Upheld, recommendations

Summary

Mr C complained on behalf of his late father (Mr A). He raised concerns that staff at Dumfries and Galloway Royal Infirmary failed to provide Mr A with appropriate medical treatment and about the board's handling of his complaint.

Mr A attended the hospital for a hernia operation. The operation was performed and Mr A was discharged. However, Mr A became unwell and was readmitted to hospital the same day. Mr A's condition continued to deteriorate and he died some months after the operation. The board conducted a significant adverse event review (SAER) and complaints investigation. These processes identified a number of failings, including an error in the prescription of bisoprolol (a beta-blocker, used to treat high blood pressure) and a failure to review blood tests.

Mr C questioned whether the board had appropriately identified all the issues in Mr A's care and whether they had appropriately taken action to address these failings. In addition to the issues with the medication and the review of blood tests, Mr C raised concerns about monitoring Mr C's fluid levels, attending to his catheter and the actions of the consultant surgeon and anaesthetist prior to and after Mr A's admission, including whether staff should have undertaken the operation. Mr C also raised concerns about the way the board's investigations had been conducted, including the interaction between the two processes and delays in responding to his correspondence.

After receiving independent advice from a consultant in general medicine and a nurse, we upheld Mr C's complaints. We found that the prescription of bisoprolol was unreasonable. We also found the board failed to review Mr C's blood tests. We found the board had subsequently taken appropriate action in relation to these issues. However, we also found there was a lack of specific medical review prior to Mr A's discharge and we were critical of this aspect of Mr A's care. We also found failings in respect of monitoring Mr A and in attending to his catheter. In relation to the decision to proceed with Mr A's operation, we found that Mr A had given his informed consent to the procedure, and as Mr A had capacity to make this decision, it was appropriate to proceed with the operation.

We also found that the board's handling of Mr C's complaint was unreasonable. In particular, we found there was confusion about the interaction between the SAER and the complaints process, which lengthened the process and resulted in significant errors in communication with Mr C.

Recommendations

We recommended that the board:

• take steps to ensure the clinician responsible for the error in giving Mr A his heart medication is made aware of the findings of this investigation for reflection and learning;
• confirm that the consultant surgeon will discuss this case in their appraisal;
• provide this office with a progress report on the actions taken to address the issues in the case, including catheter care;
• apologise for the clinical failings identified in this investigation;
• take steps to ensure that staff explain to complainants how the SAER and complaints handling processes are being taken forward in each case;
• feed back the findings of the investigation to the relevant staff for reflection and learning; and
• apologise to Mr C for the failures in complaints handling.

Summary

Ms C complained to the prison governor after a prison officer refused to let her visitors attend a pre-booked children's visit. She was unhappy with the governor's response. In particular, Ms C said the governor failed to acknowledge or respond to points that she raised in her PCF2 complaint. PCF2 is the name of the form used to make a confidential complaint about a sensitive or serious issue.

We reviewed the information available and this confirmed that the governor appropriately obtained a statement from the officer who took the decision to refuse Ms C's visitors. The governor also communicated his findings to Ms C. However, he did not respond to the specific outcomes Ms C noted that she was looking for. We considered that doing so would have been reasonable and would have demonstrated good complaints handling. Therefore, we upheld Ms C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• take steps to remind governors that they should respond appropriately and in full to issues raised in PCF2 complaints.

Summary

Mr C complained about how his prison dealt with a PCF2 confidential complaint. PCF2 is the name of the form used to make a confidential complaint about a sensitive or serious issue. We found the prison failed to give Mr C reasons for not regarding his complaint as being about a confidential matter of an exceptionally sensitive or serious nature. The prison also incorrectly said that Mr C made no proposal about how his complaint could be resolved, when in fact he did. Given that the prison did not follow the instructions on the PCF2 complaint form or in the prison service complaints guidance, we upheld Mr C's complaint.

Recommendations

We recommended that Scottish Prison Service:

• remind relevant staff of the need to follow the instructions on the form and the prison service complaints guidance when dealing with PCF2 complaints.

Summary

Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have contacted either off-duty staff or trained responders to assist his wife, who was in pain.

We found that the ambulance service had acknowledged from the outset that there had been a delay in the ambulance being dispatched. We considered the ambulance service had acted in accordance with their call-out procedures in relation to off-duty staff and trained responders (including GPs) because there was no apparent threat to life.

