Some upheld, recommendations

Summary

C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder injuries.

The board’s response highlighted several areas for improvement. Firstly, there should have been a referral for A’s wounds, with more robust documentation. Staff training has been conducted to address these issues. Secondly, A fell twice in the ward, prompting a thorough medical review after each fall. Staff training regarding falls has been provided. Thirdly, although A was on regular pain medication, there should have been a pain recording chart in place. Staff will receive training on this aspect. Lastly, A’s hip dislocation likely stemmed from their stroke rather than a fall, with no evidence of shoulder dislocation occurring the ward.

C was dissatisfied with the board’s response and brought their complaint to us. We took independent advice from a nurse with a speciality in wound care and a consultant geriatrician (a specialist in medicine of the elderly). We found that staff failed to follow the board’s policy on wound management. We also found that whilst the medical care of A’s falls was reasonable, the nursing documentation about A’s falls was unreasonable, because documentation was incomplete and at times inaccurate. A’s care plan was also poor, making it difficult to manage A’s pain, and there was a delay in A receiving a medical review over the weekend. Therefore, we upheld these parts of C’s complaint. We found that the board’s explanation of A’s injuries was reasonable. We did not uphold this part of C’s complaint.

We also found that the board’s complaint response did not provide C with a timely, full and informed response to their complaints about the board’s management of A’s wounds and falls. Therefore, we made an additional recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures in A’s care. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

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

• Nursing staff should be competent in the accurate completion of falls documentation.
• Patients should receive appropriate pain management including regular structured assessment of their pain, e.g. through the use of a structured pain assessment tool or chart. This should be documented. Patients should receive appropriate medical review on escalation, and reviews should be carried out promptly.
• Patients should receive care as required and prescribed in care rounding bundles. Those requiring wound care should be appropriately managed in line with local and national guidance on wound management. This should be appropriately documented.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; timely; and that failings and good practice are identified.

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

C is an advocate for and representative of A. C complained that a social worker acting on behalf of the council failed to timeously apply for state benefits on A’s behalf despite providing an undertaking to do so. C complained that this failure lead to a loss of income for A resulting in rent and council tax arrears and that the council subsequently sought direct deductions from A’s state benefits to pay for these council tax and rent arrears. C further complained that the council failed to adequately communicate with A and their representatives. Finally, C complained that the council failed to adequately investigate or respond to the complaint. The council did not consider that there was any failure to apply for and manage A’s state benefits.

Upon investigation, we found that there was an appointment of a social worker to undertake the application for state benefits on A's behalf. However, we found that there was a delay by the council in submitting an appointee application form. We found that A experienced an actual loss of income as a result. We also found that the council unreasonably sought direct deductions from A’s state benefits for council tax and rent arrears caused by these delays. We therefore upheld these aspects of the complaint.

Whilst we did not uphold the aspect of C’s complaint that the council failed to communicate adequately with A, we found that the council failed to adequately investigate and respond to their complaint. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the delay in progressing A’s application for state benefits and for unreasonably seeking direct deductions from their state benefits to recover rent and council tax arrears. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Either; 1. calculate the amount of Universal Credit (considering each component allowance) and council tax reduction that A lost out on due to their delays and reimburse A for any shortfall of Universal Credit, rent and council tax reduction (taking into account of the discretionary housing payment already made). Or 2. agree a settlement payment with A through their representative C.

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

• Where the council undertakes to apply for benefits on behalf of an individual, this should be progressed promptly in order to ensure that entitlement to benefit is not lost. Deductions from benefits should not normally be sought when arrears have been caused by the council’s inaction.

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

C complained to the council about the way that their child’s school had responded to an incident of bullying in the playground. C also complained about the way this matter had been communicated to them as a parent of some of the children involved.

We found that the council had responded to the incident in keeping with their policies and procedures and we did not uphold this part of C’s complaint.

In relation to the school's communication with C about the incident, we found that there were inconsistencies within the councils own records about the point at which they became aware of C’s child being involved in the incident, and in relation to the school’s position on whether or not there was an area of the playground that was known to be difficult to supervise. Given the discrepancies within the council’s records, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the complaint response about the playground incident was not supported by the evidence/ the school’s documentation of the incident. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate and supported by the evidence. Comments on complaints provided to the SPSO should be consistent with the documentation of the incident being investigated.
• Complaint responses should be accurate and supported by the evidence.

