Some upheld, recommendations

Summary

Mrs C complained about the care and treatment provided to her late husband (Mr  A). Mr A was admitted to hospital as an emergency with abdominal pain, and investigations were carried out over the next few days. Following a request by the family for medical review, Mr A was reviewed by a surgeon and a scan was carried out, which showed a bowel obstruction. Mr A had surgery the next day. Following this, Mr A was transferred to the high dependency unit (HDU) where he contracted a chest infection. He was then transferred to a ward, but his condition deteriorated and he developed sepsis. Mr A was transferred back to the HDU four days later, and then into intensive care. His condition deteriorated further, palliative care (end of life care) was started and Mr A later died.

Mrs C complained to the board about the care and treatment provided to Mr A. The board met with Mrs C about her complaints and carried out a significant clinical incident review. Mrs C was not satisfied with the outcome, or the way the board handled her complaint, and so she brought her complaints to us. She complained that the board did not provide reasonable medical treatment to Mr A, did not provide reasonable nursing care to Mr A, did not communicate reasonably with the family during Mr A's admission, and did not respond reasonably to her complaints.

We took independent advice from a consultant in general medicine, a nurse and a consultant radiologist (a doctor who uses medical imaging such as x-rays, ultrasounds and scans to diagnose and sometimes treat ilnesses). We found that there were delays in investigating and diagnosing Mr A's condition, and in identifying, responding to, and recording the deterioration following the surgery. We also found that there was no documentation of the reasons for transferring Mr C from the HDU, and poor documentation of a decision to commence using a ventilator. We found that, while aspects of the communication with the family were reasonable, on the whole the standard of communication fell below a reasonable standard, especially in light of the fact that the family held power of attorney. We upheld Mrs C's complaints about medical care and treatment, and about communication.

We did not find failings in the nursing care provided to Mr A, and so we did not uphold this aspect of the complaint.

We found that the board had failed to respond to many of the issues Mrs C had raised in her complaints, despite taking a significant amount of time to investigate. The board was also poorly prepared for the meeting they had with Mrs C about her complaints. We upheld Mrs C's complaint about the board's handling of her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in medical care and communication, and for failing to respond to the points raised in her complaint.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 reviewed regularly, with prompt consideration of the results of any investigations to inform diagnosis and treatment.
• Medical staff should clearly record the reasons for key decisions.
• Deterioration in patients should be identified and escalated to senior staff, with timely transfer to high-dependency care where appropriate.
• Welfare attorneys should be involved in decisions about care, and discussions should be clearly documented.

In relation to complaints handling, we recommended:

• The board should adequately prepare for complaint meetings by ensuring staff attending are aware of the specific complaint issues and are able to respond to the specific issues and discuss the timeframes covered by the complaint. They should also agree an agenda or format prior to the meeting, to ensure shared expectations.

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 his daughter (Mrs A) received at Royal Cornhill Hospital. In particular, he complained that the board had failed to carry out appropriate risk assessments for Mrs A.

We took independent advice from a consultant psychiatrist. We found that Mrs  A had been been provided with reasonable care and treatment and that regular risk assessments were carried out. We also noted that Mrs A had been appropriately assessed on her return to the ward after absconding from the hospital. However, we were concerned that, when Mrs A first went missing from the hospital, the board did not follow their missing persons policy. We found that there was a delay in the board contacting the police and that their missing persons policy did not specify a time period within which to initiate the actions to be followed when an in-patient goes missing from care. We were also concerned that the nursing records did not state when the first ward check was carried out after Mrs A went missing, and that there was no record of the actions taken by the board between the first check and a later check at 21:30. Therefore, we upheld this complaint.

Mr C also complained that Mrs A had not been provided with appropriate medication. We found that the board's approach to medication treatment was appropriate and reasonable and in line with relevant guidelines. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for failing to follow the missing persons policy. 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 times of ward checks should be documented.
• When an in-patient goes missing from care, the missing persons policy should be followed in relation to police contact.
• There should be clear guidance in place in relation to the timescales for taking action when an in-patient goes missing from care.

