Some upheld, recommendations

Summary

Ms C, who is an advice worker, complained on behalf of Mrs A about the care and treatment she received at Raigmore Hospital. In particular, Mrs A said that the hospital failed to communicate adequately with her and her family during her admission. She also said that the hospital failed to provide an appropriate standard of nursing care or appropriate medical treatment.

We took independent advice from a nursing adviser and a medical adviser who is a hospital consultant. We found that the level of communication with Mrs A and her family was reasonable, as was the level of communication between medical staff. However, our investigation showed that the board failed to provide Mrs A with an appropriate standard of nursing care. We were mindful that the board had accepted there were failures in relation to nursing care and had taken action to address these matters.

We found that the medical care and treatment Mrs A received in the hospital was reasonable.

Recommendations

We recommended that the board:

• consider the nursing adviser's comments about the overall standard of record-keeping and provide details about when the improvements to nursing documentation are to be implemented and evaluated;
• provide an action plan to address the failures in relation to nursing assessments and pain management identified in this case;
• consider the medical adviser's suggestion about the development of a care plan for Mrs A and report back to us on any action taken; and
• remind relevant staff of the need to label each page within medical records with the correct patient identification details.

Summary

Mrs C's mother (Mrs A) was admitted to the Glasgow Royal Infirmary with a chest infection. After initial improvement and transfer to another ward her condition deteriorated. She suffered a cardiac arrest and died while awaiting admittance to the intensive care unit. Mrs C raised a number of concerns about her mother's care and treatment. These included that the board's medical and nursing staff failed to review, monitor and treat her mother appropriately and that the board did not make reasonable efforts to communicate her mother's condition to her family.

We obtained independent advice on the complaint from a consultant physician and a nurse. The consultant adviser explained that Mrs A was reviewed by medical staff on several occasions each day, including specialist haematology input. They said Mrs A's treatment included antibiotics which were reviewed and altered according to her evolving clinical problems and results from the laboratory. The consultant adviser said all of this was reasonable.

The nursing adviser said that observations on Mrs A were carried out frequently and in accordance with the board's policy. They said that when Mrs A's condition deteriorated, the appropriate action was taken with the nursing staff reporting this to a senior clinician.

From Mrs A's arrival on the hospital ward to the point when her health deteriorated, the advisers were not critical of the level of communication with the family. However, the advisers considered that after Mrs C and her family were called to attend hospital following the deterioration in Mrs A's health, the board did not make reasonable efforts to communicate with Mrs C and her family about Mrs A's condition. We upheld this aspect of Mrs C's complaint and made a recommendation to the board.

Recommendations

We recommended that the board:

• provide us with evidence of the steps that have been taken to ensure that in future proactive communication takes place with a patient's family when a patient deteriorates.

Summary

Ms C complained about the care and treatment of her late great aunt (Miss A) in Aberdeen Royal Infirmary. Miss A had cancer which was noted to be progressing and a palliative care approach was taken. She died a few weeks later. Ms C raised particular concerns surrounding the decision to stop providing her great aunt with intravenous fluids (fluids delivered directly into the vein). She considered that this led to Miss A becoming dehydrated and potentially hastened her death. We took independent advice from a consultant physician. They advised that the decision to discontinue the provision of intravenous fluids was reasonable, as it was no longer clearly beneficial and had become uncomfortable for Miss A. They considered that this decision was appropriately discussed with Miss A and her family. We did not uphold this complaint. However, the adviser identified an issue, not raised as part of the complaint, surrounding the communication of a decision that Miss A would not be resuscitated in the event of cardiac or respiratory arrest. Healthcare Improvement Scotland had since inspected the hospital and identified a similar issue. They made a recommendation and we asked to board to provide confirmation that this has been implemented.

Ms C also complained about the nursing care provided to Miss A. We took independent advice from a nurse. They advised that appropriate nursing care was provided, with evidence of regular comfort checks and assistance with personal care. We, therefore, did not uphold the complaint. However, while appropriate care appeared to have been delivered, this was not formally planned in a detailed end of life care plan. We recommended that the board consider doing so in future.

Ms C complained that the board's response to her complaint was delayed and did not answer the specific questions she asked. We identified that the board did not adhere to the terms of their complaints procedure in responding to the complaint and, in particular, that they failed to address all of Ms C's specific concerns. We upheld this complaint.

