Some upheld, recommendations

Summary

Ms C complained about maternity care and treatment she received at Raigmore Hospital in relation to her labour and birth. Ms C had previously had a caesarean section and had planned a vaginal delivery for this birth. Ms C went to the hospital as her waters had broken, however, she was not experiencing contractions. She was admitted and the following day, a drip was administered to augment her labour. Ms C's labour progressed with continuous monitoring of the baby's heart rate. When this dropped, the drip was stopped and Ms C had an emergency caesarean section to deliver her baby. During the operation, it was discovered that a scar from a previous caesarean section had ruptured. Ms C complained about the care she received as she considered that she was left too long without action after her waters had broken and that the drip had not been prescribed at a safe level, given her previous caesarean section. Ms C was also concerned about the board's handling of her complaint as there were delays and inaccuracies in the final response.

We tookindependent advice from a consultant obstetrician (a doctor who specialises in pregnancy and childbirth). We found that the risks and benefits of vaginal delivery following caesarean section had been discussed during Ms C's pregnancy. We found that the care and treatment Ms C received was in line with local protocols and national guidance. We did not uphold this aspect of Ms C's complaint. However, we made a recommendation that the board consider recording that the Royal College of Obstetricians and Gynaecologists leaflet on birth options after previous caesarean section is provided to patients like Ms C.

Regarding complaints handling, we found that during the board's own consideration of the case, they apologised that there had been delays in Ms C's complaint reaching the appropriate team, although we were unable to determine the reason for the delay. We found the board's final response was open to misinterpretation in terms of the timeline and plan for Ms C's care. We also noted there was an inaccuracy in relation to the rate that Ms C's drip was administered at. We upheld Ms C's complaint about the way the board handled her complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the inaccuracies in the final response to Ms C's complaint. 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:

• Consider ensuring (and documenting) that the Royal College of Obstetricians and Gynaecologists Patient Information Leaflet on Birth Options After Previous Caesarean Section has been provided to patients to confirm that the risks and benefits have been appropriately shared.
• The final response to complaints should be clear, accurate and easy to interpret.

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 mother (Mrs A) who was admitted to Glasgow Royal Infirmary's Acute Assessment Unit (AAU). Mr C complained that there was a delay in providing a bed for his mother. Mrs A's complaint to the board was originally made on her behalf by an MSP. Mr C also complained that the board's handling of this complaint was unreasonable.

We took independent advice from a consultant in acute medicine and from a nurse. We found that the care and treatment provided to Mrs A was reasonable. We noted that there is often a wait for a bed to become available in a hospital ward, so that a patient can be transferred to an appropriate ward from a unit such as the AAU. However, we found that it took six hours for Mrs A to be moved from a trolley to a bed in the AAU. Given Mrs A's age and several health problems, we considered that this delay was unreasonable. Therefore, we upheld this aspect of Mr C's complaint.

In relation to the board's complaints handling, Mr C said that there were errors in their response to the complaint that the MSP had made. We found that there was an error in Mrs A's name, however, this was the name used by the MSP when making the complaint. We noted that the board could have confirmed Mrs A's name with the MSP's office and used the correct name in their response. However, we found that, other than the error in Mrs A's name, the board's response to the complaint was reasonable and appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

Recommendations

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

• The board should consider whether the current prioritisation in the hospital's AAU for moving elderly patients with additional diseases from a trolley to a bed is appropriate, taking account of the relevant 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

Ms C, an advocacy and support worker, complained on behalf of her client (Mrs B) regarding the care and treatment of her late husband (Mr A). Mr A was referred to the respiratory team at Inverclyde Royal Hospital with a worsening cough, and lung cancer was suspected. However, the diagnosis was not formally confirmed until a number of months later. Mr A was then informed that his condition was terminal and that he only had a few weeks left to live.

Ms C complained about the delay in diagnosing Mr A's cancer. Mr A was diagnosed with an empyema (a collection of pus between the lungs and inner chest wall) in the interim period and the board indicated that treating this became the priority. They said that delays caused by Mr A's impaired health meant that biopsies could not be carried out sooner.

We took independent medical advice from a respiratory consultant. We found that it was reasonable for the medical team to have focussed on the management of the empyema. It was noted that Mr A's case was discussed with the lung cancer multidisciplinary team on a regular basis. We considered that the cancer diagnosis was not unreasonably delayed and therefore, we did not uphold this part of Ms C's complaint. However, we found that there was a delay in commencing Mr A on antibiotics when an infection was identified following a bronchoscopy (a procedure that examines the inside of the lungs and airway). While we did not consider that this contributed to the delay in diagnosing the cancer, we made a recommendation in relation to this.