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 provided to his mother (Miss A) during two admissions to the mental health unit at Forth Valley Royal Hospital. In relation to Miss A's first admission, Mr C had concerns about the monitoring and treatment of blood pressure and the treatment provided to Miss A by a psychiatrist. In relation to her second admission, Mr C had concerns about medical care, nursing care and issues around communication. Mr C also complained about the gap in community psychiatric care in the period between the two admissions.

We took independent advice from a nurse and a consultant psychiatrist. We found that there were failings by nursing staff in the monitoring of Miss A's blood pressure and upheld this aspect of Mr C's complaint. However, we noted that the board had acknowledged this failing and had introduced a new system for recording observations. Overall, we found that the medical treatment provided to Miss A during her admission was reasonable and did not uphold these complaints. However, we noted that one letter sent to Mr C contained unhelpful language and we made a recommendation in light of this.

In relation to the gap in community psychiatric care in the period between the two admissions, we found that the board had not followed the clinical management plan in place once Miss A's psychiatrist left the community mental health team. Therefore, we upheld this aspect of Mr C's complaint. We did note, however, that the board had apologised for this failing and had put a new appointment system in place to address this issue.

In relation to Miss A's second admission, neither adviser identified any failings in medical care, nursing care or communication. Therefore, we did not uphold these aspects of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A and Mr C for the failure to appropriately monitor Miss  A's blood pressure and the content and tone of the letter sent to Mr C. 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:

• Blood pressure monitoring should be carried out in line with the instructions by the medical team.

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, who works for an independent advocacy service, complained that there was unreasonable delay in providing the required care and treatment to her client  (Miss A) when Miss A was admitted to Crosshouse Hospital after her Percutaneous Endoscopic Jejunostomy tube (PEJ tube - a feeding tube that is put inside an outer tube which goes into the stomach. The inside tube goes into the small intestine) became blocked. Mrs C also complained that the board's handling of her complaint was unreasonable.

We took independent advice from a gastroenterologist (a doctor who specialises in the digestive system). We found that the board's staff referred Miss A for an initial review, specialist review, arranged investigations and arranged for a replacement PEJ tube in a reasonable time. In view of this, we did not uphold Mrs C's complaint regarding the time taken to treat Miss A. However, we identified that there was no nutrition team involvement in Miss A's care, and that a nutrition assessment was not carried out. We were critical of this and made a recommendation to the board to address this matter.

Regarding complaints handling, we found that there was a lack of clarity as to how the board were investigating the issues raised by Mrs C. In addition, we found that the board did not adhere to the timescale required, nor did they appropriately update Mrs C on their progress. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failure to clarify how the complaint would be handled and for not keeping her reasonably informed about the progress of the complaint. 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 involvement of a nutrition team should be considered where stopping of nutrition due to a blocked feeding tube is the reason for admission, and the patient cannot be easily assessed with regards to nutrition status. Nutritional assessment of such patients should be documented.

In relation to complaints handling, we recommended:

• Complaints should be dealt with in accordance with the complaints procedure.

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

Summary

Mrs C complained about the care and treatment provided to her late father (Mr  A) at University Hospital Ayr. Mr A was elderly and had a visual impairment. Mrs C complained that nursing staff failed to take into account her father's visual impairment when communicating with him and that they failed to recognise he needed extra assistance when reaching for food and drinks. Mrs C also complained about the handling of the discharge process. She felt that the nursing staff did not give accurate information to the social work department about Mr A's mobility, which resulted in difficulties in managing his care at home. Mrs C also raised concerns about the board's handling of her complaint.

The board acknowledged their communication with Mrs C could have been better and that they should have consulted with her more regarding her father's discharge planning. The board also acknowledged that nursing staff communication with Mr A was not acceptable. Mrs C remained unhappy and brought her complaints to us.

