Upheld, recommendations

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer. C also complained that the board failed to reasonably meet their obligations in accordance with Duty of Candour.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to a failure to mark an MRI scan request as urgent, and a failure to report the results of scopes in the normal way. We upheld this complaint. We also found that the board failed to meet their obligations in accordance with Duty of Candour. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

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

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

• Patients should receive reasonable and timeous care.

Summary

C complained about the care and treatment provided to their late parent (A) by a GP Practice when A was a resident in a care home. Care home staff had reported that A was agitated and unsettled, possibly in pain and with poor sleep at night. The practice requested that care home staff take a set of observations (temperature, oxygen saturation, pulse, blood pressure) and obtain a urine sample. When observations were later taken by care home staff, the practice advised that they were all normal, thereby giving a NEWS Score (a tool used to quickly determine the degree of illness of a patient and identify acute deterioration) of 0. They said that no visit was indicated at that time and queries about medication for agitation would be discussed on the next GP round to the care home. C was of the view that the report of agitation and confusion should have led to GP review.

We took independent advice from a GP. We found that the care and treatment provided to A was unreasonable, as A had delirium until proven otherwise and should have been seen and assessed for this. We also noted that the practice appear to have relied on a NEWS score to decide no visit was needed, but NEWS is not validated for use in primary care. We therefore upheld the complaint.

During the course of our investigation the practice carried out a Significant Event Review. As a result, they had developed a protocol, to be used alongside physiological measurements, for assessing delirium in the care home setting and had shared and discussed this with the care home. We considered these actions to reasonably address the failings in this case, so aside from apologising to C, we made no further learning and improvement recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to assess A for delirium. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .

Summary

C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and A fell, sustaining a fractured shoulder and a fractured knee. C was concerned about A’s medical and nursing care and about the communication from the board.

We took independent advice from a nursing adviser and a consultant geriatrician.

We found that the falls screening questions were not completed on A’s admission, safe care pauses were not demonstrable from the daily care plan or nursing documentation, A’s walking aid was not within reach and a decision was made to mobilise A when the floor was wet, rather than call for help and ensure the environment was safe. We found that the board’s investigation into A’s fall did not make attempts to identify the second staff member who witnessed the fall and take a statement from them. There was also a failure to activate the Duty of Candour process in this case. We found that A’s B12 injection should have been administered in a more timely way and that medical staff did not promptly inform C and their family of the results of the X-rays and the implications of the fractures for A. Finally, we found that the board did not respond to all of the concerns that C raised. We upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

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

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

• Appropriate steps should be taken in the prevention and management of falls.
• Where appropriate, patients and/or their families should be informed of the results of X-rays by medical staff.
• When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay.
• Where a patient has fallen and sustained harm, attempts should be made to identify and take statements from all the staff who witnessed the fall.
• Where clinically appropriate, B12 injections should be administered in a timely way.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded toin accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with a long backlog of patients. When C did subsequently undergo a colonoscopy, this led to a diagnosis of cancer.

We took independent advice from a consultant gastroenterologist and hepatologist. We found that the board failed to identify C as someone at significant increased risk that needed the procedure to be re-booked as a priority. We found that it was unreasonable that C’s colonoscopy was an overdue procedure that was not clinically reviewed. Therefore, we upheld this complaint. We also found that it was unreasonable that the board had not carried out a significant adverse event review into the matter.

C also complained that the board failed to provide a reasonable response to their complaint. We found that the board’s complaint handling of C’s complaint was unreasonable, as the failure to clinically review C’s overdue procedure and failure to identify C as someone at significant increased risk, were inadequately investigated as part of the complaints process. In light of that specific failing, we also upheld this 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/meaningful-apologies.

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

• The board should have a robust clinical prioritisation process for rescheduling endoscopy procedures that may have been delayed for whatever reason
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaints investigators should fully investigate and address the key issues raised, identify and action appropriate learning and apologise where issues have been identified. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C, a Patient Advice and Support Service (PASS) adviser, complained on behalf of their client (B) about the care and treatment provided to B's late spouse (A). A was under the care of two health boards for treatment of a concurrent bladder and colorectal cancer. C complained about the care and treatment received for their colorectal cancer. They also complained about the adequacy and conclusions reached by a Level 2 Adverse Event Review and a Level 1 Significant Adverse Event Review carried out by board A, as well as a lack of transparency under the Duty of Candour and the way that they had handled the complaint. While the bladder cancer was timeously treated, A died without having received treatment for the colorectal cancer.

In responding to the complaint, the board outlined their management of A’s colorectal cancer through the regional multi disciplinary team process, having reviewed the care and treatment as a Level 2 adverse event review and a Level 1 significant adverse event review.

