Some upheld, recommendations

Summary

C complained about their care and treatment following a hysterectomy (a surgical procedure to remove all or a part of the uterus). C complained that they were not provided with adequate pain relief following the surgery, and that they were not fitted with an abdominal drain (a thin plastic tube which is inserted into an abnormal collection of fluid to help remove it from the body). C was discharged a few days later but disputes whether they were fit to be discharged home at this point. C was later readmitted suffering from a blood clot and an infection. C was discharged with oral antibiotics and again disputes whether they were fit to be discharged at this point.

A few days later, C began to bleed heavily. An ambulance was called but the wait was likely to be significant and C was taken to hospital by their partner. C was triaged but asked to sit on a chair in a corridor, despite suffering from obvious heavy vaginal bleeding. C was reviewed by a consultant and sent up to the gynaecology ward where they were then taken for emergency surgery.

We took independent advice from a consultant obstetrician (specialists in pregnancy and childbirth) and a consultant in emergency medicine. We found that C received a reasonable standard of care following their surgery and was appropriately discharged on both occasions. Therefore, we did not uphold these parts of C's complaint.

In relation to C's attendance at A&E, we found that they were not triaged sufficiently quickly and the way C was asked to wait was not appropriate given their condition. C was medically assessed within an appropriate timescale within A&E and appropriately transferred. The board had accepted there were failings in C's care, but they had not set out clearly how they planned to address these issues. Therefore, we upheld this part of C's complaint.

C also complained that the board failed to handle their complaint reasonably. We found that the board handled C's complaint appropriately and did not uphold this part of their complaint.

Recommendations

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

• Complete an assessment of the delay in triaging C.
• The board should consider what it can do to improve the experience of patients who require privacy when awaiting medical assessment.

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

C complained about the care and treatment provided to their late partner (A). A had a history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung conditions that cause breathing difficulties). A was suffering from constipation which was treated by the district nursing team at home. When this did not resolve, A was admitted to hospital for review and treatment of their constipation. C said they asked that A be treated and discharged home as quickly as possible. A fell whilst in hospital and fractured their shoulder. A developed a chest infection and subsequently died in hospital.

C believed A's condition could have been treated in the community. C felt A's vulnerability had not been recognised by nursing or clinical staff in hospital. C said that A had been designated as an adult with incapacity (AWI) and do not attempt cardiopulmonary resuscitation (DNACPR) without discussion with them as A's power of attorney (POA). C felt A's fall was avoidable had staff listened to the family's requests for 1-to-1 nursing.

We took advice from a registered nurse and a consultant respiratory physician. We found that A was not provided with a reasonable standard of nursing care in the community, as more could have been done to treat their constipation at home. Therefore, we upheld this part of C's complaint.

In relation to A's care while in hospital, we found both the standard of nursing and medical care to be reasonable. Therefore, we did not uphold these part's of C's complaint.

In relation to communication with C as A's next of kin and POA, we found there was a lack of communication regarding A's care and in particular decisions around designating A as AWI and DNACPR. Therefore, we upheld this part of C's complaint.

Finally, we found that A's death certificate should have included the fall as a secondary factor in their death. Initially it was believed that C would need to request this amendment, but the responsibility in fact lay with the board, who have been asked to ensure that the death certificate is amended. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the board develop a bowel management guideline to ensure appropriate prescribing and escalation if no response to treatment. This should include clear escalation pathways for patients with deteriorating health.
• That the board remind the clinical team of the importance of discussing and recording discussions about DNACPR and AWI decisions with patients and their next of in/powers of attorney, including ensuring that all parties understand how and why the decision has been reached.
• The responsible consultant should contact the Death Certificate Advisory Service and have the full amendment made as soon as possible.

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

C complained about the care and treatment they received from the board in relation to knee replacement surgery. C said that a surgeon failed to adequately advise them of the potential risks of a total knee replacement and therefore failed to obtain their informed consent for the operation. C also complained that the surgeon failed to adequately examine their leg either pre or post operatively. C said that they had experienced a mal-alignment of their leg as a result of the operation leading to significant pain and loss of mobility.

The board was unable to identify the cause of the mal-alignment of C's leg, but did not identify any failings in their care and treatment.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that, despite some failings, the consent process in C's case was reasonable. We also found no evidence that the board's surgeon failed to adequately examine C's leg either pre or post operatively. Therefore, we did not uphold these parts of C's complaint.

