Upheld, recommendations

Summary

Ms C complained to us about the care and treatment she was given when she went into the Princess Royal Maternity Unit to give birth to her daughter. When her labour was slow to progress and other alternatives were unsuccessful, her baby was delivered by caesarean section (an operation to deliver a baby which involves cutting the front of the abdomen and womb). However, doctors noted that she was not recovering from surgery as expected. She was taken back into surgery when she collapsed, two hours and twenty minutes after her caesarean section, and was found to have had a major internal bleed. Ms C raised concerns that her caesarean section was not carried out appropriately, and that doctors did not notice her deterioration quickly enough. She said that this resulted in a prolonged recovery time for her, and difficulties relating to her time with her new-born baby.

We sought independent advice from an obstetric adviser. They reviewed Ms C's medical notes in detail and did not raise any concerns about the way Ms C's caesarean section had been carried out. However, they did raise concerns about how medical staff responded to her deteriorating condition in the two hours after her caesarean section. They noted that a blood test had been taken but not followed up. They noted that medical staff did not maintain appropriate records of their decisions and plans. They also considered that Ms C's deterioration was not appropriately escalated to both anaesthetic and obstetric teams. They said that, if all this had been done, it was likely that Ms C's second operation could have been undertaken 45 minutes earlier, before her condition had become so critical.

We noted the obstetric advice on Ms C's care and treatment and upheld her complaint. We made a number of recommendations to address the failings we identified.

Recommendations

We recommended that the board:

• review the post-operative escalation policy, to ensure concerns are escalated to both obstetrics and anaesthetics when post-operative concerns persist;
• share these findings with the staff involved, and remind them of the need to record their findings, working diagnoses, plans and timescales for review;
• review mechanisms for receiving blood test results to ensure that results are identified and acted on promptly;
• review staff competencies and potential training needs on the early diagnosis of occult/internal haemorrhage and on scanning an acute surgical abdomen; and
• apologise to Ms C for the failures we identified, and for the distress caused to her and her family.

Summary

Mrs C complained about the standard of medical and nursing care and treatment her late mother (Mrs A) received as an in-patient at New Victoria Hospital in October and November 2014. Following a hip operation, Mrs A was transferred from another hospital to a rehabilitation ward at the New Victoria Hospital. She had underlying health conditions (including hospital acquired pneumonia, lung disease and heart disease) and contracted clostridium difficile (a common bacteria that infects the colon). Whilst in hospital, her condition deteriorated and she died less than a fortnight after being transferred to the New Victoria Hospital.

We took independent advice from a medical adviser and a nursing adviser. Turning first to medical issues, we found that while appropriate investigations were carried out within a reasonable time and treatment decisions were reasonable, there were shortcomings. These included that senior clinicians should have been more involved in Mrs A's care and medical staff had failed to implement the relevant do not attempt cardiopulmonary resuscitation (DNACPR) policy. We also found that there was a failure to discuss the possibility of Mrs A's death with her family within a reasonable time. Also, the day before Mrs A's death, medical staff should have discussed her condition with an intensive care unit doctor sooner and it would have been reasonable for medical staff to have had a discussion with them the day before. Related to this, it was not clear whether the on-call doctor had followed up contact from a member of nursing staff about Mrs A's condition or whether they had been informed of her condition following the change of oxygen supply.

Turning now to nursing issues, we found that there were shortcomings in relation to infection control and nutrition which the board had addressed. However, we also found shortcomings around the implementation of an early warning system guidance (the National Early Warning Score - NEWS) and that nursing staff failed to monitor and assess Mrs A on the day before her death in line with this guidance. We also found failings in record-keeping.

Recommendations

We recommended that the board:

• consider the issues around end of life care including communication and take steps to ensure no recurrence;
• bring the medical adviser's comments in relation to record-keeping, implementing the DNACPR policy and escalating difficult significant clinical decisions to relevant staff, and take steps to ensure no recurrence;
• bring the nursing adviser's comments about shortcomings in implementing NEWS policy to relevant staff; and
• apologise for the failures this investigation identified.

Summary

Ms C was referred to the former Southern General Hospital in Glasgow by her GP for investigation of secondary infertility. A HyCoSy scan (a procedure to detect whether the fallopian tubes are damaged or blocked) and blood tests were arranged. The board took ten months to arrange the scan. Ms C said that because of the time it was taking to see a consultant gynaecologist to discuss the results of the scan and as the board could not provide her with a timescale of when she would get an appointment and as she was suffering severe abdominal pain, she arranged to be seen privately by a consultant gynaecologist abroad. The private consultant gynaecologist reviewed the results of her HyCoSy scan and carried out an ultrasound scan and, as a result, recommended a laparoscopy to confirm and, if necessary, treat endometriosis. A laparoscopy is surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis through a small hole in the skin.

