Upheld, recommendations

Summary

C complained on behalf of their parent (A) about the care and treatment provided by the board. A was scheduled for a hip operation after experiencing increased pain which was affecting their daily function. The operation was cancelled on the day as the anaesthetist was not prepared to go ahead due to the high level of risk associated with the procedure and significant concerns about complications. C complained about the hospital’s process which they said caused great distress.

We took independent advice from a registered consultant physician. We found that there was a failure by the surgeon to share their concerns about A’s surgery with clinical colleagues in a timely way. There was also a break-down in communication between the key teams involved in the pre-assessment, resulting in failures in process and cancellation of surgery on the day. We also found that there was a lack of coordination in arranging A’s discharge home when the operation did not go ahead.

We also found failings in the board’s handling of the complaint, such as the complaint not addressing all the issues raised by C. We therefore upheld the complaint.

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 the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to addressing all the elements of a complaint and accuracy of information.

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

A’s spouse (B) was admitted to hospital for a knee replacement. The operation went well but during B’s recovery their condition began to deteriorate and B was transferred to the High Dependency Unit. B went into cardiac arrest, CPR was administered but it was unsuccessful and B died.

C raised complaints on A’s behalf about B’s treatment during their admission. The board undertook a Local Adverse Event Review (LAER), identified issues with B’s care and treatment and made recommendations to address these issues. The board also responded to the complaints raised by C regarding B’s treatment. In their response the board reiterated the conclusions of the LAER, their recommendations made in relation to some aspects of B's treatment, and concluded that other aspects complained of by C had been reasonable.

In relation to specific questions about B’s admission that C had shared, the board indicated that responses to most of these had been provided at a meeting that had taken place between B’s family and a consultant orthopaedic surgeon (branch of surgery concerned with conditions involving the musculoskeletal system) or in the LAER report. The board provided a response to one other question in the response to C.

We took independent advice from a specialist in orthopaedic surgery. We found that observations of B should have been increased, their care escalated and that antibiotics should also have been commenced sooner. We upheld this aspect of the complaint.

In relation to the provision of answers to questions raised in the complaints submitted, we found that clear responses from a clinician were available to the board’s complaints team within a month of the questions having been raised. The board provided answers to some of the questions at a meeting the following month but clear answers to the remaining questions were not provided until SPSO became involved and specifically asked for them almost two years later. Given this, we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for an unreasonable delay in an urgent assessment being undertaken, a failure to escalate B to the medical team and the decision to administer antibiotics not being made sooner. The apology should meet the standards set out in the SPSO guidelines on apology available at www. spso. org. uk/information-leaflets.
• Apologise to A that clear answers to the questions raised were not provided within a reasonable timeframe. 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 receive timely medical review and if appropriate antibiotic therapy commenced without delay.

In relation to complaints handling, we recommended:

• Complaints are properly responded to in line with the Board’s Complaints Handling Procedure.

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 spouse (A) about the board not issuing a discharge plan at the point A was discharged from hospital for palliative care before A passed away. As their carer, C wanted to know how to provide care and support for A. C said that this plan was subsequently requested a number of times but not provided. C also complained that following A’s death, their GP provided a copy of the Inpatient Discharge Summary which said ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR). C said that they had not been aware a decision had been made on this and as A’s Power of Attorney, and in order to safeguard A, DNACPR should not have been discussed with A without C being present.

We took independent advice from a registered consultant geriatrician (a doctor specialising in medical care for the elderly). We found that the board could not have provided C with a discharge plan as C did not attend hospital that day. We also found that A was not given clear discharge information despite this being complex and their care needs being high. There was also a failure to subsequently provide C with a copy of the discharge plan when requested, and record keeping failures during A’s discharge. We also found that the board failed to communicate with C that a DNACPR decision had been made with A. We upheld the 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:

• Open and honest discussions should be held with the patient and relevant others with regard to timely decisions about DNACPR and in accordance with relevant DNACPR guidance. This is particularly important where patients have Aphasia (language disorder) and where patients are discharged home for end of life care.
• Patients should be discharged with appropriate documentation which is clear and should be completed so that full discharge information is provided. This should include post discharge requests for further copies.

