Some upheld, recommendations

Summary

Mrs C complained that the council had unreasonably failed to act in line with their responsibilities in overseeing a programme of works that was carried out on her home by a third party company. Mrs C considered that the works carried out at her home had not been done to a reasonable standard and also complained that the council had not handled her complaint about this appropriately.

After investigating Mrs C's concerns about oversight of the programme of works, we did not uphold her complaint about this. We found that the council had used a managing agent to oversee the programme of works and that there was evidence that a supervisory service was provided by them. While the council had no liability or responsibility for the works, we found that when issues arose at Mrs C's property, they took an active co-ordination role to work towards resolving these.

We did, however, uphold Mrs C's complaint about the way the council had handled her complaint. We found that the council accepted that Mrs C's initial complaint had not been dealt with appropriately in terms of their complaints handling procedure. We also found that Mrs C had not received a response to her complaint within the prescribed timescales and that, while she had been contacted about the delay, a revised timescale was not offered. This was not in line with the council's complaints handling procedure. We made recommendations to address these issues.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in complaints handling. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints should be handled in line with the complaints handling procedure. Any revised timescale should be agreed with the complainant or approved by senior staff in line with the policy and the reasons for this explained to 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 complained about the care and treatment that was provided to her following her admission to Ninewells Hospital for induction of labour. Mrs C complained that the midwifery care around her induction, labour and birth was unreasonable. She also complained about the way the board handled her complaints.

During the birth, Mrs C's baby became stuck after delivery of the head due to shoulder dystocia (where one of the shoulders becomes trapped behind the mother's pubic bone) and additional help had to be called to assist the midwife who was attending to her. The baby was delivered following this, but died a few days after the birth.

After Mrs C raised her complaints with the board, they carried out a local adverse event review and also had an external review conducted by a senior midwife from another NHS board area. These reviews identified some failings with regards to aspects of Mrs C's care. However, it was found that these failings did not affect the outcome, which was considered to be unavoidable.

After taking independent advice from a midwife, we upheld Mrs C's complaint about the induction of her labour. We found that there had been delays which affected her access to pain relief and that there had been poor communication. We did not make any recommendations relating to this as these failings had already been addressed by the board.

We also upheld Mrs C's complaint about her care during labour. We found that the board had already identified issues, including the way that examinations were carried out to monitor Mrs C's progress. The advice we received highlighted further concerns about monitoring of blood pressure and listening to and recording Mrs C's preferences during labour. We made recommendations to address these matters.

We did not uphold Mrs C's complaint about the care that was provided to her during the birth of her baby. The advice we received was that this care was timely and that the shoulder dystocia could not have been identified earlier or avoided.

We upheld Mrs C's complaint about the way her complaint was handled by the board. We found that the timescale for completing the investigation of her complaint had not been met and that Mrs C had not been kept updated during the process. We made a recommendation in relation to this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to provide reasonable care during induction and labour, and for failing to handle her complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should be listened to. Their preferences and concerns should be responded to. Clear and accurate records of this should be kept.
• Blood pressure should be recorded in line with national 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 underwent a pubovaginal sling procedure (a surgical procedure used to manage urinary incontinence) and a cystoscopy (a bladder examination using a narrow tube-like telescopic camera) to address her stress incontinence. She was reviewed a few months later, and she reported a loss of sensation and significant distress about the appearance of her scars. She was referred to plastic surgery to see if anything could be done about the scarring.

Mrs C complained to the board about her treatment, and one month later she was advised that her complaint had been forwarded for investigation. Five months later Mrs C wrote to the board to raise concerns about the long wait for a response to her complaint. Upon receiving Mrs C's letter, the board discovered that her complaint had inadvertently been closed five months previously. Some weeks later, the board phoned Mrs C to explain that the complaint had been inadvertently closed and to discuss Mrs C's concerns about the delay in responding and her concerns about her treatment. The board then referred Mrs C to a different consultant urologist, and agreed that they would look into why the complaint had been closed. They also suggested that they would arrange an external review of the case, and they said that they would update Mrs C when they had further information. Despite phoning several times over a period of a further four months, Mrs C heard nothing from the board about her complaint. When she did manage to speak to the board again Mrs C asked to be sent a letter with the findings of the board's investigations. Mrs C did not receive a letter, and she then brought her complaints to us.

Mrs C complained to us about the medical treatment she received and the board's handling of her complaint. We took independent advice from a urologist. We found that the treatment that had been carried out was reasonable, and that it had achieved the outcome of restoring continence, even though there were some problems with loss of sensation. We found that Mrs C's scarring was considered to lie within the bounds of what can be seen following the types of surgery she had underwent. We did not uphold Mrs C's complaint about her treatment.

