Some upheld, recommendations

Summary

Ms C, who is a patient adviser, complained on behalf of her client (Mrs A) about the care and treatment provided to Mrs A at the Royal Infirmary of Edinburgh. Mrs A attended hospital for a planned coronary artery bypass graft (a surgical procedure used to treat coronary heart disease). After a week of in-patient care, medical staff were satisfied that Mrs A had recovered well and was fit to be discharged. Mrs A became unwell shortly following discharge and was re-admitted to a different hospital with an infection. Ms C raised a number of concerns on behalf of Mrs A, who felt that the care provided by the board was inadequate.

Firstly, Ms C complained that staff failed to monitor Mrs A's condition appropriately. We took advice from a cardiac surgery adviser and a nursing adviser. We found that appropriate monitoring did take place during Mrs A's recovery from surgery and that appropriate records of this were maintained. We did not uphold this part of the complaint.

Ms C also raised concern that staff did not listen to and document concerns raised by Mrs A, and did not keep appropriate records of attempted blood tests. We found no evidence in the records that staff did not listen to and document Mrs A's concerns about her health. We were also satisfied that the medical and nursing records were maintained to a reasonable standard. We did not uphold this aspect of the complaint.

Finally, Ms C complained that Mrs A was inappropriately discharged home with an infection. Ms C raised concern that Mrs A was left waiting for a number of hours in the discharge lounge whilst her condition deteriorated and that staff then failed to readmit her to the ward. We found no evidence from the records of the admission that Mrs A had an infection prior to discharge. However, the advice we received highlighted that Mrs A remained in atrial fibrillation (fast irregular heartbeat) on the day of discharge, and that medical staff should have discussed this, and any potential issues that might ensue, with Mrs A prior to discharge. We found no evidence that Mrs A or her husband had reported that her condition was deteriorating whilst she was in the discharge lounge. However, we noted that the board had advised that the senior charge nurse responsible for the discharge lounge had reminded their team that patients who became unwell should be returned to the ward and they were satisfied that the correct procedure would be followed in future.

We were unable to conclude that the complication Mrs A experienced following discharge was as a result of unreasonable care and treatment from staff at the Royal Infirmary of Edinburgh. However, we upheld the complaint and made recommendations because there was no evidence that staff discussed atrial fibrillation with Mrs A prior to discharge.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs A for failing to discuss atrial fibrillation, and what she should do if she became more unwell, with her prior to discharge. 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:

• Where a patient is in atrial fibrillation, but is otherwise ready for discharge, staff should inform the patient of any complications atrial fibrillation might present, what to do if they become more unwell, and confirm with the patient that they feel ready for discharge. This discussion should be documented in the patient's 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 about the care and treatment her father (Mr A) received from the board at Caithness General Hospital. Mrs C complained that the board unreasonably failed to take into account her father's dementia, unreasonably failed to establish that Mrs C held a welfare power of attorney in respect of her father and unreasonably failed to obtain appropriate consent for a gastroscopy procedure (an examination of the inside of the gullet, stomach and the first part of the small intestine).

We took independent advice from a nurse and from a consultant in acute medicine. Based on the information in Mr A's records and the advice we received, we considered that the board did not unreasonably fail to take into account Mr A's dementia while he was in hospital and we did not uphold this part of the complaint. However, we were concerned that some documents relating to this were not completed by hospital staff and so we made a recommendation regarding this.

On the issue of welfare power of attorney, we found that attempts should have been made to establish if Mr A had a welfare power of attorney within 24 hours of admission. We found that this had taken the board three days and that this was an unreasonably long time for this to take. We upheld this aspect of the complaint.

