Some upheld, recommendations

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.

Summary

Mrs C complained about the care and treatment provided to her late mother (Mrs A) by the practice. In particular, she complained that Mrs A had not been seen by a medical professional before antibiotics were prescribed to her, and, futher, that she had not been seen when the antibiotics were subsequently changed.

We took independent advice from an advanced nurse practitioner. We found that a home visit should have been carried out before the antibiotics were prescribed to Mrs A and that, as such a visit did not take place, it was even more important that a review should have been undertaken of Mrs A before her antibiotics were changed. The advice we received was that there was a lack of detail in the clinical records and that it was not clear from the records what symptoms Mrs A had when the decision to change antibiotics was made. We were concerned that the practice had failed to follow guidelines that all older patients suspected of having a urinary tract infection, like Mrs A was, should be seen and fully examined. In light of these failings, we upheld this aspect of Mrs C's complaint.

Mrs C also complained that the practice had inappropriately decided not to undertake a home visit after she had contacted them a number of times. We found that, when the visit was requested, Mrs A had deteriorated and she needed to be seen or arrangements needed to be made for admission to hospital. We also found that, whilst reasonable advice had been given to Mrs C to contact the ambulance service if Mrs A's condition deteriorated, there was a delay in this advice being given to Mrs C. The practice accepted that a home visit should have been carried out. We upheld this aspect of Mrs C's complaint.

Finally, Mrs C complained that the member of staff she was complaining about had responded to her complaint. We found that neither the Scottish Government guidance on complaints handing which was in place at the time of the complaint, or the new NHS Scotland model complaints handling procedure introduced since the complaint was made, specified that the person being complained about should not handle a complaint. In view of this, we did not uphold this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in relation to the clinical treatment provided to Mrs A and for the failure to carry out home visits.

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

• The practice should follow guidelines in relation to diagnosing urinary tract infections in adults aged 65 and over.
• The practice should maintain records in line with relevant guidelines.

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 of her late mother (Mrs A), initially by an out-of-hours doctor and then following an admission to Aberdeen Royal Infirmary. The out-of-hours doctor visited when Mrs A became unwell and diagnosed infection, prescribing antibiotics. Two days later Mrs A was admitted by her GP to a GP unit in a local care home. From there she was admitted to hospital in the early hours of the following morning with sepsis (a blood infection) secondary to pneumonia. After an initial improvement, she deteriorated and died five days later.

Mrs C complained that the out-of-hours doctor should have admitted her mother to hospital. We took independent advice from a GP adviser, who considered that the doctor appropriately assessed Mrs A and treated her in line with relevant guidelines. We were advised that there were no clear signs at the time that might reasonably have led the doctor to suspect a diagnosis of pneumonia and necessity for hospital admission. We accepted this advice and did not uphold the complaint.

Mrs C also complained that the family were told by hospital staff to administer Mrs A's regular medication from her own supply, and also that there was a 12 hour delay in commencing treatment for her presenting condition. We took independent advice from a hospital adviser, who confirmed that it was not good practice to expect relatives to administer medication. However, the board had already acknowledged this and appropriately highlighted the issue to staff. The adviser noted that the medication was appropriately recorded so no safety issues were apparent. In terms of treating Mrs A's presenting condition, the adviser noted that she had a NEWS score (an aggregate of a patient's 'vital signs' such as temperature, oxygen level, blood pressure, respiratory rate and heart rate which helps alert clinicians to acute illness and deterioration. A NEWS score of five or more is linked to increased likelihood of death or admission to an intensive care unit ) of seven on admission. This elevated score should have prompted early recognition of the severity of the illness and more timely treatment. The adviser considered that a 12 hour delay in commencing antibiotics was unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the unreasonable delay in commencing antibiotic treatment following Mrs A's admission. The apology should meet the standards set out in the SPSO guidelines on apology available at: https://www.spso.org.uk/leaflets-and-guidance.

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

• Patients with an elevated NEWS score should be promptly investigated and treated.