We were highly critical of the board's complaints handling. We found that there were delays, and that some of the board's communication with Mrs C about her complaint was misleading. We found that the board failed to investigate her complaint as agreed. We upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for closing Mrs C's complaint in error, for including misleading information in their communication with Mrs C and for failing to investigate her complaint as agreed. This apology should comply with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Complaints handling staff should ensure that complaints are not closed unless there is clear evidence that this is the correct course of action.
• Key staff should receive refresher training in complaints handling, in particular in relation to managing the expectations of complainants.

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, who is a solicitor, complained on behalf of his client (Mrs B) about the care and treatment provided to Mrs B's late brother (Mr A) during three admissions to Monklands Hospital in the months leading up to his death. Mr A suffered from alcohol liver disease and hepatic encephalopathy (a deterioration of brain function due to liver failure). Mr C complained that the medical care and treatment provided to Mr A was not of a reasonable standard, that the nursing care was unreasonable, that the communication with the family was poor and that the board failed to adequately investigate and respond to complaints.

Regarding medical care and treatment, the family were particularly concerned that Mr A had been discharged following his second admission when they felt he was not medically fit to be discharged. We took independent advice from a consultant physician and from a senior nurse. We found that Mr A's fitness was appropriately assessed at that time. We also found that, while on the whole Mr A received a reasonable standard of care and treatment, there were some failings in medical care and record-keeping. Specifically, we noted that a final discharge summary was not completed following Mr A's first admission, and that the actual date of discharge was not clear from the notes. We also found that, when Mr A suffered a fall overnight, he was not reviewed by a doctor until the following afternoon. The advice we received was that this review should have happened in the morning. We were also critical that, when this review did take place, the doctor who reviewed Mr A failed to document this assessment. The family had also expressed concerns about Mr A's weight loss and the board had said that this was due to deliberate fluid loss. Whilst we found that deliberate fluid loss was a factor, we considered that there was also a nutritional element that should have been acted upon sooner. In light of these failings, we upheld Mr C's complaint about medical care and treatment.

Mr C raised several concerns about the nursing care and treatment provided to Mr A. We identified that nursing staff had failed to make medical staff aware of a vomiting episode on the morning of Mr A's discharge following his second admission which, had it been shared, may have influenced the medical staff's thinking when assessing Mr A's fitness for discharge. However, we found that this appeared to be an isolated failing, which the board had already acknowledged and apologised for. The family had also been concerned that an appropriate package of home care was not in place for Mr A following his second discharge. We found that adequate arrangements were made, and we noted that responsibility for the delivery of these arrangements lay with social services and not the board. We did not uphold Mr C's complaint about nursing care.

In terms of communication, we found inconsistencies and a lack of clarity in the information conveyed to the family about the seriousness of Mr A's condition. We found that the language used may not have helped the family to fully understand that Mr A's illness was terminal. The family had also raised concerns that their repeated requests to speak to another consultant were not actioned. The board had noted that these requests did not appear to have been passed on, and they had agreed to implement a process to document requests for meetings with medical staff in the future. Overall, we concluded that the communication with the family was not of a reasonable standard and we upheld this complaint.

In relation to complaints handling, we considered that the board could have responded in more detail and could have provided clearer explanations in some instances. However, given the complexity of the complaint and the significant number of issues raised, we were satisfied that, on the whole, the board's response was reasonable and proportionate, and that considerable time and effort had been spent attempting to address the family's concerns. On balance, 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 A's family for the identified failings in relation to medical care and treatment, medical record-keeping and communication.

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

• Patient discharge dates should be clearly recorded in the clinical notes.
• Medical reviews should take place within a reasonable timeframe following patient falls.
• Medical reviews should be documented in patient records.
• Medical staff should ensure they remain aware of patients' nutritional status and take appropriate action to address any identified malnutrition.
• Consistent information should be provided, and clear language should be used, when communicating with patients and their relatives regarding the patient's condition and prognosis.

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 Raigmore Hospital over a number of months leading up to his death. In particular, she said that his medical care was poor. Mrs C said that, despite his many illnesses and poor prognosis, Mr A underwent surgery which may have extended his life but that this was at the expense of his quality of life. She also raised concerns about the nursing care provided to Mr A and complained that the communication with herself and Mr A about his illnesses was not clear.

We took independent advice from a consultant surgeon and from a nurse. We found that Mr A's medical care and treatment had been in keeping with standard practice in Scotland. We found that his care had been fully discussed with him and that he had agreed to the treatments he was given. Accordingly, we did not uphold this aspect of Mrs C's complaint. Similarly, we did not uphold Mrs C's complaint about poor communication as there was evidence to show that matters had been fully discussed with Mr A and Mrs C. However, we found that Mr A's nursing care had not been reasonable as we found that the notes kept were poor and were not completed in accordance with the Nursing and Midwifery Council code. We upheld this part of the complaint.