Mr A had more than one gastroscopy and Mrs C's complaint was that the board had not obtained appropriate consent for the first gastroscopy. We found that it was reasonable for staff to conclude that Mr A had sufficient capacity to give his consent for his first gastroscopy procedure and that appropriate consent was obtained. We, therefore, did not uphold this part of Mrs C's complaint. However, we were concerned about the consent process for Mr A's second gastroscopy and we found that an adult with incapacity form (completed for patients deemed not to have capacity to consent) should have been completed and that the procedure should have been discussed with Mrs C. We also found that the board's response to Mrs C's complaint was inadequate. We, therefore, made recommendations on these matters.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C, Mr A and their family for the failings in establishing if Mr A had welfare power of attorney, the failings in record-keeping and the complaints handling failures. 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' Admission/Care Records and Treatment Escalation Plans should be completed fully and accurately.
• In cases such as this, staff should establish if patients have a welfare power of attorney in a timely manner.
• In cases such as this, staff should obtain appropriate consent for patients' surgical procedures.

In relation to complaints handling, we recommended:

• Information in internal investigations of complaints should be accurately reflected in complaint responses and full explanations of decisions should be provided.

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 the board failed to provide him with clinic appointments within a reasonable timescale. He also raised concern that the board failed to provide him with adequate notice of the cancellation and rescheduling of appointments, and he was unhappy with the board's handling of his complaint.

The board did not provide us with records and correspondence about Mr C's appointments, cancellations and rescheduled appointments. We also found that their own complaints file did not include relevant evidence, such as records of actions taken by staff in relation to Mr C's appointments and the initial handling of his complaint. The board did not explain why they offered Mr C an appointment for nine months after the originally scheduled appointment, and seven and a half months after the first rescheduled appointment that was offered (which Mr C told the board he could not attend). As we did not receive this information from the board, we had to assume that relevant records were not made at the time. We found that the board failed to follow their complaints procedure, as they did not give Mr C a written explanation for delays, updates on progress, or indicate when they expected to be able to reply. In addition, the board failed to send a response to Mr C's second complaint email, apparently due to an administrative error. We upheld all of these aspects of Mr C's complaint.

Mr C also complained that the board did not consult him about his availability for rescheduled appointments. We did not find evidence that the board were required to consult Mr C about his availability for rescheduled appointments, 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 for failing to provide him with adequate notice of the cancellation and rescheduling of appointments, failing to provide rescheduled appointments to him within a reasonable timescale, failing to inform him of the cancellation of a specific appointment, and for handling his complaint unreasonably. 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:

• Relevant staff should be reminded of the process for dealing with cancelled or reduced clinics, and the necessity of keeping records.

In relation to complaints handling, we recommended:

• Staff investigating complaints should obtain the actual evidence, in addition to comments from colleagues on such evidence, and include it in their complaints file.

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 clinical and nursing care and treatment provided to her late husband (Mr A) when he was admitted to the University Hospital Ayr. We took independent advice from a consultant in emergency medicine, a consultant in acute medicine and a nursing adviser.

In relation to the clinical care and treatment provided to Mr A, having considered the available evidence and the advice provided to us we found that, overall, the medical care and treatment Mr A received was reasonable. The advice we received from the consultant in acute medicine was that Mr A's death was not preventable by the time he was admitted to hospital. We did not uphold the complaint. However, whilst the advice we received from the consultant in acute medicine was that cardiac monitoring would not have saved Mr A's life, they considered that the board should have a clear policy regarding which patients require cardiac monitoring. We made a recommendation regarding this.

Regarding the nursing care provided to Mr A, we found that there were gaps in the assessment and monitoring of Mr A and that the board wrongly focussed on anxiety being the cause of Mr A's shortness of breath. We also found that the guidance on using the Modified Early Warning Score (the monitoring of vital signs such as respiratory rate which helps alert clinicians to patients with potential for clinical deterioration or with established critical illness) was not followed, in that Mr A's Modified Early Warning Score was not repeated in line with guidance and there were gaps in the recording of his vital signs which was unreasonable. We further found that Mr A's Modified Early Warning Score should have been repeated on transfer to a new care area. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide a reasonable standard of nursing care and treatment to 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:

• There should be clear a policy regarding which patients require cardiac monitoring shared between the emergency department, the critical care unit and the acute medical unit.
• A Modified Early Warning Score should be checked within the recommended time frames. In line with good practice, a Modified Early Warning Score should be checked and documented when a patient is transferred to a new care area.
• When a patient or relative raises concerns about breathlessness, a Modified Early Warning Score should be rechecked and documented.
• Relevant staff should be aware of the importance of Modified Early Warning Score in anticipating deterioration in a patient.