C also complained that the board failed to adequately investigate or respond to their complaint. We found that the board's complaint response was unreasonable and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflet.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. The investigation should be thorough, and the complaint response should be accurate in their findings and conclusions and supported by relevant evidence such as medical records. Where there have been failings in surgery, the case should be presented and discussed within a departmental surgical morbidity and mortality meeting.

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

C complained about the care and treatment provided to their infant (A). C's concerns related to A's urinary function. C had concerns about the monitoring they had received whilst pregnant with A, the care provided to them and A immediately post- birth as well as during A's early years. C raised issues about the assessment of A's bladder function, A's renal health and the pain and discomfort A was suffering. C also felt that the family had not been listened to and their concerns dismissed or minimised. C had sought a second opinion at a hospital in England and believed board medical staff criticised the family for taking this step. They also said that the board failed to liaise with the hospital in England, resulting in A not receiving treatment or care for an extended period.

The board had accepted that communication with the family could have been better but considered the standard of care and treatment provided to A was reasonable.

We took independent advice from a consultant paediatrician. We found that A's symptoms were reasonably investigated initially and that they were referred to urology timeously. We also found no clear evidence that A's bladder had been damaged by failings on the part of the board. Therefore, we did not uphold these parts of C's complaint.

We found that the impact on A and their family of their condition was not adequately acknowledged and that the board had failed to communicate appropriately with C and their family. We also found that the board did not act when it became apparent that A was no longer being cared for by a hospital in England, resulting in avoidable delays in their care. Finally, we considered that the board failed to handle C's complaint reasonably. We upheld these parts of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's parents for the failures identified in this report. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• The board should share this decision with the staff involved in A's care with a view to identifying any aspects of the care and treatment that could have been improved. This should include consideration of whether there are any immediate actions which need to be taken to address A's ongoing issues.
• Patients' families should receive clear explanations and be provided with appropriate information which addresses their concerns.
• The board should reflect on the experience of A's family with a view to identifying any ways that communication and care planning for A could have been better managed.

In relation to complaints handling, we recommended:

• The board's complaint monitoring should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service improvement.

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

C complained about the care and treatment provided to their parent (A) during their admission to hospital for a knee replacement. A said that they woke up during their surgery.

The board responded to the complaint noting that there was no evidence A woke up during surgery. C and A were unhappy with this response and brought their complaint to our office.

We took independent advice from a consultant anaesthetist (specialist doctors responsible for providing anaesthesia and pain management to patients before, during and after operations and surgical procedures) and asked the board to comment on issues we had identified.

The board explained that A had been under a deep sedation during the procedure and provided further details about the management of A's sedation. They confirmed that A had to receive a 'top up' in medication during the procedure and had reflected on the manner of their complaint response and the detail they had originally provided and offered to make an apology to A.

We found that the procedure was undertaken with a spinal anaesthesia and sedation rather than under general anaesthetic. We noted that the board's explanation with respect to managing A during the procedure was reasonable but confirmed that A did wake up. A did not appear to be aware this could be a possibility given they were not under general anaesthetic.

We considered that while A did wake up, this was not due to inappropriate or unreasonable levels of care. Indeed, it was possible it could happen and it was handled appropriately. Therefore, we did not uphold C's complaint.

However, we concluded that the board should have acknowledged that A woke up during the procedure and provided C and A with an explanation as to why this happened and how this was managed. Therefore, we found that the hospital failed to appropriately investigate and respond to C's complaint and made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the lack of detail contained in the complaints response and for providing misleading information regarding the circumstances of A becoming aware during the surgery. It would be appropriate to acknowledge the significant impact the lack of a clear response from the outset has had on both C and A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

C complained that the practice failed to provide them with reasonable care and treatment. C suffered from inflammatory conditions of the skin and joints and was under the care of rheumatology (specialists in the diagnosis and management of chronic inflammatory conditions such as rheumatoid arthritis), dermatology (specialists in the in the diagnosis and treatment of skin disorders) and the practice. C was being prescribed an immunosuppressant and the practice was in a shared care agreement with the NHS board for monitoring bloods in regards to the prescription. C required a liver transplant due to liver cirrhosis induced by the treatment. C complained that the practice had not properly monitored their bloods, had not picked up on warning signs and had not communicated appropriately with the relevant specialists or with C. C noted that they had also been incorrectly prescribed an antibiotic containing penicillin.

