Some upheld, recommendations

Summary

Mrs C complained about the level and type of support her adult son (Mr A) was receiving from community support services to help him manage his mental health. Mrs C was especially concerned that there was no proper regime for cover when the regular support worker was on planned or unexpected leave. Our investigation showed that the board's investigation had not properly considered this matter and could not demonstrate that the proper level and type of support had been in place. Whilst Mrs C told us that the arrangements had improved since she complained, we upheld this complaint and made recommendations to ensure future investigations were appropriately robust and that the improved support arrangement was sustained for the future.

Mrs C was also concerned that on one occasion her son had been assessed by the community mental health team because his mental health had been deteriorating, but a decision was taken not to admit him to hospital. Mr A's condition worsened and he later became aggressive and violent towards Mrs C's property, causing her considerable anxiety and distress. The police also became involved and Mr A was admitted to hospital for compulsory treatment. Mrs C considered that Mr A met the criteria for admission when first assessed and that a psychiatrist should have been involved and should have made the decision to admit Mr A at that time. We obtained independent advice from a mental health specialist who concluded that it was not necessary to have a psychiatrist involved in the assessment and that the initial decision not to admit Mr A was reasonable. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for failing to adequately or appropriately investigate her concerns about the level of support Mr A was receiving. This apology should comply with SPSO guidelines on making an apology, found at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• All complaints submitted and accepted by the board should be thoroughly investigated and final responses should include details of investigations undertaken and the outcomes of such investigations. Guidance and standards for good investigations are set out in the SPSO Investigations Toolkit, available at www.valuingcomplaints.org.uk/learning-and-improvement/best-practice-resources/decision-making-tool.

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 treatment she received at the Queen Elizabeth University Hospital during labour. Mrs C's concerns included that during the delivery, she sustained a tear which resulted in significant bowel problems. Mrs C also said the board failed to provide her with appropriate follow-up treatment for her bowel problems.

We obtained independent medical advice on the complaint from a consultant obstetrician and gynaecologist. The adviser explained that Mrs C sustained a third degree perineal tear (a tear which involves the muscles around the anus which contract to provide continence of faeces) during labour. They said that third degree perineal tears were a recognised complication of vaginal birth, and that Mrs C's records suggested that she was informed of the risk of this complication before the birth of her baby. We noted that the board apologised for the added pain and discomfort Mrs C experienced as a result of the tear. We considered this to be reasonable and did not uphold this part of Mrs C's complaint.

The adviser confirmed that Mrs C was appropriately seen in a specialist clinic 11 weeks and 25 weeks after the delivery of her baby daughter and that the treatment she received during the appointments was reasonable. However, it appeared that Mrs C did not receive the planned physiotherapy treatment following her first clinic appointment. We were critical of the board in this regard and upheld this part of Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Mrs C with a written apology.

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

• Staff should arrange follow-up physiotherapy treatment for patients in cases such as this.

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 works for an advocacy and support agency, complained on behalf of his client (Mr A) about the care and treatment that was provided to his late wife (Mrs A) at Queen Elizabeth University Hospital. Mrs A had been referred to the board by her GP after she was diagnosed with Cushing's syndrome (a collection of symptoms caused by high levels of the cortisol hormone in the body). Mrs A attended the hospital and remained there until she died two months later.

In investigating Mr C's complaints, we took independent advice from a consultant in acute medicine. On the basis of the advice we received, we upheld Mr C's complaint that the board failed to provide reasonable care and treatment for Mrs A during her admission to the hospital. The advice we received was that when Mrs A's condition deteriorated, this was recognised and responded to in an appropriate manner. However, there were aspects of her care that were unreasonable. In particular, she had recurrent bouts of sepsis which were not adequately investigated and her elevated blood glucose and low potassium levels were not investigated. Mrs A also had a fever of unknown origin and this was not recognised or investigated promptly. In addition, the advice we received was that Mrs A was moved unreasonably on multiple occasions between wards and hospitals. We found that, despite an elevated national early warning score (a system that determines the degree of illness of a patient), Mrs A was transferred to a hospital that was unable to look after a patient who required oxygen, and so she was subsequently transferred back to the Queen Elizabeth University Hospital.

We also upheld Mr C's complaint that the board had failed to communicate with Mr A about his wife's condition during her admission. The advice we received was that there was little evidence in the medical records to demonstrate that Mr A was informed of Mrs A's multiple transfers, or the rationale for these transfers. We considered that the level of communication was unreasonable.

