Some upheld, recommendations

Summary

Mrs C complained about the care and treatment that her mother (Mrs A) received prior to her death in University Hospital Ayr. Mrs A underwent major surgery and experienced post-operative complications. She was transferred to the medical high care ward for non-invasive ventilation (NIV, assistance with breathing using a mask). She had difficulty tolerating this treatment and it was recorded that she refused to continue with it. The family were called to come to the hospital and when they arrived they requested that NIV treatment be further attempted. However, the doctor did not agree to this. Mrs C complained that Mrs A had been confused since her surgery and that she did not have the capacity to refuse treatment.

We obtained independent medical advice from a consultant physician, who found that the evidence in the records showed that Mrs A had capacity to withdraw consent for further NIV treatment. The adviser explained that while the doctor considered the family's wish for further NIV, it was reasonable for them to decide that this would not be appropriate in view of Mrs A's expressed wishes and her clinical condition. In light of this, we did not uphold this aspect of the complaint.

However, we found that the family should have been involved in the decisions about NIV at an earlier stage, which the board had already acknowledged and apologised for. The adviser also noted that the decision not to continue treatment could have been explained more clearly to the family. In particular, it was noted that Mrs A's condition was poor and that further treatment was very unlikely to have been successful. This should have been sensitively communicated to the family, when instead the decision appeared to have been explained to them solely in terms of Mrs A having declined treatment. The adviser noted that national NIV guidelines had since been updated to require an individualised patient plan to be recorded at the start of treatment, which documents the agreed measures to be taken in the event of NIV failure.

Mrs C also complained that it took the board almost two years to address the issues she raised. We agreed that there was an unreasonable delay in the board responding to the complaint, and that their initial investigation was not thorough and robust. When they subsequently reviewed their initial findings, they reached a different view. Mrs C was provided with a copy of this review but we considered that she should also have received a further response specifically addressing the issues she had raised. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the time taken to investigate her complaint and the contradictory responses she received.

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

• Ensure that our findings are fed back to the doctor involved for reflection and learning.
• Review their NIV protocol in light of recent guidelines to ensure that the patient is involved wherever possible in formulating an individualised patient plan setting out the measures to be taken in the event of NIV failure.

In relation to complaints handling, we recommended:

• Review their arrangements for assessing new complaints to ensure that the level of investigation or review required is considered at an early stage.
• Review how their complaint procedure interacts with the procedure for reviews to ensure that the complaint response is not unduly delayed by the review and that a full response addressing the points of complaint is provided at the end of the process.

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 Business Stream. Mr C runs a charity shop and had applied for water rates exemption for the premises. Mr C was unhappy about the way that Business Stream handled his request for water rates exemption (a scheme where property owners can be exempt from paying part or all of a water bill for a property, based on various criteria). In particular, he was concerned about communication between Business Stream and his organisation. He was also concerned that Business Stream did not submit the application for exemption to Scottish Water to make the final decision, as he felt this would be the usual process. Mr C also had concerns about the amount he was paying for his water and, following investigation by Business Stream, his previous meter had been removed and replaced. Mr C was unhappy with the rateable value Business Stream used for his premises when calculating the outstanding balance.

Following investigation we found that Business Stream had failed to provide Mr C with a reasonable level of service in relation to his application for exemption as they had failed to respond to his correspondence in a timely manner. They had also failed to provide a clear explanation of why the information submitted was not sufficient to allow them to pass the application onto Scottish Water. Therefore, we upheld Mr C's complaint. However, following receipt of information from Scottish Water, we established that it was not unreasonable for Business Stream not to send the application to Scottish Water when they did not have all of the information required to support the application.

We also found that Business Stream had used the correct rateable value in line with their rateable value policy. We therefore did not uphold this aspect of Mr C's complaint. We did not see any evidence that Business Stream had responded to Mr C's correspondence asking them about this issue and we therefore recommended that they now respond to him about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to respond to his correspondence in a timely manner and for failing to provide a clear explanation of why they did not pass the application to Scottish Water. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance.
• Respond to Mr C's correspondence regarding the rateable value of the property.

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

• Correspondence from customers about exemption applications should be responded to in a timely manner. Replies should provide clear explanations to customers if Business Stream considers that information submitted in an exemption application is incomplete.

