Some upheld, recommendations

Summary

Miss C complained that the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed.

We took independent advice from a dental surgeon. The adviser explained that there are two different types of orthodontic referral, one for consultation and the other for actual treatment. The advice we received was that Miss C's initial appointment was to assess whether she met the criteria for orthodontic treatment. The adviser said that Miss C had not met the required criteria and, therefore, she had not been placed a waiting list for orthodontic treatment. The adviser said that this decision was reasonable. The adviser also said that the board's decision not to provide Miss C with orthodontic treatment in subsequent years was reasonable and was in keeping with relevant guidance. We found that, as a result, Miss C had not been put on a waiting list for orthodontic treatment, which we found was reasonable. As she had not been put on a waiting list, she could not have been told that she had been removed from such a list. Therefore, we did not uphold those aspects of Miss C's complaint.

However, we found it concerning that, over a period of several years, Miss C appeared to be under the impression that she had been placed on a waiting list for orthodontic treatment. The adviser commented that Miss C may not have understood that there were two different types of waiting lists and that she did not appear to have been informed about the option of private orthodontic treatment until she complained to the board. We considered that it is essential that a patient understands their treatment plan and that this did not appear to have happened in Miss C's case. For this reason, we upheld Miss C's complaint that the board had not provided her with a reasonable explanation of why she had been removed from the list.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss C for failing to appropriately communicate with her about her treatment and for failing to ensure that she fully understood her treatment plan, the different types of orthodontic waiting lists and the option of private orthodontic treatment. 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:

• Dental staff should explain to patients and ensure that they understand:
• their treatment plan
• the different types of orthodontic waiting lists
• the option of private orthodontic treatment when they are not entitled to NHS orthodontic treatment.

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's late partner (Ms A) was given drug treatment for multiple sclerosis (a condition which can affect the brain and/or spinal cord). During the treatment, Ms A experienced stomach pain. After this she was referred for tests and she was diagnosed with cancer. Ms A underwent surgery to treat the cancer, however her condition deteriorated after the surgery and she later died.

Ms C complained that Ms A was not appropriately monitored during her multiple sclerosis treatment. Ms C considered there was a delay in diagnosing the cancer and that cancer treatment options were not fully discussed with Ms A. In addition, Ms C complained that the risk of surgery was not fully explained to Ms A and that the decision to go ahead with the surgery was unreasonable. Ms C also had concerns about the nursing care Ms A received after the surgery and about how the board dealt with her complaint.

We took independent advice from a consultant neurologist, a consultant gynaecologist and a nurse. We found that Ms A was appropriately monitored during her multiple sclerosis treatment. We found that there was no unreasonable delay in diagnosing Ms A's cancer. We also found that the decision to proceed with surgery was appropriate and that the nursing care Ms A received afterwards was of a reasonable standard. Therefore, we did not uphold these aspects of Ms C's complaint.

However, we did find that the discussions with Ms A about the cancer treatment options available to her were not properly recorded. We found that the consent form she signed for the surgery did not document all of the risks. We also found that the board did not respond appropriately to all of the concerns that Ms A raised and that there were delays in investigating the complaint, which the board had acknowledged. Therefore, we upheld these aspects of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to properly document any discussions with Ms A about the cancer treatment options available. Also apologise that the consent form Ms A signed for the surgery did not document all of the risks. Also apologise for failing to appropriately address all of Ms C's concerns in their response to her complaint. These apologies 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:

• Every discussion with a patient about treatment options should be documented in the medical records.
• The risks of surgery discussed with a patient should be documented, in order to reduce the likelihood of a miscommunication or misunderstanding.

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, who is an advocacy and support worker, complained on behalf of her client (Miss A) about the clinical treatment Miss A received for her urinary problems. In particular, Miss C complained about the board's decision to withdraw support from community nursing services. Miss C also complained about a delay in actioning Miss A's request for a second opinion from the urology service.

We took independent advice from a consultant urologist. We found that a number of clinicians involved in Miss A's care had taken the decision to withdraw the support from community nursing services as the care being provided was no longer clinically appropriate. We found that there was no evidence of failings in the urology care provided to Miss A. We were also satisfied that Miss A's needs had been taken into account in arriving at the decision. As such, we did not uphold this aspect of Miss C's complaint.

We found that there had been a delay in actioning Miss A's request for a second opinion from urology services. We considered this to be unreasonable and we upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Miss A for the delay in actioning the request for a second opinion.

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

• Requests for second opinions should be actioned timeously.