The ambulance service provided information on the action they took as a result of the delay. They have reviewed their shift capacity and put further measures in place including the training of staff and new posts.

In terms of the ambulance service's handling of Mr C's complaint, we considered that there was an unreasonable delay of around six months in responding to additional questions Mr C had asked. The ambulance service accepted that there were failings in relation to the time they took to reply to Mr C. Therefore they introduced a pilot method to record contact from individuals as part of their complaints handling.

Recommendations

We recommended that the ambulance service:

• apologise to Mr and Mrs C for the delay in dispatching an ambulance and the delay in responding to the additional questions Mr C raised as part of his complaint; and
• provide documentary evidence on the outcome of the pilot they conducted in order to ensure appropriate steps have been taken to address the failings in relation to record-keeping and responding to complaints correspondence.

Summary

Miss C complained that her dentist failed to provide her with appropriate dental treatment. Miss C was advised by her dentist that she needed a crown on one of her teeth. She subsequently suffered problems with her tooth and had to receive further treatment. She questioned the advice to place the crown. Miss C also complained about subsequent treatment and the management of her pain during this time as well as the dentist's handling of her complaint.

After receiving independent advice from a dentist, we upheld Miss C's complaints. We found that the dentist failed to provide Miss C with appropriate options, including risks and benefits, and therefore failed to get informed consent. We also found that placing the crown was not the best option, given Miss C's periodontal (gum) disease. Finally, we found that the dentist failed to respond to Miss C's formal complaint in line with the NHS complaints procedure.

Recommendations

We recommended that the dentist:

• review their consent process regarding treatment options, risks and benefits in line with General Dental Council (GDC) standards;
• apologise for the clinical failings identified by this investigation;
• refund the cost of either root canal treatment and a new crown or, if necessary, replacement by means of a denture or bridge on receipt of an appropriate invoice when treatment has been completed;
• refund Miss C the cost of treatments for the crown and x-rays;
• review the complaints handling requirements under the Scottish Government's 'Can I Help You?' guidance; and
• apologise for the failings in complaints handling identified by this investigation.

Summary

Ms C complained to us about the care and treatment she received when she was admitted to the Royal Infirmary of Edinburgh with significant pelvic girdle pain (a collection of uncomfortable symptoms that can cause severe pain due to a misalignment or stiffness of the pelvic joints at either the back or front of the pelvis) in the late stages of pregnancy. She also complained that the board did not reasonably respond to her complaints.

We took independent midwifery advice. We found that the care and treatment provided to Ms C in relation to pelvic girdle pain and pitting oedema (a build-up of fluid under the skin that holds the imprint of a finger when pressed) had been appropriate. We also considered that the pain relief provided to her was appropriate, although we acknowledged that pelvic girdle pain is difficult to manage in severe cases. Ms C's pressure areas had been frequently checked in the hospital and the steps taken once the sore skin on her inner thighs had been noted was appropriate and timely.

However, we found that the board had not followed the guidance from NICE (National Institute for Health and Care Excellence) on caesarean sections as they had not provided her with information in order for her to make an informed choice on her mode of delivery given her concerns and anxiety about childbirth at that time. The delivery plan should have been reassessed when Ms C was admitted to hospital with excessive pain and mental health concerns. There was also a delay in providing her with a swivel turntable and other disabled-friendly equipment and the nursing records indicated delays in emptying her catheter. In addition, Ms C should have had an occupational health review prior to discharge to ensure she was safe to manage and care for her baby at home and had the assistance she required. We therefore upheld her complaint.

We found that there was a delay in the board responding to Ms C's complaint. We therefore upheld this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• ensure that relevant staff in the maternity unit are aware of our decision on the complaint;
• take steps to ensure that the staff are aware of and understand the NICE guidance in relation to requesting a caesarean section;
• provide evidence that steps have been taken to ensure that moving and handling equipment is easily accessible for staff;
• review the maternity ward to ensure that there is suitable disabled access;
• review the discharge arrangements for women with pelvic girdle pain;
• issue a written apology to Ms C for the failings identified; and
• make the staff involved in the handling of Ms C's complaint aware of our decision.

