Some upheld, recommendations

Summary

Ms C complained about the care and treatment she received at Queen Elizabeth University Hospital. Ms C attended a follow-up orthopaedic (the branch of medicine involving the musculoskeletal system) clinic at the hospital after hip surgery and explained she was experiencing discomfort in her ankle. She was found to have deep vein thrombosis (DVT, a blood clot in a vein) in her calf. However, other tests also showed that she may have secondary liver cancer. It was later found that she had primary breast cancer which had spread to her liver. Ms C complained about the way she was told about her diagnosis and that she was given inconsistent information about her illness. She also complained that her care was not appropriately personalised for her.

We took independent advice from consultants in acute medicine and clinical oncology (cancer treatment). We found that the doctor who told Ms C about her diagnosis had made a conscious decision to wait overnight before giving her the details because they wanted the opportunity to discuss the matter first with the breast cancer team. While we considered that this was a reasonable approach, when Ms C was told the following day, she was alone. This does not follow Scottish Cancer guidelines and Ms C appeared not to have been appropriately supported. Therefore, we upheld this aspect of Ms C's complaint. However, we did not find that Ms C had been given inconsistent information and we found that staff had adapted her care, as far as possible, to suit her needs. Therefore, we did not uphold these aspects of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to support her properly when giving her bad news. 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 adequately supported when being given bad news and discussions with patients/relatives should be fully documented in medical records.

Summary

Mr C complained about the clinical treatment he received at Inverclyde Royal Hospital. Specifically, that the treatment that he had to remove debris from his ear (known as microsuction) caused him to develop tinnitus (a ringing or buzzing noise in the ears) and that he should have had a hearing test before the treatment. Mr C also complained that questions which he raised at a follow-up clinic appointment were not fully responded to.

In response to the complaint, the board did not identify any failings in treatment or the communication that took place with Mr C about the questions he had raised at a follow-up appointment. The board also said that tinnitus is not a recognised complication of microsuction.

We took independent advice from a consultant ear, nose and throat surgeon. We found that the treatment Mr C received was of a reasonable standard and in accordance with ear care guidance issued by Health Improvement Scotland. In addition, we found that there was no requirement in terms of consent guidance issued by the General Medical Council to warn patients of the risk of tinnitus, as it is a less serious side effect that does not occur frequently with this type of procedure. We did not uphold this aspect of the complaint. However, we considered that tinnitus is a recognised risk of any noise or mechanical trauma to the ear and provided feedback to the board that they may wish to consider displaying a notice or providing a leaflet for patients in this respect.

Mr C should have received responses to the questions he had raised at his follow- up appointment. Therefore, we upheld this part of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not responding fully to the points he raised. 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:

• Full responses should be provided to patients regarding their care and treatment, either in writing or verbally, with documentation to demonstrate what was discussed.

Summary

Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of the surgery. Mr C complained that he had not been reasonably informed of all the recognised complications when consenting to his surgery. Mr C was also concerned that his surgery was not carried out properly, that he was discharged too soon from hospital after the inginual hernia repair, and that there was an unreasonable delay in receiving a review appointment following the operation to remove his testicle. The board apologised that they were unable to offer him a review appointment within the original planned timescale due to a high volume of patients and took action to address this problem. The board identified no other issues with Mr C's treatment. He was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant general surgeon. We considered that the board's handling of the consent process was below a reasonable standard. It was not clear to what extent the term testicular atrophy (shrinkage/wasting) was explained to Mr C at the time of his clinic appointment or whether he understood this, nor was any additional patient information on the procedure provided to Mr C for reflection at this time. In addition, the consent form Mr C signed was completed on the day of surgery instead of at the out- patient clinical consultation and it did not list the possible but rare risk of testicular complication. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the procedure, we considered that this was completed to a reasonable and appropriate standard. The adviser noted that the rare complication Mr C suffered was not a result of a failing in the surgery. However, we noted that the board incorrectly suggested in their response to Mr C's complaint that a consultant surgeon had performed the surgery when in fact they were supervising it to ensure the quality of the procedure. We did not uphold this aspect of Mr C's complaint but made a recommendation in light of this finding.