Ms C said that although she presented this information to the board's consultant gynaecologist, they refused to arrange a laparoscopy. Ms C said she paid for the laparoscopy procedure abroad. It confirmed a diagnosis of endometriosis and she had surgery to treat and cure her symptoms.

We took independent advice from a consultant gynaecologist. We found that there was an unacceptable delay in arranging Ms C's HyCoSy scan, the result of which was not normal and that a laparoscopy should have been arranged for Ms C by the board. Based on the clinical advice we received, we were satisfied that the board should have offered Ms C a laparoscopy to provide the definitive diagnosis. Therefore, we upheld Ms C's complaint.

We were also critical that the board were unable to locate and provide us with Ms C's complete clinical records and we made a recommendation to address this.

Recommendations

We recommended that the board:

• apologise to Ms C for the delay in arranging a HyCoSy scan, the failure to offer her a laparoscopy and for losing her medical records;
• refund to Ms C the invoiced cost of her ultrasound scan, laparoscopy and associated treatment arranged abroad;
• provide evidence that the delay in carrying out the HyCoSy scan has been addressed;
• feed back the comments of the adviser and the findings of this investigation to the consultant gynaecologist for reflection and learning, to include the importance of the management of medical records; and
• take steps to ensure that they are complying with 'Records Management: NHS Code of Practice (Scotland)'.

Summary

Miss C complained about the community nursing care provided to her late mother (Mrs A) who was elderly. Miss C said that the community nurse undertook a procedure which caused Mrs A severe distress and brought her to the point of collapse. Miss C said that she and her mother had not consented to the procedure and believed it was unreasonable given Mrs A's health and age.

We took independent advice from a nursing adviser. We found that the procedure undertaken was necessary and failing to intervene could have had serious clinical consequences. We also found that the clinical decision-making was reasonable and that the procedure was within the community nurse's professional remit. However, there was no evidence that verbal consent was obtained for the procedure, which was unreasonable. We made a recommendation to address this.

Recommendations

We recommended that the board:

• bring the failings around consent to the attention of relevant staff and ensure that they are addressed; and
• apologise for the failures this investigation identified.

Summary

Mrs C complained about the care and treatment she received from the board at University Hospital Crosshouse following her inner labial reduction surgery (reduction of the two flaps of skin on either side of the vaginal opening). Her concerns included that the board failed to provide her with a reasonable standard of care when she reported problems after the procedure and that the entire area of tissue from the inner labia had been removed during subsequent corrective surgery without reasonable discussion or explanation.

We obtained independent medical advice on the case from a consultant gynaecologist. They said that at the first sign of post-operative problems, Mrs C should have been seen as a matter of priority and the surgeon who carried out the operation should not have refused to see her. The adviser said that the surgeon suggesting that Mrs C's GP contact the plastic surgery service was not appropriate and caused further delay in Mrs C's treatment. We therefore upheld this part of the complaint. However, we noted that the adviser said that they did not feel that the outcome would have been materially different if the subsequent corrective surgery had taken place sooner. We also noted that the board had taken appropriate remedial action as a result of Mrs C's complaint.

In terms of the corrective surgery, the adviser said that almost the entire area of the inner labia was removed without consent or proper explanation. We therefore upheld this part of Mrs C's complaint. Although we noted that the board had taken reasonable remedial action in relation to their consent process, we made two recommendations.

Recommendations

We recommended that the board:

• feed back our decision on Mrs C's complaint to the staff involved; and
• provide Mrs C with a written apology for the failings identified.

Summary

Mr C lost an item of property. Although the Scottish Prison Service (SPS) had admitted responsibility for losing the item, Mr C was unhappy with the amount that had been offered in compensation. We asked the SPS about this and they confirmed that the valuation of Mr C's lost property had been made using an inappropriate method. They agreed to re-visit the claim. They also agreed to ensure that more appropriate methods were used in future. As such, we upheld the complaint but made no further recommendations.

Mr C then complained again following this reassessment, as he remained unhappy with the way it had been carried out. On further investigation, we found that the relevant staff were unaware of the procedure they were supposed to follow and there had been a number of procedural errors as a result, affecting the investigation of Mr C's claim. As such, we upheld the complaint, this time making recommendations.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified;
• repeat their compensation offer to Mr C for his lost item of property; and
• provide us with details of the outcome of the stated reviews being carried out to the SPS' processes for the recording of prisoner property and assessing claims of lost property, taking account of the failings identified.