In relation to complaints handling, we recommended:

• The board's complaint handling monitoring and governance system should ensure that failings (and good practice) are identified and that learning from complaints is used to drive service development and improvement.

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 when they were admitted to an acute medical unit, specifically that they were discharged too soon and that there was a delay in diagnosing that they had suffered a stroke.

We took independent advice from an adviser that specialises in acute medicine. We found that the board incorrectly documented that a CT scan had been carried out. Given the seriousness of C’s symptoms and their outcome, it was of concern that this incorrect information was documented in C’s medical records. We found that C should have remained in hospital to be assessed in more detail before they were discharged. We found that more consideration should have been given to C’s symptoms and the possibility that they were related to a stroke. In particular, a CT scan should have been carried out earlier, which could have led to an earlier diagnosis and treatment with medication. On C’s readmission, C’s stroke was visible on a CT scan. It therefore was possible that a CT scan, on their first admission, could have shown C’s stroke.

In relation to C’s nursing care, we found that we would have expected to have seen more detailed nursing notes about C before their discharge, for instance, in relation to C’s walking ability. The board apologised for the miscommunication which occurred between nursing staff in relation to C’s fitness for discharge and said that learning had been put in place for effective communication. The board said that this was communicated verbally and therefore there was no paper evidence. We considered this to be unsatisfactory and we upheld the 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 HYPERLINK "http://www.spso.org.uk/information-leaflets" www. spso. org. uk/information-leaflets .

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

• Where a patient presents with neurological symptoms after a colonoscopy, consideration should be given to the possibility that they may be related to a stroke, that their suitability for discharge should be appropriately assessed and their condition appropriately reviewed to see if their symptoms settle and for relevant scans to be carried out prior to discharge. The rationale for a patient’s discharge should be properly documented with details of all relevant assessments fully documented. Information recorded in a patient’s records should be accurate.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Model Complaints Handling Procedure. The board should comply with their complaint handling guidance to ensure that a full and proper investigation is carried out. Where learning is identified, there should be clear evidence of the action subsequently taken.

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 partnership had not provided the correct care and treatment for their ear infection in their right ear. C did not consider that the ongoing ear infection had been correctly diagnosed or treated, noting that the antibiotics which were prescribed had not been effective. C was concerned that although a referral to ENT had been made, the referral was not correctly prioritised, which had caused a significant delay. It was only when C saw a doctor, who phoned ENT, did C receive specialist input.

We took independent advice from a GP adviser. We found that C had not been seen face to face for a six month period, the first was a routine referral and the second expedited referral did not reflect the clinical situation because C had not been examined. We also found that the overuse of antibiotics had likely aggravated the situation. Overall we considered that more could have been done to clinically assess and seek specialist input for C’s ear infection. We therefore upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not receive a face to face consultation for a six month period. Apologise to C that specialist input was not sought from ENT, on an urgent/high priority basis, at an earlier stage. 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:

• Ensure that Advanced Nurse Practitioners know when to request support and input from a GP.
• That written referrals to ENT have sufficient information and are prioritised at the appropriate time. Also that specialist ENT advice is sought via the on-call service when appropriate.

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 spouse (A) about the care and treatment provided by the board before they died. A was an end of life patient having been diagnosed with incurable lung cancer. A developed symptoms likely caused by an obstruction of one of the major blood vessels attached to the heart and was scheduled to have a stent inserted through the blockage. C complained about their experience on the ward on the day of the procedure which, they said, caused great pain and distress.