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 on behalf of her daughter (Miss A) about a number of failings by the university. During her final year at university, both of Miss A's parents were admitted to hospital unexpectedly. Miss A approached her dissertation supervisor to advise of this and the information was also passed to Miss A's academic mentor. Neither the supervisor nor the mentor advised Miss A of the university's process for having mitigating circumstances taken into account. Miss A was dissatisfied with her final degree classification and, particularly, the mark awarded for her dissertation. Following advice on the university's website, she approached her mentor to seek information about appealing these decisions. The mentor told Miss A that she could not make a complaint or an appeal at that time, but that she could graduate and then appeal her degree classification. The mentor called Miss A shortly before the scheduled graduation to advise her that the information they had given her had been incorrect. A number of complaints and an appeal were then submitted, however, Miss A said that the mentor encouraged her to drop her appeal. In considering the appeal, the university identified that a number of procedural errors had occurred. The university decided that there were mitigating circumstances that had affected Miss A's final year but that they could not measure the impact this had on her academic performance, as only her dissertation had been affected. Mrs C then brought a complaint to us.

Mrs C complained that:

the university did not provide reasonable academic support to Miss A during her studies;

the university did not correctly signpost Miss A to the appropriate processes when she approached her dissertation supervisor with mitigating circumstances;

the university provided Miss A with inaccurate information regarding complaints and appeals;

Miss A's academic mentor inappropriately encouraged her to withdraw her appeal on the evening before, and the morning of, her year group's graduation;

the university did not consider Miss A's appeal in line with university procedures;

the university did not respond reasonably to the complaints lodged on Miss A's behalf; and

the university's conclusions on Miss A's appeal were unreasonable.

We found that the university had accepted that they had not provided reasonable academic support to Miss A during her studies and that they had not correctly signposted her to the appropriate processes when she approached her dissertation supervisor with mitigating circumstances. They also acknowledged that they had provided Miss A with inaccurate information regarding complaints and appeals and did not consider her appeal in line with relevant procedures. Therefore, we upheld these four complaints. Although the university identified these failures, they did not apologise to Miss A. Therefore, we also upheld Mrs C's complaint that the university did not respond reasonably to complaints lodged on Miss A's behalf.

In terms of the university's conclusions on Miss A's appeal, the university said that there was no evidence that the mitigating circumstances had impacted any area of her studies except her dissertation. However, they could not explain their reasoning for this. We considered that the university did not provide a reasonable explanation for this decision and, therefore, we upheld this complaint.

Finally, we found no evidence that the mentor had inappropriately encouraged Miss A to withdraw her appeal during phone conversations shortly before her year group's graduation ceremony. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for:
• the lack of academic mentoring provided to her during her studies;
• not alerting her to concerns about her work and well-being that were shared between the supervisor and the mentor;
• not reasonably signposting her to the university's mitigating circumstances process;
• not considering her appeal in line with the university procedures;
• not apologising for the failings identified by their consideration of her appeal; and
• not providing a reasonable explanation for their conclusion that they are unable to measure the impact of her mitigating circumstances on her dissertation.
• The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.
• Provide Miss C with the opportunity to have her appeal considered by separate mitigating circumstances and examination committees, with membership in line with relevant procedures.
• Provide Miss C with a reasonable explanation for their conclusion that they are unable to measure the impact of her mitigating circumstances on her dissertation.

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

• The university should review the responsibilities of supervisors and mentors to ensure that they include clearly advising and signposting students to appropriate support functions or processes.

In relation to complaints handling, we recommended:

• The university should take steps to ensure that any failings that are identified in appeal considerations are formally apologised for.

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 he was unreasonably discharged from the Royal Infirmary of Edinburgh following hip replacement surgery, as he was unable to pass urine and was constipated at the time of discharge. Mr C eventually had a catheter fitted and was advised by a consultant at the Western General Hospital that he would be put on a waiting list for transurethral resection of the prostate (a surgical procedure that involves cutting away a section of the prostate - a small gland in a man's pelvis located between the penis and bladder). Mr C complained that the board misled him about the date for his surgery and that they failed to carry out his operation within a reasonable time.

