Upheld, recommendations

Summary

C’s parent (A) suffered a number of falls during an admission to hospital where A sustained a head injury and subsequently died. C complained to the board that A’s falls risk was not effectively managed.

The board identified some failings in relation to A’s falls care, including a lack of personalised falls prevention plan and a lack of falls risk signage over A’s bed. However, they noted that staff were fully aware of A’s falls risk and took measures to reduce this, and they did not find that A fell due to a lack of reasonable care.

We took independent advice from an experienced mental health nurse. We found that there was a failure to effectively assess A’s significant falls risk and tailor interventions to their individual needs. We noted that the board did not consider it appropriate for A to have received one-to-one nursing or be moved to a more observable area, however, no evidence was provided of consideration having been given to the risks and benefits of such interventions. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for failing to reasonably manage A’s falls risk. 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:

• Falls prevention assessment and planning should be personalised and carried out in line with up-to-date board policies and procedures.

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

Summary

C complained about the care and treatment given to their late sibling (A) who had a history of schizoaffective disorder. After a change in the consultant responsible for A’s care, A’s diagnosis was changed and their medication withdrawn over an extended period which led to A becoming unwell. They required admittance to hospital on a number of occasions before their death by suicide.

The board carried out a significant adverse event review (SAER) into what happened which identified a number of failures and made a number of recommendations as a result. Later the board issued their complaint response to C’s complaint which detailed the consultant’s position that A’s symptoms were not in keeping with a continuing psychotic illness, and that, this view was shared by the wider clinical team.

We took independent advice from a consultant psychiatrist and a mental health nurse. We found that the decision to change A’s diagnosis was not supported by their presentation, that the various diagnoses were referred to with no explanation and that the consultant involved in A’s care held an incorrect belief that schizoaffective disorder and schizophrenia were, in essence, the same condition and were interchangeable. We also found that NICE guidelines were not always followed appropriately, that there was an over-reliance on remote methods of assessment, that changes were made to medication without having seen or assessed A and that clinicians unreasonably maintained that A did not present with psychotic symptoms when the evidence demonstrates otherwise. Finally, we found that the nursing care was reactive and treatment was crisis led and failed to provide support and strategies for early interventions, that there was a failure to create a community care plan and that there was a lack of multi-disciplinary working, and therefore, a lack of challenging decisions on patient care. As such, we found the care and treatment both in hospital and from the community nursing team to have been unreasonable and we upheld this aspect of the complaint.

We also considered the way in which the board handled C’s complaint. We noted that the board provided a brief complaint response as they considered the SAER had addressed the main issues. We also found that the board’s complaint response directly contradicted the findings of the SAER, as it included the consultant’s view that A did not present with psychotic symptoms. We considered this to be unreasonable. Therefore, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified. 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 .
• Appropriate clinical guidelines should be followed when providing treatment to patients.

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

• i) Appropriate clinical guidelines should be followed when providing treatment to patients.
• ii) Clinician’s should have up-to-date accurate knowledge of the descriptions and classifications of conditions within their sphere of expertise.
• iii) Diagnosis reviews should be carried out when appropriate and in line with current disease classifications and treatment guidelines.
• iv) Clear rationale for decisions made to maintain or change a diagnosis should be recorded timeously in clinical records.
• v) Diagnoses should be clear, consistent, and evidenced.
• vi) When decisions are made to change, reduce, and/or withdraw medication there should be clear rationale recorded for this and close assessment of the patient should be carried out.
• vii) The emergence of symptoms or change in presentation should be assessed and considered thoroughly and the preferred diagnosis or treatment plan reviewed and adjusted in light of a patient’s presentation and changing needs.
• Mental health nursing staff should have in place pro-active, person-centred support planning for their patients. Person-centred support plans should be reviewed and updated regularly. Concerns about patient care and safety should be escalated by nursing staff appropriately, either to medical staff or nursing supervisors.
• Appropriate clinical guidelines should be followed when providing treatment to patients.

In relation to complaints handling, we recommended:

• Complaints should be investigated in line with the NHS Model CHP. Complaint responses should be full, factual, clear, and easy to understand. Decisions reached should be evidenced, proportionate, and objective. 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.

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

Summary

C complained about the standard of medical care and treatment provided to their late partner (A) by the board in relation to their risk and diagnosis of liver cirrhosis (permanent scarring of the liver which leads to dysfunction) and gastrointestinal haemorrhage.

