Upheld, recommendations

Summary

Ms C attended Glasgow Royal Infirmary with a swollen right leg and foot for investigation of a possible blood clot. Whilst at the hospital, staff took several blood samples from Ms C. Ms C complained that the laboratory at the hospital unreasonably lost one of her blood samples. She said her complaint was not about the length of time she waited for the results, but the fact that the blood sample went missing and that she was told by staff at the hospital that this was a regular occurrence.

We obtained independent medical advice from a nursing adviser. The evidence showed that on the day in question, the board's electronic healthcare information system was not operating properly and staff had to resort to manual recording of blood sample requests. Ms C's blood sample was taken at 14:00 and was received by the laboratory at 17:50. The accounts of staff involved indicated that there was some confusion over the method of transportation which was used to deliver the sample to the laboratory. Staff initially believed that the sample had been delivered by the pneumatic tube system (a network of tubes using compressed air to transport the samples to the laboratory). They then discovered that the sample was on a table in the A&E department waiting to be collected by a porter, and there had been a collection problem. The adviser said that the board's investigation and records indicated that the sample was lost, albeit temporarily, and then found by a member of staff and sent to the laboratory. We were critical of the board in this regard and we upheld Ms C's complaint.

On the matter of Ms C's concern that staff told her that blood samples being lost was a daily occurrence, the board indicated that there had been no previous complaints and their external accreditation review found that the laboratory met the quality standards. The adviser said that the board's response was reasonable.

Recommendations

We recommended that the board:

• review their written procedures for transporting samples to the laboratory to minimise the risk of this situation recurring; and
• provide Ms C with a written apology for the failings identified.

Summary

Mr C attended A&E at Glasgow Royal Infirmary following a sports injury. On discharge he was advised to take painkillers and use an ice pack. Mr C was later referred back to the hospital as he was continuing to suffer pain. Mr C complained to the board about his treatment but the board said that the examination, diagnosis and management plan he received at the time of his injury were appropriate.

Mr C complained to us that his condition had not been reasonably assessed by the hospital. We took independent advice from an emergency nurse practitioner. They found that although Mr C had been examined, there were shortcomings. Mr C's medical records did not properly record 'when, how, where, what and why', including the time of the injury and the advice given to Mr C about what to do should his pain continue. Had this advice been given, Mr C may have returned to hospital sooner and been given an earlier diagnosis. We upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology; and
• ensure that our findings are made available to the member of staff concerned and that they review the Nursing and Midwifery Council code in relation to record-keeping.

Summary

Mr C complained to the Scottish Prison Service (SPS) about the time it took prison staff to escort him to the health centre located within the prison. Mr C, who has diabetes, was unhappy it took two hours to receive assistance with his insulin pen. He also felt the SPS's response to his complaint was inappropriate.

We were unable to clearly determine why it took two hours for Mr C to be escorted to the health centre. We took independent advice from a nursing adviser who found that the delay of two hours was an unreasonable length of time for a person having treatment for insulin dependent diabetes to wait. We considered that appropriate action was subsequently taken when Mr C transferred to another prison where he was reviewed by a diabetic nurse specialist and a clear system to manage his insulin pen was put in place.

We also found that there was a failure by the prison to properly investigate and respond to Mr C's concerns. They had acknowledged that there should have been a more thorough investigation into his complaint and that their responses should have been more detailed.

Recommendations

We recommended that SPS:

• draw the failings we identified to the attention of relevant staff at the prison; and
• apologise to Mr C for not responding adequately to his complaint.

Summary

Mr C complained about the housing association after being a resident in supported accommodation they provided for around six months. During this period, Mr C said that he experienced ongoing anti-social behaviour from one of his neighbours which he felt the association did not take appropriate action against. Mr C was eventually served with a final warning by the association for threats that he made against his neighbour and for allegedly kicking in the neighbour's door. Following this, Mr C advised that his relationship with the association staff deteriorated and he was eventually issued with notice to leave his accommodation on the grounds that he was refusing support and this was an essential aspect of the tenancy.

