Upheld, recommendations

Summary

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital.

We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in providing timely discharge information and failure to reasonably follow up two of their surgical procedures. 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:

• Discharge letters following surgical procedures should be sent out in a timely manner and clear follow-up arrangements should be given in the discharge letters following surgical procedures.

In relation to complaints handling, we recommended:

• When a complaint involves more than one NHS board, the boards should decide who will lead on the complaint and provide a joint 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 submitted a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital.

We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as 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:

• All patients must have a falls risk assessment completed on admission and after a fall a post falls assessment should be completed.
• Every patient should have a person-centred plan of care.
• All patients must have a moving and handling risk assessment undertaken within 24 hours of admission.
• Nursing documentation should be complete and reflect a person's care needs, plan of care, care delivered and evaluation of the care delivered.
• Basic moving and handling equipment should be readily accessible for all patients and staff.
• All patients should have their care needs identified and risk assessments undertaken in order to develop a person-centred plan of care.

In relation to complaints handling, we recommended:

• Complaint investigations should respond to all of the main points raised and identify failings and take learning from what happened.

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 from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable.

We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice.

We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to action the results of qFIT tests, for the delays and for the unreasonable 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:

• Administrative systems at the practice should support timely actioning of abnormal results.
• Clinical staff should be knowledgeable about the indication and interpretation of qFIT tests, as per NICE guidance.

In relation to complaints handling, we recommended:

• Complaints should be appropriately acknowledged in line with the Model Complaints Handling Procedure for NHS Scotland, and the complaint response should fully address the substantive issues raised in a complaint.

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 from the practice prior to receiving a diagnosis of a cancerous brain tumour, for which C underwent surgery, radiotherapy and chemotherapy. C had eight consultations at the practice over the course of ten months prior to receiving a referral to the neurology department.

We took independent advice from a GP. We found that there was a missed opportunity for the practice to review C in person and consider an earlier neurological referral on the basis of C’s worsening symptoms. We upheld the complaint. During the course of the investigation, the practice acknowledged these failings and took action to address them.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer a face-to-face appointment and neurology referrals, and for the practice’s shortcomings in their complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at http://www.spso.org.uk/meaningful-apologies.

In relation to complaints handling, we recommended:

• The practice’s complaints handling procedure should ensure that complaints are properly investigated and responded to, are accurate and that failings are identified.

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 late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died.

C complained to the board about their parent contracting COVID-19, which they felt must have been hospital acquired as A was shielding prior to admission. C complained that A was unnecessarily transferred between wards which increased the risk of exposure to the virus. C reported concerns that there were known COVID-19 cases in a neighbouring ward and possibly within A’s ward. C was concerned that A wasn’t offered the opportunity of home rehabilitation.

The board’s response stated that national infection prevention and control guidance for COVID-19 was followed at all times. They advised that it wasn’t always possible to accommodate all shielding patients in a single room. They advised that A was transferred between wards according to their care needs. They said that they could not meet A’s rehabilitation needs at home due to capacity issues with their community stroke team.

We took independent clinical advice from a nursing adviser specialising in infection control. We found that A required inpatient care to ensure that they received appropriate investigations and treatment for their suspected stroke. We found that the care provided to A in treatment for their stroke was reasonable and in keeping with their diagnosis.

We found that the board did not comply with relevant guidance on COVID-19 by failing to document the assessment of A’s COVID-19 risk pathway during their admission. We found that there was an unreasonable delay in isolating A from the other patients once A’s diagnosis of COVID-19 was suspected. Given these failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to triage A’s level of risk, for failure to document A’s shielding status and failure to isolate and follow airborne precautions from the point at which COVID-19 was suspected. 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:

• Feedback the findings of this investigation to relevant staff for reflection and learning, and to inform future practice.
• Medical records should contain all relevant information including the outcomes of assessments and the information required to clarify the decision making regarding the delivery of care.

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 nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without food or water, and that they were allowed to aspirate on pureed food because they were not safely positioned in bed.

The board maintained that overall the nursing care was of a reasonable standard, but they accepted that documentation had been poor. They provided us with a detailed action plan which they were implementing in response to the failings that they had identified.

