Some upheld, recommendations

Summary

Mrs C complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's late father (Mr A). Mr A suffered from heart problems and had a history of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) and a previous stroke. Over a period of about 18 months he had several hospital admissions and underwent two cardiac catheterisation procedures (where a tube is inserted into a blood vessel near the heart, to look at the condition of the blood vessels and/or insert a stent to widen them), but no stent was inserted. Doctors then referred Mr A for consideration of coronary bypass surgery (surgery to bypass a section of existing blood vessel that is narrowed with a graft). However, while he was waiting for review, Mr A suffered a further stroke and heart attack, and he died in hospital a few weeks after this. Mr A's family felt he should have been offered surgery earlier. They also raised concerns about the medical and nursing care during his admissions, and the board's response to their complaint.

The board considered the medical care and communication was reasonable. However, they agreed there were some failings in the nursing care for Mr A's pressure ulcers and they apologised for this and took action to prevent a recurrence.

We took independent medical, cardiology and nursing advice. We found that the overall management of Mr A's heart problems was reasonable, and it was appropriate that surgery was not offered earlier as this would have been a very high risk for Mr A (in view of his pre-existing conditions). We did not uphold this aspect of Mrs C's complaint. However, we found that there was no evidence Mr  A or his family were told about Mr A's heart attack for several days, and we made a recommendation in light of this finding.

We upheld the complaint about nursing care, as we found failings in relation to fluid monitoring, pressure ulcers, falls monitoring and communication with the family about Mr A's palliative care.

We also upheld the complaint about complaints handling, as there were errors in the board's complaint response, which appeared to be due to the medical records being misread.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A's family for the delay in informing them about the heart attack, the failings in nursing care and communication, and the errors in the complaint 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:

• Patients and/or family should be promptly updated about significant events, such as a heart attack, and a record made of the communication.
• Good palliative care should ensure a comfortable and peaceful time for the patients, with support for relevant others and person-centred communication.
• There should be clear handover communication between staff, to ensure all staff are aware of a patient's needs.
• Fluid balance charts should be completed for patients requiring fluid restriction.

In relation to complaints handling, we recommended:

• Complaint investigations should involve a careful and thorough review of the medical records, having particular regard to the points of complaint raised.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Mr A). He said that the board had failed to provide Mr A with reasonable care and treatment in Monklands Hospital. We took independent advice from a general medical adviser, a nursing adviser and from a consultant orthopaedic and trauma surgeon.

Firstly, Mr C complained that the board had unreasonably discharged Mr A with a bacterial infection and that he then had to be readmitted to hospital. We found that Mr A's discharge had been reasonable, as his symptoms appeared to be acceptably controlled at that time on oral medication; he had been appropriately reviewed; and no concerns about his discharge were raised. The blood tests results showing the infection did not become available until after he was discharged. We did not uphold this complaint.

Mr C also complained that staff failed to prevent Mr A falling on two occasions when he was readmitted to hospital. We found that there had been a failure to complete and document a falls risk assessment when Mr A was admitted in line with standards of care for older people in hospital. There was also a failure to document communication with the family. We upheld this complaint.

Mr A also complained that staff delayed in obtaining an X-ray after Mr A's falls. We found that an X-ray had not been clinically indicated after the first fall. An X- ray was then obtained after the second fall. On balance, we did not uphold this complaint.

Mr C also complained that staff had given Mr A too much morphine (a medication for pain relief). We found that the approach to this and the doses prescribed had been reasonable. We did not uphold this complaint.

Mr C also complained that staff failed to follow-up Mr A's care after his discharge from hospital. We found that, although an interim discharge letter was issued, a follow-up discharge summary was not issued. There was also insufficient information about how Mr A's hypertension (abnormally high blood pressure) was to be followed up. We upheld this complaint.

