Some upheld, recommendations

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.

Summary

Mrs C complained about the care and treatment that was provided to her late father (Mr A) by the practice on two occasions. Mr A was initially suffering with urinary problems and later, with symptoms of heart failure. Mrs C was concerned that there had been a failure to identify urinary retention as the cause of his symptoms and that, when he was seen by a GP registrar (trainee GP), a few months later, they attributed a seizure-like episode to medication changes, when he was actually suffering from aspiration pneumonia (a complication of pulmonary aspiration. Pulmonary aspiration is when you inhale food, stomach acid, or saliva into your lungs).

We took independent advice from a GP. We found that there had been no unreasonable failure to diagnose urinary retention and that Mr A's symptoms were more consistent with urinary infection when he was seen by the practice. Therefore, we did not uphold this aspect of Mrs C's complaint.

We found that, when Mr A was seen by the GP registrar, the relevant guidance for diagnosis of heart failure had not been followed. We found that it was not possible to rule out the medication changes as a cause of the seizure-like episode and there was no indication in the medical records that Mr A was suffering from aspiration pneumonia at the time he was seen by the GP registrar. We upheld this aspect of Mrs C's complaint as the issue around diagnosis of heart failure had not been identified as a training issue for the GP registrar.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in the management of Mr A's suspected heart failure. 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:

• Suspected heart failure should be managed in line with national guidance. Where this is not considered appropriate, a clear rationale for alternative action should be recorded.
• Issues with care and treatment provided by GP registrars should be taken forwards as part of the training process. Clear information should be available on a daily basis so GP registrars know who to approach for help and supervision.

Summary

Mrs C complained about a delay in diagnosing her child's (Child A) kidney condition. Mrs C was concerned that despite several years of symptoms, appropriate investigations to diagnose Child A's condition had not been carried out and that this had resulted in loss of kidney function. Mrs C also considered that the issue could have been identified on an antenatal scan. Mrs C complained to the board but was unhappy with their response to her complaint.

We took independent advice from a consultant paediatrician (a doctor who specialises in child medicine). We found that Child A's condition would now likely be identified during antenatal anomaly scanning but that at the time of Mrs C's pregnancy, there was no requirement for this type of scan to be carried out. We did not find that the diagnosis had been unreasonably missed. We noted that the board had already reflected on this case and now have a lower threshold for referring children for scans where they report pain moving towards the back. We did not uphold this aspect of Mrs C's complaint.

In relation the board's handling of Mrs C's complaint, we found that the board had not addressed her comments about the potential for diagnosing Child A's kidney condition during an antenatal scan. Therefore, 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 not addressing the issues raised about prenatal diagnosis in the complaint investigation or explaining why it was not considered reasonable to do so. The apology should meet the standard set out in the SPSO guidelines on apology available at: www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Issues raised in complaints should be addressed or an explanation provided as to why it is not considered reasonable to do so.

Summary

Ms C complained about a delay in the results of a magnetic resonance imaging (MRI) scan being reported which showed that a small pancreatic tumour, which was being monitored, had grown in size. Ms C also complained that when a computerised tomography scan (CT - a scan which uses x-rays and a computer to create detailed images of the inside of the body) was carried out around four months later, there was a failure to identify a breast lump.

We took independent advice from a consultant radiologist (a doctor who specialises in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans) and a consultant in acute medicine. We considered that there was an unreasonable delay in the MRI scan being reported which would have impacted on the time taken to carry out further investigation of the pancreatic tumour. We upheld this aspect of Ms C's complaint and noted that the board were taking steps to address the delays in the service. We also recommended further action to be taken.

In relation to the CT scan, we found the actions of the board to be reasonable. The scan was intended to concentrate on Ms C's pancreas and liver rather than a general look for cancer anywhere. We found that it was reasonable that every organ was not examined in great detail given Ms C did not have concerning symptoms. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Patients receiving MRI scans should have them reported within a reasonable time frame.

Summary

Ms C complained about the care and treatment her partner (Mr A) received during his admission to Queen Elizabeth University Hospital. After Mr A had been discharged he became unwell and was readmitted the following day. On the day of Mr A's readmission he was transferred to another hospital for specialist care where he died two days later.

Ms C raised concerns about the administration of an iron infusion which led to Mr  A receiving an overdose of iron. Ms C questioned whether this may have contributed to Mr A's death and wondered if a blood transfusion would have been a more appropriate treatment. Ms C also questioned Mr A's discharge and whether, if he had been in hospital rather than at home when he became unwell, this would have affected his outcome.

The board had acknowledged that although the total dose of iron calculated for Mr A was accurate, he received a dose of iron higher that the recommended dose for a single infusion. They said that Mr A was monitored appropriately in case of an infusion reaction and his observations were stable on his discharge. The board also acknowledged there was an error in Mr A's medication on his discharge.

We took independent advice from a consultant in acute medicine. We found that all appropriate investigations and interventions were undertaken and it was reasonable to have discharged Mr A with the follow-up plans the board had set out. We also noted that Mr A was well enough for these to be arranged on an out-patient basis.

In relation to the iron infusion, we found that it was reasonable to have given this to Mr A to treat his anaemia and that this was more appropriate than a blood transfusion. While we could not exclude it absolutely, we considered that there was no evidence to suggest that the larger dose of iron that Mr A received had contributed to his death. We noted that Mr A's' sudden deterioration appeared to have been due to a rare cardiac problem that was unpredictable. However, Mr A did receive an overdose of iron and there was an error in his medication on discharge. Therefore, we upheld this aspect of Ms C's complaint and asked the board to provide evidence of action they said they had taken.

Ms C also complained about the nursing care Mr A received. We took independent advice from a nursing adviser. We found that the nursing care was reasonable and appropriate. Therefore, we did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C and her family for Mr A having received too high a dose of intravenous iron and the error in Mr A's medication on his discharge. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C attended Queen Elizabeth University Hospital for a hernia repair operation (an operation to correct a hernia, which is a bulging of internal organs or tissues through the wall that contains them) but complained that he was not properly advised of the risks. After the surgery Mr C suffered from significant bleeding and swelling and was discharged from hospital nine days after the operation. Mr  C returned a week later as he had to be readmitted for his wound to be cleaned and re-stitched. Mr C complained that both the medical and nursing care he received was unreasonable and that the board's communication with him was unreasonable.

We took independent advice from a consultant general and colorectal surgeon (colorectal surgey is the branch of surgery which deals with repairing the damage caused by disorders of the rectum, anus and colon) and from a registered nurse. We found that Mr C had signed a consent form which detailed the possible risks of surgery and did not uphold this aspect of Mr C's complaint.

In relation to the medical care received, we found that there had not been consultant involvement in Mr C's discharge and that he should have been followed-up afterwards given his significant complications. Therefore, we upheld this aspect of Mr C's complaint.

We found that Mr C's nursing care had been reasonable and that their records were clear and detailed. We did not uphold this aspect of Mr C's complaint.

Finally, we found that there was little documentation of an explanation for Mr C's complications, of the treatment options available and what he could expect. There was also no indication that Mr C had been provided with reasonable reassurance at a time when he was suffering understandable anxiety. We considered that communication with Mr C was unreasonable and 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 give proper consideration to his complications after surgery. 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:

• Where significant complications develop, patients should be offered an explanation and this should be documented.
• When significant complications develop after hernia surgery, an appropriate consultant should be involved in the decision to discharge and a follow-up appointment should be made.