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

C complained about the standard of care and treatment provided to their parent (A) whilst A was in hospital. C's concerns covered A’s medical care, nursing care and physiotherapy care.

C said that A’s myeloma (blood cancer) treatment was delayed by a failure to provide the specialists treating A with blood samples for analysis. Additionally, A was not given an infusion correctly, as nursing staff failed to give A intravenous fluids first to ensure A was hydrated. C felt A’s pain relief was inappropriately managed, with A’s medication being unnecessarily reduced, resulting in A suffering significant and avoidable pain. C also believed that A was injured during a physiotherapy session and that this contributed to A’s decline.

We took independent advice from a registered nurse, a consultant haematologist (specialist in the the diagnosis and treatment of patients who have disorders of the blood and bone marrow) and a chartered physiotherapist. We found that nursing staff had not followed written instructions for the administration of A’s treatment, and A’s records showed that they had consumed only around 15% of the food and water that they should have in the period leading up to the infusion treatment. Nursing staff could not therefore have ascertained that A was properly hydrated. Nursing staff did not appear to have taken all the requested blood samples from A, and they had not taken steps to address A’s pain management. Therefore, we upheld this part of C's complaint.

In relation to A's medical care and treatment, we noted that their condition was progressing rapidly and that they had already had a number of treatments. The decision that A was not suitable for further treatment was not impacted by the missing blood sample and overall, we found that the medical care A received was reasonable. Therefore, we did not uphold this part of C's complaint.

In relation to A's physiotherapy care, we found that there was no evidence within the physiotherapy records that A had sustained an injury. Although there were some unexplained gaps in A’s physiotherapy records, it was clear that the decision to cease physiotherapy treatment was driven by the decision to designate A for palliative care only, rather than active treatment. Therefore, we did not uphold this part of C's complaint.

C also complained about the way that their complaint was handled. We found that the board’s complaint investigation had fallen below a reasonable standard. The evidence showing the failings in A’s nursing care should have been identified by the board’s own investigation. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable standard of nursing care and for failing to provide C with a reasonable response to their 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:

• Patients fluid and nutrition needs should be appropriately monitored. Where there is evidence that fluid and hydration needs are not being met, appropriate action should be taken.
• Patients’ level of pain should be reviewed and where the patient is unable to comply with the administration of pain relief orally, action should be taken to explore alternative means of medication delivery.
• Staff should ensure that written instructions by medical staff and, where appropriate, manufacturer’s guidance is followed when administering infusions and that, where appropriate, the patient is adequately hydrated.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring, and governance system should ensure that responses are accurate and reflect the information available in the clinical record.

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

C complained that the board failed to provide reasonable care and treatment to their sibling (A) after they were admitted to hospital. A had a cardiorespiratory arrest (the cessation of effective ventilation and circulation) in the hospital and suffered a brain injury as a result of this.

We took independent advice from a consultant in critical care. We found that the board had provided reasonable care and treatment to A and we did not uphold this aspect of the complaint.

C also complained that the adverse event review that the board subsequently carried out was unreasonable. In relation to this complaint, we found that the board had carried out a level 2 review when a level 1 review should have been carried out. The level 2 review had also been allocated to an inexperienced review team, it reviewed only part of A’s care journey, and it was short and poorly detailed. We also found that the record-keeping on the ward immediately before and after A’s cardiorespiratory arrest was limited and not of the standard expected. Detailed retrospective entries should have been completed shortly after these events occurred, by both medical and nursing staff. We therefore upheld this aspect of the complaint.

We also found that the board’s complaint handling of C’s complaint was unreasonable.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for causing confusion in their responses which related to the new structure that had been put in place. Apologise that part of the complaint handling process was uncoordinated and delayed and that they added to the stress and anxiety the family were feeling at that time. Finally, apologise that they failed to deal with C’s complaints in a timely or satisfactory manner. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C that a level 1 review should have been performed in place of the level 2 review and that the level 2 review that was performed was allocated to an inexperienced review team, it reviewed only part of A’s care journey and it was short and poorly detailed. 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:

• For a level 1 review to be carried out.
• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant medical and nursing standards.
• Before an adverse event review is carried out, the board should appropriately identify the review level, identify the terms of reference (part of the patient’s care journey to be reviewed) and allocate a suitable staff review team.