Finally, Mr C complained that the board had unreasonably prescribed an antiepileptic drug to Mr A beyond the maximum of ten years. There is no guidance that states it should not be prescribed for more than ten years and there was no clear evidence that this had caused Mr A's health problems. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the failure to complete an appropriate risk assessment to prevent falls when he was admitted to hospital and to appropriately document communication with Mr A's family. 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:

• Risk assessment and care planning in relation to falls prevention should be carried out in line with guidance and policy, when the patient is admitted to hospital.
• Nursing staff should involve patients and families in care planning where appropriate and should keep clear records of conversations with families/carers using the relevant documents.

Summary

Ms C complained about the treatment which she received at Peterhead Hospital and Aberdeen Royal Infirmary. Ms C had been treated for heart issues although she had not been reviewed by a cardiologist (a doctor who specialises in disorders of the heart). Ms C was subsequently admitted to hospital on two occasions where the medication for her heart issues was continued. Ms C sought a private opinion which found that she did not have a heart problem and her medication was withdrawn. As a result of the medication withdrawal, Ms C's health improved. Ms C complained that she was unreasonably prescribed heart medication and that this medication was not kept under regular review.

We took independent advice from a consultant cardiologist. We found that it was appropriate for Ms C to have been treated for suspected angina (chest pains) in view of her presenting symptoms. We considered the prescription of heart medication to be appropriate and did not uphold this aspect of Ms C's complaint.

However, there was a failure to keep Ms C under review pending the outcome of further out-patient cardiology investigations which may have identified that she was suffering from potential side effects of the medication. There was an incident on discharge from hospital that Ms C had been prescribed two calcium channel blockers (medication to relax and widen the blood vessels) which was inappropriate, although it was unlikely that harm was caused due to the low dosages involved. We also found that there were failings in record-keeping regarding discussions with cardiology staff and that it would have been advisable that Ms C should have been physically examined by a consultant cardiologist. We considered that the board failed to keep Ms C's medication under review and upheld this aspect of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failure to keep her under review pending the outcome of further out-patient cardiology investigations. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Apologise to Ms C for the failure to recognise that she had been discharged from hospital while on two types of calcium channel blocking medication. 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:

• Staff should be aware to keep patients under review pending the outcome of further out-patient cardiology investigations.
• Pharmacy and ward staff should be aware that when patients are discharged from hospital that their medication is appropriate.

Summary

Mr C complained on behalf of his late grandmother (Mrs A) about the care and treatment she received at Aberdeen Royal Infirmary (ARI) and Kincardine Community Hospital (KCH).

Mrs A suffered from severe pain in her back and a suspected chest infection. She was referred by her GP to ARI, discharged on day five and then re-admitted to KCH ten days later. Mrs A was transferred back to ARI over a month later, and then back to KCH, where she later died.

Mr C complained that the board failed to provide a reasonable standard of medical care and treatment, failed to provide a reasonable standard of nursing care and failed to handle his complaint appropriately.

Regarding medical care, Mr C complained about Mrs A's pain management and a lack of communication around her treatment. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). We found that Mrs A did not receive sufficient attention for her pain relief requirements. We found that this was an issue that could have been easily avoided, and one that caused Mrs A pain and the need for readmission. We also found that there was a lack of consideration for Mrs A's decision-making capacity regarding an operation that she underwent, and that there was a failure to discuss her care with Mr C and the family at this time. We upheld this aspect of the complaint.

With regards to nursing care, we took independent advice from a nursing adviser. We found that, while the communication did not meet Mr C's family's needs for specific periods of time, there was no evidence in the nursing records to indicate that the overall level of nursing care Mrs A received was unreasonable. We did not uphold this part of the complaint.

Lastly, regarding the board's handling of Mr C's complaint, we found that the board had apologised to Mr C for a delay in handling his complaint. However, we were concerned that, having given Mr C a revised timescale for providing a response, this was not then met and the board were not proactive about keeping him advised about the subsequent process of his complaint. We were also concerned that the complaint response appeared to be incomplete and did not address all of the questions Mr C raised. 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 his family for the failure to provide Mrs A with sufficient attention for her pain relief and for the failure to adequately communicate with Mr C and his family about Mrs A's pain and its management. 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' pain relief needs should be fully assessed at the time of discharge from hospital. The management of a patient's pain after discharge should be fully discussed with patients and their families.
• Where a patient lacks decision-making capacity, their mental health should be respected and their care discussed with their family.