On investigation, we found that there was some confusion among staff about whether or not the association's general anti-social behaviour procedure applied to supported accommodation. At the time of the complaint, support staff were of the opinion that this procedure applied but association staff considered that no set procedure was in place. Following our enquiries, the association confirmed that no procedure was in place for anti-social behaviour in supported accommodation, which we considered to be unreasonable. We also considered that their records did not sufficiently evidence thorough communication of their findings in each instance of anti-social behaviour.

On reviewing the final warning that had been served to Mr C, we found that there were a number of errors in communication which had reduced Mr C's understanding of the reasons for which the warning had been served. We also found that the association had incorrectly advised that the police had corroborated the incidents leading to the warning.

We also found a number of errors in the notice of termination served on Mr C, asking him to leave the accommodation. This included failing to clearly explain the reasons the notice was being served and incorrectly referencing sections of his occupancy agreement which were not grounds for eviction. As part of this investigation we also identified that Mr C's occupancy agreement made reference to associated schedules which the association were unable to supply.

Finally, we found that Mr C had submitted a complaint which, despite clearly constituting a formal complaint under the terms of the association's complaints handling procedure, was dealt with as a report of anti-social behaviour and not a complaint. This led to Mr C failing to receive a response to his complaints until submitting them again some months later.

As a result of this, we upheld all of Mr C's complaints.

Recommendations

We recommended that the association:

• review the anti-social behaviour procedures for the supported accommodation and either make clear to staff that the general anti-social behaviour procedure applies or draft a suitable alternative;
• consider implementing a standard letter template for formal warnings to guide staff and help ensure that clear, well-evidenced reasons are communicated to occupants when warnings are served;
• review the supported accommodation occupancy agreement to ensure that any schedules referenced are included or such references removed;
• consider implementing a standard letter template for notices of termination to guide staff and ensure that all the necessary information mentioned above is clearly communicated to occupants when notices are served;
• provide training to relevant staff on the relevant section of the complaints handling procedure;
• apologise to Mr C for the failings identified;
• carry out a review of the procedures in place at the supported accommodation to ensure that the respective roles of association staff and support workers are clear to both staff and occupants; and
• reflect on the outcomes of this investigation to establish the root cause of the failings identified and take action to address these.

Summary

Mrs C raised a number a number of concerns about the care and treatment given to her late mother (Mrs A) during an admission to Ninewells Hospital. Mrs C had complained to the board about the general clinical and nursing care that her mother had received. She had complained about the standard of communication and the delay in diagnosing and treating her mother, and she said that her mother had suffered unnecessary pain due to the non administration of medication. Mrs C was also unhappy with the board's handling of her complaint.

During our investigation, we took independent advice from a consultant geriatrician and a nursing adviser.

When responding to Mrs C's complaints the board accepted that there had been a number of failings and had taken action to address these. This included putting in place an improvement plan. However, notwithstanding the failings identified by the board, the advice we received and accepted from the geriatrician adviser was that there were failings in relation to the clinical treatment provided to Mrs A. These related to failings in communication within and between departments. We also found that the consent process for a procedure to fit a stent had not followed the relevant guidance.

While the board had already accepted failings in relation to the nursing care provided to Mrs A, the advice we received from the nursing adviser was that there had been other failings by nursing staff. We found that there were gaps in nursing care, particularly around the use of the malnutrition universal screening tool (MUST - a way to screen patients to identify and treat adults at risk of malnutrition), and checking Mrs A's food, fluid and nutritional care.

In relation to complaints handling, the board accepted that they had failed to deal with Mrs C's complaints in a timely and reasonable manner, so we upheld all aspects of Mrs C's complaint.

Recommendations

We recommended that the board:

• provide an update on the improvement plan put in place as a result of this case;
• investigate further the actions taken in relation to the stent procedure and provide details of the reasons for the delay, including the provision of anaesthetic staff for this process, to ensure lessons are learned;
• bring to the attention of the relevant staff the consultant geriatrician's comments, that a number of doctors were involved in Mrs A's care but there was no clear indication of who was in charge overall;
• bring the geriatrician adviser's comments in relation to the management of Mrs A's medication and an error which occurred in relation to her medication to the attention of relevant staff;
• ensure that relevant staff are able to complete the MUST and carry out actions as appropriate and report back to us on this;
• formally apologise to Mrs C for the additional failings identified by this investigation and for the handling of her complaint; and
• provide an update on the review being carried out on their complaints process.