In relation to complaints handling, we recommended:

• The board should ensure all complaints are handled in line with the guidance set out in the NHS Model Complaint Handling Procedures, in particular, respond in writing and in a timely manner and address all issues raised that the board is responsible for.

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

C complained about the care and treatment that they received over a series of interactions with the practice. C believed that their symptoms had not been properly investigated. C subsequently suffered a stroke and felt that the outcome for them could have been better if they had been listened to when they contacted the practice. C also felt that the practice’s complaint handling had been unreasonable, failing to provide C with information that they were entitled to and incorrectly directing them to the local NHS Board as part of the complaints process.

We took independent advice from a GP adviser. We found that some of the assessments of C did fall below a reasonable standard, although it was not possible to conclude that the stroke could have been predicted or prevented. Therefore, we upheld and did not uphold aspects of these complaints around the assessment of C's symptoms over different periods. We also found that the handling of C’s complaint fell below a reasonable standard. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets

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

• Patients should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.

In relation to complaints handling, we recommended:

• The practice should provide clear information about their complaints process.

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

C complained about the care and treatment provided to their late parent (A) by the board. A was under the care of another board and investigations undertaken were suggestive of cancer in the bile drainage system, which was initially thought to be operable. A was referred to the board and admitted to hospital for a percutaneous transhepatic biliary drain (a procedure to drain bile to relieve pressure in the bile ducts caused by a blockage) and biliary biopsies. This was carried out and the three biopsies taken were sent back to the ward with A.

The duty consultant and the clinical nurse specialist met with A and relayed the findings of the multi-disciplinary team discussion the previous day. The specialist radiologists felt that there was a thickening of the lining of the abdomen that may suggest the disease had spread and that the nature of the tumour was unresectable. A check tubogram (a dye test to check whether the stent had opened up) indicated that the stent inserted had not fully drained the bile ducts and a second stent was inserted, with the external component of the biliary drain removed.

A was discharged shortly afterwards. At a multi-disciplinary team discussion less than two weeks later, it was highlighted that there were no biopsies currently in the pathology laboratory. Further investigation found that A’s biopsies had been disposed of. Four months on, A was made aware by the referring board that the biopsies had not reached the laboratory. A died after a short period.

We took independent advice from a general and colorectal surgeon. We found that whilst A had been given sufficient information regarding their care and treatment and the need for a biopsy, the board unreasonably lost biopsy samples and failed to inform A that they had been lost. We also found that the communication between departments, wards and with another board was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to C for the specific failings in communication with them, between departments and with another board. 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 treating hospital should ensure all outstanding results are reviewed and subsequent forward planning is done. The episode of care should not be viewed as complete until all results are reviewed rather than the discharge status.
• Biopsy samples should have the correct form, details of the responsible clinician on the form and should be sent from the originating area. There should be a process in place to correct errors in specimen direction.
• The treating clinician should be responsible (directly or delegated) for notifying a patient as soon as is reasonably possible regarding a biopsy loss.
• Investigation of a datix incident should be thorough and ensure appropriate and adequate learning from the events.
• There should be clear communication between departments and wards regarding planned procedures. Patients should be informed without delay of any cancellation, and where appropriate a prompt apology made to reduce distress.

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

C complained on behalf of their parent (A) who was suffering from dementia. A had been found in a neglected state by C’s sibling. A had vomited and it appeared that A had been left unattended overnight with no personal care. A’s incontinence pad had not been changed for what appeared to have been a significant period and was soaked in urine. C believed this failure in care led to A’s resulting aspiration pneumonia (inflammation that's caused by bacteria entering the lungs and causing a severe infection) which was the cause of their death. C also had concerns about other aspects of A’s nursing care including the frequency, quality and recording of care, A's skin care and the monitoring and recording of their vital signs. Lastly, C complained that their complaint had initially been designated a “concern” rather than a formal complaint.

We took independent advice from a nurse and a consultant geriatrician (a doctor specialising in medical care for the elderly). We found that there had been a failure to provide reasonable nursing care to A which had been acknowledged by the board. However, we found further issues with respect to ongoing risk assessment, skin care in relation to pressure ulcers, malnutrition screening and the implementation of person centred care planning. It was noted that there were difficulties in definitively assessing the standard of care delivered due to failures to adhere to Nursing and Midwifery Council record keeping standards. Therefore, we upheld this aspect of the complaint. Additionally, we found that unreasonable care had been provided with respect to pain relief. We upheld this aspect of the complaint.