In relation to complaints handling, we recommended:

• Communication about revised complaint response timescales should be accurate and further contact should be made if it emerges that the revised timescale is not achievable. Responses to complaints should be accurate and address all the issues raised.

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A) by the urology service (the service which deals with the male and female urinary-tract system and the male reproductive organs) at Victoria Hospital. Mr  A had a diagnosis of metastatic prostate cancer (prostate cancer that had spread to his bones) and had been reviewed roughly every three months by prostate cancer nurse specialists. Mr A received hormone therapy injections and his PSA (prostate specific antigen - a protein produced by normal cells in the prostate and also by prostate cancer cells) levels were measured to monitor his disease.

Over two years following his diagnosis, Mr A experienced back pain and he had a number of consultations with his GP. After Mr A's condition did not improve, the GP made a referral to the urology service to request urgent investigation. The urology service received the referral one day later and then made a referral to the radiology department to request a scan. A week passed following the initial GP referral, and by this time Mr A was struggling to move. Mr A was then admitted to hospital and a scan was performed. This indicated that he had a spinal fracture and cord compression from metastatic cancer. As a result of his condition, Mr A became paralysed below the waist.

Mrs C complained that the urology service did not carry out scans following Mr  A's diagnosis, even though it was known that the cancer had already spread to his bones. 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 oncologist (a doctor who specialises in cancer). We found that it was reasonable for the board to monitor Mr A's prostate cancer using PSA testing and not with routine scans. We did not uphold this complaint. However, we noted that the board had failed to respond to this part of Mrs C's complaint and had not handled a request for a meeting about this appropriately.

Mrs C also complained that there was an unreasonable delay in arranging a scan when Mr A's condition began to deteriorate. The board acknowledged that there were issues with how the urology service made the referral for a scan and also how it was handled by the radiology department. The board provided us with details of a process improvement that aimed to help avoid delays in future. However, we found that the referral from the urology service was made using the incorrect pathway. We concluded that the Malignant Spinal Cord Compression Pathway should have been used, which would have resulted in a scan within 24 hours of the referral. We concluded that if this had happened, Mr A would have had an improved chance of receiving treatment to maintain mobility. We informed the board of this finding and asked them to consider what action would effectively reduce the chance of the issue reoccurring. We upheld this complaint and made a recommendation. We also asked for evidence of the actions the board had already said they were taking or planned to take.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the delay in arranging a scan when Mr A's condition deteriorated; not fully responding to all the points Mrs C raised in her complaint; and not responding to Mrs C's request for a meeting appropriately.The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

Summary

Mr C complained about the care and treatment provided to him during two admissions at Dumfries and Galloway Royal Infirmary.

Mr C had Hodgkin's Lymphoma (a cancer of the lymphatic system, which is part of the immune system). Mr C complained that he should not have been discharged after he felt unwell during an admission for a blood transfusion. We took independent advice from a consultant haematologist (a doctor who specialises in blood). We found that the follow-up arrangements made prior to discharge were unreasonable. We, therefore, upheld this part of Mr C's complaint.

During a subsequent admission, Mr C experienced a build-up of fluid in the lining of his lungs. He complained that there was a delay in carrying out a procedure to drain the fluid. We found that medical staff appropriately monitored whether a drain was needed to improve Mr C's symptoms and we did not consider that there was an unreasonable delay. We did not uphold this aspect of the complaint.

Mr C also experienced a build-up of fluid around his heart which required a procedure (pericardiocentesis) to drain the fluid. Mr C complained that the two attempts to carry out this procedure were not of a reasonable standard. We found that the first attempt was halted after Mr C became uncomfortable. The second attempt was stopped after concern was raised that Mr C's heart was damaged. Mr C was then transferred for emergency assessment, where the procedure was carried out successfully and no significant damage to Mr C's heart was identified.