In relation to Mr C's discharge, we found no evidence to suggest that he was unreasonably discharged following the inguinal hernia repair. We did not uphold this aspect of Mr C's complaint.

Finally, we found that given the distressing complication Mr C experienced following his surgery, it was unreasonable for him to wait over 26 weeks to be reviewed following removal of his testicle rather than within the planned six to eight weeks. We upheld this aspect of Mr C's complaint but noted that the board had already taken action to address this issue.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in the consent process and the failure to provide accurate information in relation to who had performed the surgery. 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:

• Surgeons should complete the consent process in the pre-operative clinic; ensure the risks are clearly explained to the patient, checking that the patient understands the information and that this is documented; and ensure the patients take a copy of the consent form to enable reflection. Information for patients should be available concerning inguinal hernia repair in a separate booklet that details 'the risks inherent in the procedure, however small the possibility of their occurrence, side effects and complications'.

In relation to complaints handling, we recommended:

• The board should ensure transparent and open communication with patients. In particular, the board should ensure that patients are informed about who undertook their surgery.

Summary

Mrs C complained on behalf of her father-in-law (Mr A) about the care and treatment he received from Victoria Hospital and Glenrothes Hospital over a six  month admission period. Mrs C's concerns related to surgical treatment, nursing care, physiotherapy, speech and language therapy (SALT) and medical care.

We took independent advice from a general and colorectal surgeon (a surgeon who specialises in conditions in the colon, rectum or anus), two registered nurses and a consultant geriatrician (a doctor who specialises in medicine of the elderly). In relation to Mr A's surgical treatment, Mrs C felt that a perforated ulcer should have been identified at the time Mr A underwent an emergency operation. We found that it was reasonable that the perforated ulcer was not recognised at the time of the emergency surgery given a number of relevant factors. We did not uphold this aspect of Mrs C's complaint.

In relation to the nursing care, Mrs C was concerned that Mr A developed as significant pressure ulcer, monitoring of his fluid intake/output was poor and Parkinson's medication was not administered when it should have been. We found no evidence that administration of Mr A's Parkinson's medication was unreasonable. However, we found significant failings in relation to the prevention, monitoring and management of pressure ulcers and that fluid intake/output charts were not adequately completed. We upheld this aspect of Mrs C's complaint. However, we noted that the board had identified failings in regards to pressure ulcer damage and fluid monitoring and had taken steps to address these issues.

In relation to the physiotherapy treatment Mr A received, Mrs C was concerned that there was a lack of regular visits from the physiotherapist. We found that Mr  A received regular visits from physiotherapy staff and that their care was appropriate. We did not uphold this aspect of Mrs C's complaint.

Mrs C was also concerned that there was a lack of visits from SALT and a lack of effective communication with other staff regarding Mr A's altered diet. We found that review by SALT was sporadic and not carried out in a timely manner at either hospital. We considered that Mr A's risk of aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) would have been reduced had timely SALT review taken place. We upheld this aspect of Mrs C's complaint.

In relation to Mr A's medical care, Mrs C was concerned that communication about placing a do not attempt cardio-pulmonary resuscitation (DNACPR) mandate in place was inappropriate, Mr A's usual Parkinson's medication was not prescribed causing problems with his movement and interaction, and transfer arrangements were unreasonable. We found that the conversation which took place about DNACPR were appropriate and that the changes made to Mr A's Parkinsons medication was reasonable. We also found overall that the transfer arrangements were reasonable, however, we were critical that there was no evidence to show that a formal record of discharge was documented to support a thorough hand-over. We did not uphold Mrs C's complaint but made a recommendation to the board in light of this finding.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the delays in SALT review and follow-up. 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 carry out pressure ulcer prevention and management in accordance with national guidance.
• SALT should ensure patients with complex needs are seen within agreed timescales.
• Complex patients should have a careful and thorough hand-over documented.

Summary

Mr C complained about his care and treatment when he attended Crosshouse Hospital after experiencing stroke-like symptoms. Mr C was taken to the emergency department (ED) and was told he would be admitted to a ward but he was discharged a few hours later. Mr C suffered a seizure later that day and was returned to hospital by ambulance. He was admitted to the high dependency unit and kept in for two days for investigations. Mr C complained that it was not reasonable for staff to discharge him when he first attended. He was concerned he was not monitored frequently and that staff did not give him a clear explanation or diagnosis.

