Some upheld, recommendations

Summary

Mr C complained to the council, on behalf of his sister (Ms A), about the company that the council contracted to provide her care. Mr C said that they inappropriately charged her for Personal Protective Equipment (PPE) for staff, that they had failed to evidence that Ms A received a warm home discount each year and had unreasonably failed to calculate and refund costs associated with the use of Ms A's phone by staff. Mr C also complained that the council failed to provide a reasonable response to his enquiries. The council confirmed that a refund was being looked into regarding the PPE and that a refund had been issued for one year of phone bills, with five years in total to be assessed. This remained unresolved and Mr C brought his complaint to us.

The council advised a different care provider was contracted for the first two years of care. They did not have evidence of the phone bills or PPE for that period as the company in question has since ceased to exist. The council have since provided Ms A with a refund for three years for the PPE. They provided three years of phone bills but did not offer to issue a further refund in this regard. We considered that the council unreasonably failed to calculate and refund costs for the PPE and use of Ms A's phone by staff. We upheld these aspects of Mr C's complaint and asked the council to examine the full five years in question.

In relation to the warm home discount, the council were able to evidence that Ms A had correctly received this. We did not uphold this aspect of Mr C's complaint.

Finally, we considered that the council had failed to provide a reasonable response to Mr C's enquiries. We noted that the company providing care to Ms A delayed in their response to the council but considered that the delay in responding to his enquiries was unacceptable. 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 process the appropriate refunds for PPE and phone bills to Ms A; for failing to provide him with information in relation to this; and for the unacceptable delay in responding to his enquiries and complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• The organisation should calculate the PPE and phone bill refunds for five years, evidence this, and refund Ms A accordingly. If information is not available, the council should explain how any estimate has been determined.

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

• Evidence that there is a clear process in place when the council is seeking evidence from a contracted company to prevent future delays of this nature.

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

Miss C suffered ongoing complex urological problems (problems relating to the urinary tract, bladder or kidneys), and underwent a dilation and cystoscopy procedure (a procedure to look inside the bladder and stretch the urinary opening) at Ninewells Hospital. During the procedure biopsies (samples of tissue) were taken. Miss C complained about the medical and nursing care during this procedure, which she found very painful and distressing. Miss C also complained about her medical care following the procedure, and that it took several months for the board to refer on to a urological specialist in another board area after she requested this.

Medical and nursing staff met with Miss C to discuss her concerns. The board apologised for some aspects of the nursing care, and said the day-of-surgery admission pathway had not been suitable for Miss C, as it could not provide much of the support she required. Miss C was not satisfied with this response, and she brought her complaint to us.

We took independent advice from a consultant urologist and a nurse. We found that most of the medical care Miss C received was reasonable. However, the operation note was not sufficiently detailed to show why it was necessary to take biopsies, which caused Miss C post-operative pain. We upheld this aspect of Miss C's complaint.

In relation to the nursing care, we noted that the board had acknowledged certain aspects of care were staff could have acted differently and had taken action to discuss Miss C's concerns with staff. We considered these actions to be reasonable and found that the nursing care Miss C received was appropriate. We did not uphold this aspect of Miss C's complaint.

Finally, we found that there was a delay in referring Miss C to a specialist. We noted that some of the delay was due to her requiring urgent hospital admission in this period; however, part of the delay was due to a lack of cover arrangements during an unexpected staff absence. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for the delay in referring her to a specialist and for the failure to document why the biopsies were necessary. 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:

• Operation notes should include sufficient detail to explain the clinical decisions taken during the operation.

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

Ms C, who is a patient adviser, complained on behalf of her client (Mr B), who was unhappy about the care and treatment provided to his mother (Mrs A) at Hairmyres Hospital. Mrs A experienced a stroke and was assessed in the emergency department before being transferred to a medical ward. A week following her admission to the ward, Mrs A was admitted to a specialist stroke ward. Soon after the transfer, she experienced a further stroke and died a number of days later.

Mr B complained that there had been a delay in assessing and treating Mrs A in the accident and emergency department. We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly) with experience in stroke care. We found that the records showed that Mrs A was assessed almost immediately following admission and that a scan was arranged promptly. We did not find evidence that there was an unreasonable delay in assessing and treating Mrs A, and we did not uphold this part of Ms C's complaint.

Mr B was also concerned about the care provided on the medical ward. We found that the board had apologised to Mr B for the delay in transferring Mrs A to a stroke ward. We considered that it was unreasonable that Mrs A was not transferred to a stroke ward sooner. While we considered that the general medical care provided was reasonable, we were critical that Mrs A did not receive the benefit of specialist stroke unit care sooner. We upheld this aspect of the complaint.

Finally, Mr B was unhappy with the level of communication with the family. We found limited evidence of staff communicating with the family in the period following Mrs A's admission and prior to her deterioration. We, therefore, upheld this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr B and his family for the lack of communication in the period following Mrs A's admission and prior to her deterioration. 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:

• Stroke patients requiring admission to hospital should be admitted promptly to a stroke unit staffed by a co-ordinated multi-disciplinary team with a special interest in stroke care, in accordance with Scottish Clinical Guidelines.
• Medical staff should be mindful of the needs of family members/ significant others of the patient, as described in Scottish Clinical Guidelines, and ensure that there is adequate communication.

