Upheld, recommendations

Summary

Ms C works for an advice and support agency. She brought the complaint on behalf of her client (Mr B). Mr B had concerns about the treatment his daughter (Miss A) received at Ninewells Hospital after she was referred by her GP with suspected appendicitis. Miss A was reviewed and appendicitis was considered to be unlikely. She was prescribed antibiotics for a urinary tract infection and was discharged home. Miss A did not improve and had to be taken back to the hospital two days later. Although initial assessment found appendicitis to be a possible cause of her symptoms, she was discharged after two days with a diagnosis of gastroenteritis (inflammation in the intestines caused by infection). Her condition did not improve and she had to be readmitted four days later. Miss A underwent surgery to investigate further. During this procedure her appendix was removed as it was found to be gangrenous. An abscess was also discovered. Miss A did not recover well and had to undergo more surgery as she had developed a deep pelvic abscess. In addition to his concerns about the treatment provided to his daughter, Mr B was dissatisfied with the time the board had taken to deal with his complaint.

After taking independent advice on this case from a consultant surgeon, we upheld the complaint about the treatment provided to Miss A. The adviser considered that Miss A's appendicitis could have been diagnosed and acted on at her second attendance at the hospital. We were advised that this would have lessened the risk of a pelvic abscess developing and the further problems that she experienced. The adviser also commented that the information about risks of the initial surgery had not been recorded comprehensively enough. As the board had introduced a new patient pathway document for children with suspected appendicitis following Mr A's complaint, the adviser was asked to review this. The adviser considered that it would benefit from further consideration by the board in light of our findings, and we made a recommendation about this.

We also upheld the complaints handling concerns that were raised. The board accepted that they had not responded within a reasonable timescale and had not met a reasonable standard as a result. They explained that their process had since been changed.

Recommendations

We recommended that the board:

• apologise for the failings we identified;
• take steps to ensure that all relevant paediatric and surgical staff are made aware of the findings of our investigation;
• consider the use of a clinical scoring tool for paediatric appendicitis;
• review the care pathway previously developed in light of the independent advice received in our investigation and provide us with a copy of this for review; and
• ensure that adequate details of the risks of surgery are explained and documented during the consent process.

Summary

Miss C complained about the clinical treatment provided to her late brother (Mr A). Mr A was admitted to Ninewells Hospital with chest pain. He was diagnosed with a chest infection and discharged the next day. Mr A died of a heart attack a few weeks later. Miss C was concerned that the hospital did not find a problem with Mr A's heart, particularly as he was admitted with chest pain and had a family history of cardiac (heart) problems.

In response to Miss C's complaint to them, the board said Mr A did not show signs of a heart attack during his admission and that they considered the care provided to have been reasonable. They noted that recovering from a chest infection can put an extra strain on the heart, which may have precipitated a heart attack, but that this could not have been predicted.

After taking independent medical advice, we upheld Miss C's complaint. While we were advised that the care provided was reasonable at first, it was not clearly recorded in the medical records that Mr A was properly reviewed before discharge and that he had no ongoing symptoms of concern.

However, we were not critical of the hospital not identifying a problem with Mr A's heart. The adviser explained that the investigations carried out were reasonable and supported the diagnosis of a chest infection. Based on the information available to the hospital at the time, the adviser considered it was reasonable that the doctors did not investigate a possible cardiac cause for Mr A's pain.

Recommendations

We recommended that the board:

• apologise to Miss C and her family for the lack of a detailed assessment on the day of discharge; and
• ensure the consultant reflects on our findings as part of their next annual appraisal.

Summary

Mr C complained to us about emergency treatment he received at the Royal Infirmary of Edinburgh after injuring his knee. He attended A&E at the hospital, where his injury was diagnosed as a soft tissue injury. Mr C was given advice on pain relief and told to see his GP if the pain persisted.

About a month later Mr C saw his GP, as the pain was continuing. An x-ray was taken of his leg and this showed a stress fracture.

The independent advice we received from a specialist in emergency medicine, which we accept, was that Mr C should have received an x-ray when he first attended A&E. As such, we upheld the complaint. However, we were advised that due to the nature of Mr C's injury it was unlikely this x-ray would have identified the fracture and it was therefore unlikely that this would have altered his treatment.