The board acknowledged that nurses should have recorded more frequent ward rounds and apologised for this. However, they explained that Mr C was also kept under observation via electronic monitors. The board considered that the medical care and treatment was reasonable. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a consultant in emergency medicine, a consultant in general medicine and a nurse. We found that Mr C was given prompt treatment for tonsillitis (inflammation of the tonsils) and suspected meningitis (infection of the coverings of the brain). We noted that this was investigated further but it was found that he did not have meningitis. Mr C was followed up by the neurology department (branch of medicine that deals with the anatomy, functions, and disorders of nerves and the nervous system) after his discharge and was diagnosed with hemiplegic migraine (a rare and serious type of migraine that has symptoms similar to those of a stroke). We considered that Mr C's medical care and the decision to discharge him was reasonable. We did not uphold these aspects of Mr C's complaint.

In relation to the nursing care Mr C received, we found that nurses had not clearly recorded what action was taken when he had a high National Early Warning Score (NEWS, an indicator of a patient's overall health) or why the plan had changed from admitting him to discharging him from the ED. 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 not repeating his observations before discharge and for the gaps in record-keeping. 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:

• Nurses should record what action is taken in response to an elevated NEWS and repeat the NEWS check before discharging the patient.
• Where a plan of care changes, the nursing records should show the reasoning behind this.

Summary

Mr C complained that the council failed to take enforcement action about a neighbour's replacement UPVC windows, which were a breach of planning control. He also complained that the council had failed to take action about the amenity of the same property, due to construction works at the property. Mr C was also unhappy with how his complaint was handled. In particular, he did not feel all the information he provided was fully considered by the council before they responded to his complaint.

The council said that the initial concerns raised about the replacement UPVC windows were not submitted through the appropriate enforcement complaint process. Therefore, they were not investigated as a breach of planning control at that time. The council said that they had investigated Mr C's concerns about the condition of the site but did not consider that there was a level of harm to amenity to justify taking formal action. Mr C was unhappy with this response and brought his complaint to us.

We took independent advice from a planning adviser. The planning adviser considered that the council should have investigated the replacement UPVC windows as a breach of planning control, even though it was not raised through their enforcement complaint process. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the amenity of the property, we found that the council had taken reasonable steps to investigate the complaint about the condition of the site and to assess the harm caused to amenity. Therefore, we did not uphold this aspect of Mr C's complaint.

Finally, we did not uphold Mr C's concern about the council's complaints handling, as we considered that they had taken reasonable steps to address his concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not investigating the breach of planning control.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:

• Allegations of a breach of planning control should always be properly recorded and investigated, in line with the relevant planning guidance.

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

Mrs C complained that she had been experiencing issues with the heating system in her home for a considerable length of time and that the actions taken by the housing association to resolve the situation were inadequate. Mrs C complained to the association on four occasions in a two year period as at times the heating system was not providing hot water or heating, or at other times was providing uncontrollable heat. The association responded within timescales to her reports of faults, however the repairs carried out did not resolve the issues. Mrs C's final complaint was escalated to senior management and the entire heating system was replaced. The association acknowledged that it had taken too long to fix the problem and upheld her complaint. Mrs C remained dissatisfied and brought her complaint to us.

Whilst we acknowledged that there were elements of the response to the faults that were outwith the association's control, we considered that the responsibility for managing the issues and co-ordinating a response ultimately lay with the association. We acknowledged that during the process the association had provided good customer service; providing an alternative heating supply, installing an electric shower, offering a good will payment and reimbursing Mrs C for her extra energy costs. However, on balance, we upheld this part of the complaint as we found that it had taken the association too long on the whole to fix the problem.

Mrs C also complained about the response she had received from the association to her complaints. We found that the association had provided a reasonable explanation regarding the actions taken to resolve the heating system issues, mitigated the financial impact of the problem and apologised to Mrs C. We did note that the association failed to signpost Mrs C to the next stage of the complaints process on a number of occassions. However, on balance, we did not uphold this part of Mrs C's complaint.