Summary

Mr C's property was subject to a statutory notice. When the bill for works was provided, a number of years after the notice was issued and the work undertaken, it was significantly above the estimate. Mr C requested the council provide justifications and itemised bills reflecting the reasons for the cost increases. During correspondence on this matter the council offered to deduct an administration charge, stating that the works were subject to lengthy timescales and poor customer service. Mr C sought clarification of a number of points before accepting the overall offer that this was part of. The council decided that the costs were justified but did not provide the requested justification or itemised bills and withdrew their offer to deduct the administration charge. Mr C complained about the lack of explanation as to the costs for the work and the decision to withdraw the offer to waive the administration fee.

We found that the cost of the project escalated substantially due to a number of emergency notices being served during the works. Whilst many of these costs were deducted from the final account, the overall cost was still significantly higher than the original estimate. We were critical of the council for failing to provide a breakdown of these costs as required by their own guidance. We also concluded that it was inappropriate of the council to withdraw their previous offer to waive the administration fee.

Recommendations

We recommended that the council:

• apologise to Mr C for their failure to provide a clear, itemised explanation of the costs for work carried out at his property;
• take steps to ensure they have mechanisms in place to accurately itemise and communicate project costs in line with their guidance;
• reinstate their offer to deduct the administration fee and provide Mr C with a revised cut-off date for acceptance; and
• offer to meet with Mr C to clarify any outstanding points before the cut-off date for accepting their full and final offer.

Summary

Mr C applied to the council for a Community Care Grant from the Scottish Welfare Fund after moving into a new, unfurnished home. He was initially awarded the majority of items he requested but was refused others, including hallway and bathroom carpets, a washing machine, and a microwave. Dissatisfied with this, he requested a review of the decision and was awarded a washing machine. He then requested a further review stating that he felt that not having a microwave and hallway or bathroom flooring was unacceptable due to his medical circumstances. However, this was refused, prompting Mr C to complain to us.

We found that the council had acted correctly when considering Mr C's medical circumstances at the first and second stages. However, they failed to evidence that they had considered his medical circumstances when assessing his final request for review and we found the level of information recorded at this stage to be poor. They had also failed to follow up on an offer from Mr C to provide supporting evidence from his doctor or social worker, which we found unreasonable in the circumstances. For these reasons, we upheld his complaint.

Recommendations

We recommended that the council:

• apologise to Mr C for the failings highlighted by our investigation; and
• seek advice from Mr C's doctor and social worker regarding the medical circumstances he described and then reconsider his Community Care Grant application.

Summary

Ms C complained that after moving into a new flat she experienced ongoing issues with her bins not being emptied by the council.

It was clear from the evidence that Ms C's bins were not collected on multiple occasions. We were satisfied that the council had taken steps to arrange bin collections when Ms C contacted them and also that they had made sure that the refuse crews and the supervisor were aware of the situation and the need to include Ms C's property on the weekly bin run. However, despite this, there were still occasions when Ms C's bins were not emptied.

The council provided a number of different reasons for the missed bin collections. We found that the reasons supplied by the council were confusing and inconsistent. However, the council later advised that the main issue was the lack of a working key to access the bin store in Ms C's property, which they had resolved. We considered it was unreasonable that the council had taken five months to resolve this and arrange access to the bin store. We therefore upheld Ms C's complaint and made two recommendations to address this.

Recommendations

We recommended that the council:

• apologise to Ms C for their repeated failure to collect her refuse; and
• conduct a review of bin collections at Ms C's property since the bin store key issue was resolved; inform us of the outcome of that review, and what, if any, further action is taken on collections that have been missed.

Summary

Mrs C complained about an ambulance crew who attended her following a fall in her garden. After the fall, Mrs C knew she had damaged her back; she was in severe pain and could not move her legs. The crew attended without carry equipment and pulled her up into a garden chair and gave her gas and air. The crew appeared to be unsure about whether or not to take Mrs C to hospital but eventually did so (after an hour) and she was diagnosed as having fractured three vertebrae.

We took independent advice from an A&E consultant and found that, given Mrs C's reported symptoms, the location and severity of her pain, it was highly suggestive that Mrs C had suffered a lumbar (lower back) spinal fracture. As a result, she required a hospital assessment for an x-ray or CT scan (a scan that uses x-rays and a computer to create detailed images of the inside of the body) as required. It was not appropriate for the crew to have attempted an assessment of Mrs C on scene or to have tried to sit her on a chair, and her spine should have been immobilised. We upheld the complaint and noted that the service had already arranged for the Area Service Manager to review the case and allow the crew to reflect on their actions.

Recommendations

We recommended that Scottish Ambulance Service:

• apologise to Mrs C for the failings identified.