We took independent advice from a GP. We found that the practice had monitored bloods appropriately, and where there were gaps in monitoring, C's attendance had been requested. We also found that the practice had sought specialist advice and followed NICE guidelines appropriately. We noted that the practice had verbally apologised for the penicillin mistake. Therefore, we did not uphold this part of C's complaint but fed back to the practice that it would be appropriate to apologise in writing.

C also complained that they were immediately removed from the practice register after making a comment on social media expressing concerns about their treatment. C noted that they were given no warning and that their poor health, vulnerability and their requirement for continuity of care were not taken into account. We found that the practice had not followed guidelines in respect of removing the patient from the register, without warning. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for prescribing an antibiotic containing penicillin, which they were allergic to. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for the manner in which their removal from the practice register was handled. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Reconsideration of the social media policy and patient removal policy and process, such that they are in line with BMA and GMC 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

C complained about the care and treatment provided to their parent (A) who had dementia.

C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact this would have on A's mental health. C said that there were issues in arranging for suitable equipment to allow A to be transferred out of bed. C also complained about the communication of decisions about A’s care with them, A's next of kin and registered power of attorney. C said that after they complained, the Partnership told them that A was receiving end of life care but that this was not true and was a rationalisation of what had happened after A’s death.

C also noted that the Partnership had been obliged to respond more than once to their complaint, after they had pointed out factual inaccuracies in their response. C suggested that this showed that there had not been a proper investigation into their complaint.

The Partnership accepted that communication with C could have been better. They maintained, however, that A’s care had been of a reasonable standard and that staff had been clear that A was being provided with end of life care. They accepted that this should have been specifically set out in A’s care plan and noted improvements were being made to ensure this going forward.

We took advice from a registered nurse with experience of medicine for the elderly. We found that A’s care and treatment had been reasonable. We did not uphold this aspect of the complaint.

We found that there was failure to communicate with C appropriately. The communication with C fell below a reasonable standard, particularly as C was not informed that A was receiving end of life care. We upheld this aspect of the complaint.

The Partnership acknowledged that staff could have done more to ensure A had the requisite specialist equipment. There could have been better communication between the professionals involved in sourcing the specialist mattress A required. We upheld this aspect of the complaint.

We also found that the handling of C’s complaint fell below a reasonable standard, as the Partnership had issued a response containing factual errors. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this complaint, which resulted in inaccurate complaints responses being issued. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

C complained about the care and treatment of their late partner (A) during multiple admissions to hospital. C raised concerns that a coronary angiogram (a scan to check for blockages in the blood vessels) was unreasonably delayed, which in turn meant necessary vascular surgery could not take place. C complained about a lack of cohesion between vascular, cardiology and renal teams, and a lack of communication with the family.

We took independent clinical advice from a cardiology adviser and a vascular adviser. We found that there was a lack of cohesion and coordination in the management of A’s treatment plan. We considered that multidisciplinary meetings should have taken place to agree a treatment plan, and provide the cohesion that was lacking in the approach to A’s treatment. Overall, however, we found that the clinical decisions made by each team were reasonable and reflected A’s clinical condition at the time. We found nothing to suggest that the lack of cohesion impacted directly on the treatment A received or the eventual outcome for A. In particular, we found that there were good reasons not to proceed with the coronary angiogram, and that it was unlikely any vascular intervention could have been provided due to A’s competing illnesses. On balance, therefore, we did not uphold the complaint that A’s clinical care and treatment was unreasonable.

However, we upheld the complaint about the communication with A and their family. The board had already apologised for the poor communication and acknowledged that the multidisciplinary team did not keep the family as informed as they could have. Notwithstanding this, the board considered that A had capacity to make decisions regarding their own care and treatment. However, this assertion did not appear to have been based on any formal assessment. We found that there was evidence only once in the records of a capacity assessment having been undertaken. We found this concerning, particularly as C had raised concerns that A had become confused as a result of their illness and strong pain medication. We also found that there was a failure to complete existing documentation to record A’s communication preference, which was suggestive of a systemic failure rather than an issue that affected only A. Overall, we found that the communication with A and the family was very poor. A had a complex illness with a number of competing factors which affected the types and timings of treatments that were available. We concluded that clearer communication with the family, and between healthcare professionals, may have avoided a lot of the distress and anxiety the family experienced.