We took independent nursing advice. We found that the nursing care provided to Mr A was below an acceptable standard and that the discharge planning could have been improved by holding a case conference. We upheld these two aspects of Mrs C's complaint. However, we found that the board did take adequate steps to ensure that Mr A received appropriate post-discharge care at home. We did not uphold this aspect of the complaint.

Regarding complaints handling, we found that the board did not handle Mrs C's complaint in line with their complaints handling procedure. We upheld this part of the complaint.

Recommendations

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

• Staff should be more aware of how to take into account and accommodate the individual needs of visually impaired patients and should ensure these needs are recorded appropriately in the records.
• The board should recognise the importance of personalised discharge planning, particularly when patients are elderly and frail and are already receiving complex care at home.

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 treatment he received from the prison health care service and from the hospital he attended. In particular, he was concerned about the treatment he received for both a hand injury and hip pain, withdrawal of medication and how his complaint was handled.

We took independent advice from a consultant orthopaedic surgeon and from a GP adviser. Mr C said that he had not received reasonable and appropriate treatment in relation to an injury to his hand. We found that the treatment Mr C had received when he attended the accident and emergency department about the injury had been reasonable. Mr C was also referred to an orthopaedic consultant in another board for a second opinion. However, we found that there had been an unacceptable delay in supplying Mr C with a physiotherapy exercise ball in relation to the injury. Therefore, we upheld this aspect of his complaint. We noted that the board had already apologised for this.

Mr C also complained that the board had failed to provide reasonable and appropriate treatment in relation to his hip pain. Whilst there had been a delay in informing Mr C of the result of a scan, this had been carried out by another board and it was their responsibility to act on this. We found that the treatment Mr C had received from the board for his hip pain had been appropriate. We did not uphold this aspect of his complaint.

Mr C complained that the board had withdrawn his medication after he was found to have too many tablets in his possession. We found that the prison health care service's actions in relation to this matter had been reasonable. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained that the board had failed to deal with his complaints adequately. Mr C had made a large number of complaints, but we found that there had been a significant delay in responding to one of the complaints. Therefore, we upheld this aspect of his complaint.

Recommendations

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

• The board should ensure that physiotherapy equipment that has been approved for prisoners is provided within a reasonable timescale.

In relation to complaints handling, we recommended:

• Staff should be aware of the timescales for responding to complaints.

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 way that the council dealt with a planning application. In particular, she raised concerns about the pre-application consultation (PAC) process to give the local community an opportunity to provide their views. Ms C was also concerned that the council did not hold a biodiversity duty document. Ms C also complained about the way the council responded to her complaints.

We took independent advice from a planning adviser. We found that the PAC process had been carried out appropriately, and we did not uphold this aspect of the complaint.

We found that the biodiversity document was not held by the council, despite a statutory requirement for them to hold this. We upheld this part of Ms C's complaint.

Regarding the council's complaints handling, we found that, until the related planning application had been finally determined, it was premature for complaints about its handling to be made to the council. However, we found that this was not explained to Mrs C and that there were delays in responding to her. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to deal with her complaints appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Staff should be familiar with the council's stated complaints procedure and follow it as required.

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 fell on a pedestrian railway crossing and injured himself. He complained to the council that they had not taken steps to ensure that the walkway was safe for members of the public, including providing adequate lighting and warnings of steps on the approach to the bridge. The council responded that they considered the footbridge was adequately maintained and that there was no obligation to provide lighting. Mr C was unhappy with this response and brought his complaint to us.

We found that the council had entered into an agreement with the rail company, and their predecessors, that stated the rail company was responsible for the maintenance of the footbridge. They were also responsible for specifying what lighting was required. Therefore, we determined that it was not the responsibility of the council to ensure that the footbridge was safe. We did not uphold this aspect of Mr C's complaint.

