Upheld, recommendations

Summary

C complained about the care and treatment provided to their late parent (A) during two admissions to hospital. C complained that during their first admission A was given insulin that was for another patient and C was not timeously informed. C complained that during the second admission, A was initially diagnosed and treated for sepsis but when a CT scan was later performed a major stroke was discovered. C considered that stroke should have been considered and a CT scan should have been carried out earlier. A was given an infusion of both insulin and glucose to manage diabetes. C complained that A was inappropriately given intravenous (IV) glucose for 38 hours after IV insulin had stopped, noting that A became hyperglycaemic (when the level of sugar in the blood is too high) and then developed seizures. C also complained that nursing records were incomplete and that the board’s incident management and review process did not go far enough to recognise or rectify failings.

We took independent advice from a registered nurse and a consultant specialising in medicine of the elderly. We found that the insulin error should not have happened. In relation to sepsis treatment, it was reasonable to treat the infection in the first instance but when C informed medical staff of A slumping to one side a medical assessment for stroke should have been carried out and a CT scan should have been booked. We also found that it was unreasonable to continue IV glucose after insulin had been stopped, record keeping was inconsistent and incomplete such that it could not be said that nursing care was reasonable and that incident management and review was also unreasonable. Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable care and treatment provided to A. In particular in relation to the treatment of A’s constipation, the incorrect administration of insulin, the failure to undertake a detailed stroke assessment and book a CT scan, and the fact that fluids were not reviewed or considered on after A’s insulin infusion was stopped and their blood glucose increased. 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 for the unreasonable incident management of the insulin error, for not recording a Datix incident for the glucose error, that the SAER report was not sufficiently detailed to provide reassurance in regards to the quality of incident management and review and that learning and action in relation to medical care during the second admission was not appropriately considered in the SAER. 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 for unreasonable record keeping. 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:

• Errors in relation to the management of a patient’s care should be appropriately recorded e.g. using Datix. Adverse event reviews should be thorough and should appropriately identify the failings, learning and improvement from the event.
• Patients should receive appropriate treatment including any relevant checks and scans booked in accordance with their symptoms.

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 provided to their parent (A) over two admissions to hospital. A attended the emergency department following a fall at home and was treated with painkillers for a pain in their neck. They were admitted to the ward for further monitoring of their fast and irregular heartbeat. A was reviewed the next morning and discharged that day. However, A returned to hospital later that day after another fall. A was reviewed and admitted to the ward where they were later diagnosed with a fracture of a bone in their neck.

C complained that the board failed to diagnose the fracture on the first admission to hospital and about the decision to discharge A. In response to the complaint, the board did not identify any failings with respect to assessment of A, but acknowledged that the communication of their diagnosis and discharge could have been better. With respect to the second admission, the board explained that symptoms of neck fracture are not straight forward and the examinations carried out within the emergency department were appropriate. C was dissatisfied with the response and brought their complaint to our office.

We took independent advice from an emergency medicine consultant and a consultant geriatrician (specialist in medicine of the elderly). In relation to A’s first admission, we found that the initial assessment of A’s condition in the emergency department was reasonable, although there was a missed opportunity for further assessment before A went to the ward. However, the examination and assessment of A’s neck pain on the ward was unreasonable, as was the assessment of A’s suitability for discharge, given the failure to properly assess A’s neck injury, mobility, and cognitive function. We found that the board failed to provide A with appropriate care and treatment during their first admission and upheld this part of C's complaint.

In relation to A's second admission, we found that A’s neurological examination did not include a cervical spine assessment. The board acknowledged in their correspondence with our office that the care provided at this time was not to an acceptable standard. Therefore, we determined that the care provided in the emergency department was unreasonable. We found that the care and assessment provided during A's admission to the ward was reasonable, and there was no delay in arranging further investigations. Given our findings in respect to the care provided in the emergency department, we upheld C's complaint regarding A’s second admission to hospital.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failures identified. 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:

• Clinical staff should be familiar with relevant NICE guidelines on the management of suspected cervical fractures. Relevant departments concerned should review their practices regarding the assessment of pain and investigation of potential head/neck injury.
• Patients should only be discharged following appropriate review and assessment of all clinical factors relevant to the decision to discharge a patient from hospital.