Ms C also complained that there was a lack of communication with Mrs B and Mr A by the medical team. We found that the medical records documented reasonable efforts by staff to communicate with both Mrs B and Mr A. However, the board reflected that their communication fell short of what they would expect. In particular, they acknowledged that sickness absence of key staff directly impacted on the level of support Mr A received. Therefore, we upheld this part of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B for the unreasonable delay in commencing Mr A on antibiotic medication for the infection identified following the bronchoscopy procedure. 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:

• When test results identify the need for antibiotic treatment, medical staff should ensure that this is commenced within a reasonable timeframe.

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's child, (child A), was born with a cleft palate (an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together during development in the womb) which led to difficulties in breathing and feeding. After treatment at one hospital, child A was transferred to Forth Valley Royal Hospital. They were discharged 11 days later, however, Mr C had to return child A to Forth Valley Royal Hospital that night because they had been struggling to breathe since their discharge. Child A was admitted and within a few days they were referred to another hospital. Mr C complained that child A should not have been discharged from Forth Valley Royal Hospital given their medical condition at the time. Mr C also complained that the board failed to address his complaint in a reasonable way.

We took independent advice from a paediatrician. We found that the decision to discharge child A was reasonable given his medical condition at the time. There were no medical concerns noted in the days prior to their discharge and we considered that the board's actions were appropriate. Therefore, we did not uphold this aspect of Mr C's complaint.

In relation to complaints handling, we found that the board fully addressed Mr C's concerns. However, we found that there was an unreasonable delay in arranging a meeting and that there had been a lack of communication with Mr C regarding this. Therefore, we upheld this aspect of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to deal with his complaint in a reasonable way. 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:

• Meetings with complainants should be arranged within a reasonable time; complaint files should record any delays; and complainants should be told within a reasonable time of any alterations to the arrangements.

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 to us about the care and treatment that her late father (Mr A) had received from the practice. Mr A had attended the practice as he was feeling some discomfort in his chest after exertion and increasing fatigue. He was referred to hospital urgently for a chest x-ray. The GP also increased the dose of Verapamil (a medication used for high blood pressure and angina) Mr A was receiving. Mr A had a scan of his heart at the hospital approximately ten days later This showed valve disease in Mr A's heart, which can lead to heart failure. An appointment was made for him to see a consultant cardiologist (a doctor who specialises in finding, treating and preventing diseases of the heart and blood vessels) and the Verapamil was stopped and his medication changed. Mr A's condition deteriorated and he returned to the practice several days after the hospital appointment. He complained of chest pain radiating to his back and said that he was no better with the new heart medication. The GP thought that this might be caused by gastric irritation and increased his medication for stomach acid. Mr A died from heart failure the following morning.

Ms C complained about the practice's decision to increase her father's Verapamil. We took independent advice from a GP adviser. We found that Mr A had been referred to hospital because it was considered that he had worsening angina. The GP had consequently increased Mr A's Verapamil, which is a recognised and common treatment for angina. The GP could not have foreseen the echocardiogram result at that time and, therefore, could not have foreseen that increasing the Verapamil was not the best treatment. Mr A's valve disease had not been caused by Verapamil, but is a condition that deteriorates over many years. We did not uphold this aspect of Ms C's complaint.

Ms C also complained that the GP did not examine Mr A's chest at the appointment after his hospital visit. We found that the GP should have examined Mr A, as he was complaining of persistent chest pains and had no improvement with cardiac medication, despite recent cardiology confirmation that he had developed new heart failure. We upheld this aspect of Ms C's complaint, although we were unable to say if an examination by the GP would have changed the overall outcome for Mr A.

Finally, Ms C complained that the practice had delayed in processing a medication request for Mr A. The practice had accepted that there had been failings in relation to processing this request and had apologised to Ms A for this. We also, therefore, upheld this aspect of her complaint. We made no further recommendations regarding this, but we asked the practice for evidence of the action they said they had taken.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to carry out an examination of Mr A. 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 of the symptoms, signs and management of unstable angina and should carry out and record an adequate clinical assessment in appropriate cases in line with General Medical Council 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's father-in-law (Mr A) attended the Emergency Department (ED) at Victoria Hospital with severe facial injuries following a fall from a bicycle. He was reviewed by a doctor and transferred to oral and maxillofacial surgery (OMFS - surgery which treats diseases and injuries of the mouth, head, neck, face and jaws) for treatment of the cut to his face, then discharged.