Summary

Ms C was diagnosed with breast cancer. Following treatment, she decided to have reconstructive breast surgery. Ms C was placed on a waiting list and was told that the Patient Rights (Scotland) Act 2011 applied, which meant that her treatment would start within a maximum of 12 weeks. After 12 weeks, Ms C contacted the board and found out they could not meet the treatment time guarantee. Ms C complained that the board acted unreasonably by failing to meet the 12-week waiting time; that they did not acknowledge her request to meet with the chief officer or medical director; and that they failed to respond to her complaint within a reasonable time.

We took independent advice from a specialist in plastic surgery. We found that the lack of expertise available at the private-sector service provider chosen by the board was a reasonable reason for Ms C not being treated elsewhere. However, it appeared that the board had not taken sufficient steps to consider the provision of treatment by other NHS providers throughout the UK who may have had the required expertise. We determined that the board did not reasonably take into account their statutory responsibility to take all reasonable and practical steps to arrange treatment with other service providers. Also, while the board explained satisfactorily the reasons why Ms C's surgery could not be provided within the 12-week treatment time guarantee, it was unacceptable that she had to take the initiative to find out what was happening once the 12 weeks had passed. We were also concerned about the lack of information provided to us about arrangements the board have in place when they cannot meet the treatment time guarantee within their own area to arrange the provision of treatment by alternative service providers. The board apologised that a meeting was not arranged to address Ms C's complaints. We also found that there was an unreasonable delay in providing a response to Ms C's complaint.

Recommendations

We recommended that the board:

• revise their plastic surgery waiting list letter so that any potential breach of the 12-week treatment time guarantee is made clear to patients;
• inform us of action taken (or that will be taken) to reduce waiting times for breast reconstruction patients;
• inform us of arrangements in place to provide treatment by alternative service providers when they cannot meet the treatment time guarantee for breast reconstruction patients;
• apologise to Ms C for the failings identified in this investigation;
• offer Ms C a meeting with the chief nurse and/or relevant medical director; and
• inform us of the actions taken to deal with complaints in a reasonable time.

Summary

Mrs C complained about the care her son (Mr A) received at Hairmyres Hospital after he attended the A&E department on three separate occasions. Specifically, that he had a fracture of the scaphoid bone in his wrist which caused him significant pain for over 18 months before it was identified.

In responding to the complaint, the board said that there was a missed opportunity to recall Mr A for a specialist scan which may have diagnosed the fracture.

We took independent medical advice and found failings by staff in A&E and radiology when Mr A attended on the second occasion with ongoing pain over the scaphoid bone. Whilst such fractures can be difficult to diagnose, we considered that the second x-ray showed a mildly displaced fracture which should have been reported by radiology. In addition, we found there was a lack of assessment by a senior member of staff in A&E given the ongoing wrist pain and tenderness over the scaphoid bone.

Recommendations

We recommended that the board:

• apologise to Mr A for the failings identified;
• ensure that the A&E staff involved reflect on the failings identified in this case at their annual appraisal as part of their professional development;
• review their procedures with a view to ensuring there is provision for a senior doctor to review patients who make an unplanned return to the emergency department; and
• share these findings with the radiologists involved in this case and identify any training needs in relation to the reporting of scaphoid fractures.

Summary

Mrs C complained about the treatment she received for her injured hand following a fall. Mrs C attended A&E at Caithness General Hospital. An x-ray was taken the next day and no bone injury found. Further x-rays were taken after Mrs C attended her GP. However, a fracture was only identified seven months later, following a scan. Mrs C complained that she had not been provided with reasonable treatment and that she had not been referred to a specialist within a reasonable timescale.

The board had accepted that they were not meeting the 48-hour target for a formal report to be issued in relation to x-rays and had taken action. They also accepted and apologised for the delay in diagnosing the fracture Mrs C suffered.

During our investigation we took independent advice from three advisers: a consultant in trauma and orthopaedic surgery (adviser 1), a consultant radiologist (adviser 2) and a consultant musculoskeletal physiotherapist (adviser 3).

Adviser 1 noted that the overall orthopaedic treatment Mrs C received was correct but that access to treatment was not as timely as it could have been. This related to the delay in a scan being carried out. However, the adviser also said that the delays experienced by Mrs C would not have altered the treatment or long-term outcome from an orthopaedic point of view.

Both adviser 1 and adviser 2 were of the view that the board's decision to delay carrying out an x-ray until the day after the injury was sustained was not reasonable. Adviser 2 did not agree with the board's policy of waiting on a formal report of an x-ray before taking a further x-ray. The advice we received from adviser 3 was that overall the physiotherapy treatment Mrs C received was reasonable.