We took independent nursing advice. We found gaps in record-keeping in relation to food and fluid intake. We found that the board had failed to evidence that A was cared for in a dignified and respectful manner. Comfort rounding was not provided as frequently as it should have been, taking into account A’s frailty and general condition. A had pressure ulcers and we found that the board had failed to demonstrate sufficiently frequent skin checks and repositioning. The board also failed to maintain wound charts, recording wound sizes and grade. There was no evidence of oral care having been provided.

We did not find evidence to support the account that A was left to choke on pureed food on the day before they died. The records indicated that A was being checked on regularly that morning, and that A was asleep much of the time and noted to be ‘too drowsy for oral intake’. A was being treated for secretions, which we considered may have accounted for the gurgling sound reported. Although it was not possible to establish precisely what had happened on this date, it was regrettable that this incident caused so much distress to the family, and we noted that the board had apologised for the distress caused.

Taking all of the above into account, we upheld the complaint. We found that the board’s action plan did not adequately address the failings in this case and we therefore made our own recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the failings our investigation has found. 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 should receive appropriate pressure ulcer care, prevention and grading in line with relevant guidance.
• Records should document what is required to capture that person-centred care has been assessed, planned and the outcome of the plan evaluated.
• Patients should have wound charts completed as appropriate and in line with relevant guidance.
• There should be a discussion with family/carers as appropriate when a patient moves onto a palliative care treatment plan to facilitate understanding and an awareness of what to expect particularly in relation to fluid and nutrition in line with relevant guidance.

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 child (A) by the medical practice. C was concerned that A had been misdiagnosed by their GP during a telephone appointment. During the appointment, A reported shortness of breath, experiencing breathlessness, and feeling faint when walking upstairs and putting on their shoes. A was diagnosed with anxiety and prescribed a beta blocker (drug that blocks the action of hormones like adrenaline). Later that week, A died suddenly due to pulmonary embolism (a blood clot that blocks and stops blood flow to an artery in the lung). C raised concerns that there was a delay in A receiving treatment, the treatment that A received was inappropriate, and that harm was caused as a result of A being given the wrong treatment.

We took independent advice from a GP adviser and subsequently from another GP adviser with a specialism in sexual and reproductive health. We found that there are numerous risk factors for pulmonary embolus and, in this case, the main risk factors were BMI, family medical history and prescription of combined oral contraceptive. Neither risk alone would preclude prescribing combined oral contraceptive, but consideration would be made for two risks, as in this case. We found that the health centre failed to provide A with reasonable medical care and treatment. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for all the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at https://www.spso.org.uk/information-leaflets.

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

• Patients presenting with similar symptoms should be carefully considered and where appropriate face-to-face appointments offered.
• Prior to prescribing the combined oral contraceptive pill for patients who have two or more risk factors for pulmonary embolus, careful consideration should be given to the risk factors, and a shared discussion should take place with the patient on the additional risks, ensuring that they understand that there may well be additional risk. This should be documented.

In relation to complaints handling, we recommended:

• The health centre should ensure that all complaints are handled in line with the NHS Model Complaints Handling Procedure (MCHP), particularly in terms of the requirement to respond in a timely manner. In particular, where a response to a complaint cannot be provided within the MCHP timescales, complainants should be provided with an updated timescale as to when they can expect to receive a response. Significant Adverse Event reviews should be accurate and reflect and record the available evidence and information, which should be reflected in the investigation report (and where appropriate, complaint responses).

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 solicitor, complained on behalf of a student at the University (A). C said that A had suffered a serious assault and due to the impact of this on their mental health, had sought an exemption allowing them to study remotely. This had been denied by the University on the basis that only individuals needing to shield from COVID-19 or caring for someone shielding were entitled to remote study. The University said that these were the sole criteria considered by the committee that refused C’s application.