Recommendations

We recommended that the board:

• inform us of the steps they have taken to implement the relevant Healthcare Improvement Scotland recommendation following their inspection of Aberdeen Royal Infirmary in August 2015;
• consider the use of an end of life care plan as outlined in the Scottish Government's guidance on 'Caring for people in the last days and hours of life';
• apologise to Ms C and her mother for failing to appropriately respond to their complaint; and
• ask complaints handling staff to reflect on the findings of this investigation and ensure future adherence to their complaints procedures, with particular focus on timescales, comprehensiveness and language.

Summary

Miss C raised her concern about the care she received from Forth Valley Royal Hospital during her pregnancy, labour and postnatal period.

During our investigation, we took independent advice from a consultant in reproductive medicine and surgery, a consultant obstetrician and a midwife. We also received advice on general nursing issues from a nursing adviser.

The board accepted that there had been errors in relation to the initial ultrasound scans Miss C received and, as a result, she had been incorrectly advised that she had suffered a miscarriage. The board had apologised for those errors and had taken action. The advice we received and accepted from the consultant in reproductive medicine and surgery was that it had been too early to diagnose a miscarriage and that there was no evidence consultant advice had been obtained. The adviser also said that there was a failure to record / obtain a complete menstrual history at the time of the scans.

The advice we received from the midwife was that carrying out an ultrasound scan before six weeks gestation would not normally happen. The midwifery adviser also said that it happened in this case in an attempt to meet Miss C's needs, given that she had recently undergone surgery. The adviser said that this was not clinically appropriate.

In the circumstances, we considered that the board had failed to provide Miss C with appropriate care and treatment and we upheld this aspect of the complaint.

We were satisfied that an appropriate assessment had been carried out when Miss C first attended the hospital when she believed her labour had started. However, while the advice we received and accepted from the consultant obstetrician and the midwife was that aspects of her care and treatment were reasonable when she returned to the hospital (in particular, that the obstetrician adviser did not consider that there was an unreasonable delay before the decision was taken to proceed with a caesarean section), we were concerned about a number of communication failings and a failure in record-keeping. We made recommendations to address these failings.

The board had apologised for Miss C's concerns in relation to her postnatal care and had taken action. The advice we received and accepted from the nursing adviser was that the action taken had been reasonable.

Recommendations

We recommended that the board:

• remind staff of the need to record/obtain a complete menstrual history at the time of ultrasound scans;
• bring to the attention of relevant staff the findings of this investigation, in particular the need for experienced medical involvement in a similar situation and the need for further scans;
• consider the suggestion received from the midwifery adviser that additional training in relation to dealing with bereavement surrounding early pregnancies should be provided for midwives who regularly work in this area; and
• remind midwifery staff of the need to maintain full and accurate nursing records in line with Nursing and Midwifery Council guidance.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A) at Borders General Hospital. He raised concerns that staff unreasonably put in place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order without discussing this with him, despite him holding welfare power of attorney. We took independent advice from a consultant physician. They found no evidence of the decision having been discussed initially with Mr C. We were critical of the board for failing to properly involve Mr C in discussions and we upheld this part of the complaint.

Mr C also complained about the actions of staff in relation to his mother's feeding. In particular, he questioned the process surrounding the insertion of a PEG (percutaneous endoscopic gastronomy) feeding tube. The advice we received indicated that Mrs A's nutritional intake was appropriately monitored throughout her stay. We were satisfied that Mr C was appropriately consulted and involved in decisions in this regard, including the decision to insert a PEG tube. We did not uphold this part of Mr C's complaint. In addition, Mr C complained about the general nursing care provided to his mother. We took independent advice from a senior nurse who reviewed the records and advised that the overall nursing care provided to Mrs A was of a good standard. We did not uphold this aspect of Mr C's complaint.

Finally, Mr C complained about the adequacy of the board's response to his complaint. We found their response generally to have been of a reasonable standard. However, in addressing Mr C's concerns surrounding the DNACPR decision, they provided some information that was not supported by the medical records. Furthermore, while the board acknowledged and apologised for a failure to prescribe some of Mrs A's usual medication, they did not identify a subsequent gap in the prescribing chart. We upheld this aspect of Mr C's complaint. We made some recommendations in relation to both the complaints handling and prescribing failures identified.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to properly involve him in discussions about Mrs A's DNACPR status;
• remind their medical staff of the importance of involving patients and their carers in discussions about end of life care and of documenting such discussions;
• review their process for checking and prescribing relevant medication following admission and inform us of the steps they have taken to avoid a repeat of the failings this investigation has highlighted;
• apologise to Mr C for the inadequate response to his complaint; and
• remind complaints handling staff of the importance of investigating and responding to complaints comprehensively and accurately, ensuring that the information provided is supported by available evidence and that any discrepancies are reflected in their correspondence with complainants.