A was initially under the care of the board’s rheumatology service for psoriatic arthritis, which was treated with medication. The board’s gastroenterology service then began to care for A, and, after testing, found that A had liver cirrhosis with portal hypertension (elevated blood pressure in the portal vein).

After several months, A’s condition began to deteriorate and they attended the medical ambulatory care unit and A&E within a few weeks. A was discharged home both times. A died two days after their contact with A&E.

We took independent advice from four advisers who are consultants in rheumatology, gastroenterology, general medical and emergency medicine. We found that the standard of rheumatology, general medical and emergency medicine was reasonable. However, we found that the standard of gastroenterology was not reasonable in that A’s signs of deterioration were not taken seriously enough by the gastroenterology service including that the signs of abnormalities were not reasonably investigated, that A’s portal hypertension should have been identified following an endoscopy and that A should have been referred to a liver transplant unit. We found that the multidisciplinary team meetings unreasonably failed to pick up A’s clear deterioration and arrange appropriate investigations and treatment, and discussions were brief and decisions were deferred. We found that keeping A in the specialist nurse led clinic when they were diagnosed with liver cirrhosis and portal hypertension, and deemed suitable for a transplant, was unreasonable. Finally, we found that there were record keeping failings including clinic letters that failed to contain important information about A’s diagnosis and condition and we found that an urgent referral for a gastroscopy should have been considered sooner. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

• Patients with liver disease should be managed and receive treatment in line with the relevant guidelines. Additionally, patients with advanced liver disease should have a clear management plan and be reviewed by a consultant or medical staff when their condition deteriorates. Nurse led clinics should have a clear protocol on when to refer patients for a consultant or medical review. Finally, Multidisciplinary team meetings should have sufficient time to review patients and blood results over time, and further investigations, treatment etc. should be acted on fully and within a reasonable time. This includes referrals to liver transplant unit within a reasonable time.

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 on behalf of their sibling (A) in relation to the care and treatment that the board provided to A after presenting at an out of hours service with symptoms including epigastric pain, vomiting and shaking. A was sent home with treatment for dyspepsia (indigestion) but died shortly afterwards from acute haemorrhagic pancreatitis.

C complained that the board did not adequately take into account A’s full presentation and relevant background information in considering a treatment plan.

We took independent advice from an experienced emergency medicine adviser. Overall, we found that the care and treatment that A received was unreasonable because A’s physiological observations showed a significant degree of abnormality, and the board did not have appropriate systems in place to identify the deteriorating patient in the acute community setting. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that it was not recognised that the physiological observations documented in A’s notes were abnormal when they were seen in the OOHS. 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 ensure that there are systems in place that identify the deteriorating patient in the acute community setting inline with SIGN 167 Care of deteriorating patients.

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 broke their leg and underwent an operation. Following a scan the next day, C was told that the results were fine and that they could be discharged home. However, a few days later, C was contacted and told that a further review of the scan indicated that they would require further surgery, and this was performed by another surgeon a few days later.

C complained to the board about several aspects of their treatment. The board apologised that C was told two different things about their scan results and explained that there was an anomaly in the image that wasn’t seen at first, but was noticed on further review. C remained dissatisfied and raised their complaints with the SPSO.

We took independent advice from an adviser specialising in orthopaedic surgery. We found that a note of a discussion between clinicians in C’s medical record does not accord with another clinician’s later view, and that the board’s position that the discussion was wrongly recorded was the most likely explanation of what occurred. This meant that, from C’s perspective, the board had unreasonably reached different conclusions following the two reviews of the scan. Given these circumstances, the complaint was upheld.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for giving them incorrect information about the scan, for the inaccurate clinical record, and for the incorrect explanation in the complaint response. 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:

• Medical records should accurately record discussion outcomes.

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

Summary

C complained that the disconnection date of their water supply was not accurately reflected in their billing. C owned a dog grooming studio that had ceased trading. C said that the original supply to this building was from their home. C had always paid correctly for any water usage. When the business closed, the building was being converted for domestic use. The water supply had been physically disconnected and the building was uninhabitable.

C and Clear Business Water (CBW) were in dispute over fixed water charges for the premises. CBW’s position was that a property could not be disconnected until Scottish Water registered it as such. C believed that they had been clear at the outset that this was what they required but CBW had not responded reasonably to C's request, meaning that they had been subject to fixed charges over an extended period.

We found that CBW did not make it clear to C that they had the option of de-registering their water connection or applying for permanent disconnection. Had this been done at the earliest opportunity, the responsibility would have lain with C to decide what action to take. We also found that CBW failed to challenge Scottish Water’s refusal to back date charges sufficiently, given that C as their customer was unable to raise a dispute directly with Scottish Water. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failures identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Refund C’s charges back to the date specified, as set out in their email to Scottish Water requesting backdating of charges.