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 to us about the council's handling of planning conditions for a quarry near his home. He complained that planning officers had discharged conditions without referring them to the council's planning committee. We took independent planning advice on Mr C's complaints. We found that, although the council's scheme of delegation had not been entirely clear, it had been appropriate for the officers to deal with the matter and that it did not need to be referred to the planning committee. That said, Mr C also stated that the information provided by the developer regarding the discharge of the relevant conditions amounted to a substantial change and should have been treated as a variation to the planning consent. We found that the council should have obtained further information before the conditions were discharged. We found that they needed to establish what material was to be extracted from the site to in order to consider whether the original consent had been breached. They also needed to consider whether their decision to discharge the relevant conditions was safe and investigate the possible mechanisms available to them to rescind that decision, should they consider this necessary. In view of this, we upheld this aspect of Mr C's complaint.

Mr C also complained that the council had failed to take appropriate steps to ensure the protection of the nearby high pressure gas pipeline. We found that it had been reasonable for the council to rely on the alternative controls and measures available to the organisation that manages the gas network in Scotland, rather than pursue the issue through the planning process and the application of planning conditions. We did not uphold this aspect of Mr C's complaint.

Mr C also complained about the council's actions in relation to assessing the flood risk of a proposed loch at the quarry. The council considered that they had all the information they needed in relation to this to discharge the conditions, and were closing the matter. This was a planning decision that the council were entitled to take as the planning authority. However, we found that there was no documentary evidence in the information we received from the council that set out how they had arrived at their decision. We considered that there should be some form of technical explanation in the records of the council's decision. In view of this, we upheld this aspect of Mr C's complaint.

Mr C also complained that the council failed to properly assess the risk of drowning at the site. We found that the loch would be subject to a number of statutory health and safety requirements outwith the planning process. The planning process should not be used to duplicate or form an alternative to using other more appropriate statutory controls and we did not uphold this aspect of the complaint.

Finally, Mr C complained that the council had failed to investigate the relevance of the Reservoirs Act in assessing the impact of the proposed loch. We found that the council had given adequate consideration to this matter and had received advice from their legal adviser confirming that the legislation was not applicable to the loch. We did not, therefore, uphold this aspect of the complaint.

Recommendations

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

• The scheme of delegation should be clear on what is meant by the term, 'approval required by a condition'.
• The council should be clear about, and able to explain, the volume and constituent make-up of the material to be extracted from the site to enable a satisfactory assessment to be made as to whether the terms of the original consent have indeed been breached. They should consider whether their premature decision to discharge the relevant conditions on the basis of the details contained in the submitted plans is safe and investigate the possible mechanisms available to them to rescind that decision, should they consider this necessary.
• An adequate technical explanation of how they reached their decision on the risk of flooding at the site should be recorded in the records.

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 to us that the board had failed to properly assess his mother (Mrs A) before she was discharged from Perth Royal Infirmary. He said that, as a result of this, Mrs A had to go into a care home for full-time care, which had cost the family over £20,000 in charges. We took independent advice from a consultant geriatrician. We found that Mrs A had been discharged without being adequately assessed. There was no evidence of a multi-disciplinary team discussion or of adequate occupational therapy input in the discharge planning process. In addition, we found that that the physiotherapy and nursing notes indicated that she should have had further assessment. Mr C had also raised concerns several times to different members of staff about Mrs A's ability to return home. We found that Mrs A should not have been discharged on the day that she was. In view of this, we upheld the complaint. However, it was likely that she would have been reviewed again a week later and it was possible that a reasonable decision could have been made at that time that she could be discharged. This could have been either to her own home or to a nursing home.

Mr C also complained that the board had not informed him of, or acted in accordance with, the relevant Scottish Government guidance on intermediary care following hospital discharge. The relevant guidance is normally used where care homes are being considered. In view of the fact that Mrs A had been discharged home, we found that there was no need to use the guidance. Although we found that staff had not taken sufficient account of Mr C's views at the time of Mrs A's discharge, on balance, we did not uphold this aspect of the complaint.

Finally, Mr C complained to us about the board's handling of his complaint. We found that the board had delayed in responding to Mr C and that the communication with him about a meeting had not been clear. In addition, the board's response said that it had been reasonable to discharge Mrs A. In view of these failings, we upheld the complaint.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for the failure to appropriately assess Mrs A before she was discharged from hospital;
• reimburse Mrs A for the first seven days of her nursing home costs;
• provide evidence to us that they have taken steps to ensure that patients in the hospital receive care in line with Standard 5 of the 'Scottish Standard of Care for Hip Fracture Patients' in relation to discharge planning;
• issue a written apology to Mr C for their failings in relation to the handling of his complaint;
• feed back our findings on the handling of Mr C's complaint to the staff involved; and
• provide evidence to this office that they have taken steps to ensure that multi-disciplinary team meetings are documented in the records of patients.