We took independent advice from a registered senior nurse. We found that A lacked person centred information to prepare them for admission which caused distress, that there was a failure to provide a clear pathway for a patient diagnosed with end stage lung cancer the Peripheral Vascular Cannula (PVC)(insertion of a plastic conduit across the skin into a vein) process was not followed. We found that a pressure ulcer risk assessment was not undertaken and a plan of care not developed or implemented to prevent pressure damage. We also found that there was a failure to provide A with their prescribed steroids, despite requesting this. We noted record keeping failures during A’s admission and found failings in the board’s handling of the complaint, with the complaint not addressing all the issues raised by C and failings to fully investigate and respond to C about the PVC process. We upheld the 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:

• Patient records should be accurately completed, signed and dated with the appropriate level of information included, in accordance with the relevant nursing and midwifery standards.
• Patients should be appropriately assessed to prevent pressure ulcer damage, in accordance with the current pressure ulcer prevention and management standards.
• Patients should receive appropriate information to prepare them for a procedure, and to manage expectations about the admission. The board has said a draft patient information leaflet relating to the Superior Vena Cava Stent Insertion procedure has been developed and awaits final approval. The board should consider updating this leaflet to address person centred concerns.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to investigating and addressing all the elements of a complaint.

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 adult child (A) received from the board about symptoms of productive cough, breathlessness and occasional wheeze. A was referred by their GP to the board and received two outpatient chest x-rays. Separately, A also self-presented at the A&E owing to their symptoms, where they were discharged with a trial of steroids and inhaler. A’s first of the two outpatient chest x-rays was reported as normal and their GP routinely referred them to the respiratory department for further investigation of their symptoms. The second of the two outpatient chest x-rays was considered to show changes suggestive of pulmonary oedema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). At this point, A’s GP upgraded the respiratory referral to urgent. On vetting by a respiratory consultant, A’s GP was contacted with advice to commence a diuretic (drugs that enable the body to get rid of excess fluids) straight away and urgently refer A to cardiology, on suspicion of heart failure.

A was seen at the cardiac function clinic, with the plan being made to see them at the heart failure clinic. A’s condition deteriorated before being seen at the heart failure clinic and the GP arranged for their immediate admission to the coronary care unit (CCU). A suffered a cardiac arrest shortly after admission requiring resuscitation, and they were subsequently transferred to another health board for surgery where they died.

C complained about the delays by the board to assess, diagnose and treat A’s condition, especially as A had presented to the A&E, and after the follow-up x-ray showed significant deterioration within a 4 week period. Having been referred to cardiology, C complained that the board failed to treat A’s condition with the urgency it required. C also complained that A had been transferred to another health board for surgery when it was known A’s condition was such that this intervention would have been futile.

The board’s response to C’s complaint advised that the treatment A received at the A&E was appropriate to their presenting condition at the time. The board did not comment on the timings of the cardiology appointments or assessments, however they explained the immediacy of A’s condition was understood at the time of the admission to CCU, with appropriate treatment being provided at the time, including in relation to A’s transfer to another health board for surgery.

We took independent advice from three clinical advisers, a consultant radiologist, a respiratory and general medical consultant and a consultant cardiologist (specialist dealing with disorders of the heart). We found that the treatment provided to A at the A&E was reasonable, based on what was known at the time.

We found that the first of the outpatient chest x-rays which had been reported as normal was in fact abnormal and required clinical correlation in respect of A’s presenting symptoms. Had this happened, a cardiac cause for A’s symptoms could potentially have been made sooner. With regards to the second chest x-ray, we found that the board failed to use the radiology alert system in place to flag urgent and/or unexpected findings.

We also found that the vetting process by the respiratory consultant had been reasonable, as was the advice to urgently redirect to cardiology and immediately commence A on a diuretic. On the matter of the timing of A’s cardiology review, we found that this was unreasonable in light of them having significant indicators of heart failure, known to date back. We found that A received reasonable care and treatment on being admitted to CCU and ICU. On balance of the above, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in assessing and treating A’s condition. 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 presenting with signs of heart failure should be appropriately assessed including in relation to deciding to manage patients in an inpatient or outpatient setting.
• Abnormal findings on x-rays should be appropriately identified and reported.
• X-rays which are considered critical, urgent and/or where unexpected significant findings are identified should be flagged to the referrer using the significant finding alert system.