We did not uphold Mr C's complaint that the board had failed to respond fully to Mr A's complaint. We were satisfied that the board had reasonably responded to the issues raised by him in his letter of complaint to them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to provide Mrs A with appropriate care and treatment. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Apologise for failing to communicate adequately with Mr A. This apology should comply with 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:

• Where possible, moving a patient multiple times should be avoided. The rationale for necessary moves should be clearly recorded in the medical records.
• Patients with elevated national early warning scores should not be transferred without further medical review and adequate handover.
• Communication between 'giving' and 'receiving' units regarding a patients needs should include national early earning scores and any requirement for oxygen.
• The handover process should ensure that events that happen overnight, even those perceived as small, are relayed to the day team for action. Abnormal blood results should be appropriately flagged and consideration given to an alert if the same patient has
• Patients with ongoing low potassium levels should be reviewed by appropriate specialist teams.
• Microbiology input and review should be sought for patients with recurrent sepsis.
• Families should be given sufficient opportunities to discuss their concerns and raise questions with clinical staff; especially in situations where the admission is prolonged and complex.

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 son (Mr A) is in long-term foster care. He has ear problems requiring him to attend hospital. Ms C complained that she was not always informed of Mr A's appointments and that, on occasion, appointments for him were cancelled without her knowledge or permission. She said that although she wanted to discuss Mr A's diagnosis and prognosis with his consultant, her request to do so was refused. She further complained that the board refused unreasonably to send her a detailed consent form in advance of the surgery he required.

Ms C made her complaint to the board who confirmed that there had been difficulty in always keeping her informed of Mr A's appointments because of the limitations of their current patient management system and also due to human error. They apologised that this had been the case but said that they had had discussions to improve the system. They said that in the interim they had appointed a member of staff to regularly check the system in order to update Ms C. However, they denied that appointments for Mr A had been cancelled unreasonably or that staff had not been prepared to discuss his care with Ms C. They said that she had been spoken to and given explanatory information about Mr A's condition and about the operation he needed.

We made further enquiries of the board and also sought confirmation of Mr A's status as a looked after child. We obtained independent advice from a medical adviser on the matter of consent. We found that there had been problems in keeping Ms C up to date about Mr A's medical appointments but that, where appointments had been cancelled, cancellations had been made in accordance with the board's procedures. The board had also offered to meet with Ms C to discuss Mr A's diagnosis and prognosis but she had been unable to attend. We found that they had discussed it with her immediately before Mr A's operation and provided her with explanatory documentation. However, they could have given these explanatory leaflets sooner and so we upheld 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 always keep her informed of Mr A's appointments.
• Apologise to Ms C for failing to provide her with information that she had requested about Mr A's diagnosis, prognosis and treatment. The apology should comply with SPSO's 'Guidance on Apology', which can be found 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 C complained about the care he received at a prison healthcare centre after he was diagnosed with diabetes. Mr C was concerned that he did not receive appropriate medical care and treatment or support in relation to his diabetes. He also complained that there had been a delay in providing treatment for thrush, and complained that when he was admitted to hospital, staff at the prison health centre had not informed his next of kin. Finally, Mr C felt that his complaint had not been dealt with appropriately.

After taking independent GP advice, we upheld Mr C's complaint about medical care and treatment. While we found that most aspects of his diabetes care and treatment were reasonable, the adviser highlighted two separate days following hospital discharges where Mr C had not received his prescribed medications. We made recommendations to the board to address this.

We found that the board had taken reasonable steps to provide help and support to Mr C for his diabetes and identified no delays in the provision of thrush treatment. Consequently, we did not uphold these elements of Mr C's complaint. We also did not uphold his complaint about the health centre staff failing to inform his next of kin when he was admitted to hospital as we found that this was a matter for the Scottish Prison Service.

Finally, we upheld Mr C's complaint about the board's handling of his complaints as we found that they had not addressed all the issues raised. We made a recommendation to address this failing.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing to Mr C for failing to give him his prescribed medication on two dates.
• Apologise in writing to Mr C for failing to address one of the concerns of his complaint.

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

• Medications that have been prescribed to a prisoner in hospital should be made available following discharge.

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 that GPs at her medical practice had misdiagnosed her after she attended several appointments complaining of earache. Ms C was later found to have chronic tonsillitis. She complained that the GPs had not diagnosed this when she presented with her symptoms. She also complained that she was not prescribed anything for her pain during this period.

