurse. We confirmed that compression bandaging was the recommended treatment plan for Mr C, as advised by the vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) who assessed him and as directed by the board's guidance. We found that there were unreasonable delays in relaying the recommended treatment plan to the prison health centre, in referring Mr C to a leg ulcer nurse specialist, and in initiating the recommended treatment plan. The vascular team could not initially provide this treatment to Mr C at an out-patient clinic and they recommended compression stockings as an alternative. We did not consider this was a reasonable alternative, and noted that the reason for not initially being able to provide compression therapy to Mr C was not recorded. Therefore, we upheld this aspect of Mr C's complaint.

Mr C also complained that he suffered significant pain that was not appropriately managed. We took independent advice from a GP. We found that Mr C was appropriately reviewed on a regular basis and was prescribed appropriate medication. We considered that the prescription was in line with relevant guidelines, including those which consider the safety and security implications of prescribing pain killers in a prison setting. Therefore, we did not uphold this aspect of Mr C's complaint.

Finally, Mr C also complained about the handling of his complaints and particularly that some did not receive a response. We noted that the board's file on the complaint did not appear to provide a comprehensive record, and did not demonstrate that the complaints were progressed through the Complaints Handling Procedure (CHP) in a timely and efficient way. We found that the response timescales were unreasonable and there was little evidence of the board having contacted Mr C to explain the delays and agree revised timescales. The responses also failed to demonstrate that each element of the complaint had been fully and fairly investigated. The board acknowledged that they did not comply with their CHP and informed us they have since been reviewing ways of working to ensure future compliance. We upheld this aspect of Mr C's complaint and made further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in providing him with compression therapy for his leg wounds, and for failing to clearly explain the reasons for this delay.
• Apologise to Mr C for failing to appropriately deal with his complaints. The apologies 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 board should reflect on Mr C's care and identify the reasons for the delay in providing him with compression therapy. They should then take appropriate steps to prevent similar future delays.

In relation to complaints handling, we recommended:

• When responding to complaints the board should follow their CHP, and all staff should be aware of this and the NHS Scotland Model CHP.

Summary

Mrs C complained about the treatment she received at an appointment with a gastroenterologist (a physician who specialises in the diagnosis and treatment of disorders of the stomach and intestines) at Ninewells Hospital and the response to her subsequent complaint. Mrs C said the doctor failed to properly investigate her condition given her symptoms/medical history and that there were failings in communication.

We took independent advice from a specialist in gastroenterology. We found that there were failings in relation to documenting Mrs C's medical history and this meant she was left with the impression that the doctor did not take her symptoms seriously, especially her neurological symptoms. While we note not everything that would have been discussed was in the consultation records, we determined that the standard of medical care was not reasonable and this led to a breakdown in the relationship with Mrs C. We upheld this part of the complaint.

In relation to complaints handling, we found that the board's response to the clinical issues raised was reasonable based on Mrs C's medical records. Therefore, we did not uphold this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings in the way the consultation was conducted. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• The doctor involved should reflect on the complaint and our findings in their next appraisal.
• The board should consider a neurology referral in light of our findings.
• Sufficient time/input from experienced clinicians should be accomodated for consultations anticipated to be complex.