Summary

Ms C complained about the care and treatment of her brother (Mr A). Mr A was diagnosed with liver disease and admitted to the acute medical unit at Ninewells Hospital a few weeks later. During the admission, he was also given medication for alcohol withdrawal. Mr A was diagnosed with acute kidney injury and treated with dialysis (a form of treatment that replicates many of the kidney's functions). Mr A's condition worsened suddenly, and he was transferred to intensive care, where he died.

Ms C raised a number of concerns, including that Mr A was missed during the doctor's ward round the morning after his admission and that he was not referred to kidney specialists sooner. Ms C felt the hospital was under-staffed over the weekend, and she felt this meant that Mr A's condition was not taken seriously until it was too late. Ms C was also concerned that Mr A was given varying doses of medication, instead of commencing with a high dose which is slowly reduced.

The board conducted an adverse event review of Mr A's admission. They acknowledged some failings, including that Mr A was missed on the ward round, that some of the nursing documentation was not fully completed, and that the family should have been told sooner how serious Mr A's condition was. The board apologised to Mr A's family, discussed the learning from the complaint with staff and agreed a new process for ward rounds to ensure that patients who are being moved are not missed. The board also met with Ms C to discuss the complaint, but Ms C found the meeting unhelpful and brought her complaint to us.

After taking independent medical and nursing advice, we upheld Ms C's complaints about medical care and communication.

While we found there were some omissions in nursing documentation, we found that the overall standard of nursing was reasonable. We found the administration of the medication was appropriate, as this was given as needed, using a scoring system to assess Mr A's symptoms. While we noted that Ms C disagreed with many points of the board's response to her complaint, we did not find failings in their complaints handling. However, we made some suggestions regarding how the board could improve their complaints handling practice by inviting people who request a meeting to confirm the issues they want addressed in advance of the meeting.

Recommendations

We recommended that the board:

• demonstrate to us what steps they have taken to reassure themselves that the new system for ensuring consultant reviews of incoming patients on the acute medical unit is effective.

Summary

Ms C complained that a dentist failed to carry out reasonable investigations to find the cause of her dental pain over the course of a year. She also complained that the dentist broke the root of her tooth and left it in her gum during the extraction of her tooth. We took independent advice from a dental surgeon and found that the dentist took reasonable steps to identify the cause of Ms C's dental pain, and that the delay was due to the time she had to wait for an appointment with a specialist. We did not uphold this aspect of the complaint. Whilst the adviser considered the tooth extraction was carried out properly, they felt that Ms C should have been advised that the likelihood of her tooth fracturing during the extraction was high, and offered a referral to a specialist to carry it out. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide Ms C with a written apology for failing to tell her that the risk of fracturing her tooth was high, and for not offering her a referral to a specialist to carry out the extraction. The apology should meet the standards set out in the SPSO guidelines on apology, available at www.spso.org.uk/leaflets-and-guidance.

Summary

Ms C complained about the medical and nursing treatment she received over a series of hospital admissions to Wishaw General Hospital. Ms C suffered from problems with the discs in her spine and had required spinal surgery on more than one occasion. Ms C said that she had been subjected to lengthy delays during each admission and that there had been an absence of medical review. Ms C said her nursing care had been unprofessional and had resulted in some humiliating incidents. Ms C also complained that she had not been referred for physiotherapy. Ms C further complained that the board's communication with another health board regarding her care was unreasonable.

We took independent medical advice from a consultant neurosurgeon, a nursing adviser and a physiotherapist. We found that Ms C had received inadequate treatment and that there were delays in her receiving scans. This meant that the outcome of a surgery Ms C had to treat cauda equina (a disorder that affects the nerves) was not as good as it might have been. The board had accepted this and had taken appropriate action to improve the diagnosis of cauda equina. We found that, during the later admissions, Ms C had suffered from extended trolley waits in the A&E department before being reviewed by an appropriate specialist. We found it to be unreasonable that Ms C had been left for long periods of time without being seen by medical staff due to failures in communication between the on-call team and Ms C's original consultant. We recommended that the board implement a protocol to cover the re-admission of patients with recurrent problems, so that staff are aware of when they need to refer the patient to the original consultant who had been responsible for treating them. We found that Ms C was, on occasion, denied access to the radiography department due to capacity issues. We considered this inappropriate and said the board should alter their procedures to allow for urgent scanning in spinal cases.

We found that the board had correctly acknowledged the failures in Ms C's nursing care across all of her admissions. We found that, whilst some of the failings were significant, they were due to poor judgement by individual staff members rather than procedural failings. We noted that the board had made reasonable efforts since Ms C's experience to improve and monitor standards of nursing care.