We took independent advice from a nurse. They said that it was appropriate for Mr C to be discharged from hospital, as his notes indicated that he was not experiencing any issues with passing urine or that his bowels were not working. Therefore, we did not uphold this part of the complaint. However, we noted that the board recognised they should have provided Mr C with oral laxatives on discharge and will take action to address this issue in future.

Based on the information available we did not consider that the board misled Mr C about the date for his surgery and we did not uphold this part of the complaint. However, we noted that the board had indicated that they had taken steps to try to ensure that in future, the medical team and their secretaries were kept notified of waiting times for procedures and we asked the board to provide evidence of this.

The adviser said that Mr C's surgery was completed outwith the 12 week treatment time guarantee and as the procedure was classified as 'urgent', this appeared unreasonable. The board explained the steps that they had taken to try to reduce the waiting times for patients and identify alternative providers and we asked for further evidence of this. We also found that there was poor communication between the board and Mr C regarding the delay in his surgery, advice and support available to him and in their handling of Mr C's complaint. Therefore, we upheld this part of Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the unreasonable delay in providing surgery, not discussing the advice and support available to him and for the communication error in complaints handling. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/leaflets-and-guidance.

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

• The board should inform patients as soon as possible of any inability to meet treatment targets and provide them with all the required information. This should include options available to them in the circumstances and how to provide comments/feedback or make a complaint about the delay.

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 an advocacy and support worker, complained on behalf of her client (Mrs B) about the care and treatment provided to Mrs B's son (Mr A) at the Royal Edinburgh Hospital. Mr A had a range of complex psychiatric and physical health conditions and spent long periods of time in hospital. Mr A's health deteriorated while he was in the hospital and he was transferred to another hospital for treatment and died the following day. Ms C complained that the board failed to provide Mr A with appropriate treatment for both his mental health and his physical health. She also complained that the board failed to respond appropriately to Mr A's deteriorating physical health in the two weeks leading up to his death.

We took independent medical advice from a psychiatrist, a mental health nurse, and a consultant in general medicine. We found that Mr A received appropriate mental health treatment and that the board had followed the relevant guidelines. We did not uphold this part of the complaint.

In terms of Mr A's physical health conditions, the psychiatric adviser said that a more systematic approach to assessing/managing Mr A's risk of infection should have been taken. We also found failings in Mr A's nursing care, including a failure to adequately complete charts to monitor his weight, food and fluid intake. We upheld this part of the complaint.

On the events leading up to Mr A's death, we found that his deteriorating physical condition was not responded to adequately, on occasion, by nursing staff and that there was a delay in requesting a medical review. Based on the evidence provided, we upheld the complaint. However, the advisers said that the remedial action taken by the board in relation to this part of the complaint was reasonable and we therefore had no further recommendation to make regarding this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs B and her family for the failings in care and treatment that Mr A received in hospital. 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:

• Charts used by nursing staff to monitor patients weight, nutritional screening and food and fluid intake should be completed in full and in line with organisational expectations.
• Nursing care should be effectively and transparently planned and evaluated.

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 on behalf of her husband (Mr A) who was treated for cancer at Aberdeen Royal Infirmary. Mrs C complained that there was a lack of communication about Mr A's care between the staff and his family and between the staff themselves. Mrs C also complained that Mr A was over-sedated which was causing periods of delirium and that his feeding and nutritional needs were not met.

We took independent advice from a nursing adviser and a consultant physician. We found that communication between hospital staff and Mr A's family and between hospital staff themselves was reasonable. However, Mrs C had raised concerns about Mr A having delirium and this was not appropriately acted upon in line with the Health Improvement Scotland (HIS) programme on identifying delirium in patients. On balance, we upheld this part of Mrs C's complaint.

In relation to over-sedation, the adviser said that the medication Mr A received is often accompanied by side effects and that it could have been a contributing factor to him developing a period of delirium. However, these side effects were not sufficient to say that Mr A's care was unreasonable or that he was over-sedated. Therefore, we did not uphold this aspect of Mrs C's complaint.