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 palliative care and treatment provided to her late husband (Mr A) at Cowal Community Hospital. Mrs C highlighted concerns about the prescription of pain relief, arrangements for a blood transfusion and communication with the family. Mrs C particularly felt that meetings with staff had been misrepresented in his medical records. She also complained that the board had failed to handle her complaints reasonably.

As the doctors who cared for Mr A at the hospital were general practitioners, we took independent advice from a GP adviser. The advice we received was that Mr A's pain relief had been appropriately reviewed and adjusted, and that there had been no indication that a blood transfusion was necessary. We did not uphold these aspects of Mrs C's complaint.

We did not uphold Mrs C’s complaints about communication or meetings. We found evidence that there had been regular and appropriate communication with Mr A's family, although we acknowledged that Mrs C's recollection differed from that recorded in the medical notes and other records. The advice we received was that the actions taken by the board were reasonable, on the basis of what was recorded in the relevant records.

We upheld Mrs C's complaint about the way that the board had handled her complaint. We found that there was an inaccuracy in the final response around the timeframe of Mr A dying and the complaint being raised. We also found that an issue Mrs C had raised had not been fully addressed when the board responded to her concerns. We made two recommendations to address these issues, including one regarding the new model complaints handling procedure introduced in April 2017.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the complaints handling issues identified. 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:

• In keeping with the new complaints handling procedure, complaint responses should be accurate and address the points made by the complainant.

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 has a background of lupus (an autoimmune condition that affects the body's defences against illnesses and infections) had a tumour detected during a scan. Her case was discussed by the multi-disciplinary team (MDT) and she was given an appointment with an oncologist to discuss chemotherapy (a treatment where medicine is used to kill cancerous cells) and radiotherapy (a treatment using high-energy radiation). The oncologist was concerned that, due to her background of lupus, Mrs C could suffer significant side effects from this treatment. The oncologist asked for further discussion of the case at a second MDT, where the possibility of surgery was also discussed.

Following this, the oncologist outlined the options of surgery or oncology treatment (chemotherapy and radiotherapy) to Mrs C and Mrs C agreed to have surgery. The surgery was carried out, but did not remove enough of the tumour to give a good chance of a cure. Mrs C was then offered oncology treatment as well.

Mrs C complained to the board that she was not told before the surgery that there was a high risk that she would also need oncology treatment. She said that she would not have chosen to have major surgery if she had known that she might still need the full oncology treatment. The board took several months to respond to Mrs C's complaints, because the surgeon and oncologist disagreed about some parts of the response. Eventually, the response was sent without the surgeon's agreement. Mrs C remained dissatisfied and brought her complaints to us.

Mrs C complained that the communication with her about her condition and treatment options was unreasonable. She also complained that the care and treatment provided was unreasonable. We took independent oncology and surgical advice. We found that, whilst the oncology treatment carried a high risk of significant side effects, the surgery also carried a high risk of being unsuccessful, and Mrs C would then need the oncology treatment as well. We found that there was insufficient evidence that these two options had been fully explained to Mrs C. We also found that consent for the surgery had only been sought on the day of the operation, and there was no evidence that the risks of the surgery had been discussed with Mrs C before this point. We also found that there was an occasion where Mrs C could have been given an update on her pathology results more quickly. We upheld these two aspects of Mrs C's complaint.

Mrs C also complained that there were unreasonable delays in her treatment. We found that the timeframes were reasonable and that quicker treatment would not neccesarily have impacted on Mrs C's outcome. We did not uphold this aspect of Mrs C's complaint.

Mrs C also raised concerns about the board's handling of her complaint, and particularly raised concern that she was unable to contact the complaints team by phone at certain points. We found that the board's complaint response was delayed for several months, that they had misunderstood part of her complaint and that Mrs C was not kept updated in this time. We upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication, care and treatment and 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:

• Patients should be given full information about all their options before deciding on a treatment.
• Consent should not be sought on the day of surgery, unless there is an emergency situation.
• Consultants should be mindful of the need to communicate clearly and avoid misunderstandings.
• Patients should be fully informed and kept up to date on information relevant to their illness. Information should not be withheld unless they specifically request this, or if there is a potential risk of harm.
• In a similar situation, surgery should not be offered as a first line treatment without a full discussion of the multi-disciplinary team's views (both for and against) and options with the patient.

In relation to complaints handling, we recommended:

• The board should have a clear process for escalating disagreements about complaints responses, with senior management involvement, to ensure a whole-of-board response to the complaint.
• The board should contact the complainant to confirm the issues complained about as the first step in their investigation, in line with the Model Complaints Handling Procedure.
• The complaints team should be contactable by phone, with the facility to leave a message if there are no staff available.