In relation to complaints handling, we recommended:

• The board should ensure SPSO requests for documentation and evidence are responded to in line with the time frames requested and that they are fully compliant with their complaints handling guidance when responding to SPSO enquiries.

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.

When this report was first published on 21 February 2024, it referred to A as 'late child' of C.  However the summary was amended to read 'late adult child' on 26 March 2024 for clarification.  We apologise for any confusion caused.

Summary

C complained about the actions of the council in relation to repairs required at their home. They considered the communication, quality of repairs and time taken to carry out and fully resolve the repairs were unreasonable.

While it was noted that there were significant efforts made to seek to resolve the issues, and some delays were outwith the council’s control, overall, we considered the council failed to reasonably respond to repairs. While some repairs were completed in the target timescale, others were not, and for other repairs there was no record provided to indicate whether they were complete and no mechanism to escalate the situation where repeated attempts to repair the same fault were unsuccessful. As such we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably respond to C’s repair requests. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Ensure that the seven repair requests have now been completed.

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

• Have a system in place to ensure repairs information for each property is recorded in a way that is clear and accessible. Ideally this will also include a record of seeking verification from the tenant that they are also satisfied with the repair.
• Have a system in place to identify and respond to situations where multiple repairs have not resolved the issue.

In relation to complaints handling, we recommended:

• Responses to complainants and the SPSO are thorough and complete, ideally in one response.

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 surgery performed to remove material from their leg was not carried out to a reasonable standard. C broke their leg and underwent an operation to insert pins, plates, and a device known as a ‘TightRope’ (a device where string is passed through a channel in the bone and secured with ‘buttons’ at each side) to stabilise their leg. C developed an infection in their leg and subsequently underwent a further procedure to remove the ‘TightRope’. The procedure was not successful, some material was retained in C’s leg and the infection persisted. C then underwent further procedures to have the material removed completely, however, the infection proved to be too advanced and C had a below knee amputation. C complained that the board did not appropriately remove the ‘TightRope’ material during the initial procedure when they should have done.

The board said that although there was an intention to remove all of the ‘TightRope’, the material is not always visible. Cutting through the ‘TightRope’ in order to pull it through, staff expected all of the material to come out. Staff assumed that they had removed all of the suture, however, some of the material had stayed behind. The only way to have fully confirmed this would have been to make a larger hole through the bone, which could have allowed further spread of the infection.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that the surgeon who carried out the initial procedure to remove the ‘TightRope’ should have been familiar with the device, including the volume of material, and should therefore have been able to assess whether removal was complete. The surgeon should have curetted (cleaned/scraped) the channel in the bone to ensure that all material was removed. We noted that an experienced surgeon would likely have undertaken a more complete removal of the material and suggested that the board could consider reviewing their arrangements for supervision of surgeons who are not experienced in a specific procedure. We considered that the initial surgery performed to remove the ‘TightRope’ material was not carried out to a reasonable standard. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to carry out the procedure to an acceptable standard resulting in some material being retained in the TightRope channel and for the impact this had on C. 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:

• Operations should be carried out to a high standard.

In relation to complaints handling, we recommended:

• Complaint investigations should be carried out in line with the NHS Complaints Handling Procedure. Particular notice should be given to the responsibility to ensure that staff learn from complaints, especially when mistakes have been identified. Good practice should be followed when compiling the complaint response.

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 arterial surgery. The board accepted that there were issues related to the systems in place at the time for the sharing of information between board sites and communication, and apologised for this.

We took independent advice from a cardiology adviser. We found that there was nothing to suggest that there was poor clinical practice or decision making and found that, the issues related to the sharing of information between board sites and communication meant that aspects of the care and treatment C received fell below the standard C could reasonably expect. We upheld C’s complaint.

Recommendations

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

• That the board review their policies and practice regarding inter-hospital transfers, specifically around documentation accompanying patients and verbal ward-to-ward handovers and that the board feedback the findings of this investigation to the medical team involved with C to highlight the poor communication with C and their family whilst they were in hospital.

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.