Recommendations

What we asked the organisation to do in this case:

• That the board apologise to C for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• That the board conduct an audit into the hospital staff’s compliance with their obligation to complete the existing documentation and take steps to ensure the documentation is being used effectively to ensure patient-centred care.
• That the board provide us with evidence of the steps that they have taken to ensure multidisciplinary team meetings take place to discuss and plan treatments for patients with complex medical conditions.
• That the board share this decision notice with the teams that were involved in A’s care and treatment with a view to identifying any points of learning.

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

C complained about the care and treatment their grandparent (A) received when they were admitted to hospital. A was acutely unwell with a poor prognosis and was treated in the COVID-19 ward for a number of days. A's condition improved and they were discharged home. C complained that A did not have capacity to consent to treatment and that treatment to address A's confusion made their symptoms worse. C believed that clinicians failed to clearly communicate the treatment plan for A, that it was unreasonable for clinicians to focus on end of life treatment and that staff failed to meet A's basic needs.

In response to the complaint, the board explained that A was admitted with possible aspiration pneumonia and COVID-19. They said A was treated for COVID-19 and with antibiotics and that the care and treatment in this regard together with the assessment of A's capacity, was appropriate. Nursing staff gave A regular oral hygiene, but due to high flow oxygen therapy this was difficult. Appropriate assessment and treatment was undertaken with respect to A's skin.

We took independent advice from a consultant geriatrician (specialist in care and treatment of the elderly) and a nurse. We found that whilst many aspects of A's care were reasonable and of a standard expected, there was a significant failure with respect to the assessment of A's delirium. We also found that there were significant failures with respect to the level of personal care provided to A. Therefore, we upheld C's complaints relating to medical and nursing care and treatment.

In relation to communication with C and their family, we found that the records documented an appropriate level of communication with respect to decisions made about A's care. Therefore, we did not uphold this part of C's complaint.

C complained that the board failed to handle their complaint reasonably. We found that there was discrepancies and apparent inaccurate information contained in the board's response. Therefore it was reasonable to conclude that the board failed to carry out a reasonable investigation and upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and C for the failure to handle and respond to the complaint reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C and A for the failures identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Staff to be compliant with HIS (2020) Prevention and Management Standards. All staff assessing pressure ulcer risk fully understand the risks and are able to put in place measures and equipment to minimise risk. Staff completing care rounding able to identify that patients at risk of pressure damage must have their position changed and not nursed in the same position for 24 hours.
• Relevant staff are familiar with the adult with incapacity process and the importance of delirium screening tools with patients where delirium is observed and evident.
• Staff responsible for undertaking oral care are trained and competent in assessing oral hygiene requirements, carrying out oral hygiene and accurately documenting this in the records.
• To ensure a person centred approach to assessment of continence and appropriate prescribing of continence management products.

In relation to complaints handling, we recommended:

• Complaints handling staff to be familiar with the complaints handling procedure. Clinical staff to be aware of the significance and importance of a thorough consideration of clinical records and reflecting on these in an open and transparent manner when offering responses to specific aspects of complaint.

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

C complained about the actions of South Lanarkshire Council in relation to work that they carried out to a property adjoining C’s home. The work related to the change of position of a gas boiler flue. C considered that this has had an adverse effect upon them and their property. The council did not identify any failings, but changed the orientation of the flue as a result of C’s concerns. C remained unhappy.

C complained that, as a result of the change in position, the flue discharged dangerous gasses into their home. C also complained that the council had failed to respond to their complaint in line with their published Complaints Handling Procedure (CHP).

We found that the council had acted reasonably regarding the change in position of the flue. We did not uphold this aspect of the complaint. However, we found multiple failures by the council to adhere to their CHP. We upheld this part of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings, in particular, the unreasonable delays identified in the handling of their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The necessary systems and procedures should be in place to ensure that complaints are handled in line with the council’s complaints policy and procedure and that all staff are aware of the complaints handling policy and procedure.

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