Upheld, recommendations

Summary

C was diagnosed with a kidney stone by a neighbouring board. Shortly after, they attended Greater Glasgow and Clyde's Urology Department and received an X-ray. C complained that the board failed to identify the kidney stone, resulting in surgery several weeks later and a kidney injury.

We took independent advice from a consultant urologist. We found that while it was not possible to determine whether the board failed to identify a kidney stone on the X-ray, the board did have doubt about whether the stone had passed. At this point the board should have checked this by means of a CT scan. We found that it was not possible to determine whether failing to confirm a kidney stone, and delayed treatment, would result in a kidney injury. We upheld this part of the complaint because it was unreasonable for the board to have doubt about whether there was a stone present, but not to confirm this.

C complained that the board had failed to arrange a follow-up appointment within an appropriate time period. We found that when passage of the stone was not confirmed, a follow up CT scan should have been arranged within 2 weeks, and that the plan to wait a further 6 weeks in these circumstances was unreasonable. Therefore, we upheld this part of C’s complaint.

C also complained that the board did not clearly communicate their diagnosis, and their subsequent request for clarification on how they came to have surgery after being told there was no kidney stone present. We found that there were shortcomings in the board’s communication with C, both in relation to the kidney stone and in providing an explanation as to how they came to have surgery. Both of these might have been relatively easily avoided or resolved. We therefore upheld this part of C’s complaint.

We asked the board to reflect on the imprecision of using plain X-rays and consider the possibility of updating practice by using low dose non-contrast CT scans as standard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific communication and process failings identified in respect of their complaints. 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 have a full understanding of what is happening in relation to their diagnosis and ongoing treatment plan. The board should ensure that patients are sign posted to the relevant complaints procedure when they raise concerns.
• Relevant staff should be aware of the requirements of ensuring that patients are stone free, either by spontaneous passage or clinical removal after 4 to 6 weeks of initial presentation, in accordance with the 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 that the board failed to provide them and their baby (A) with appropriate care and treatment both during and after A’s delivery at the hospital. This included failing to advise C that one of the doctors involved in the delivery of A was a first year speciality trainee doctor and that the use of forceps in A’s delivery resulted in them suffering permanent injuries, erb’s palsy (a condition often caused by birth trauma that can affect the movement and feeling in a baby's arm) and phrenic nerve palsy (respiratory distress which can be caused by nerve damage during birth). C also complained that there was a failure by the board to carry out further investigations of A’s erb’s palsy, a failure to deal with A’s respiratory distress and diagnose that they had phrenic nerve palsy and a failure to adequately monitor A’s weight.

We took independent advice from two medical advisers, a consultant obstetrician and gynaecologist and a consultant neonatologist.

We found that birth injuries could occur even though there were no obvious difficulties with the birth. Given this and the evidence available, it was not possible to establish the cause of A’s injuries. However, we found there was a lack of communication with C during the consent process, C was not consented for the involvement of junior trainee speciality doctors at the birth of A and it was not explained to C that teaching of staff would take place during the birth. We found that no consideration was given to the use of ultrasound to determine the position of A prior to delivery, in accordance with Royal College of Obstetricians and Gynaecologists guidance, and medical documentation around the events of A’s birth was not of the expected standard in terms of the level of detail recorded. We, therefore, upheld this part of C’s complaint.

In terms of the care and treatment of A following delivery, we found that, overall, this was reasonable. We found that there were no concerns about the diagnosis and treatment of A’s Erb’s palsy and that A did not have respiratory problems, or the key signs associated with phrenic nerve palsy. However, we found that the board failed to adequately monitor A’s weight during their hospital stay, which was acknowledged by the board, and we upheld this part of C’s complaint on that basis.

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.

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

• Patients should be informed when junior trainee speciality doctors are to be involved in their care and treatment and when teaching of staff will be included. These discussions should be clearly recorded as part of the consent process. The following issues should be included in the board’s guidance on obtaining consent: (i) staff should provide an explanation to the patient as to who will be overseeing the birth, and if they will be assisted by other doctors in training; (ii) that members of the clinical team introduce themselves to the patient and explain what their role will be.
• Routine consideration should be given to the use of ultrasound for determining and confirming the position of the fetal head in accordance with the RCOG Guidance, especially when rotation of the baby is required.

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) about the care and treatment A received from the board while they were in hospital.

C complained that the hospital failed to consider the relevant medical and practical considerations, particularly with respect to A’s medication and whether it may have contributed to delirium and the falls A suffered while in hospital. C also complained that the board had failed to adequately consult with family members when the decision was made to discharge A. C further complained that the board’s handling of their complaint was unreasonable.