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, the complainant, is a tenant of the council. They complained about the council’s refusal of an application for mutual exchange with another council tenant. C found out through the other tenant that the council had told them the application was refused because of ‘management concern for C’. C contacted the council to enquire about the decision and they were advised that they would receive a written response detailing their right to appeal. C heard nothing further and submitted a complaint.

In their complaint response the council apologised that C had not received a letter confirming that the application had been refused. The council said that their officers had worked within the relevant legislation and policies/procedures to refuse an exchange, on the basis that complaints had been made to the Safer Neighbourhood Team in connection with C’s tenancy.

In response to our enquiries, the council provided us with their Mutual Exchange Policy, Mutual Exchange Process Map and Mutual Exchange Guidance Note. The council said that they had followed their policy and provided more detail about alleged anti-social behaviour on the part of the tenant.

We found that the council had failed to follow their policy when considering C’s application. They should have carried out a home visit, sent out a letter with their decision, and given adequate reasons for the decision. The council’s failure to issue their decision on time also prevented C from being able to appeal the decision. Taking all of this into account, we upheld the 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/information-leaflets.
• The council should reconsider the application. In the event that the mutual exchange is no longer an option, the council should consider whether any alternative remedy is available to C. If, after an assessment in line with their policy, the council decide to refuse the mutual exchange, their decision must clearly explain why they have taken this decision.

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

• The council’s staff understand the steps that they require to follow when a mutual exchange application is received.

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 council approved an application for non-material variation (NMV) to a planning consent, despite the variation significantly altering the originally agreed plot levels and having major effects on existing properties that bordered onto the new development. We took independent planning advice, which highlighted that it is it is ultimately a matter for the planning authority to determine whether or not a proposed change to a planning application is material. However, there should be clear and transparent records to support the council’s decision making and justify their decision. The council accepted that was lacking in this case, in terms of the content of the worksheet for the NMV.

We found that the NMV worksheet did not contain sufficient information to explain why the council concluded that the change was non-material. The records did not adequately demonstrate that the council considered the potential impact on neighbouring properties, and continued compliance with the relevant Development Plan in this regard. It was not demonstrated e.g. via adequate / relevant cross sections through the site, how the council concluded that there was sufficient separation distances between new and existing properties. It would also have been good practice for the council to keep a record of any site visit carried out, recognising that there is no statutory requirement to visit the site.

While we found that the council failed to keep adequate records to justify their decision, it was not possible for us to determine that the decision to approve the changes as a NMV was incorrect. That remained a discretionary matter for the council. However, on the basis of poor record keeping, we concluded that the council’s handling of the NMV application was unreasonable, and we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues identified in this decision notice. 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:

• Worksheets for future applications for NMVs should provide sufficient detail to make it clear why a particular conclusion has been reached, including continued compliance with all relevant Development Plan policies. When a site visit is carried out in respect of an application, a record should be kept of that visit. The council should ensure that they have sufficient information to determine the application e.g. adequate / relevant cross sections.

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’s elderly, visually impaired and partially deaf parent (A) was in receipt of social care from the partnership. C raised concerns with the partnership about a number of matters related to A’s care, including the arrangement of an Adult Support and Protection (ASP) conference, that the partnership did not reasonably adhere to the Code of Practice in relation to A’s care and action around referring A to other appropriate services. A had been referred to ASP by their social worker. An ASP case conference was scheduled and held and invitations for A and their family to the conference were not received until after the meeting date. C considered that the Adult Support and Protection (Scotland) Act 2007 Code of Practice had not been reasonably adhered to in relation to actions around A’s care.

In their responses, the partnership accepted that there were some areas where their practice had fallen short of the standard that A and their family could expect and provided some apologies for these. As they remained dissatisfied, C raised their complaints with SPSO.

We took independent advice from a social work adviser. We found that elements of the partnership’s record keeping, provision of information, advice and support to A and their family regarding the ASP conference were unreasonable. We also found that the partnership had not reasonably considered aspects of the format of the conference and had not reasonably provided a written care package for A. The effect of this was that A’s voice was not heard in the conference. Given the close connection between this and the contents of the Code of Practice, we upheld this aspect of the complaint.

In relation to the partnership’s handling of C’s complaints, the partnership had provided a response to C in relation to some of these matters and that response addressed some of those issues and identified some areas for improvement. However, we found that the partnership had not directly addressed C’s concern that the social workers assurances had been accepted without evidence or verification.