Recommendations

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

• Documentation should be completed as required in accordance with the Nursing and Midwifery Council code.

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 a number of aspects of the care and treatment provided to her late mother (Mrs A) during two admissions to Queen Elizabeth University Hospital. Ms C complained that the standard of clinical care and treatment provided to her mother was not reasonable. Ms C also complained that the nursing care provided to Mrs A was not reasonable. Ms C's third concern was regarding the board's communication with Mrs A and the family during the admissions.

We took independent advice from a cardiologist and a nursing adviser. We found that the clinical care and treatment provided to Mrs A was reasonable. We found that the medications prescribed were appropriate and that Mrs A was reasonably reviewed. Whilst there was a failure to refer Mrs A to a heart failure nurse when she was discharged, we found that this was picked up at a later out-patient appointment and that an earlier follow up would not have impacted on Mrs A's treatment. We did not uphold this aspect of Ms C's complaint.

With regards to nursing care, we found that, whilst for the most part the nursing care was reasonable, the fluid balance charts were not always complete. We found this to be unreasonable and we upheld this aspect of Ms C's complaint.

Finally, based on the records available, we found that the board's communication with Mrs A and the family was reasonable. We did not uphold this aspect of Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for failing to complete fluid balance charting.

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

• Nursing staff should complete all care rounding charts, including fluid balance charts, as required.

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

Summary

Mrs C complained to us about the care and treatment provided to her late husband (Mr A) at the Victoria Infirmary. Mr A had been referred to the board for investigation of macroscopic (visible) haematuria (blood in urine). Mr A had subsequently died from cancer of the bladder.

Mrs C complained that a discharge letter inappropriately referred to Mr A as having been treated for microscopic (non-visible) haematuria. We found that the letter did incorrectly say that Mr A had undergone a cystoscopy (a procedure to look inside the bladder using a thin camera) for microscopic haematuria instead of macroscopic haematuria. The board said that this had been due to a typing error. We upheld the complaint and recommended that the board apologise to Mrs C for this. However, we noted that the investigations that had been carried out where appropriate for a man presenting with macroscopic haematuria and that this typing error had not impacted on Mr A's care.

Mrs C also complained that the board failed to carry out a CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) at the time that Mr A underwent the cystoscopy. We took independent advice from a consultant urologist and we found that there had been no requirement at that time for the board to carry out a CT scan. We did not uphold this aspect of Mrs C's complaint.

Mrs C also complained that the board's response to her complaint had incorrectly stated that there had been no subsequent contact between Mr A's GP practice and the hospital after Mr A's cystoscopy. Mrs C provided evidence which showed that the GP practice had phoned the hospital after Mr A's cystoscopy to report that there was still blood in Mr A's urine. We found that, in line with the relevant guidance, this should have prompted the board to request a CT scan at that time. However, we found that even if a CT scan had been carried out, it was unlikely that Mr A's outcome would have been significantly different. Due to the evidence we saw that there had been contact between the GP and the hospital, we upheld this aspect of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the incorrect information on the discharge letter which inappropriately referred to microscopic haematuria. Also apologise for incorrectly stating in the complaints response that there was no subsequent contact from Mr A's GP practice after the cystoscopy. These apologies should be in line with SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

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

• When a GP surgery contacts a hospital with additional information, it should be recorded and acted on.

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 (Ms B) about the care and treatment provided to Ms B's daughter (Miss A) in the final months of Miss A's life. Miss A had Fanconi anaemia (a genetic disease that can lead to bone marrow failure and cancer) and had a complex medical history of complications following a bone marrow transplant. Miss A received treatment at the Beatson West of Scotland Cancer Centre over a number of admissions. She was treated for numerous health issues, including a bowel condition.

Ms C raised concerns that staff failed to inform the family of the severity of Miss A's bowel condition. We took independent advice from a consultant haematologist and from a registered nurse. We were unable to find evidence that staff had discussed with Miss A, or Ms B, the severity of Miss A's bowel condition. We concluded that communication with the family was poor and we upheld this complaint.

Ms C also complained that the board did not provide a reasonable standard of treatment during Miss A's final admission. We found that the treatment provided for Miss A was in line with the relevant guidance, but the advice we received was that no consideration appeared to have been given to the fact that Miss A was dying and needed palliative therapy to keep her comfortable. We found that this was unreasonable and we upheld this complaint.

Ms C also raised concern that the board did not make reasonable transport arrangements when Miss A was discharged on one occasion when she became unwell in the car of a volunteer driver. We found that Miss A was noted to be well prior to discharge, and that it seemed that she became suddenly unwell during the journey. We were satisfied that the transport arrangements in place were reasonable and we did not uphold this complaint.