The board accepted that they were not meeting the 12-week target for out-patient appointments and apologised that the specialist in this case had been unable to prioritise Mrs C and for the delay in being seen by the specialist. While the board outlined the action being taken, adviser 1 was concerned about the approach being taken by the board to restrict urgent appointments in the orthopaedic clinic and on referring patients to other board areas.

Recommendations

We recommended that the board:

• use the findings of this complaint to develop a multi-disciplinary (orthopaedic, radiology and A&E) action plan;
• feed back the findings of this investigation to the relevant staff;
• consider adviser 1's comments in relation to the approach being taken to restrict urgent appointments in the orthopaedic clinic and on referring patients to another board; and
• provide details of the steps taken/action plan to address how the 12-week target will be met in future.

Summary

Mr C complained about the care and treatment of his late mother (Mrs A). Mrs A had multiple health problems and was admitted to Victoria Hospital with back pain. She was subsequently transferred to Queen Margaret Hospital but became unwell a few weeks later and was transferred back to Victoria Hospital. She deteriorated quickly due to sepsis (an infection of the blood) and died the following morning. Mr C complained about various aspects of the nursing care provided to Mrs A.

We took independent advice from a consultant physician and a nurse. We noted that there was a failure to correctly label a urine sample, resulting in the laboratory being unable to process it and a subsequent delay in obtaining a repeat sample. This resulted in a two-day delay in Mrs A receiving antibiotics. The medical adviser considered that had there been no delay, Mrs A may have had a better chance of survival, although they could not be certain that this would have been the case. We also noted a failure to assess and document Mrs A's leg wound upon admission, leading to a delay in appropriate treatment.

Mr C had alleged that a nurse's physical handling of Mrs A amounted to assault and, although the nursing adviser considered that this complaint was taken seriously and dealt with sensitively, they advised that consideration should have been given to handling this more formally through the relevant incident-reporting system.

Mr C also complained about a delay in responding to the family's request for the toilet to be cleaned and while we could find no evidence of a delay, we noted that the board had not directly addressed this concern. While we noted that the board had already acknowledged many of the identified failings and taken appropriate remedial steps, we upheld this complaint.

Mr C also complained about the communication with his family, in particular a lack of opportunity to speak with medical staff about Mrs A's care. The medical adviser agreed that there was minimal evidence of good communication between medical staff and the family. They considered that an 'Adults with Incapacity' form should have been completed earlier in the admission and discussed with the family.

We found no evidence of inadequacies in relation to the communication surrounding Mrs A's transfer back to Victoria Hospital or when a DNACPR decision was taken (a decision that means a healthcare professional is not required to resuscitate the patient if their heart or breathing stops). In addition, we were also unable to evidence specific occasions where Mr C described inappropriate communication and attitude of particular members of nursing staff. However, we upheld the complaint. We noted that the board had acknowledged and acted upon failings but we made some recommendations for further remedial action.

Finally, Mr C complained about the board's handling of his complaint and in particular the time it took to respond. We noted that his complaint was very detailed and asked a significant number of specific questions. We were satisfied that the board's response was reasonable and proportionate in the circumstances. We were also satisfied that they took appropriate steps to keep Mr C updated regularly throughout their investigation. However, we considered that the investigation was not concluded in a timely manner and that there was an unreasonable failure to set a revised target response date when it became clear that the response would be delayed beyond the standard time frame. Therefore we upheld the complaint. While the board had already provided an explanation and apology for the delay, we made a further recommendation.

Recommendations

We recommended that the board:

• take steps to ensure that allegations of the nature of those raised by Mr C are handled in line with their formal incident reporting system;
• highlight to relevant staff the family's concerns about the failure to respond to their request for the toilet to be cleaned, and remind them of the importance of responding promptly to such requests;
• review the use of 'Adults with Incapacity' forms in the relevant ward/department to ensure that the appropriate processes are being followed and that the actions being taken are in keeping with Health Improvement Scotland visit standards;
• remind nursing staff of their responsibility to facilitate good communication between families and medical staff; and
• highlight to complaints handling staff the importance of aiming to provide complainants with a revised response timescale when it becomes clear that the 20-working-day target will not be met.