We took independent advice from a consultant specialising in the care of the elderly. We found that C had raised legitimate concerns that the medication could contribute to delirium and the risk of falls. It appeared that the dose prescribed had changed on a number of occasions without a clear rationale recorded in the records and that the care provided with respect to prescribing and monitoring A’s medication fell below a reasonable standard. We therefore upheld this aspect of the complaint.

We also identified a lack of detail in the pre-discharge assessment of A, and a lack of discussion with the family. We upheld this aspect of the complaint.

Lastly, there were elements of C’s complaint that were not adequately or accurately addressed in the board's complaint response and on this basis we upheld this aspect of C’s 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.

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

• A patient’s suitability for discharge should be appropriately assessed. The rationale for discharge should be properly documented and any relevant documentation completed. Where appropriate, the patient’s family should be included in discussions about planning for the patient’s discharge.
• Decisions about medication prescribed for a patient and any changes to that medication should be accurately recorded in the patient’s medical records and contain details of all pertinent information.
• Staff are aware of the importance of prescribing and monitoring a patient’s medication appropriately.

In relation to complaints handling, we recommended:

• Complaint responses should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. Complaint responses should address the key issues raised, should be factually accurate and should acknowledge the concerns of the complainant.

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 during their attendance at A&E. A was seen in A&E as a GP referral to the hospital’s medical team. C complained that the medical team failed to recognise the nature and severity of A’s condition and their general vulnerability, that they failed to institute an appropriate and timely treatment plan and that there was a failure in record keeping. C also complained that A was discharged home without appropriate medication, without an appropriate discharge letter and without alerting their family and that the board had ignored their Duty of Candour and Ethics Code.

When responding to C’s complaint, the board accepted that there were failings in relation to some aspects of A’s care and treatment. They apologised that C had not been informed about A being discharged. They explained that this had been shared with relevant staff and that they were making changes to ensure families and carers were contacted prior to the patient being discharged. The board also accepted that A should have been provided with a copy of their discharge letter given their vulnerability. They explained that consideration would be given to printing off discharge letters and giving them to medical patients in certain circumstances. Further, the board accepted that there had been failings in relation to record keeping and in relation to A’s medical notes. They indicated that this would be brought to the attention of the relevant staff, would be part of the medical induction and would be discussed in a clinical forum.

We took independent advice from a consultant in emergency medicine. We found that the care and treatment given to A whilst in A&E was reasonable as was the decision to discharge A. There was no evidence to suggest that A's death was linked to any aspect of the care and treatment they received in A&E. However, we found that, in addition to the failings identified by the board that are detailed above, there was no evidence that the board had any process in place to examine this type of case to ascertain whether it met the threshold for a Significant Adverse Event Review (SAER). We upheld the complaint.

We also found that there was a failure by the board to fully address the issues raised when responding to C’s complaint and that there were undue delays in updating C and responding to them about their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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:

• There should be clarity around the board’s policy and processes for identifying and initiating a SAER (Significant Adverse Event Review) in cases where a patient has come to series harm (death) shortly after discharge.

In relation to complaints handling, we recommended:

• Complaint responses should consider and respond fully 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. Additionally, 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, a support and advocacy worker, complained on behalf of their client (A) who had looked after their grandchild since the sudden death of the child’s parent (B). A approached the council for both general and financial assistance. In particular, to support them in obtaining a residence order (a court order that regulates the arrangements made about where a child lives). The council decided that A was not eligible for financial support to apply for an order or for a kinship care allowance. A was later granted a residence order.

C complained to the council. The council confirmed that A had not been initially entitled to a kinship care allowance. However, following the granting of the order a kinship allowance was granted and was backdated to the date of the order.

We took independent advice from a social worker. We found that the assessment carried out by the council when the child was placed in A’s care was reasonable and in line with guidance and legislation. However, there had been a failure to initiate appropriate follow-up and support when A contacted them again a few months after the assessment. We also found that there had been a failure to action referrals to other agencies who could have offered support to A. In addition, we found that there had been a failure to provide written evidence that they had fully reviewed the information provided by A when they contacted them after the assessment or that they had contacted A at the conclusion of the review. Finally, there had been a failure to capture critical information in the case records. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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:

• Staff should be reminded that kinship procedures are not only about financial support but about offering practical parenting advice and support to kinship carers. Staff should be reminded of the importance of recording critical information, including action taken and decision-making consideration in case notes.

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, an advocacy worker, complained on behalf of the family of A, about a failure to appropriately investigate A’s symptoms, and a consequent delay in diagnosing and treating their cancer.

We took independent medical advice from a radiology consultant (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans), an Ear, Nose and Throat (ENT) consultant and a general medical consultant. We found that the initial scans A received were reported reasonably and did not show any malignancy. When A’s GP later referred them to ENT, we noted that consideration should have been given to upgrading this to urgent. It remained routine and A was not seen until nine weeks after the referral, at which point their cancer was diagnosed.