We took independent advice on this from a consultant cardiologist (a doctor who specialises in the heart and blood vessels). We found that the first attempt at pericardiocentesis was not performed to a reasonable standard and was not documented adequately. However, we found that the board had carried out an internal investigation and that the operator involved had since reflected on what had happened and identified learning points. Despite the complication, we were not critical of the second attempt at the procedure as we found that staff took appropriate action once it was apparent that Mr C's heart had potentially sustained damage. On balance, we upheld this aspect of the complaint.

Lastly, Mr C complained about the level of communication with him during his second admission. We found that haematology staff did not update Mr C about the overall picture frequently enough, which may have added to his anxiety about his situation. We noted that Mr C had not been informed of the small risk of death prior to the attempts at pericardiocentesis. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that they did not make sufficient follow-up arrangements prior to discharge; did not adequately explain the risks of pericardiocentesis; and did not communicate with Mr C frequently enough during his second admission. 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 be aware of what to do if they become unwell after discharge and how to contact the haematology department for advice. Patients with low blood cell count should be carefully monitored for changes in blood cell count.
• The approach and technique used in invasive procedures should be adequately documented in a patient's clinical records.
• Patients should be fully informed of the recognised risks, including death, as part of the consenting process prior to performing pericardiocentesis.
• Patients should receive the information they want or need to know in a way they can understand.

Summary

Mr C complained about the council's handling of a planning application. In particular that the council had failed to consider their waterside development policy (policy Des 9), had failed to consult with the Scottish Environment Protection Agency (SEPA) and had unreasonably accepted that works for the planning application were initiated on time. Mr C also complained about the council's communication with him.

We took independent planning advice. We found that that policy Des 9 should have been referred to in the report of handling (a report containing information on a planning application). It was not possible to know whether this policy had been taken into consideration during the processing of the planning application, as was required. We also found that it was not possible to say whether consideration of policy Des 9 would have resulted in a different outcome. We upheld this aspect of the complaint.

We also found that SEPA should have been consulted and we upheld this aspect of the complaint.

We did not find any evidence that the council had unreasonably accepted that works for the planning application were initiated on time and we did not uphold this part of the complaint.

Regarding communication, we found that some of the issues raised by Mr C had been not been adequately addressed, however, other issues raised by him had been reasonably clarified. We were concerned that a further response letter had had to be issued to Mr C. The council had accepted that there had been a delay in responding and that Mr C should not have had to submit a formal complaint to prompt a full response to his enquiries. We upheld this aspect of the complaint.

Recommendations

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

• Development plan policies relevant to the processing of any particular application should be referenced in the report of handling.
• Where a statutory consultation appears to be required as part of the processing of a planning application, but has not taken place, this should be explained in the report of handling.

Summary

Mr C raised a number of concerns about the council's handling of his planning application.

Firstly, he complained that the council granted and then withdrew planning permission. The council had acknowledged that they had made an error when issuing his listed building consent, by using the template for planning consent rather than the correct listed buildings consent template. They were of the view that this was an administrative error and that, as such, the planning consent had not been legally granted. We were critical that the council had issued a decision on the wrong template, and we highlighted to the council that this could give the impression that plannng consent had been granted. As a result of this failure, and the failure to promptly and clearly clarify why the mistake was made and what would be done to correct the error, we upheld this aspect of the complaint.

Secondly, Mr C raised concern that the council unreasonably disputed that his planning application included an access through a wall into a council car park. We took independent planning advice and concluded that the council had not disputed that access arrangements were included in the application. We did not uphold this aspect of the complaint.