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

• Customers should be provided with all the information they need to make informed decisions about their accounts.

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

Summary

C complained that the association did not reasonably address reports of antisocial behaviour. C is the Chief Executive of a charity who owns a property in a block where other properties are owned by the association. The charity's tenant complained of antisocial behaviour from one of their neighbours and the charity reported this to the association. A few weeks later, C complained that these reports of antisocial behaviour had not been addressed. C did not receive a response until they followed it up some months later. The association explained that they considered their policies and procedures had been followed. C was dissatisfied and raised their complaints with SPSO.

We found that the association did not progress the reports of antisocial behaviour in line with their antisocial behaviour procedure. They did not update C regarding the situation and did not advise C when the case was closed. We found that the association did not keep full and accurate records of telephone calls and verbal discussions regarding an investigation which contributed to the association making an inaccurate statement to the charity. The association also failed to update the relevant recording system in relation to a report of antisocial behaviour, failed to categorise the report or to consider whether the report was substantiated as the antisocial behaviour procedure required.

We found that the association did not recognise some of their failures when investigating and responding to C’s complaint. Therefore, they missed the opportunity to take steps to ensure that there could be no recurrence of this at a time when this could have been effective for A and the other residents at the property. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to the charity and, via the charity, their residents that that they did not take reasonable action in response to reports of antisocial behaviour. The apologies 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 association should follow their antisocial behaviour procedure in responding to reports of antisocial behaviour.

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

Summary

C complained that the association did not respond reasonably to their requests for repairs. After an initial acknowledgement of C’s concerns there were periods over the following months where the association did not respond or follow up on the matters that C had raised.

We found that in some cases the association exceeded their stated timescale for repairs and did not advise C of the delays or respond to their enquiries. We upheld this part of C's complaint.

C also complained that a response from the association incorrectly stated that a contractor's report regarding leaks at C's property noted that "any leaks were likely caused by installations made by C".

We found that there was no firm, supportable evidence of what the contractor reported to the association. The association acknowledged that this information was received during undocumented, informal discussions. We found that it was unreasonable to describe information given in undocumented, informal discussions with a contractor as being information that ‘the contractor’s report notes’. This form of words suggests a contemporary written report, either directly from the contractor or a record of a discussion verified as accurate by the contractor. We upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not respond reasonably to C’s requests for repairs and that they made an inaccurate statement about a contractor’s report in their response to C’s complaint. 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 association should respond to requests for repairs, and importantly record information regarding these, in line with their Repairs and Maintenance Policy.

In relation to complaints handling, we recommended:

• The association’s complaint responses should be accurate. 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.

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

Summary

C complained about the care and treatment that they received during an admission to hospital. C attended A&E and the Acute Medical Unit for symptoms that were later diagnosed as an acute ischaemic stroke.

We took independent advice from a consultant physician. We found that some aspects of C’s care were reasonable, particularly the communication between the board and C and their partner.However, we found that C’s assessment in A&E was unreasonably delayed in relation to their triage category. In addition, no structured stroke assessment was carried out.

We also found that there was a delay in senior medical review and a lack of specialist stroke input. Furthermore, a prescription for aspirin was not made timeously after a CT scan excluded bleeding. Therefore, we upheld C's 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/information-leaflets.

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

• Patients presenting to hospital with symptoms potentially indicative of stroke should receive timeous assessment, investigation and 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.

Summary

C complained that the practice unreasonably failed to take the appropriate action in response to C's elevated prostate-specific antigen (PSA, a protein in the blood) test result. C requested a PSA test due to having a family history of prostate cancer. C complained about the failure to refer them to urology (specialists in the male and female urinary tract, and the male reproductive organs) based on the test result. The practice had said it was appropriate to advise C to repeat the test in one month’s time. This did not happen and C was diagnosed with prostate cancer 13 months later.

We took independent advice from a GP. We found that the practice failed to follow Scottish Referral Guidelines for Suspected Cancer. According to the guidelines, due to C’s age, their family history and the test result, the GP should have referred C to urology for further investigation. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the Scottish Referral Guidelines for Suspected Cancer and to refer C to urology in light of their PSA test result. 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:

• Practice staff should be familiar with Significant Event Analysis (SEA) guidelines: https://learn.nes.nhs.scot/984.
• The GP involved should be informed of the findings of this case.

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.