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 about the care and treatment he received at Wishaw General Hospital (WGH) when he attended the emergency department after falling at home and injuring his lower back. Mr C was concerned that he was discharged home without having had an x-ray. He was also dissatisfied about the in-patient hospital care he received after being admitted to hospital two days later at which time an x-ray confirmed a spinal fracture. Mr C was unhappy about delays in transferring him to a different hospital spinal unit and being informed that he had a second spinal fracture.

We took independent advice from a consultant in emergency medicine and a consultant orthopaedic surgeon (a specialist concerned with the musculoskeletal system). In relation to the care Mr C received in the emergency department, we considered that the decision not to do an x-ray and the delay in diagnosis were reasonable given that a number of factors made this type of injury unlikely in Mr C's case. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to the orthopaedic care received, the board acknowledged that it would have been appropriate to have discussed Mr C's case again with the spinal unit of another hospital. We found that there was a lack of communication with Mr C in relation to his second fracture and that a more senior discussion with the spinal unit may have led to more timely transfer. Therefore, we upheld this aspect of Mr C's complaint. However, we noted that these issues were unlikely to have influenced his subsequent treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failings in communication regarding his second fracture. 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 informed of relevant test results and this should be fully documented in the medical records.

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 to us on behalf of her late sister (Ms A). Ms A had cancer and was receiving radiotherapy treatment (a treatment using high-energy radiation) in hospital. Mrs C complained that there was an unreasonable delay in providing Ms A with radiotherapy treatment and Mrs C felt that Ms A should have been prioritised due to her pain levels. Mrs C also complained that the board did not investigate her complaint reasonably.

We took independent advice from a consultant oncologist (a doctor who specialises in cancer treatment). We did not find that there was an unreasonable delay in providing Mrs A with treatment. The adviser commented that it is not routine practice to prioritise patients' scans or treatment slots based on symptoms. We also considered that the board took reasonable steps to manage Ms A's pain whilst in the hospital, as she had been provided with pain relief medication during her admission. We did not uphold this aspect of the complaint.

Regarding complaints handling, we were unable to definitively assess how accurate or inaccurate the board's response to Mrs C's complaint was as they could not provide us with evidence on Ms A's admission timings. The board, therefore, failed to demonstrate that their response to Mrs C's complaint was evidence-based and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not investigating her complaint reasonably. 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 and Mrs C complained on behalf of their daughter (Ms A) about the orthodontic treatment (a speciality field of dentistry that deals with malpositioned teeth and the jaws) she received. Ms A underwent orthodontic treatment to treat mild crowding of her teeth (when there is not enough space for all teeth to fit normally within the jaws). Four of her teeth were removed, and braces were fitted. After the braces were removed Mr and Mrs C were concerned that the treatment had changed Ms A's facial profile and affected her lip support. They believed that there had been other methods of treatment available, which they felt that the orthodontist had failed to discuss with Ms A.

We took independent advice from a dental and orthodontic adviser. We found that Ms A's overcrowding was treated appropriately and that a good result was achieved. We did not uphold the complaint about the treatment provided.

Mr and Mrs C also complained that the orthodontist failed to obtain Ms A's informed consent before proceeding with the treatment. We found that there was no evidence of a proper discussion of the problem that Ms A presented with or the expectations she had of any treatment. We also did not see any evidence of any information being given to Ms A about what treatment options were availale. We upheld this aspect of the complaint.

Finally, Mr and Mrs C complained about their way that their complaint was handled by the orthodontist. We found that the complaint had been handled appropriately and in a timely manner. We did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to obtain valid consent to the treatment plan, with recognition of the implications of failing to obtain full consent on the choices made. The apology should meet the standards on apology 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 quality of the orthodontist's clinical treatment notes should be improved. In particular, they should focus on improving the way they document orthodontic assessments, gather orthodontic records and use them to ensure that a comprehensive explanation

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

Ms C complained about the care and treatment provided to her at Victoria Hospital. Ms C had several admissions for pain associated with gallstones. She complained that the nursing care during two of her admissions was not of a reasonable standard, and that she was not provided with pain relief in a timely manner. Ms C also complained about the treatment provided to her for a wound infection when she attended after surgery to remove her gallbladder.

We took independent advice from a nursing adviser and from a consultant physician. We found that nursing care had not been of a reasonable standard and upheld this aspect of Ms C's complaint. However, as the board had already apologised for this matter and taken action to address it, we made no further recommendations. We did ask for evidence of the steps they said they had already taken.

We found that pain relief had not always been provided to Ms C in a timely manner. We upheld this aspect of the complaint and made a recommendation to address this.

Finally, we found that the treatment provided to Ms C for her wound infection was reasonable and we did not uphold this aspect of Ms C's complaint.

Recommendations

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

• Pain levels should be assessed regularly and pain relief provided in a timely way.