We took independent advice from a colorectal surgeon. We found that there was a failure to provide a reasonable standard of care and treatment to A, particularly in relation to delays in initiating treatment for their colorectal cancer. We upheld this complaint. We found that the Adverse Event Review and the Significant Adverse Event Review (SAER) conducted by the board were inadequate, with inaccuracies in the timeline and unsupported conclusions. We upheld this complaint. We found that there was a failure by the board to meet their Duty of Candour obligations, and we upheld this complaint. We also found that the board’s handling of the complaint was unreasonable, and we upheld this 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/meaningful-apologies.

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

• Patients should receive reasonable and timeous care.
• When an unexpected or unintended incident occurs, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type, including but not limited to adverse event reviews and Duty of Candour.

In relation to complaints handling, we recommended:

• Complaint investigations should be managed in accordance with HYPERLINK "https://www.spso.org.uk/the-model-complaints-handling-procedures" The Model Complaints Handling Procedures | SPSO. Complaint investigations should fully investigate the matters of complaint made and identify actions for learning and improvement.

Summary

C complained about the care and treatment provided to them in relation to their health in prison. C experienced difficulties in relation to their medical needs, including staff not attending when C requested, not receiving their medication, lack of communication and that the complaint response did not answer all of C’s concerns.

We took independent advice from a qualified GP. We found that the board seemed to lack appreciation that without medication for stomach acid, C would be left very symptomatic and sore and that they failed to supply the alternative medication to C when it was due. Once the medication had been obtained, they failed to locate C within the prison to give them the medication and failed to follow protocol to store the medication for reissue. We found that the board failed to communicate the problem with their medication to C and failed to reach a solution about C’s missing medication. We also found that the board failed to attempt to reach a solution about the poor communication between them and the Scottish Prison Service (SPS). Therefore, we upheld this complaint. We acknowledged that the board had taken learning and improvement action in relation to a number of these failings.

C also complained that the board unreasonably failed to respond to all of C’s concerns in their complaint response. We found that the board’s first complaint response was unreasonable, and while the second response was generally reasonable, the length of time it took for the board to issue this was unreasonable.

On balance, we upheld this complaint. We also acknowledged that the board had taken some learning and improvement action in relation to these matters going forward.

Recommendations

What we asked the organisation to do in this case:

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

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

• All staff should follow relevant processes and procedures in relation to prisoners medication and medical needs. There should be clear communication between staff and prisoners in relation to their medication and medical needs
• When it is decided that a prisoner needs to be seen by medical / nursing staff, this should be adequately communicated.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. The board should investigate and respond fully to the key issues raised, identify and action appropriate learning, and signpost to other relevant organisations as soon as practical. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in confusion and told C that they had not received food or hydration, had not been washed and had not been able to sleep. C returned A to the hospital on the condition that A was moved to a ward, which they were. The next day C was told that A had suffered an unwitnessed fall and was to be discharged to attend an oncology appointment. A also had lesions on their groin which had developed and not been cared for during their admission. A died within two weeks of being discharged.

C complained to the board. The board accepted that there were a number of areas for improvement in the care and treatment that A had received, apologised and advised of actions that they would take or had taken to address these matters. C was dissatisfied with the board’s responses and raised their complaints with SPSO.

The board identified further areas where the care they had provided to A had not been reasonable and advised of further actions that they would take to address these. Given this, we upheld C’s complaint that the board did not provide reasonable care to A, with specific reference to care of lesions on A’s groin and the discharge of A.

We took independent advice from a nursing adviser. We found that the board, in considering how best to reflect on A’s care and treatment, had focussed too narrowly on A’s fall, that they should have considered the experience of A and their family more broadly and that relevant guidance indicates a Significant Adverse Event Review should have been carried out. We also found that there was a delay in providing a response to C’s complaints and that C had not been updated regularly while the complaints were being considered. We also found that the actions proposed and taken by the board to address the issue of patients remaining in the CAU for prolonged periods would not fully address the areas for improvement identified. Therefore, we upheld the complaint that the board did not respond reasonably to C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Provide a further apology to C which acknowledges that specific areas of unreasonable care provided to A were found as a result of both the board’s consideration of C’s complaint and the Board’s consideration of subsequent enquiries by the SPSO. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/meaningful-apologies" www.spso.org.uk/meaningful-apologies .
• Provide a further apology to C which acknowledges that:
• relevant guidance indicates an SAER should have been carried out regarding A’s experiences,
• regular updates were not provided to C during the investigation of their complaint
• the actions proposed and taken by the board did not fully address the areas for improvement identified by their investigation of the issue of patients remaining in the CAU for prolonged periods.
• The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The Board develop policies on actions to be taken to escalate discharge for patients remaining in the CAU for prolonged periods, and to address the lack of access to shower facilities for patients in the CAU.
• The board’s consideration of whether to undertake SAERs takes into account patient experiences reasonably widely and relevant guidance.

Summary

C complained that nursing staff had failed to properly supervise their parent (A) resulting in a fall and that there was a lack of documented information about A's plan of care in the medical records. A was admitted to hospital for hip surgery following a fall at their home. A few weeks later, A fell and hit their head. This led to A sustaining a subdural haematoma (SDH, a brain injury) and A died as a result.