We also found that the complaint had not been handled in line with the board’s complaints handling procedure. While there were areas for improvement, on balance, communication with the family had not been unreasonable and we did not uphold this aspect of the complaint. In relation to Cs complaint around the handling of their complaint, we found that the board failed to appropriately handle the complaint in line with their complaints handling procedures. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A’s family for the failings in nursing care. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to C and A’s family for the failure to increase A’s medication. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.

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

• Patients should receive the relevant assessments and care planning that reflects their needs. All relevant patient documentation should be completed and recorded in the nursing records in accordance with the NMC Code.
• Patients should be prescribed and receive appropriate palliative medications at all times.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints 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

C complained that when they developed complications in their pregnancy, the care that they received fell below a reasonable standard. C was six weeks pregnant and considered a high-risk pregnancy due to four previous caesarean section procedures, as well as surgery to reverse a previous sterilisation. C said that they were treated with a lack of empathy and courtesy by staff during scanning. C also complained that they were refused admission despite being known to be a high-risk pregnancy and despite developing vaginal bleeding. When C was admitted they believed that their surgery was unreasonably delayed, resulting in an avoidable rupture to their fallopian tube.

We took independent advice from both a registered nurse and a consultant obstetrician (the branch of medicine and surgery concerned with childbirth and midwifery). We found a number of failings on the part of the board. However, the board submitted new information, which included sections of C’s medical records which had not been provided previously. The board acknowledged that this was a failing on their part. We reviewed this information and determined that some of the original questions over the actions of the board were answered by this information. We upheld the complaint that the board failed to provide a reasonable standard of care during C's admission. In relation to C's complaint about being unreasonably refused admission, we found that C was treated reasonably and that the board demonstrated that their procedures were followed by staff. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. 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:

• A standard operating procedure (SOP) should be developed for the reporting of results in early pregnancy, so that the roles and responsibilities of those working in this area are clearly defined.
• Consideration should be given by the board to identifying appropriate communication training for healthcare workers in the early pregnancy unit.

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

C complained about the care and treatment that they received from the board. In particular, C complained that the board failed to adequately investigate their presenting symptoms of pain and nausea, or keep adequate medical records during an attendance at the Surgical Immediate Assessment Unit (SIAU).

Following their attendance, C wrote an account of their experience on Care Opinion (an independently operated platform for individuals to post comments about their care experiences). The board contacted C in response to their post asking that they write to them about their concerns. Despite doing so, C said that they did not receive a response from the board, and that they subsequently submitted a formal complaint through the board’s complaints handling procedure.

The board’s response to the complaint said that C had been assessed properly and that the clinical findings did not indicate that further investigation was required. The board acknowledged that C had not been seen by a senior clinician as planned, however, they noted that they had left the SIAU against advice before they were able to see C.

We took independent advice from a consultant general and colorectal surgeon. We found that C did not receive an adequate clinical examination. We found that the documentation of this encounter was unreasonable, noting that there was little information relating to the discussion which took place with a senior clinician, and no documentation of the worsening advice given to C. As C had already followed a 4-week plan by their GP to ‘watch and wait’ without any improvement in their symptoms, it was unreasonable to discharge C without undertaking or planning further investigation at this time. It was also noted that the emergency and final discharge letters from this attendance were not sent until several months after this attendance. We upheld this aspect of the complaint.

In relation to the board’s handling of C’s complaint, we noted that C had first posted a comment about their experience on Care Opinion. C later complained to the board directly when they did not receive a response, despite the board contacting them about their Care Opinion post. Once C had made a formal complaint via the board’s complaint process, we found that this had been timeously managed in keeping with the board’s complaint handling procedure. While we noted some factual inaccuracies in the board’s letter of response to C, we were otherwise satisfied that a reasonable investigation of the complaint had taken place. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in relation to the physical examination and assessment that they received at the SIAU, and in relation to the documentation of the episode of care. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.

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

• Medical records should clearly and accurately document consultations with patients, including where senior advice or guidance has been sought. Decisions regarding discharge and worsening advice should be documented. All entries should be signed and dated and, where appropriate, the record should identify the name of the person providing senior clinical advice.
• Patients should be offered a chaperone, and the decision should be documented in the medical record.
• Staff should introduce themselves to patients by name and grade.
• Patients should be assessed and examined appropriately in keeping with their presenting symptoms and relevant past medical history.

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.