Within the following week, Mr A attended two out-patient appointments at Queen Margaret Hospital to check his wound and remove the stitches. While waiting for the second appointment, Mr A collapsed at the hospital. Medical and nursing staff attended, but no record was made. They told Mr A to visit the ED after his out-patient appointment. However, Mr A remained quite unwell and the family returned to the hospital to ask for help. An ambulance was arranged to take Mr A to Victoria Hospital where a scan showed that he had a skull fracture and bleeding inside the skull. Mr A died shortly afterwards.

The board undertook a Rapid Event Investigation which found failings in the clinical care and processes. They said that there was no communication about head injury care when Mr A was transferred from the ED to OMFS. This meant that nursing staff did not carry out neurological observations (observations of the brain and nervous system), and Mr A was not given information about head injuries when he was discharged. Mr A was also given the wrong advice following his collapse in the hospital, as he should have been taken to the minor injuries unit for further assessment and transfer to Victoria Hospital. The board apologised for the failings found. The family felt that the board's response was unreasonable, and Mr C brought the complaint to us.

Mr C complained that the medical care and treatment provided to Mr A throughout his attendances at Victoria Hospital and Queen Margaret Hospital was unreasonable. We took independent advice from consultants in emergency medicine and OMFS. We found that regular neurological observations should have been taken while Mr A remained in hospital (either in the ED or OMFS) and he should have been given information on head injuries on discharge. Whilst we acknowledged that the board had taken appropriate action to address some of the failings, we were concerned that some of the Rapid Event Investigation recommendations were not specific and clearly linked to the failings found, and two recommendations had been marked off as complete without any evidence of action being taken. In light of this, we upheld Mr C's complaints about medical care and treatment.

Mr C also raised concerns that the nursing care provided to Mr A at Victoria Hospital was unreasonable. We took independent advice from a nurse. We did not find any evidence that nursing staff had missed any concerning signs or symptoms, and we found that the nursing care provided to Mr A was reasonable. Therefore, we did not uphold Mr C's complaint about the nursing care provided to Mr A.

Mr C also complained that the board's response to the complaint was unreasonable. We found that, although it could have been more clearly written at points, the board's response was reasonable. We did not uphold this part of Mr C's complaint.

Recommendations

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

• Patients with an injury to the head should receive neurological observations, regardless of where they are cared for.
• Patients with an injury to the head should be given head injury information on discharge from the ward.
• Recommendations arising from a review of a patient's care should clearly identify changes to prevent the situation reoccurring.

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 that her late mother (Mrs A) received at Dumfries and Galloway Royal Infirmary. Mrs A was admitted for emergency treatment of a bowel issue and after some time in the intensive care unit, she was moved to the high dependency unit (HDU). Mrs A's condition deteriorated while she was in the HDU and she later died. Ms C was concerned about the standard of both medical and nursing care that Mrs A received. Ms C also complained about the level of communication with family members and the way that the board dealt with her concerns.

We took independent advice from a critical care consultant and a nursing adviser. We found that the care and treatment provided to Mrs A by both medical and nursing staff was appropriate and reasonable. Therefore, we did not uphold these aspects of Ms C's complaint.

However, we found communication with the family during Mrs A's time in hospital to be unreasonable. The nursing adviser noted that staff will refer to the 'ceiling of care' indicating the level of intervention that is appropriate for that particular patient. We considered that the records made of discussions with Mrs A's family were insufficient as they did not document enough information about ceiling of care and to what extent this was discussed. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had already identified areas for improvement.

In relation to complaints handling, we found that there had been a short delay in issuing a final response to Ms C and that the board had not arranged an extension or apologised for this. Therefore, we upheld this aspect of Ms C's complaint. However, we noted that the board had acknowledged this failing and had made improvements to their approach to complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in responding to her complaint. 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:

• Communication with patients and their families should be in line with the General Medical Council's Good Medical Practice guidance, particularly sections 33 and 49. Ceilings of care should be discussed, agreed, documented and reviewed with all involved (patient, medical and nursing staff). The board should consider using a separate section within the notes to document discussions with relatives or carers.

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 attended two consultations with the practice who had recently taken over from her previous practice. She had attended her previous practice five years earlier after she had experienced an increase in epileptic seizures.