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 mother (Mrs A) at Queen Elizabeth University Hospital. Mrs A was admitted to hospital with an infection in her knee. During the admission, Mrs A sustained an injury to her calf area whilst nursing staff were moving her to sit on the side of the bed. The day following the injury, a doctor inaccurately informed one of Mrs A's daughters that the injury was the result of a fall. Over the following days, Mrs A's condition deteriorated and she died.

Mrs C raised concern that nursing staff did not take appropriate steps to prevent her mother from sustaining an injury. We found that the board had completed an incident report for the injury which noted that Mrs A's skin was very fragile and concluded that nursing staff had provided appropriate care such that the injury was unavoidable. We took independent advice from a nursing adviser. We were satisfied that appropriate falls risk assessments had been carried out during the admission and we considered that the actions of nursing staff were reasonable and in keeping with the board's moving and handling policy. The nursing adviser agreed with the conclusion of the board's incident report, and we were unable to conclude that nursing staff failed to take appropriate steps to prevent the injury. We did not uphold this aspect of Mrs C's complaint.

Mrs C also raised concern about the way staff communicated with the family about the injury and the level of information provided about Mrs A's condition over the following days prior to her death. We took independent advice from the nursing adviser, as well as an adviser in general medicine. We found that the family were not told about the injury until the following day. The board said that this was because Mrs A wished to tell her family of the injury herself, yet we did not find evidence that Mrs A had stated this. When one of Mrs A's daughters was contacted, we found that a doctor provided inaccurate information about what had happened to Mrs A. We found that this should not have happened given that the injury was documented accurately in the nursing notes.

We also considered that there was evidence of a delay in recognising and responding to a deterioration in Mrs A's condition. The medical adviser was unable to conclude that Mrs A would have survived her illness if she received better care, however they did consider that the care was unreasonable. The medical adviser noted that the family did not seem prepared for Mrs A's death. The medical adviser was satisfied that the consultant did try to communicate that Mrs A might deteriorate further and that death was a possibility, but found that they may not have been quite explicit or clear enough when doing so. On balance, we upheld Mrs C's complaint about communication.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and her family for failing to immediately inform the family that Mrs A had sustained an injury and for the delay in recognising and responding to a deterioration in Mrs A's condition. 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:

• In a similar situation staff should promptly contact family members or significant others (as appropriate), in line with the protocol for informing next of kin when a serious incident occurs. If a patient states that they wish to inform their family of an incident themselves, this should be documented in the records.
• Medical staff should be aware of information documented in the nursing records when providing patients and their families with information about their condition.
• Staff should ensure that deteriorations are recognised promptly and should be aware of how to respond.

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 (Mr A) who underwent knee replacement surgery at Royal Alexandra Hospital. Following the operation, Mr A experienced a number of complications and continued to feel pain and discomfort.

Ms C complained that Mr A was not informed about the risks and complications of the procedure, including the possible outcomes. The board said that there were four interactions with Mr A prior to the surgery and that these interactions focussed on the need for, undertaking of and preparation for surgery. The board considered that this would have afforded the space and time to offer information and to answer any concerns that Mr A had. We took independent advice from a consultant orthopaedic surgeon. Whilst we noted that a consent form for surgery had been signed by Mr A, the adviser did not find evidence that the benefits and risks of surgery had been explained to Mr A. We were unable to conclude that Mr A was given the information he needed to understand the procedure and its risks in order to make an informed decision to consent to the treatment offered. We upheld this complaint and recommended that the board apologise for this failing. However, we noted that the board had since updated their consent form and consent procedure and we were satisfied that appropriate steps had been taken to try and prevent the same failing from happening again. Therefore, we did not make any further recommendations in connection to this.

Ms C also complained that the surgery provided to Mr A was not reasonable. The adviser explained that the complications Mr A experienced following the surgery were recognised complications of the procedure. The adviser did not find evidence of failings in the surgery performed on Mr A and we did not uphold this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to obtain informed consent for the procedure. 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.

Summary

Mr and Ms C complained about the care and treatment that their daughter (Miss A) received from the board's Child and Adult Mental Health Services (CAMHS) and other agencies, which they believed to be inadequate and ineffective in terms of assisting her recovery from bipolar disorder. Specifically, the issues related to the provision of psychiatric treatment; the provision of adequate specialist services; a delay in a referral to another clinical specialist; delays in the board preparing a detailed care plan and delays in conducting a case review.