We also found that the partnership did not indicate that they had taken, or intended to take, any action to address the areas for improvement that they had identified. We found that it was unreasonable that the partnership did not consider what action was necessary as a result of their findings on C’s complaints, and that they did not advise C, as part of the complaint response, of these. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A and their family that they did not reasonably arrange or conduct the Adult Support and Protection case conference in relation to A. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.
• Apologise to C that they did not respond reasonably to C’s complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• A written care plan is provided to A.

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

• Adult Support and Protection case conferences are arranged and conducted reasonably, and service users and, where appropriate, their families are reasonably advised of, and facilitated to be properly involved in, the process, and their wishes reasonably taken into account.

In relation to complaints handling, we recommended:

• Complaints are properly investigated and responded to in line with the partnership’s complaints handling procedure.

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

Summary

C complained on behalf of their parent (A) who passed away in hospital. During the admission, A was diagnosed with B cell lymphoma (a type of blood cancer) and received palliative radiotherapy treatment.

C complained that A’s pain medication was incorrectly managed as they experienced both delirium and extreme pain, that A’s nutrition and fluid intake was incorrectly managed as A became dehydrated and lost weight, that A was left in a general ward rather than being moved to a cancer ward and that A was not offered chemotherapy. C complained that there had been a lack of communication regarding A’s palliative treatment plan, A’s deterioration and death.

The board advised that A’s pain medication had been appropriately reviewed and adjusted. C’s fluid intake was difficult to manage but there was no indication for nasal gastric feeding. They apologised that there were gaps in the records in relation to fundamentals of nursing care, including nutrition, fluids and skin care and that nurses had since undertaken training. They noted that A was deemed too unwell to tolerate chemotherapy or a move and they stated that a number of discussions took place with the family to explain A’s changing condition.

We took independent advice from a consultant geriatrician, a registered nurse and a consultant haematologist. We found that A’s pain had been reasonably controlled and the decision not to offer chemotherapy was reasonable. However, medical staff should have considered nutrition support earlier and nursing care had been unreasonable in relation to nutrition, fluids and skin care. Communication from doctors and nurses on the ward was reasonable, but there had not been any communication from a specialist about A’s cancer prognosis and palliative radiotherapy treatment. Therefore, we upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that no specialist explained the lymphoma diagnosis and treatment plan to the family. 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 nursing care and recording was unreasonable, in regards to pain assessment, nutrition, hydration and skin care. Apologise to C that medical staff did not offer nutritional support at an earlier stage. 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:

• Person centred care plans should be recorded and followed for each patient. If radiotherapy patients are treated in general wards, nursing staff in those wards should be trained on how to manage radiotherapy skin damage. Nutritional support should be considered for vulnerable patients and medical staff should be aware of alternative methods of weight loss assessment in patients with oedema.
• A specialist explains the cancer diagnosis and treatment plans to the patient and family.

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 their spouse (A) received from the board whilst they were a patient of the cardiology ward. C complained that A collapsed on arriving home having been discharged after undergoing a coronary angiogram (a type of x-ray used to take pictures of the heart’s blood vessels, the coronary arteries) and stenting procedure. A was found to have experienced a vascular complication (a large haematoma, where blood leaks from a large blood vessel) in front of the femoral artery (the main blood vessel supplying oxygen rich blood to the lower body) and had surgery to remove the haematoma. Following the second surgery, A developed an infection in the wound site.

The board said that due care was taken to weigh up the risks and benefits of various treatments in A’s case. Whilst there were signs of a haematoma at the puncture site after the procedure, this was not increasing in size when A was discharged, and A’s blood pressure was normal.

C complained to SPSO highlighting concerns about the decision to carry out an angiogram, the decision to discharge A, infection control and failures to follow protocol and use an ultrasound to assess the puncture site.

We took independent advice from an appropriately qualified consultant cardiologist. We found that carrying out an angiogram was appropriate in the circumstances. We considered the care and treatment following the procedure and on A’s readmission to be reasonable. However, there were a number of factors which should have triggered staff to consider delaying discharge and seeking an ultrasound scan. We found that the need for an ultrasound scan was clinically indicated and that the decision to discharge was unreasonable. As such, on balance, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. 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:

• The threshold for considering an ultrasound scan should be lowered for patients who have a higher bleeding risk and who develop painful haematomas post procedure. A lack of pulsatile haematoma should not preclude performing an ultrasound scan if there is clinical concern.