Summary

Mr and Mrs C complained about the care and treatment provided to their daughter (Ms A) at Ayr Hospital. Ms A had a complex medical history and had required several operations over the course of her life.

Ms A suffered repeated urine infections and underwent an operation for this in the hospital. During the operation, Ms A breathed in fluid from her stomach. She was admitted into the intensive care unit (ICU) and placed on a ventilator. Ms A deteriorated over the weekend and did not recover, and she died shortly afterwards in the ICU.

Mr and Mrs C complained Ms A's care was inconsistent and that there was an inadequate level of medical staffing over the weekend. Mr and Mrs C said they had been given contradictory accounts of Ms A's condition and it had been a shock when they were informed treatment was to be withdrawn from her. They believed this should have been discussed with them and that the way the staff broke the news to them was inappropriate. They also complained that, after she died, Ms A was left connected to drips and monitors, which they felt was inappropriate.

The board met with Mr and Mrs C following their complaint. They did not discuss Ms A's care and treatment but they apologised if staff had increased the family's distress through their language or actions.

We took independent advice from a consultant in intensive care medicine and a senior nurse. The advice we received was that the care and treatment was reasonable. The medical records showed an appropriate level of medical review, along with the correct treatment for Ms A's condition. We found that communication with Mr and Mrs C was appropriate. It was, however, unreasonable for the family to have been left with Ms A after she died, without any attempts by staff to ascertain their wishes. We found this had added significantly to the family's distress. Although the care and treatment was reasonable, the board had accepted there were failings in communication with the family. We found they had apologised appropriately but that they needed to provide evidence of the actions taken to prevent a recurrence. We upheld this part of Mr and Mrs C's complaint and made recommendations to the board.

Recommendations

We recommended that the board:

• provide evidence that the actions identified in Mr and Mrs C's meeting with the board (following their complaint) have been carried out; and
• remind nursing staff of the importance of establishing family members' wishes should a patient die whilst in the ICU.

Summary

Mr C complained about his wife (Mrs A)'s neurological consultation which they both attended, the correspondence following this consultation, and the way the board handled his complaints. Mr C said that the way the consultation at Crosshouse Hospital had been conducted failed to meet Mrs A's specific needs and requirements arising from the fact that she was autistic and had dyslexia, Asperger's syndrome and anxiety. Mrs A was subsequently diagnosed with a disc protrusion (a common form of spinal disc deterioration that causes neck and back pain) by another consultant and Mr C said that the failure to meet Mrs A's needs meant that the first consultant missed the diagnosis.

We took independent advice from a medical adviser and an equalities adviser. We found that it was not reasonable to expect the first consultant to have diagnosed a disc protrusion and the findings from a later investigation were not evidence that the diagnostic process had been hindered. In relation to the equalities aspect of the complaint, however, it was not clear that the consultation booking process and the consultation procedure would meet the needs of people with disabilities generally. While we found that the consultant was aware Mrs A had specific needs and requirements and had made adjustments in line with their understanding of them, the current process (whereby information about the consultation was normally read by the consultant just before the patient was seen) did not enable the board to plan ahead and make reasonable adjustments once a patient's needs were known. It was also not clear if staff had received appropriate training about making reasonable adjustments. We therefore upheld the complaint in light of the evidence in relation to the equalities aspect of the consultation booking process and consultation procedure.

With regard to the other aspects of Mr C's complaint, we found that the subsequent correspondence about the consultation was reasonable and that the board handled Mr C's second complaint in a reasonable way. However, we were concerned about the way that the board had handled Mr C's first complaint in that there was an unreasonable delay and staff were not as proactive as they should have been in keeping Mr C informed about the delay and the reasons for it. Moreover, the complaint was only resolved when the board revisited it after their substantive response to the complaint and it was not clear why this did not happen when they first investigated it.