Summary

Mr C complained about a delay in being referred for psychology treatment. He was referred to the community mental health team and was seen initially by a consultant psychiatrist and a community psychiatric nurse (CPN). He continued to see the CPN over the following months but it was deemed that no psychiatric follow-up was necessary. However, the CPN subsequently discussed Mr C with the psychiatrist when the Mr C had reported experiencing vivid dreams, and the psychiatrist recommended a referral to psychology. Mr C raised concerns that he was not seen by a psychologist until several months later, when he considered that he should have been referred directly after his initial appointment.

We obtained independent advice from a senior mental health nurse, who did not consider that there was any indication for a psychology referral initially and deemed it reasonable for this to have been proposed when it was. However, the adviser noted that the CPN did not make the referral until almost three months later, despite having indicated that she would progress this. While Mr C was seen by a psychologist within the national 18 week waiting target from referral to treatment, the adviser considered that the delay in making the referral was unreasonable. We were critical that the board did not identify the delay when investigating this complaint and their response inaccurately indicated that the referral had been made around the time it was first proposed. We upheld this complaint.

Mr C also raised concerns about the contribution of a medical secretary at a meeting he attended with the psychiatrist and clinical director to discuss his complaint. He complained that the secretary inappropriately intervened to speak on the psychiatrist's behalf. The minutes of the meeting and the board's response to the complaint confirmed that this happened, although not to the extent described by Mr C. Nonetheless, the adviser considered that the secretary's documented input was inappropriate, noting that she was at the meeting solely as minute taker and should have left any explanations and/or apologies about care and treatment to the professional clinicians in attendance. We also upheld this complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the delay in referring him to psychology;
• ask the staff involved in Mr C's care to reflect on the findings of this investigation and take steps to ensure that psychology referrals, once deemed appropriate, are progressed without any avoidable delay;
• highlight to complaints handling staff the importance of establishing the facts and accurately reflecting them in complaint responses;
• apologise to Mr C for the psychiatry secretary's inappropriate contributions at his complaint review meeting; and
• ensure clear directions are given to administrative staff taking on the role of minute takers at meetings, setting out the limitations of their role in this regard.

Summary

Mr C complained about the care and treatment he received from the medical practice. In particular, he raised concerns about a specific consultation where he felt that he should have been referred to a psychiatrist due to him suffering from severe depression. He was not referred to psychiatry until around a year later and he considered this to have been to the detriment of his mental health in the interim period. He also complained that the practice had increased his dosage of antidepressant medication to what he considered to be an unsafe level.

We obtained independent medical advice from a GP. They noted that details of the consultation in question had not been recorded and they were, therefore, unable to assess whether a referral to psychiatry was indicated at that time. While they did not consider that there was any indication for a referral at subsequent consultations six and eight months later, due to the fluctuating nature of Mr C's mental health difficulties we could not conclude that the same applied at the time of the relevant consultation. With regard to Mr C's medication, the adviser noted that it was prescribed at dosages within recommended levels and they could find no evidence of unsafe prescribing.

In light of the identified record-keeping failure, we were unable to evidence that Mr C had been appropriately assessed and, in turn, whether the decision not to refer him to psychiatry was reasonable. Therefore, on balance, we upheld the complaint and made some recommendations to the practice relating to record-keeping.

Recommendations

We recommended that the practice:

• apologise to Mr C for the identified record-keeping failure; and
• reflect on the identified record-keeping failure and seek to ensure compliance with the relevant General Medical Council guidance at all times.

Summary

Mr C complained about the time he had to wait for a gastroscopy procedure (a procedure where a thin, flexible telescope called an endoscope is used to look inside the gullet and stomach) at Raigmore Hospital. Mr C was referred for the procedure by his GP after he complained of symptoms of indigestion. Mr C was offered an appointment 16 weeks after referral, but when he attended the appointment the procedure could not go ahead as the endoscopy department did not have the required equipment available. Mr C complained to the board about the delay and expressed concern that the anticoagulation medication he was taking (treatment with drugs that reduce the body's ability to form clots in the blood) could have posed a risk to his health in the period while he waited for the procedure. The board apologised to Mr C and noted that the equipment was not available at the previous appointment because of a delay in the return of endoscopes following decontamination.