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 about the care provided to his late father (Mr A) during his admission to Victoria Hospital. Mr A lacked capacity and had appointed Mr C as power of attorney for his care. In particular, Mr C complained that the board failed to give Mr A appropriate treatment for his heart attack and questioned why more invasive treatment was not considered in Mr A's case. Mr C also complained about a lack of communication with him about the care and treatment Mr A was given, despite having power of attorney. In their response to the complaint, the board accepted that Mr A lacked capacity and that there were failings in their communication with Mr C.

We took independent advice from a consultant geriatrician (a doctor who specialises in medicine of the elderly). The adviser considered that it was reasonable that more invasive treatment was not considered appropriate for Mr A, given his age and pre-existing health conditions. We considered that the care provided to Mr A was reasonable, and we did not uphold this aspect of Mr C's complaint.

The adviser considered that there was an unreasonable failure to discuss Mr A's care and treatment with Mr C, as power of attorney. The adviser also said that there was a failure to follow the required Adults with Incapacity process after Mr A's admission, as an Adult with Incapacity certificate and treatment plan were not prepared. We accepted this advice, and upheld this aspect of Mr C's complaint. In light of our findings, we made some recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to communicate appropriately with him. The apology should comply with the SPSO guidelines on making an apology, available at: www.spso.org.uk/leaflets-and-guidance.

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

• Decisions about care and treatment should be discussed with a welfare power of attorney, in the same detail they would be discussed with a patient who has capacity to understand the decision themselves.
• An Adult with Incapacity certificate and treatment plan should be prepared for all patients who lack capacity.

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 made a number of complaints about the care and treatment that his late wife (Mrs A) received in University Hospital Crosshouse. Mrs A had a complex medical history and was admitted in relation to a skin condition. Mrs A became increasingly unwell during her admission and developed hospital acquired pneumonia (an infection of the lungs). Mr C complained about the nursing care that Mrs A received. Mr C also complained about the medical care that Mrs A received in relation to the insertion of a central line (a tube placed by needle into a large, central vein in the body to administer drugs or take blood samples), prescription/management of fluids, how she came to develop hospital acquired pneumonia and the prescription of pain relief. Mr C was also concerned about the DNACPR (do not attempt cardiopulmonary resuscitation) that was in place for Mrs A and that no post-mortem was carried out following her death. Mr C also considered that the handling of his complaint by the board was unreasonable.

We took independent advice from a nurse in relation to Mrs A's nursing care. While we did not find failings in relation to many aspects of Mrs A's care, we found that the appropriate skin assessment had not been carried out following her admission. The adviser highlighted that appropriate care and assessment could have avoided a pressure ulcer that Mrs A later developed. We upheld this aspect of Mr C's complaint.

We took advice from a consultant in acute medicine in relation to Mrs A's medical treatment. We noted that most aspects of Mrs A's care had been reasonable and that Mrs A's very low weight on admission to hospital made management of her fluid balance difficult. We found no failings in relation to the prescription of pain relief. The adviser highlighted that hospital acquired pneumonia is a risk for all patients, but particularly those who are frail and bed-bound. However, we found that there was a lack of evidence of an appropriate consent process for the insertion of the central line. Therefore, we upheld this aspect of Mr C's complaint.

In relation the DNACPR decision, we found that this was appropriate in Mrs A's case and that there was evidence that it was discussed reasonably. We also found that there was no clear answer as to whether or not a post-mortem should have been carried out for Mrs A. Therefore, we did not uphold these aspects of Mr C's complaint. However, we did note that a care after death checklist had not been completed and made a recommendation to the board in light of this.

Finally, we found that the board's complaint response was not issued within the prescribed timescales and did not address all the concerns that 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 for failing to carry out appropriate pressure area assessment and care, for the failures around the consent process for the central line, and for failing to handle his complaint reasonably. The apology should meet the standard set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• The board should ensure that all registered nursing staff carry out appropriate assessment and monitoring of patients at risk of pressure ulcers.
• Appropriate consent should be obtained and documented or an adults with incapacity form completed to cover the insertion of a central line.
• The board should ensure that all relevant staff are aware of and complete the care after death checklist for every patient who dies.

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 father (Mr A) about the care and treatment Mr A received from his GP practice. Mr C complained that Mr A was not referred to dermatology (the branch of medicine dealing with the skin, nails, hair and its diseases) when he first attended the GP Practice, even though his facial lesion had changed shape and colour. Mr C was later diagnosed with skin cancer. Mr C also complained that Mr A was not given appropriate treatment when he later developed health issues, such as a persistent cough, in the last months of his life.

We took independent advice from a GP. We found that the practice should have referred Mr A to dermatology at the outset. The adviser considered that Mr A's lesion was of concern because it had enlarged and changed character. Therefore, we upheld that aspect of Mr A's complaint and we made recommendations to address this. We found that the practice gave Mr A appropriate treatment for the health issues he experienced later and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for not referring Mr A to dermatology. 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:

• Patients with suspicious lesions should be referred to dermatology.

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.