We found that Ms C should have been referred for physiotherapy treatment. We did not agree with the board's view that treatment was not appropriate for Ms C and found that the failure to commence physiotherapy could have delayed her recovery.

We did not find that the communication between the board and another health board regarding Ms C's care was unreasonable and we did not identify any significant failings in this regard. We did not uphold Ms C's complaint about communication between health boards.

We found that Ms C had received an unreasonable standard of medical and nursing care during her admissions to hospital. The board had accepted this and made the appropriate changes to address the failings she experienced in most areas. We found, however, that on the basis of the advice we had received, there were still areas where the board needed to improve and we therefore upheld Ms C's complaints about her care and treatment.

Recommendations

What we asked the organisation to do in this case:

• Apologise in writing for failing to provide physiotherapy. 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:

• A protocol should be developed to ensure that scans for patients with suspected cauda equina are not delayed.
• A protocol should be developed so that when patients are re-admitted with a recurrent problem, staff are clear when care should be transferred to a patient's original consultant.
• The general assessment of when physiotherapy is justified should be reviewed.

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

Summary

Mrs C, who works for an advocacy and support agency, complained on behalf of her client (Mrs A). Mrs A fractured her ankle in a fall and was admitted to Victoria Hospital, where she had surgery to insert a plate and pins. Mrs A returned to hospital a few weeks later with signs of infection. Her wound was washed out, but staff decided not to remove the plate and pins at that time. Mrs A's health deteriorated and she spent some time in intensive care. Mrs A also suffered a heart attack while in hospital, and she remained in hospital for about six weeks. Following her discharge, Mrs A had a further fall and the fracture in her ankle was displaced again. Staff considered it was no longer possible to reconstruct the ankle, and Mrs A's leg was amputated.

Shortly after this, Mrs A returned to hospital feeling unwell, and with pain in her other foot. Surgery was planned to bypass an artery in her leg (to improve blood flow to her foot). This was not possible in view of Mrs A's underlying vascular disease, and her other leg was also amputated.

The board sent a written response to Mrs A's initial complaint, and also met with Mrs A and Mrs C. They considered the care and treatment were appropriate. At the meeting, Mrs A raised some additional concerns that were not in her original complaint and the board agreed to investigate these. Mrs C contacted the board numerous times to follow this up, and was told a response was being prepared. However, the investigation was not begun until four months after the meeting. By the time a response was prepared, managers decided not to send this, as so much time had elapsed and they did not realise that Mrs C had been following up a response.

After taking independent medical advice, we did not uphold Mrs C's complaints about care and treatment. We found the surgery and treatment for Mrs A's infection were reasonable, and the clinical records indicated the wound was healing well before Mrs A's second fall. We also found the problems with Mrs A's fractured leg did not contribute to the amputation of her second leg, which was due to her underlying vascular disease.

We upheld Mrs C's complaint about the board's complaint handling. We were critical of the significant delays and the failure to respond to the additional points, as well as the poor communication between staff and with Mrs C.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C and Mrs A for their poor communication and failing to respond to the additional points of the complaint. This apology should comply with SPSO guidelines on making an apology, available at www.spso.org.uk/leaflets-and-guidance
• Finalise and send the written response to the additional points of complaint.

In relation to complaints handling, we recommended:

• Where a complaint response takes more than 20 working days, the board should explain the reasons for the delay and agree a new timeframe.
• The board should meet any commitments they make about responding to complaints, unless otherwise agreed with the complainant.
• There should be effective communication between the staff handling a complaint and the managers making decisions about it.

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 works for an advocacy and support agency, complained on behalf of her client (Mr A) about the care and treatment he had received before being diagnosed with colorectal cancer. Mr A had previously had a colonoscopy (an examination of the bowel with a camera on a flexible tube) and was diagnosed with diverticulosis (disease of the colon). He subsequently had a bowel screening test, which showed hidden blood in his bowel motion. He was initially told that a colonoscopy was the best way to look for the cause of bleeding, which in some but not all cases, may be due to bowel cancer. However, he was then told that a further colonoscopy would not be necessary.

Mr A subsequently attended his GP with abdominal pains and diarrhoea. He was referred to a general surgery clinic at Gartnavel General Hospital and an upper gastro-intestinal endoscopy (a medical procedure where a tube-like instrument is put into the body to look inside) and flexible sigmoidoscopy (a procedure that is used to look inside the back passage and lower part of the large bowel) were arranged. It was recorded that these showed mild gastritis (when the lining of the stomach becomes inflamed after it has been damaged) and that it was likely that diverticular disease (a group of conditions that affect the colon) had caused the positive bowel test.