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 refused to offer a face-to-face appointment to their child (A) who is immunosuppressed with asthma and had a cough for over three weeks.

The practice advised that if A had shown symptoms of shortness of breath or wheezing, a face-to-face appointment would have been arranged. C did not identify these symptoms and so C was advised to double the dose of A’s inhaler and get in contact if A worsened. It was also noted that A had an appointment with paediatrics later that day.

We took independent advice from a GP. We found that it was not reasonable to rely on a parent / carer to determine whether a child is wheezing or short of breath. A was immunosuppressed and at higher risk of infection. While it is acknowledged that A had a paediatrics appointment later that day, there is no record that this rationale for declining to see A was a factor in their decision making at the time. As such, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

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

• The clinicians involved should reflect on the findings of this case and the relevant guidelines.

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, a support and advocacy worker, complained that the board failed to provide reasonable nursing care and treatment to their client (A).Specifically, they had concerns that while A was a patient in hospital, there was an unreasonable lack of attention, poor attitude from nursing staff and unreasonable nursing care. C was also unhappy about the board’s complaint handling.

We took independent advice on this complaint from a nursing adviser. We found that the board’s nursing documentation was a poor standard, not in line with guidance and was in breach of the Nursing and Midwifery Council: The Code requirements. We also found that board’s lack of documentation had led to the board being unable to evidence that care was carried out to a reasonable standard. Lastly, we found that the board unreasonably failed to respond accurately to the complaint. We therefore upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for breaching the NMC Code requirements. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the failings around poor person centred care planning and poor record keeping. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully and accurately to the issues raised in accordance with The Model Complaints Handling Procedure. They should take into account any relevant national or local guidance in both the investigation and response, and identify and action learning. Complainants should also be kept updated on their complaints in line with the Model Complaints Handling Procedure. Learning from complaints and the learning should be shared throughout the organisation so that actions and improvements can be implemented to prevent the same issues happening again.

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 provided to their late spouse (A) by the practice. A was provisionally diagnosed with torticollis (where the head becomes persistently turned to one side associated with painful muscle spasms) by the practice. Six months later A was admitted to hospital and diagnosed with transitional cell carcinoma (a type of bladder cancer) and a secondary tumour was growing on the spine. A died a few month's later. C complained that the practice failed to provide a reasonable standard of care and treatment in the months before A’s diagnosis and once A was discharged from hospital.

We took independent advice from a GP. We found that the practice unreasonably failed to arrange face-to-face appointments, or carry out more detailed clinical examinations, history taking and assessment of red flag symptoms. There was a lack of continuity in the care A experienced and it was unreasonable that there was a delay in actioning a referral upgrade to urgent. While we accepted that there was a poor prognosis, earlier intervention might have improved the management of A’s pain. Therefore, we upheld this part of C's complaint.

In relation to A's care after their hospital admission, we found that it was unreasonable that A was not reviewed by a GP until seven days after discharge and not directly examined by a clinician when they reported a new symptom. We also noted that no detailed assessment was carried out of A’s analgesic (painkiller) requirements. We found that the practice did not provide reasonable care in accordance with the relevant standards on discharge. Therefore, we upheld this part of C's complaint.

We also found that while the practice completed a Significant Event Analysis, this learning could have been carried out in a more timely way. We noted that the practice's own complaint investigation did not identify the full extent of the failings in this case. While areas for learning and improvement have been recognised and acknowledged by the practice, these were only identified in response to our enquiries.

Recommendations

What we asked the organisation to do in this case:

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

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

• Wherever possible and where it is clinically appropriate, patients should receive face-to-face appointments, where a detailed clinical examination can be carried out, a detailed history taken and assessment of any red flag symptoms, and receive continuity of care.
• Patients with new diagnoses of cancer should receive prompt review by a GP, including appropriate Anticipatory Care Planning, completion of an eKIS summary and be added to a Palliative Care disease register to facilitate multi-disciplinary care planning.
• When a relevant adverse event occurs, the practice should promptly carry out an appropriate adverse event review to investigate the cause and identify any potential learning in line with the National Framework for Scotland (www.healthcareimprovementscotland.scot/).

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should ensure that failings, as well as good practice are identified and that learning and information gathered from complaints is used to drive service improvement.

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.