Mr C also complained that the council unreasonably failed to respond to his complaint. We found that the council's response was insufficient as it failed to explain that the rail company was responsible for the maintenance of the footbridge, and that they were the appropriate party to deal with the complaint. We also found that there was an unreasonable delay in providing Mr C with a response to his complaint. 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 unreasonably failing to respond to his complaint and provide Mr C with a full explanation. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complainants should be informed of any delays in providing a reponse ahead of the deadline set and revised timescales should be agreed.

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 about the care provided to her mother (Mrs A) by the practice. In particular, Mrs C complained that the practice unreasonably failed to re-start Mrs A's diuretic medication (medication that can help reduce fluid build-up in the body which occurs when the heart is not functioning properly) which had been stopped in hospital. Mrs C felt that this resulted in a deterioration of Mrs A's longstanding heart condition. Mrs C complained that the practice unreasonably failed to liaise with Mrs A's cardiologist in this regard. Mrs C also raised concerns about the decision to commence Mrs A on anti-depressant medication. Mrs A was subsequently reviewed by a consultant geriatrician (a doctor who specialises in the medicine of the elderly) who restarted the diuretic medication and stopped the anti-depressants.

We took independent medical advice from a GP. We found that there was no evidence that Mrs A's diuretic medication should have been restarted earlier, or that the practice missed any significant signs of deteriorating heart failure. We also took independent advice from a consultant geriatrician on the timescale for restarting this medication. They explained that restarting diuretic medication is difficult to balance as restarting too soon can worsen dehydration, but leaving it too late can worsen the heart condition. The adviser considered that Mrs A's diuretic was restarted within a reasonable timeframe. We also found that an earlier cardiology review was not indicated, and that there was not a failure by the practice to liaise with Mrs A's cardiologist. As such, we did not uphold these aspects of Mrs C's complaint.

In terms of the decision to prescribe anti-depressants, we found that Mrs A had indicated that she was feeling low and anxious and that, as such, the prescription was not unreasonable. We did not uphold this aspect of the complaint. However, the GP adviser said that the medical records kept by the practice were sparse in detail and were not consistent with the General Medical Council's Good Medical Practice (GMC GMP) guidance on record-keeping. We made a recommendation regarding this.

Mrs C also complained about the practice's handling of her complaint. The practice accepted that they did not respond to the complaint within the required timescale, and they explained that there were exceptional circumstances which contributed to this delay. We found this explanation reasonable, however, we considered that their eventual response to Mrs C's complaint lacked detail and thorough explanation. We upheld this aspect of Mrs C's complaint. We were satisfied with the remedial action already taken by the practice to address the identified complaints handling failings, however we noted that their website could provide more information about their complaints handling procedure, and so we made a recommendation in relation to this.

Recommendations

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

• Medical records should be consistent with GMC GMP guidance on record-keeping, and the practice should familiarise themselves with this guidance, available at: https://www.gmc-uk.org/guidance/good_medical_practice/record_work.asp.

In relation to complaints handling, we recommended:

• The practice should provide more information on their website about their complaints procedure.

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

Summary

Mr C underwent nasal surgery at St Johns Hospital and subsequently had ongoing issues with nasal obstruction, facial pain, breathing issues and sinus infections. Mr C complained that he was not warned of the recognised risks associated with the procedure and that the surgery itself was not performed to a reasonable standard. Mr C also complained that the board did not handle his complaint reasonably.

We took independent advice from an ear, nose and throat consultant. We found that appropriate information was provided to Mr C regarding the recognised risks of the surgery. We also considered that the nasal surgery was performed to a reasonable standard. We did not uphold these aspects of Mr C's complaint. However, we noted that there was a delay in removing Mr C's nasal splints (temporary splints which are used to stabilise the nose after surgery) and made a recommendation in light of this.

In relation to complaints handling, we found that there was a delay in issuing a response to Mr C and that there was insufficient detail about the surgery included in the letter. We considered that the board did not handle Mr C's complaint reasonably and upheld this aspect of his complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the lack of advice about nasal splints following the surgery, and the failings in complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at 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.