Mr A continued to have abdominal pain and a scan of his abdomen and pelvis was arranged. This showed an area of thickening in a part of his colon, which either represented a tumour or diverticulitis. A further colonoscopy was then carried out and Mr A was subsequently diagnosed with cancer.

We took independent advice on the complaint from a consultant general and colorectal surgeon. We found that although it had taken some time to diagnose his cancer, there had not been any failings by the board and the timings in relation to each step of his care and treatment had been reasonable. The decision not to initially carry out a second colonoscopy had been in line with national guidance, which said that this should not be done where the patient has had a colonoscopy in the previous 12 months. We did not uphold this aspect of the complaint.

Ms C also complained that the board's response to her complaint incorrectly stated that a specialist nurse had told Mr A that he should see his GP for referral to his local colorectal service. Mr A disputed this and there was no record in his notes of what, if anything, the nurse told him. It was therefore difficult for us to comment further on what information the nurse gave Mr A. However, we found that the failure to record the advice given to Mr A was unreasonable and we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise that there are no contemporaneous notes in the records of what the nurse told 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:

• The board should consider how they wish the clinical nurse specialists to communicate with primary care and with patients and how they will record this information, when decisions are made within the screening service not to proceed with investigation.

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 care and treatment she received during her pregnancy, delivery and postnatal period. Mrs C was unwell during her pregnancy and was latterly diagnosed with pre-eclampsia (a pregnancy-related condition involving a combination of raised blood pressure and protein in the urine) at the Southern General Hospital. She was transferred to the Royal Alexandra Hospital for a caesarean section as they had space available to care for her premature baby following delivery. Following the delivery, Mrs C was transferred to a maternity ward for around two days until her discharge home while her baby remained in the special care baby unit. Mrs C was seen by a community midwife at home and was subsequently readmitted to the Royal Alexandra Hospital where she was diagnosed with peripartum cardiomyopathy (a rare disease defined by heart failure towards the end of pregnancy or in the months following delivery). Mrs C was treated in the cardiology department before being transferred back to a maternity ward. While she remained in hospital, Mrs C experienced severe abdominal pain and a scan revealed that she was suffering from retained placental tissue (a condition where parts of the organ attached to the lining of the womb during pregnancy remain following birth). A procedure was carried out to remove these.

Mrs C had a number of concerns about her care and treatment and complained to the board. She complained that there had been unreasonable delays in diagnosing her with pre-eclampsia, peripartum cardiomyopathy and retained placenta. She further complained that she was discharged too early, that the placenta had not been removed during the caesarean section, that she was unreasonably encouraged to express breast milk, and that staff had not treated her compassionately. The board responded to Mrs C's concerns in writing and also arranged meetings with her to discuss her experience. Mrs C was unhappy with the board's handing of her complaints, and she brought her concerns to us for further investigation.

We took independent advice from a midwifery adviser and a consultant obstetrician during our investigation. We found that there had been no delay in diagnosing Mrs C's pre-eclampsia or peripartum cardiomyopathy, and that, taking her clinical records from that time into account, her discharge was reasonable. In relation to Mrs C being encouraged to express breast milk, our midwifery adviser highlighted no concerns. We did not uphold these complaints as a result.

We did, however, find that the placenta had not been fully removed during the caesarean section and that the risks of needing a further procedure (such that to remove retained placenta) had not been mentioned on the associated consent form. The obstetrics adviser highlighted concerns about the subsequent procedure to remove the retained placenta and pain that Mrs C suffered. We upheld Mrs C's complaints about the retained placenta and noted that the board had already offered apologies for the delay and pain she experienced. We made further recommendations in relation to these issues. We also upheld Mrs C's complaint about her treatment by staff. While the advice we received did not highlight any concerns about communication, we noted that, during their own investigation, the board apologised for poor attempts at humour on the part of a staff member and advised that Mrs C's experience would be used as a reflection and learning exercise. We made a recommendation about this.

Mrs C also complained about the way that the board had handled her complaint. We identified an issue in the way that the board determine the age of a complaint, however, this did not have a significant impact on their handling of Mrs C's case. We drew the board's attention to this but did not uphold this part of Mrs C's complaint.

Recommendations

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

• Staff should be familiar with the Royal College of Obstetricians and Gynaecologists (RCOG) guidance on the consent process for caesarean sections.
• Staff should provide patients with sufficient information to allow them to make informed choices about their treatment.

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