In the meantime, A had been admitted to hospital under the care of the general medical team. We found that the medical team did not place sufficient emphasis on A’s physical symptoms, which were ‘red flags’ for the possibility of cancer. There was a failure to scan A’s neck, which is where their symptoms were. We also found that A should have been referred to ENT more urgently, preferably as an inpatient. The general medical team wrote to ENT asking for the earlier ENT referral to be expedited, but the letter did not sufficiently emphasise the physical concerns and placed undue emphasis on the likelihood of the problems being of a psychological nature. Had an ENT review been arranged while A was an inpatient, it is likely that their cancer would have been diagnosed at this point.

We concluded that the board failed to reasonably investigate A’s symptoms and upheld the complaint. We noted that an earlier diagnosis around the time A was an inpatient would have been unlikely to have affected the outcome for A. However, we recognised it would have given A and their family more time to come to terms with the diagnosis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family for the issues 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’ physical symptoms should be thoroughly assessed and they should be appropriately referred for review and scanning/x-ray as required in accordance with their presenting symptoms.
• Referrals to ENT should be appropriately triaged and upgraded as required.

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 provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided.

We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified significant failings in how A’s ileostomy care needs were provided and significant gaps in documentation. Therefore we upheld this part of C's complaint.

C also complained about the communication with both A and C about A's health and prognosis. We found that prior to A’s decline C was communicated with in a reasonable manner. In relation to the communication with A in the days before their passing, we found that A was experiencing increasing confusion and cognitive impairment throughout their stay in hospital and at times lacked capacity. In light of this, it was unreasonable to inform A of their poor health without C present. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. 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 communicated with in a reasonable manner, and, in line with their capacity, with next of kin present for support if necessary.
• Patients should have a person-centred care plan and staff should follow this.
• The care delivered should be captured in appropriate documentation.
• Stoma care is appropriately recorded in the correct area to support correct stoma care being provided in a reasonable manner.

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 board failed to provide C with appropriate treatment for a shoulder fracture. C was admitted to hospital suffering from alcohol related seizures. It became apparent that C had also suffered a shoulder fracture. C was discharged 12 days later with an orthopaedic referral (specialists in the treatment of diseases and injuries of the musculoskeletal system) for the following week. C was then scheduled for surgery to realign the fracture. This was subsequently cancelled. When C was seen again the following week a different consultant determined that C’s fracture had now healed to the extent that surgery was no longer a viable option.

C complained that the shoulder is now misaligned, causing discomfort and a reduced range of motion affecting day-to-day life and their ability to work. C believes that opportunities were missed to prevent this outcome. The board’s response stated that C was initially too unwell for surgery, and that the cancelled procedure was because of an emergency admission that had to be prioritised. They also noted that there was reason to suspect that the injury was older than C had stated upon admission.

We took independent advice from an orthopaedic consultant. We found that there had been some challenges for the board in providing care and treatment to C. However, it had been evident from three days before C was initially discharged that the fracture was healing out of alignment. We also found that there was insufficient evidence on which to conclude that the injury was older than stated. We noted that various opportunities were missed for earlier surgical intervention and that there was a lack of ownership of C’s case from an orthopaedic perspective, contributing to a series of small delays which ultimately led to the window of opportunity for effective surgery passing. This amounted to unreasonable care and treatment. Therefore, we upheld C's 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.

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

• Discussions about patient care should be documented.
• Upper / lower limb expertise should be obtained promptly where this is appropriate. In addition, where patient care is being transferred, the board should ensure that there is effective communication and that delays are avoided / minimised.

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 on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later.

C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital.

We took independent advice from a consultant urologist.

C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this.

Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have been improved.

With regards to communication, we did not identify any issue with the volume or frequency of communication with A. However we concluded that important medical details were overlooked or not explained clearly, such as A’s urological diagnosis and overall management plans.

Our investigation also concluded that whilst it was appropriate to discharge A home due to their condition being manageable with pain relief and antibiotics, there was a failure to ensure adequate pain relief would be available to A.

We upheld all four complaints and made appropriate recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues highlighted in this decision. 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:

• That A’s case be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A’s diagnosis and ways of ensuring similar delays do not affect future patients.
• That the board review the record keeping in A’s case and take steps to ensure their junior doctors and trainees are receiving adequate training in good medical record keeping and that senior clinicians are reminded of their responsibility to maintain sufficiently detailed records of discussions with patients and relatives.
• That the senior staff involved in A’s care be asked to reflect on the way that bad news was delivered on this occasion, and in general, with a view to ensuring they do so in as inclusive and compassionate a way as possible and with reference to the MDU guidance on breaking bad news.

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 board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

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.

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

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately identify and action learning.

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.