Mrs C complained that, during these two consultations, the practice unreasonably focussed on the events of five years previously. She raised concerns that the practice placed undue focus on the reporting requirements of the Driver and Vehicle Licencing Agency (DVLA) and she found it difficult to get her health concerns across. Mrs C also complained that, during the first consultation, she was unreasonably prescribed the wrong dosage of epilepsy medication.

We found that the first of the two consultations was Mrs C's first with the practice altogether, following them taking over the running of her local practice. Her prior consultation with her previous practice noted concerns about the management of her epilepsy and an intention to notify the DVLA. We took independent medical advice from a GP, who confirmed that DVLA guidance requires patients with epilepsy to notify them. We considered that it was reasonable for the practice to discuss Mrs C's epilepsy and DVLA reporting requirements during her consultations. Therefore, we did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that she was prescribed the wrong dosage of her epilepsy medication. We found that there had been a prescribing error and that the practice did not address this when responding to Mrs C's complaint. Therefore, we upheld this aspect of Mrs C's complaint. However, we noted that the practice acknowledged that the error was their fault and that this was fixed before any medication was actually issued.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the prescribing error and for failing to address her complaint about this.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

Mrs C complained about the care and treatment provided to her late husband (Mr A) at University Hospital Ayr. Mrs C felt that Mr A was kept in the emergency department for too long before being admitted to the hospital, and that he was not appropriately assessed during this time.

We took advice from a consultant in emergency medicine and a stroke consultant. We found that, overall, the care provided to Mr A by the emergency department staff was reasonable but that they failed to complete transfer observations and handover documentation. We found that the initial assessment of Mr A by the stroke team was poor. We acknowledged that the diagnosis of a stroke, such as the one Mr A suffered, can be difficult to diagnose, however, we found that there was a failure to scan Mr A in the appropriate manner and reasoning for decisions made were not documented clearly. Therefore, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that there was a lack of communication to keep her advised of Mr A's diagnosis and treatment. We found that, overall, the medical records showed a reasonable level of communication with Mrs C and, therefore, we did not uphold this aspect of her complaint.

Finally, Mrs C complained that the board's handling of her complaint was unreasonable. We found that, throughout the complaints process, there had been a number of failings including delays and a lack of communication. Therefore, we upheld this aspect of Mrs C's complaint. However, since these events occurred, a new complaints handling policy had been implemented by the board and we therefore made no further recommendations on this point.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide Mr A with appropriate clinical treatment; and for failing to handle Mrs C's complaint in a reasonable manner. 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:

• Transfer observations and handover documentation should be completed appropriately by the emergency department to ensure patients are safe to be transferred and appropriate information is passed on to the receiving ward area.
• Assessments made by members of the stroke team, and reasoning for any decisions made, should be documented clearly.

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 Scottish Qualifications Authority (SQA)'s marking of a handwritten exam script for her daughter (Miss A). Miss A's script was considered to be illegible when it was initially marked and this resulted in her not receiving the mark she had hoped for in that subject. Miss A had two places at universities that were conditional upon her receiving a higher award than she achieved in that subject. Miss A applied for a place at a university elsewhere and accepted that place the day after receiving her exam results. Miss A's school later submitted a marking review request for her, and she was awarded a higher grade. However, this was too late for her to take up one of the conditional university places she had previously been offered. Ms C complained that pre-certification quality assurance checks had not established an issue with Miss A's script and that the SQA had unreasonably failed to provide information at the time the results were issued to advise that a priority marking review could secure a conditional university place. Ms C was also concerned that the SQA had not handled her complaint reasonably.

After considering the available evidence, we did not uphold Ms C's complaint about quality assurance checking. We found that the initial marker followed the proper process when they considered that the script was illegible and escalated the matter appropriately. The script was then reviewed by a more senior assessor, who agreed that it was illegible. Although a higher award was given following the marking review request, we found that this was as a result of a subject specialist being asked to decipher the handwriting, and so we did not consider that the initial marker and the senior assessor had acted unreasonably.

We also did not uphold Ms C's complaint regarding the information available on priority marking reviews. We found evidence that this information on priority marking reviews was available from a number of different sources and was provided to all candidates ahead of the exam period starting. This included information that this process, rather than a standard marking review request, should be used to ensure deadlines for conditional university places were met.

We upheld Ms C 's concerns about how her complaint was handled as we found that the SQA's response did not address all of the key issues raised. The SQA acknowledged this in their response to our enquiries and we made two recommendations in this connection.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to address all of her concerns in their response to her complaint. 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:

• Complaint responses should address the issues raised, in line with the complaints handling 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.