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

After the birth of her child at Borders General Hospital, Mrs C made a number of complaints about the procedures involved. She said that there was a failure to obtain properly informed consent for intimate examinations and that the board provided incorrect information about who had acted as a chaperone. She also complained that the board did not ensure that she was anaesthetised by an anaesthetist of sufficient seniority given that she had scoliosis (a musculoskeletal disorder in which there is a sideways curvature of the spine). Mrs C also complained that she and her new born baby were not given reasonable nursing care when she was in hospital.

The board said that they had followed their usual practice of obtaining implied consent to treatment set against a background of the clinical care they had already given. They also said that they had provided the correct name of the chaperone as requested and that Mrs C's spinal injection had been performed by both a consultant and a senior trainee. They were also of the view that Mrs C's nursing care had been reasonable.

We took independent advice from a consultant in obstetrics and gynaecology and a consultant in obstetrics and general anaesthesia. We also took independent nursing advice. We found that implied consent was insufficient for intimate examinations and that consent must be recorded in patients' notes. It was not recorded in Mrs C's notes and, therefore, we upheld this complaint.

Regarding Mrs C's other complaints, we found evidence in the notes to confirm who had acted as chaperone and we found that Mrs C had been given her anaesthetic reasonably by clinicians of appropriate seniority and expertise. We found no evidence of unreasonable nursing care. As such, we did not uphold these aspects of Mrs C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise for failing to seek formal consent for intimate examinations.

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

• The board should develop a guideline on consent for intimate examinations and the use of chaperones, with reference to national guidance, including documentation.

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 is the secretary for a business. Mr C complained that Business Stream had failed to notify the business of their increased water usage, that they had failed to properly investigate the cause of the issue and that they did not deal with his complaint in line with their procedures.

We found that, once they had become aware of the high water usage, Business Stream did make appropriate contact with the business to alert them of this. We received evidence of the call that was made to the business, and we also noted that the business received invoices that illustrated high meter readings. We also found that Business Stream took appropriate action in investigating the cause of the leak, in line with their responsibilities, and that they contacted Scottish Water to investigate the issue further when it was appropriate. We did not uphold these aspects of Mr C's complaint.

However, we found that Business Stream did not advise Mr C clearly of his rights to escalate his complaint to stage two of the complaints procedure. We also found that they failed to issue Mr C with a final response to his complaint. We, therefore, upheld this part of Mr C's complaint.

Recommendations

In relation to complaints handling, we recommended:

• Communication regarding a customer's complaint should clearly explain the stage at which the customer's complaint is being handled. Staff should also ensure that customers have received a final response to their complaint before referring them to SPSO.

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 way that the Scottish Prison Service (SPS) managed his prison sentence. Specifically, he complained about a delay in referring him back to the risk management team (RMT) to consider his suitability for progression to less secure conditions. Mr C was not referred back to the RMT until around two months after the planned date. The reason for this was that the RMT required his home leave report but this was not complete, as there had been a delay in the SPS sending it to social work for comment. The SPS explained that this was because Mr C's personal officer chose to wait on the outcome of Mr C's parole hearing, when in fact the home leave report should have been sent six weeks prior to completion of his management plan, which was completed ahead of his parole hearing. The SPS had already acknowledged and apologised for the inappropriate delay in referring Mr C back to the RMT. We agreed that this delay had potentially delayed Mr C's progression to less secure conditions by around two months. We upheld this aspect of the complaint.

Mr C also complained that the SPS failed to respond to his complaint within the timescales laid down in the prison rules. These allow 20 working days for a written response to be issued but, in Mr C's case, the response was delayed by over two weeks beyond this timeframe. We upheld this aspect of the complaint.

Mr C subsequently made an additional complaint directly to the prison governor, via the confidential complaints process. The governor did not investigate the matter as they did not consider the subject of the complaint to be confidential in nature. Mr C complained to us that the governor unreasonably refused to accept his confidential complaint. We noted that this was a matter for the governor's discretion. In any event, we considered that the governor had already arranged to have the subject of the complaint appropriately considered when it was brought to their attention via Mr C's previous (non-confidential) complaint. 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 the delay in responding to his complaint.

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

• Home leave reports should be submitted to social work 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.