Recommendations

We recommended that the board:

• carry out an equality impact assessment on the board's consultation booking process and consultation procedure;
• confirm the provision of training and guidance to ensure that clinical and booking staff make reasonable adjustments for patients with additional needs for consultations or, if this has already been delivered, provide us with evidence of the training and guidance;
• bring our decision, including the equalities adviser's comments, to the attention of relevant staff;
• bring our findings about complaints handling to the attention of relevant staff; and
• apologise for the failures this investigation identified.

Summary

Mr C represented a community organisation which had received an unexpectedly large bill for water use from Business Stream. Mr C said the bill had been delayed as it had been delivered to the wrong address. He felt Business Stream had acted unreasonably, since they had not responded properly to his complaint about the bill. Additionally, Mr C said Business Stream's website committed them to suspending billing and investigating the leak, which had not happened. Mr C said this delay had added a month's worth of water loss to the bill. Mr C was also aware that repairs had been carried out for free on the supply pipe for the previous owner, he considered it unfair that the same discretion was not being applied to a community organisation and believed Business Stream had an obligation to tell the organisation this when they took ownership of the property.

We found that Business Stream had failed to explain what suspension of billing meant to Mr C. They had also failed to carry out an investigation into Mr C's case. We upheld this aspect of Mr C's complaint. We found that Mr C had acknowledged difficulties in receiving mail, but that Business Stream had made reasonable efforts to inform him of the high water usage. Although Business Stream had acknowledged they had taken an unreasonable length of time to respond, Mr C still had outstanding questions, which had not been answered. We found that it was unreasonable for Business Stream to have failed to provide a full response given the length of time the complaint had been under consideration. Therefore, we upheld this part of Mr C's complaint.

Recommendations

We recommended that Business Stream:

• review the 'Water Usage Alerts' section of Business Stream's website to ensure it accurately explains what suspension of billing means and sets out what level of investigation will be carried out;
• provide evidence that all customer service staff have been reminded of the commitments given on the 'Water Usage Alerts' section on Business Stream's website;
• review its offer of financial redress to include the failings that were not addressed in its complaint response;
• review its complaints handling process to ensure that all aspects of a complaint are identified and responded to in line with complaints handling best practice; and
• apologise in writing to Mr C for the failings identified.

Summary

Mrs C raised a complaint about Business Stream's handling of charges for water and drainage services. In particular, she was unhappy about the delay in issuing an invoice for these charges which Business Stream had backdated to 2008. She also complained that Business Stream had failed to fully investigate other possible service users who were sharing her water meter.

During our investigation we found no evidence that Business Stream had been notified prior to 2011 that Mrs C had moved into the premises and that they had failed to act on this information. However, we were concerned that once Business Stream were notified in October 2011 it then took until December 2012 for an account to be opened. Business Stream also accepted that they had failed to carry out two meter readings as required. As a result, Business Stream amended the opening of the account to October 2011 and applied an ex gratia payment amounting to 50 percent of the total water consumption as a gesture of goodwill. We upheld this aspect of Mrs C's complaint.

We were satisfied that Business Stream had carried out reasonable enquiries to establish that Mrs C was not on a shared supply and that her meter only served her property. Therefore we did not uphold this aspect of Mrs C's complaint.

Recommendations

We recommended that Business Stream:

• apologise to Mrs C for their handling of this matter.

Summary

Mr C complained that the Scottish Funding Council (SFC) had produced guidelines for allocating bursary funding which were discriminatory. Mr C received an occupational pension following early retirement due to ill health and believed this should be considered as a disability benefit and not included in the calculation of his household income. Mr C said he believed the SFC had not drafted their bursary guidelines in keeping with the relevant equality legislation. Mr C also complained that his complaint to the SFC had not been properly handled.

The SFC stated that different areas of income were taken into account in the guidance on student support assessments. They had provided a detailed explanation of the various types of income and the way they were assessed. The SFC said they had not initially considered Mr C's correspondence as a complaint, but they accepted this could have been handled more proactively and they had taken steps to address this.

We took independent advice from an equalities adviser. The adviser said that the SFC had fulfilled their obligation under equalities legislation to consider the impact of their bursary policy and guidelines on individuals who were in receipt of occupational pensions. In light of this, we did not uphold this aspect of Mr C's complaint.

We upheld Mr C's complaint about the way SFC had dealt with his complaint. However, the SFC had provided evidence that they had taken proportionate and robust steps to address this failing, so we did not make any recommendations about their complaints process, though we did ask them to apologise to Mr C.

Recommendations

We recommended that the council:

• apologise for the failure to respond appropriately to the complaint.