We took independent medical advice and found that the GPs assessed and treated Ms C appropriately and in line with her symptoms. An appropriate referral had been made to the ear, nose and throat department. In relation to the matter of pain relief, the practice pointed out that Ms C was already on a number of strong painkillers for other conditions.

Ms C complained that the practice's handling of her complaint was unreasonable. We found that their response to her complaint was not professional and lacked objectivity. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The practice should apologise to Ms C for the poor quality of the written response to her complaint. The apology should comply with SPSO's 'Guidance on Apology', available at www.spso.org.uk/leaflets-and-guidance.

In relation to complaints handling, we recommended:

• Responses to complaints should use professional and objective language, demonstrating an understanding of the complainant's position and taking into account the practice's responsibilities within the NHS Complaints Handling 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.

Summary

Mr C complained about the care and treatment provided to his late wife (Mrs A) at Golden Jubilee National Hospital. Mrs A had been diagnosed with bladder cancer by another health board, but before being able to receive treatment for the cancer had suffered a heart attack. She was referred to the hospital for cardiac surgery. Mrs A was to receive treatment for the bladder cancer after having cardiac surgery. However, by the time she had recovered sufficiently from the cardiac surgery, the cancer had progressed and curative treatment was no longer possible. Mr C said that there had been unreasonable delays in Mrs A undergoing cardiac surgery, that informed consent had not been obtained for Mrs A's cardiac surgery, and that there had been unreasonable failings in communication between the specialists treating Mrs A.

We took independent advice from a cardiac surgeon. The adviser commented that the hospital could have considered treating Mrs A as an in-patient at an earlier point, as this may have been a more holistic approach given her co-existing cancer diagnosis. However, we found that although Mrs A's cardiac surgery had been postponed several times, it was still carried out in a reasonable and appropriate timeframe from a cardiac point of view.

Mr C had been concerned that staff at the hospital were aware that Mrs A would not be able to undergo treatment for her bladder cancer and therefore her consent to undergo cardiac treatment, which had been based on her understanding that without it she would not be able to have her bladder cancer treated, was not fully informed. Our investigation found that throughout Mrs A's patient journey at the hospital, all staff had been working under the impression that her bladder cancer was operable. We did not uphold this aspect of Mr C's complaint.

We found that after Mrs A's cardiac surgery, staff at the hospital failed to send a discharge letter to the other health board to inform them that the surgery had been successfully carried out. We found this to be unreasonable. We upheld this aspect of Mr C's complaint, but considered that the hospital had already taken steps to address this issue and therefore made no further recommendations.

Recommendations

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

• Treatment for patients that require heart treatment prior to cancer treatment should be planned holistically.

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 that staff at Glenrothes Hospital failed to provide her father (Mr A) with appropriate medical care and treatment, particularly regarding dehydration, confusion and breathlessness. She also complained that there were unreasonable failures to provide adequate nursing care, and that staff failed to communicate appropriately with her and her family. She said that their concerns were ignored. The family had concerns about Mr A returning home. Mrs C said that Mr A had been given inadequate physiotherapy and that, despite his poor condition, staff insisted upon completing an assessment at home. Mrs C said that after she complained about these matters she did not receive a response until three months later and she was not kept informed about what was happening.

In replying to the complaint, the board agreed that there had been some delay for which they apologised. In relation to the family's concerns about Mr A's confusion, the board said that medical staff could have treated Mr A's dehydration more aggressively by giving him intravenous fluids but that although the family had concerns, they did not consider there to have been a problem. Similarly, they considered that after Mr A reached his physiotherapy goals there was no need for further input. The board did not consider that they had undertaken an inappropriate home assessment, nor did they think that they had failed to discuss matters reasonably with the family during Mr A's admission to the hospital.

We took independent advice from a nurse, a GP and a mental health nurse. We found that Mr A's dehydration could have been treated earlier, perhaps by earlier admission to another hospital for intravenous fluids, but that this would not necessarily have prevented the deterioration in his overall health. We upheld this aspect of the complaint.

We also found that not all the records had been completed fully regarding Mr A's nursing care, particularly those concerning his fluid balances. We found that Mr A had had a surprising result during cognition tests and that this had not been monitored. We upheld this aspect of the complaint.

We found that the family were kept appropriately up-to-date regarding Mr A's condition and that where the family had concerns, these were noted and taken into account as far as was possible. We did not uphold the aspect of the complaint regarding communication.