Finally, we found that Mr A was having difficulty eating and drinking and that this was due to damage to his mouth, a common consequence of the cancer treatment he was receiving. The adviser said that the hospital staff took reasonable steps to encourage and promote Mr A's nutritional care. There was evidence that Mr A had declined artificial feeding which would have improved his ability to eat. Therefore, we did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for not appropriately acting on her concerns raised about Mr A having delirium. 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:

• Ensure that staff are following the HIS programme by involving families or carers in identifying delirium in patients and in their use of assessment tools to identify delirium in patients.

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's mother (Miss A) had lung cancer which had spread to her brain. The steroid medication she was taking to alleviate the symptoms caused psychotic symptoms, requiring an admission to Dumfries and Galloway Royal Infirmary. One day when her family went to visit they were unable to find her. They subsequently found her in a stairwell, disorientated and upset. Miss C complained about the board's failure to ensure that Miss A did not leave the ward. She also complained that the board's complaints handling was unreasonable.

We took independent advice from a nursing adviser. The adviser highlighted the importance of the balance to be struck between weighing the risks of staff monitoring patients and promoting some independence and dignity. In their response to the complaint the board said that the ward was extremely busy and that, although staff did their best to ensure that vulnerable patients were monitored, they were extremely sorry and disappointed that on this occasion they were unable to prevent Miss A from leaving. We considered the board's response to the complaint to have been reasonable and did not consider that Miss A should have been under closer supervision. We did not uphold this aspect of Miss C's complaint.

We found the board's complaints handling to have been poor. The family's complaint was initially not taken forward because it was believed that Miss A's consent was required, and she lacked capacity to give consent. We found that the board failed to communicate their reasons for not taking the complaint forward, and did not investigate until the Patient Advice and Support Service became involved. We upheld this aspect of Miss C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failings in their 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.

In relation to complaints handling, we recommended:

• Complaints handling staff should be confident about when consent is required before a complaint can be investigated. In this instance, matters could have been investigated without the need for Miss A's consent.

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 council after her child (child A) returned from a school trip abroad badly sunburned, requiring a hospital stay. She complained that the council had failed to take reasonable steps to ensure that her child would not get sunburned, that reasonable action was not taken when the severity of child A's condition was established, and that her complaint had been handled unreasonably.

We found that a full risk assessment had been carried out and that pupils were reminded several times a day to administer sun protection. We considered that the council's actions aimed at preventing pupils from getting sunburned were reasonable, even though they were not effective in preventing child A from becoming sunburned. We were critical of a decision to allow the child to wear shorts and no sun protection when their legs were uncomfortable. The council said child A was only exposed to 30 minutes of sunlight on that occasion. With hindsight, we considered this to have been a poor decision, but we noted that sunburn was not yet suspected at that point and the main concern was the child's comfort. On balance, we did not uphold this aspect of Mrs C's complaint.

We found failings in the council's actions once the severity of the child's condition was known. Staff initially took advice from a pharmacist then later took the child to a local hospital. They took the advice of doctors at the hospital and also kept Mrs C and her husband informed until the group returned to the UK. We considered these steps to have been reasonable. However, the child was bandaged from thigh to toe and was unable to mobilise independently and in need of a wheelchair. The return journey home was 36 hours by coach. We considered that staff, who could see the condition child A was in, ought to have explored with Mrs C and her husband other options for getting child A home more quickly, taking into account the child's dignity, privacy and comfort. We upheld this aspect of the complaint.

We were critical of the council's complaints handling. We found that they failed to treat Mrs C's complaint as a formal complaint, and failed to advise her of the their complaints process. We also considered that their response to her was lacking in empathy. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the poor handling of 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.
• Apologise to Mrs C, her husband and child A for failing to explore other options for child A to travel home once the severity of their condition was established.

In relation to complaints handling, we recommended:

• The relevant staff should be reminded of the council's complaints handling procedure and re-familiarise themselves with how to apply it.
• Staff should be aware of the importance of providing an empathetic response 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.