Finally, Ms C complained that the board refused to admit Miss A on one occasion when Ms B called the hospital in the early hours of the morning. The advice we received noted that Miss A was advised to attend the clinic later that day, but to call back if she became more unwell. The adviser did not find evidence that admission was requested and considered that the board's advice in this situation was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise for the failure to communicate with Ms B and Miss A reasonably about the severity of Miss A's bowel condition and for the failure to provide palliative care and support to Miss A at the end of her life. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.

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

• Patients should be provided with any information on their condition that they want or need to know in a way that they can understand. This should be communicated in a way that is considerate to those close to the patient. Staff should be sensitive and responsive in giving patients and families information and support. Communication with patients and their family members should be documented.
• Patients who are approaching the end of their life should receive high-quality treatment and care that supports them to live as well as possible until they die, and they should be supported to die with dignity.

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 given to her late husband (Mr A) when he attended the out-of-hours primary care emergency centre at the Victoria Ambulatory Care Hospital. He was discharged home but a few days later was admitted to the emergency department of Queen Elizabeth University Hospital, where he was treated for a severe chest infection with possible underlying heart problems. After some hours Mr A's condition was considered to be near to death and it was indicated that he was suffering from aortic stenosis (a narrowing of the left ventricle of the heart, which can cause problems such as heart failure) and fluid on his lungs. Mr A was later transferred to the medical high dependency unit where he was reviewed and underwent numerous tests. He was then transferred to the intensive care unit, where he later died.

Mrs C complained to the board and when she remained unhappy with their response she brought her complaints to us. Mrs C complained to us that:

the assessment of Mr A at the out-of-hours service was unreasonable

the care and treatment provided to Mr A at Queen Elizabeth University Hospital was unreasonable

the communication with herself, Mr A, and the family during Mr A's admission was poor

the board failed to respond fully to her complaints.

We took independent advice from a nurse practitioner and from consultants in emergency medicine and cardiology. We found that Mr A had been reasonably and appropriately assessed at the out-of-hours service and we did not uphold this aspect of the complaint.

We found that it would have been better if Mr A had been seen and assessed by the cardiologist shortly after his admission to Queen Elizabeth University Hospital, rather than the cardiologist only speaking to the emergency medicine team on the phone, which is what had happened. A face-to-face assessment would have allowed for a better assessment, and for a discussion with Mr A and Mrs C about Mr A's symptoms, treatment and prognosis. We also found that opportunities were missed to keep Mrs C updated on Mr A's condition. As such, we upheld Mrs C's complaints about the care and treatment provided to Mr A, and about the communication with the family.

With regards to the board's complaints handling, we found that the board addressed all of the concerns that were raised with them. We were satisfied that the responses were provided promptly and with appropriate detail. We did not uphold Mrs C's complaint about the board's complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise that a cardiologist did not see Mr A sooner. The apology should meet the standards set out in the SPSO guidelines on an apology available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for missing opportunities to keep Mrs C fully updated on Mr A's condition.

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

• In cases of aortic stenosis, a cardiologist should assess and physically examine the patient as soon as possible.
• Relatives should be updated on their family member's condition and care.

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

Summary

Mrs C complained about the care and treatment that staff at Forth Valley Royal Hospital provided to her over a number of years.

Mrs C was seen by the board's consultant orthopaedic surgeon and elected to have knee replacement surgery. She experienced some pain and discomfort following the surgery, and was seen during this time by an orthopaedic nurse. Approximately three years later, Mrs C continued to experience pain and discomfort and was then seen by two additional consultant orthopaedic surgeons.

Mrs C raised concerns that the knee replacement surgery was carried out inadequately as she felt that the board had provided her with a knee prosthesis that was too small. She also raised concerns about the monitoring that the board provided following her surgery. She also complained about the level of care and treatment that the board provided when she was seen by consultant orthopaedic surgeons over the following years.

We took independent advice from a consultant orthopaedic surgeon. We found that there was no evidence from the records and x-rays that the prosthesis was the wrong size, or that there was any other error in the initial surgery. We noted that there is an inherent risk that surgery will result in a patient experiencing ongoing pain and difficulties, without this being caused by any failure in the surgery. We did not uphold this aspect of Mrs C's complaint.

We upheld Mrs C's complaint about monitoring. We found that there was evidence of Mrs C expressing pain and discomfort during her reviews with an orthopaedic nurse that should have led to her being reviewed by a consultant orthopaedic surgeon, or should have led to some communication from a consultant.

We did not uphold Mrs C's complaint about the subsequent care and treatment she received when she reported problems with her knee in the following years. We found that the documented views of the board's consultant orthopaedic surgeons were not unreasonable, and that the treatment provided was appropriate.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in monitoring following her surgery. 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.