We took independent advice from a consultant psychiatrist and from a registered nurse. We considered that Miss A was provided with appropriate psychiatric care and had been offered therapies and interventions in line with national guidance. There was also evidence to show that efforts had been made to address difficulties that were the result of changes to staff and therapeutic approaches. We did not uphold the complaint about the provision of psychiatric treatment.

We noted that the board had accepted that the approach of outreach interventions in combination with clinic appointments had not resulted in a more consistent delivery of treatment options or an improved outcome. As a result of this, they had recommended a review of Miss A's care along with compiling a detailed written care plan. We found that there had been a lack of consistency, frequency and attendance at certain appointments. We upheld Mr and Ms C's complaint about the provision of specialist services.

In terms of the referral to another clinical specialist, we did not identify any unreasonable delay in this taking place because an appointment was offered within the national waiting time target. We did not uphold this aspect of the complaint.

Although the board had agreed to review Miss A's care and compile a written care plan, we upheld these aspects of the complaint and made further recommendations because we found that there had been an unreasonable delay in the board completing these to ensure the same issues do not happen again.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr and Mrs C and Miss A for the delay in compiling a written plan and conducting a formal review. The apology should meet the standards set out in the SPSO guidelines on apology available at https:www.spso.org.uk/leafletsand-guidance.

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

• In similar cases there should be a written care plan and agreed action, such as conducting a formal review, undertaken in a timely manner.

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) when he was admitted to the Queen Elizabeth Hospital for surgery to treat prostate cancer. In particular, she complained that the board unreasonably failed to identify possible complications of the surgery given Mr A's medical history. We took independent advice from a consultant urological surgeon. We found that the decision to offer the surgery to Mr A had been thought through in detail, and that every effort had been made to minimise the risk of bowel damage when carrying out the surgery. We also found that the consent form signed by Mr A referred to specific risks and complications associated with the surgery. Whilst we were concerned about aspects of record-keeping, the advice we received from the consultant urological surgeon was that, in recognising the possible complications of the surgery, the clinicians caring for Mr A had taken into account his medical history. We did not uphold this complaint.

Mrs C also complained about the nursing care and treatment Mr A received. We took independent nursing advice. We found that the nursing records were comprehensive and detailed and highlighted that the nursing care Mr A received was reasonable. As such, we did not uphold the complaint.

Mrs C also raised concern that the board had failed to identify the deterioration of Mr A's condition as early as they should have. We found that there was a delay in medical staff reviewing Mr A, and that consultant input should have been sought when Mr A's condition deteriorated. We also found that the level of communication with Mrs C was unreasonable when Mr A's condition deteriorated and there was a possibility of transfer to intensive care. In view of the failings identified we upheld this complaint.

Mrs C also complained that the board failed to provide a reasonable standard of treatment when complications were identified. We found that the clinicians caring for Mr A failed to acknowledge or act on a scan and x-ray finding in a timely manner, and as a result failed to recognise there was a possible bowel perforation. We upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Make a formal apology to Mrs C for the shortcomings identified in relation to the care and treatment Mr A received.

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

• Relatives should be informed when a patient deteriorates.
• There should be appropriate escalation of deteriorating patients.
• There should be a system for communicating and acting on urgent results by clinicians in the relevant departments.

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 her late mother (Mrs A) received at Aberdeen Royal Infirmary. In particular, Ms C complained that her mother was not given appropriate treatment at A&E in response to her symptoms. Ms C also considered that her mother should have been transferred to the high dependency unit when her condition deteriorated. Ms C complained that nurses delayed in administering antibiotics and failed to monitor her mother closely enough. Mrs A died of sepsis (a blood infection) several hours after her admission. The board accepted an unreasonable delay in nursing staff administering antibiotics, but considered the care to have been otherwise reasonable.

During our investigation we took independent medical advice from a consultant in emergency medicine and from a nurse. The emergency medicine adviser considered that the standard of medical care and treatment at A&E was of a high standard. They also considered that it was reasonable not to transfer Mrs A to the high dependency unit as her outlook was poor, given her age, the severity of her symptoms and her pre-existing condition. The nursing adviser considered Mrs A was appropriately monitored by nursing staff. We therefore did not uphold these aspects of Ms C's complaint. However, both advisers considered there was an unreasonable delay in nursing staff administering antibiotics, although they considered that this was unlikely to have made any difference to Mrs A's condition. We upheld this aspect of the complaint and we made a recommendation in light of our findings.

Recommendations

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

• Antibiotics should be administered by nursing staff within the agreed 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.