C complained that following A’s fall there was a failure to treat A as a priority, and raised concerns that A was transferred from a trauma ward to an orthopaedic ward. C believed that A should have been transferred to another hospital, outwith the board, for surgery.

In response, the board said that A’s care pre-fall had been in line with the relevant supervisory assessment. They apologised for a delay in A receiving a medical review following the fall, however, they said that nursing staff had carried out appropriate neurological observations. The board added that A was not considered suitable for surgery by surgeons and that the case had been considered at a local management team review (LMTR).

We took independent advice from a consultant specialising in the care of the elderly, and an experienced nurse. We found that the documentation in A’s nursing records did not evidence that the care and interventions A received to keep them safe from harm and to support their mobility were to the standard required to prevent A falling. Additionally, we found that there were failings in relation to A’s neurological observations with a lack of proper assessment, implementation and evaluation and gaps in recording. We considered that while these measures may not have ultimately prevented A’s fall, there was unreasonable care and as such we upheld C’s complaint.

We found that A’s post-fall care fell well below a reasonable level and did not meet the standards described in the board’s head injury protocol and the relevant NICE guidance for the management of head injuries. Issues identified included a lack of consultant oversight and a failure to carry out timely neurological interventions and tests when A’s condition deteriorated. Additionally, as A had suffered harm and death as a result of a fall, the board should have completed a significant adverse event review (SAER). We upheld C’s complaint on that the care and treatment provided to A was unreasonable.

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/meaningful-apologies

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

• Care and treatment should be provided in line with the relevant guidance on head injuries.
• Patients presenting with a decline in their cognitive and/or neurological functions should have their symptoms fully assessed, evaluated and monitored in a timely manner in line with relevant guidance. All nursing documentation should comply with the standards set out in the board’s guidance and the NMC The Code.
• Patients presenting with a decline in their cognitive and/or neurological functions should have their symptoms fully assessed, evaluated and monitored in a timely manner in line with relevant guidance. Where a GCS assessment has shown deteriorations in a patient who has sustained a head trauma, prompt action should be taken in respect of carrying out scanning and seeking specialist advice.
• Where adverse event(s) occur a significant adverse event review should be held in line with the board's protocols and national guidance.

In relation to complaints handling, we recommended:

• Complaint investigations and responses should be accurate in their findings and conclusions, clear, and supported by relevant evidence, such as medical records and where possible include responses from staff involved in the events complained about. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

Summary

C is a council tenant and lives with their family. C complained that the property they were living in suffered from significant problems with damp and mould. C believed that the conditions in the property were adversely affecting the family’s health and damaging their possessions. It was acknowledged by the council that C had been raising concerns for some time.

Although the council had carried out works and surveys on C’s property, damp problems remained. We found that the primary cause of damp had not been identified and the council accepted further works were required, and that the time taken to address the problem had been excessive. We found that the council could not evidence that they had considered the impact on C of their living conditions and it was not clear that the property was treated as a priority in line with the council’s revised damp and mould policy. We upheld C’s complaint that the issues with their property had not been dealt with reasonably.

Recommendations

What we asked the organisation to do in this case:

• Develop an action plan, to be shared with C, setting out clearly the steps that they intend to take to address mould and damp in C’s property, and dates for updating C on implementation.

In relation to complaints handling, we recommended:

• Responses to complainants and the SPSO should be thorough and complete, ideally in one response.

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 to the council that their teenage child (A)'s school had not taken reasonable action following the report of an assault on A and a report of bullying. A reported continued bullying behaviour early in the next term and measures were put in place, such as allowing A to leave classes early. Just over a week later A was involved in a pre-arranged fight with another pupil close to school grounds in school time.

The council’s investigation did not uphold C’s complaints about the action taken following the report of the assault and bullying. C was dissatisfied and raised their complaints with SPSO.

We found that the school did not follow their Anti-Bullying Policy following the assault on A. They did not advise C of their decision that the school could take no further action regarding the reports of bullying as there was no concrete evidence of this, and they were imprecise in how they described contact with other parents/carers to C. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A that the school did not follow their Anti-Bullying Policy following the reporting of the assault and that they unreasonably failed to manage the report of the assault. 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 that in the their complaint response they incorrectly stated that, as C knew, the lack of evidence had made it difficult to pursue the matter further. The apology should meet the standards set out in the SPSO guidelines on apology availale at www.spso.org.uk/information-leaflets.

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

• The school should follow their anti-bullying policy and advise parents/carers of any decisions reached or actions taken following reports of bullying.
• The school should follow their Anti-Bullying Policy in relation to reports of bullying.

In relation to complaints handling, we recommended:

• The council’s complaint investigations take full account of all the circumstances and their conclusions are supported by evidence. The council’s investigations and complaint responses only deal with specific matters once. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.
• The council’s responses to SPSO are properly considered and that it is clearly stated when, on reflection or further consideration, a different view or conclusion has been arrived at.

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.