Lastly, Mr C complained that the council unreasonably withdrew permission for him to form the access in the wall, despite having granted others access. He said that the council failed to take account of information he provided them with, which he considers proves his right of access. We were satisfied that the council had taken Mr C's evidence into account. Who has title or right of access is not something that we can determine, and this issue would need to be pursued through legal channels. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Write to Mr C to apologise for failing to promptly notice the error regarding the template, which gave the impression that planning consent had been granted. Also apologise for failing to provide Mr C with a reasonable explanation for what happened, and why, and for failing to provide an appropriate apology for their errors at that time. 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 public should be confident that when a formal notice is issued by the council, the notice is correct and can be relied upon. Any incorrectly issued notices should be identified promptly and steps should be taken to put right any errors, an investigation should be carried out in order to identify why the errors occurred and steps should be taken to ensure that the errors will not re-occur.

Summary

Mr and Mrs C complained that the ambulance service delayed in sending an ambulance after Mr C suffered multiple fractures in an accident at his home. They also complained that there was a further delay in sending an ambulance when his local hospital asked the ambulance service to transfer him to a major trauma centre. Mr C subsequently developed fat embolism syndrome (a life-threatening condition where fat particles within the bone are released into the bloodstream) and went into a coma. He considers that this was at least partly due to the ambulance service's delay in sending ambulances to both his home and his local hospital.

We took independent advice from a paramedic. We found that a dispatcher in the ambulance control centre had failed to identify a paramedic crewed ambulance that was available at the time of Mr C's 999 call. This had caused an unreasonable delay by the ambulance service in sending an ambulance to Mr C's home. In view of this, we upheld this aspect of Mr and Mrs C's complaint, although we acknowledged that the ambulance service had already apologised for this and had taken some action to try to prevent this happening again.

We found that the delay by the ambulance service in sending an ambulance to transfer Mr C from his local hospital to a major trauma centre had not been unreasonable. Mr C was in a place of safety and could have been upgraded to an emergency by the hospital at any time. We did not uphold this aspect of Mr  and Mrs C's complaint. However, we considered that the communication between the ambulance service and clinicians in the hospital could have been better and we provided some feedback to the ambulance service in relation to this. We also provided some feedback to the ambulance service on trauma care and the documentation of this.

Recommendations

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

• Dispatchers should be able to identify available resources and, where appropriate, ensure that these are dispatched promptly.

Summary

Mr C complained about a Do Not Attempt Cardiopulmonary Resuscitation decision (DNACPR - a decision taken that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops) taken when his mother (Mrs A) was a patient in Ninewells Hospital where she was being treated for heart failure. Mr C held Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) in relation to his mother. He had been told of the decision in a public place, without being consulted. The doctor who spoke to him said he had spoken to Mrs A, who agreed with the decision. Mr C said his mother was very confused and unable to consent to this. Mr C complained that he had not had his views taken into account in relation to the DNACPR decision despite having POA and that the board unreasonably spoke to Mrs A and gained her consent despite her lacking capacity to give consent at the time.

We took independent advice from a doctor with specialism in acute and general medicine. We found that it was inappropriate to have a discussion with Mr C about the decision in such a public setting, however, we found that the board had acknowledged and apologised for this. We noted that where a patient has granted a POA, the attorney should be involved in the decision wherever possible, with the patient as well if appropriate. However, if cardiopulmonary resuscitation (CPR - where the heart and/or breathing is re-started if it stops) is unlikely to be successful, healthcare staff are under no obligation to attempt CPR. The adviser considered that Mr C should have been involved in the discussions earlier, but ultimately it was the clinical team's decision to make. We did not uphold this aspect of Mr C's complaint.

In relation to gaining Mrs A's consent, we found that the board acknowledged that a discussion had taken place and, given it was recorded that she was confused at this time, they noted it would have been appropriate for a mental capacity assessment to have taken place. We acknowledged that assessing Mrs A's mental capacity was not the priority at the time the decision was taken as she was acutely unwell. However, the fact she was confused should have prompted an assessment of her capacity. We were also concerned that the board did not obtain a copy of the POA document. 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 and Mrs A for failing to assess Mrs A's capacity and for failing to obtain a copy of the POA document. The apology should meet the standards set out in the SPSO's Guidance on Apology at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Staff should have a working knowledge of Adults with Incapacity legislation insofar as it applies to consent issues. Staff should be clear about the importance of Adults with Incapacity documentation.