We found no evidence that Mr A had been given insufficient physiotherapy as he had achieved the goals that had been set for him and we did not uphold this part of the complaint.

We did not find evidence that a home assessment had been carried out unreasonably, or that the decision to return Mr A home was unreasonable. While the family were not in agreement, this had been what Mr A wanted. As such, we did not uphold this part of the complaint.

Finally, we found that the board had not responded to the complaint in a timely manner, nevertheless, the family had been kept updated about the delay. On balance, 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 failing to monitor Mr A's fluids and cognition properly. 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:

• Nursing staff should complete all care rounding charts as required to ensure that the fluid levels of patients is properly recorded.
• When there has been a surprisingly low cognition score, cognitive functioning should be kept under review.

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 an appointment she had attended with a psychiatrist to explore her possible learning difficulties. In particular, she complained that she had not properly consented to discussing the matters raised with her, that the questions asked of her were unreasonable given the stated purpose of the meeting, and that her privacy was ignored as these questions were asked in front of others.

We took independent advice from a mental health adviser and found that while the psychiatrist had acted reasonably in the matter of consent, they should have enquired further about Ms C's understanding of the appointment. We found that the questions asked were not unreasonable, but it should have been made clear to Ms C that she could decline to answer. We did not uphold these aspects of the complaint, but made a recommendation to address this.

In relation to Ms C's privacy concerns, we found that she should not have been asked any personal questions in the presence of others. We, therefore, upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should send Ms C a written apology.

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

• It should be made clear to patients that if they are unhappy with a line of questioning, they can ask for it to be stopped.
• Records of appointments should show, as far as is possible, an assessment of whether or not a patient has understood consent issues.

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 made a number of complaints about the care and treatment he received from a prison healthcare centre. In particular, Mr C complained that the board had not provided appropriate care and treatment for a particular medical condition he felt he had, and that they had not communicated with him reasonably about this condition.

We took independent advice from a GP adviser. We found that a number of investigations had been carried out and that none of these had confirmed the diagnosis of the condition that Mr C felt he had. We did not find evidence that the board had failed to provide appropriate treatment for this condition or that communication was unreasonable. We did not uphold these complaints.

Mr C complained further that the board failed to provide timely and appropriate care and treatment for a facial injury he sustained. We took independent advice from a nursing adviser who found that nursing staff failed to carry out a full nursing assessment of this injury and refer the issue to medical staff. We found that Mr C was then assessed by a GP after a two week delay. The GP adviser considered that the GP assessment was appropriate and noted that a timely referral to a specialist was then made. However, in view of the failings in nursing care, we upheld this aspect of the complaint and made two recommendations.

Mr C raised concerns about the pain relief medication he was prescribed and said this was ineffective. The GP adviser found that the medical records showed evidence of pain assessment and the GP's discussion with Mr C. The GP adviser said that they had no concerns about the pain relief provided to Mr C and concluded that this aspect of care was reasonable. We did not uphold this complaint.

Mr C was also unhappy about the way the healthcare centre responded to his concerns about his diet. The GP adviser found evidence that a GP made a request to the kitchens for a high fibre diet for Mr C and also found that Mr C had received dietary advice on a number of occasions. The adviser was satisfied that this dietary advice was appropriate, and overall they considered that the care provided was reasonable. We did not uphold this complaint.

Mr C also raised concern that the board failed to provide appropriate mental health input. We took independent advice from a psychiatric adviser in relation to this complaint. They found evidence that Mr C had a number of contacts with the mental health team and also noted that a mental health assessment was carried out shortly after Mr C's admission to the prison. They did not find evidence that there were delays in Mr C receiving input from a psychiatrist or mental health nurse. The psychiatric adviser concluded that the care Mr C received was reasonable, so we did not uphold this complaint.

Finally, Mr C complained that the prison healthcare centre did not provide him with appropriate treatment for his bowel condition and said that he was not prescribed a medication that helped his symptoms. The GP adviser found that this medication was initially prescribed to Mr C because the prison healthcare centre suspected that Mr C might have irritable bowel syndrome. The GP adviser found that Mr C was subsequently diagnosed with a different medical condition, which meant that this medication was no longer appropriate. The GP adviser was not critical that the prescription of this medication ended and considered Mr C received reasonable care and treatment. We did not uphold this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to carry out an appropriate assessment of his facial injury. This 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:

• Where a patient has sustained an injury, a full nursing assessment should be carried out and medical issues should be referred to medical staff, as appropriate.

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.