We took independent medical advice from a consultant physician who was critical that the time between referral and the procedure exceeded the target waiting time set by the Scottish Government. The adviser also noted that the appointment booking process should not have required two interventions from Mr C's GP. The adviser concluded that because of the delay in the procedure, Mr C suffered from his symptoms longer than was necessary, which was unreasonable. In view of this, we upheld this complaint and made two recommendations.

Mr C also complained that the board did not fully address the concerns he raised in his complaint and had exceeded their complaint response time target. The board acknowledged that a letter explaining the delay was not sent in this instance, and stated that staff have since been reminded about the requirement to send holding letters when appropriate. We were critical that, once they had received Mr C's complaint, the board failed to quickly offer Mr C an appointment, and therefore an opportunity was missed to reduced Mr C's waiting time for the procedure. We therefore also upheld this complaint and made four recommendations.

Recommendations

We recommended that the board:

• advise us of the action taken to address the waiting time delays for the endoscopy procedure identified in this case;
• provide evidence that quality improvement work regarding increasing turnaround time for decontamination has taken place;
• feed back our findings in relation to the handling of Mr C's complaint to relevant staff; and
• provide Mr C with an apology for the failings identified in this investigation.

Summary

Ms C, a voluntary agency worker, complained on behalf of Mr A that the dental treatment he had received was inadequate. Ms C said Mr A believed the treatment he had received had contributed to tooth decay in his mouth. Mr A asked for compensation for the treatment he said he received.

We took independent dental advice, which stated that Mr A had not received the appropriate dental treatment. The advice noted that Mr A had been fitted with a bridge which had only been partially attached, as it had been supported by only one tooth, rather than two, as would normally be the case. The advice said the bridge was, therefore, always likely to fail. The advice noted, however, that Mr A had not maintained the appropriate level of oral hygiene or attended review appointments which were essential for preventing tooth decay following the fitting of bridge work. The advice stated that on balance, Mr A's dental treatment had been unreasonable, since a bridge should only have been fitted if it could be fully attached.

We found that Mr A's treatment was unreasonable, and he should, therefore, have the cost of his dental treatment refunded.

Recommendations

We recommended that the dentist:

• refund Mr A the cost of the dental treatment;
• provide evidence that the dentist has reflected on the failures in Mr A's care identified in the investigation; and
• apologise for the failings identified in this report.

Summary

Mr C complained about the mental health care and treatment of his late wife (Mrs C) in the weeks prior to her suicide. Mrs C had a history of mental illness, and was referred urgently to psychiatry by her GP due to returning symptoms. Mrs C was assessed and a plan was made to treat her at home with support from the Intensive Home Treatment Team (IHTT). After four weeks, the IHTT referred Mrs C to her local team (Rehabilitation and Enablement Services Mental Health Team (RES MHT)) for further care. However, due to problems with the referral process there was a delay in transferring care and a ten day gap between appointments. Mrs C completed suicide the day after her first RES MHT appointment.

The board conducted a Significant Clinical Incident investigation into Mrs C's death. While the review team concluded the care was appropriate, they identified problems with the transfer process, and a lack of documentation about the role Mrs C's family had in her care planning. In response to Mr C's complaint, the board acknowledged failings in involving Mrs C's family in her care planning and in the referral process. The board apologised to Mr C and provided information on a number of actions underway to improve the RES MHT service.

After taking independent mental health and psychiatry advice, we upheld Mr C's complaint. We agreed with the board's findings that there was a lack of involvement of Mrs C's family in her care planning, and failings in the referral process. We also found that, while a comprehensive risk assessment was carried out, the management plan did not include a summary formulation of risk (as required by the local policy). While we considered the board had already taken appropriate action to address the issues found in relation to the RES MHT, we asked that they provide details of action taken in relation to the IHTT.

Recommendations

We recommended that the board:

• remind staff of the requirement to implement a summary formulation of risk (as well as a risk management plan) under the Clinical Risk Screening and Management Policy; and
• demonstrate that action has been taken to improve documentation of carer involvement (and patient consent to this) by IHTT staff in care planning and risk management.