We found that the evidence showed that the University had not adhered to their statement on Gender Based Violence (GBV) in their consideration of A’s appeal. The only option offered to A was for them to suspend their studies. This was at odds with the medical evidence A had submitted. It was also apparent the University’s consideration of the appeal had been concerned about the possibility of setting a precedent. We also found that the University’s refusal to treat the correspondence with C as a formal complaint was unjustified, as it related to the application of the University’s policies and procedures, which were areas which should have been covered by the complaints process. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to handle their request for remote study reasonably. 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 University should clarify what adjustments can be made for students under their gender-based violence statement and policy.
• The University should ensure the Counselling service are aware of the academic options available to students, or that they have a named point of contact within each school to signpost students to for guidance on their academic options.
• The University should remind all staff that if the remit of an appeal hearing is constrained to specific issues, they should not introduce irrelevant considerations.

In relation to complaints handling, we recommended:

• The University should remind staff in the legal department of the provisions of the complaint handling procedure and ensure they are aware of when it should be applied.

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 parent (A) received. A had sight and hearing difficulties. Following a fall at home A was admitted to hospital where they stayed as an inpatient for several weeks before being discharged to a care home. A died a few weeks later.

C complained that the care and support that A received at home to encourage movement and general wellbeing was not continued while A was in hospital. As such, A’s mobility and mental health deteriorated and they developed pressure sores due to the length of time that they were immobile in bed. C did not consider that A’s blindness and hearing difficulties were taken into account by the hospital staff and complained that A’s calls for assistance were ignored.

We took independent advice from a nursing adviser. We found that the lack of a person-centred care plan led to the failure to support A to enjoy activities that would have provided some stimulation. This along with the restricted face-to-face visits due to the COVID-19 pandemic, meant that A was unreasonably isolated and this impacted on their anxiety and mobility.

We found that there were a number of issues with documentation and the management of A’s pre-existing pressure ulcer. The lack of clear documentation was concerning and the HSCP failed to have in place documentation and equipment to record, assess, review and treat a pressure ulcer that evidently deteriorated throughout A’s admission.

Overall, we found that A was unreasonably isolated throughout their admission due, in part, to a failure to adapt A’s care in recognition of their sensory impairments and that there were clear failures to maintain important documentation. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not provide a reasonable standard of care to A. 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 hospital adopt person-centred care planning.
• The hospital are compliant with current Health Improvement Scotland (HIS) Prevention and Management of Pressure Ulcer standards 2020.

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 A by the Scottish Ambulance Service (SAS). A had a pacemaker fitted and developed a severe headache and rash. A phoned NHS 24 as they were finding it difficult to breathe. Paramedics attended A at home but A was not admitted to hospital. A phoned NHS 24 again the following day and when paramedics attended, they sought telephone advice from a consultant at the local hospital. The consultant advised that A should take paracetamol and see the GP the following morning. A phoned the GP the next day and was told to go to the COVID-19 hub where A collapsed and was taken to hospital by ambulance. A was admitted to hospital and died the following day from sepsis (blood infection). C complained about the decision not to take A to hospital and is concerned that the paramedics failed to recognise the signs of sepsis and to take the appropriate action.

We took independent advice from a registered paramedic. We found that in hindsight it was unreasonable that SAS did not recognise the seriousness of A’s condition, including applying any weighting to past medical history, in particular recent surgery and the fact that the presence of infection could have been the result of sepsis. However, we found that many of the clinical signs and symptoms observed in A would have been present in a patient experiencing COVID-19. Based on the conditions and guidelines SAS were operating to at the time we found that it was reasonable that the paramedics’ working diagnosis was COVID-19.

Whilst we considered it was reasonable that A was not taken to hospital, we were critical that there is no evidence that A was informed of the risks and benefits of the option of staying at home, going to hospital or of any alternative options available. We also found that it was unreasonable that key information was not passed to the consultant during a call and that record keeping was unreasonable. Furthermore, we found that it was unreasonable that during the paramedics second attendance, the further set of observations taken 20 minutes later unreasonably failed to include A’s temperature. Finally, in relation to the first attendance, we considered it was unreasonable to conclude that A was improving, particularly without carrying out a further set of observations. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific 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:

• Patients should be appropriately advised of the risks and benefits of the available options, for example the option of staying at home, going to hospital or of any alternative options available. This information should be documented to confirm the advice given, and details of discussions held regarding treatment options.
• Full and complete information should be obtained during observations of a patient so that advice is appropriately provided and recorded on the basis of that information. Where appropriate, consideration should be given to carrying out a further set of observations prior to reaching a view on a patient's condition.

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.