Recommendations

We recommended that the board:

• apologise to Mr C for the failure to arrange an x-ray of his leg injury; and
• share the findings of this investigation with the staff in question and ask them to reflect on this for their future practice.

Summary

Miss C raised a number a number of concerns about the care and treatment her daughter (child A) received when she attended Raigmore Hospital. In particular, she complained that staff failed to listen to her and this had an adverse effect on her daughter. Miss C also complained that there was an unreasonable delay in obtaining a jejunal feeding tube (a small tube that is passed through the nose or mouth and into the small intestine).

We took independent advice from a consultant general paediatrician. The advice we received and accepted was that, overall, the care and treatment child A received was reasonable. However, we were concerned about the delay in obtaining the jejunal feeding tube. The adviser also said that there was no evidence in the medical records of an overarching plan for child A's care and that, overall, the communication with Miss C was not adequate for her needs. We upheld Miss C's complaint. During our investigation the board met with Miss C and agreed to discuss ways in which they could improve communication with her around medical issues whilst her daughter was in hospital.

Recommendations

We recommended that the board:

• consider how staff might escalate matters when there appears to be unnecessary delays in obtaining specialist items, such as jejunal tubes, which are not kept in hospital and which result in delays in treatment;
• provide an update on the improvements implemented in relation to the communication with Miss C around medical issues whilst her daughter is in hospital; and
• consider the adviser's comments, particularly in relation to the need for an overarching care plan agreed with Miss C, in future admissions to hospital.

Summary

Mrs C raised a number of concerns about the care and treatment provided to her late mother (Mrs A). She said that the board had failed to appropriately investigate her mother's symptoms and that this led to a delayed diagnosis of a brain tumour.

Mrs A was admitted to Raigmore Hospital following a seizure. She was evaluated by the Stroke Team and various procedures were carried out including a CT scan (a scan that uses a computer to produce an image of the body) and an electroencephalogram (EEG - a test that measures and records the electrical activity of the brain). The results were reported as normal and Mrs A was discharged a few days later.

Around five months later, Mrs A was readmitted to Raigmore after suffering a further seizure. She was admitted to Nairn Hospital soon after this with a history of a loss of consciousness and episodes of twitching and seizures. There were further episodes in hospital. It was thought that these were likely epileptic seizures and an antiepileptic drug was prescribed. Mrs A was again discharged. Around seven months later, Mrs A attended a follow-up appointment at Raigmore Hospital, and the following day was admitted to A&E at Perth Royal Infirmary where Mrs C was advised that Mrs A had a brain tumour.

During our investigation, we took independent advice from a consultant neurologist. We found that, while some aspects of Mrs A's care and treatment were reasonable, there was an unreasonable delay in performing an MRI (magnetic resonance imaging - a scan used to diagnose health conditions that affect organs, tissue and bone) of her brain. This should have been arranged within four weeks of Mrs A's admission after the loss of consciousness and seizures.

We found that it was appropriate that the board started Mrs A on antiepileptic medication but that the subsequent monitoring of the medication and her condition were not reasonable. We found that there was a delay in Mrs A receiving a follow-up appointment at the neurology clinic, as best practice would have been to arrange out-patient review within a few weeks of discharge. It would also have been good practice to have involved an epilepsy specialist nurse in Mrs A's care. We also found that the management of Mrs A at the follow-up appointment fell short of best practice.

Recommendations

We recommended that the board:

• apologise to Mrs C for their handling of this matter;
• ensure that the relevant clinical teams are aware of the latest Scottish Intercollegiate Guidance Network and National Institute for Health and Care Excellence guidelines on the management of strokes, transient ischemic attacks (or 'mini' strokes) and epilepsy, and the requirements for prompt neuroimaging;
• ensure that the consultant neurologists are aware of the limitations of EEG in the diagnosis of epilepsy and that they reflect on the adviser's comments at their next appraisal; and
• consider the adviser's comments that it would be good practice to provide epilepsy specialist nurse care to patients with epilepsy.

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.