Recommendations

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

• Update their repairs policy to have a process for considering escalating repairs where issues have recurred three times or more.

In relation to complaints handling, we recommended:

• Provide information about how to escalate complaints at the end of every complaint response and stage.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C, who is an MSP, complained on behalf of his constituent (Ms B) about the support provided to her child (Child A). Child A had a number of developmental and behavioural disabilities and had attended mainstream education facilities while in primary school. However, shortly after their transition to secondary education, they started experiencing difficulties and stopped attending school. Ms B applied for self-directed support (SDS, a package that allows individuals to choose how they receive their social care and support) for Child A and an assessment took place. The SDS budget was approved but Ms A did not receive a payment for a considerable amount of time. Mr C complained about the time taken for the SDS assessment to be completed and payment to be made. He also complained about the general level of support provided by the partnership during the period that Child A was out of education.

We took independent advice from a social worker. We found that the time taken to carry out the assessment was significantly outwith the timeframe detailed in the partnership's best practice guide and we did not consider that they provided a reasonable explanation for why this happened. We also found that there appeared to be confusion about the role of the financial assessment within the SDS process and that this had caused unreasonable delays. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the general support provided by the partnership, we considered that their actions had been reasonable. The partnership acknowledged that more support would have been beneficial but explained that they could not have envisaged that Child A would have remained out of school for so long. We found that the actions carried out to support Ms B and try to get Child A back into education were reasonable based on the circumstances and available information at the time. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms B for the delay in carrying out the SDS process and releasing payment. 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:

• Reflect on the timescales detailed in the Best Practice Guide and review whether effective processes are in place to monitor whether these timescales are being met.
• Ensure that the role of the financial assessment within the SDS process is clearly understood by all relevant staff and applicants.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained that NHS National Services Scotland’s practitioner services division (PSD) had changed his Community Heath Index (CHI – a ten digit number that identifies a patient in the NHS in Scotland) number without his permission. PSD had given Mr C a new CHI number in order that his results from a national screening programme could be recorded on the relevant database. Mr C was unhappy with this and complained that he did not want to be part of the national screening programme. He asked that the new CHI number was deleted. PSD agreed to do this.

We found that, ideally, PSD should have discussed the matter with Mr C before they changed his CHI number. We also found that PSD had apologised to Mr C for any distress or upset that had been caused. However, Mr C’s complaint was that PSD unreasonably made changes to his CHI number without his permission. We found that PSD were not required to seek Mr C’s permission to make changes to the CHI number. Therefore, we did not uphold this complaint.

Mr C also complained that PSD had failed to ensure that correct information was applied to the new CHI number. He said that PSD had entered a previous GP practice on his record. However, the evidence that PSD sent us showed that the correct details had been recorded for Mr C. There was no evidence that incorrect information had been recorded and we did not uphold this aspect of his complaint.

Finally, Mr C complained that PSD’s response to his complaint had been inaccurate. We found that part of the response had been inaccurate and we upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that the response to his complaint included inaccurate information. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

Mr C complained on behalf of his late wife (Mrs A). Mrs A attended the Emergency Department (ED) at the Royal Infirmary of Edinburgh. When she attended she was unable to walk and required a wheelchair. Mr C said that Mrs A waited for nearly four hours before she was seen by a doctor, during which time her requests for pain relief were ignored. He complained that the care and treatment given to Mrs A in the ED was unreasonable. He also complained that the board gave incorrect or inaccurate information when they responded to his complaint about this.

We took independent advice from a consultant in emergency medicine. We found that in the ED Mrs A had been appropriately examined, that many aspects of her care were reasonable and that she was appropriately discharged. However, we found that she was not assessed, and reassessed, for her pain as she should have been. We found that she was given two paracetamol three hours after arriving, and then oral morphine an hour and a half later. However, we found that this delay was unreasonable and contrary to the Royal College of Emergency Medicine guidelines. We upheld this part of Mr C's complaint.

We found no evidence that the board had provided Mr C with incorrect or inaccurate information, and so we did not uphold this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C that Mrs A's pain was not promptly assessed/reassessed and for the delay in providing pain relief.

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

• The Royal College of Emergency Medicine guidelines (management of pain in adults 2014) should be implemented.

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.