Upheld, recommendations

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.

Summary

Mrs C complained about the care and treatment of her late mother (Mrs A) when she was admitted to the Royal Infirmary of Edinburgh with a urinary tract infection. Mrs A was also treated for a bacterial infection (staphylococcus aureus) and Mrs C raised concerns that medical staff did not adequately investigate the cause of this infection and relied upon the administration of strong antibiotics, which she considered wiped out her mother's immune system. Mrs A was subsequently diagnosed with a further bacterial infection (clostridium difficle) and, although plans were being made for her discharge from hospital, she suffered a gastrointestinal bleed and died two weeks later. We obtained independent advice from a consultant physician, who advised that most aspects of Mrs A's medical care were reasonable, including the investigation of her infections, the decision to treat with antibiotics and the management of her symptoms. The adviser did not consider that Mrs A's death could have been avoided. However, the adviser did query the initial choice of antibiotic and was also critical of the fluid management. In light of this, we upheld this aspect of the complaint.

Mrs C also complained about the standard of nursing care, including concerns about lack of available staff to provide assistance when required, dementia awareness and continuity of care. We obtained independent nursing advice. The adviser identified significant gaps in the recorded care of Mrs A, and a lack of care planning to meet Mrs A's changing needs. The nursing adviser did not consider it clear that staff understood how Mrs A's dementia affected her or took this into account in her care. We upheld this aspect of the complaint.

Mrs C raised further concerns about the hygiene and infection control measures in place on the ward. The available medical records did not provide sufficient evidence of the specific allegations of poor hygienic practice but we noted that the board had accepted and apologised for poor hygiene standards in Mrs A's care. We also upheld this aspect of the complaint.

Mrs C complained that the record-keeping in relation to her mother's care was inadequate. We received advice that the record-keeping fell below a reasonable standard and so we upheld this aspect of the complaint. We also upheld Mrs C's complaint that communication was inadequate, on the basis of a lack of evidence to show that nursing staff communicated reasonably with the family. In some instances we considered that the board had already taken appropriate action to address the identified failings and, in others, we made some recommendations.

Recommendations

We recommended that the board:

• confirm that the use of appropriate antibiotics will be highlighted to junior doctors as part of their induction process;
• confirm that the findings of our investigation will be reflected upon by the relevant consultant(s) as part of their annual appraisal;
• remind ward staff about the importance of completing fluid intake / output charts;
• apologise to Mrs C's family for the poor record-keeping in relation to Mrs A's care; and
• demonstrate to us that record-keeping on the ward is now of a reasonable standard.

Summary

Mr C was diagnosed with a cataract in his eye and an epiretinal membrane (a thin sheet of tissue over the centre of the eye that can restrict vision). He was referred to The Princess Alexandra Eye Pavilion for surgery to remove the cataract with a separate procedure to follow to remove the epiretinal membrane. On the day of the surgery, Mr C's consultant ophthalmologist was absent due to illness. Mr C was offered the chance to delay the surgery until he returned or to proceed with another surgeon. He opted to proceed.

Mr C experienced complications of surgery that resulted in his retina becoming detached. He found out after the surgery that the surgeon was still a trainee and felt this should have been made clear to him before he consented to the procedure. He also complained that it took several consultations over a number of weeks to diagnose his detached retina.

We obtained independent medical advice on this complaint. We concluded that, whilst Mr C's retinal detachment was not present during the first few post-operative examinations, at one appointment it was noted that the ophthalmologist could not get a clear view of his retina. We accepted the advice that, had an ultrasound been carried out at this point, the detachment may have been identified. This could have led to diagnosis a week sooner than Mr C experienced. We also found that, whilst Mr C's consent for surgery had been properly obtained, it would have been good practice for the board to tell him that a trainee surgeon was going to carry out the procedure.

Recommendations

We recommended that the board:

• apologise to Mr C for failing to arrange an ultrasound;
• share this decision with the staff involved in Mr C's care;
• apologise to Mr C for failing to tell him that the surgeon was a trainee; and
• share the adviser's comments on good practice with the ophthalmologists.

Summary

Mrs C complained about a delay in diagnosing her late mother (Mrs A)'s brain tumour. Mrs A attended A&E on six separate occasions over a six month period (five attendances at Hairmyres Hospital and one at Wishaw General Hospital), with symptoms of dizziness, fainting and disorientation. Her third attendance resulted in a hospital admission, where abnormalities with her heart were identified and a pacemaker was fitted. When her symptoms continued and she attended A&E for a fourth time, she was referred to neurology for a routine out-patient appointment. She had two further A&E attendances while she waited for this, with the second resulting in a brain scan, which diagnosed a brain tumour. She was transferred to a hospital in another health board area for urgent surgery but unfortunately this was unsuccessful and she did not regain consciousness. She died ten months later.

Mrs C considered that a brain scan should have been carried out earlier. We took independent medical advice from a consultant in emergency medicine and a consultant physician. We were advised that it was reasonable for a cardiac cause of Mrs A's symptoms to have been pursued initially. However, it was noted that she had new symptoms when she attended A&E for the fourth time, having had her heart problem addressed. We concluded that a brain scan should have been considered at this point. We also identified that there was a further opportunity to diagnose the brain tumour earlier, at Mrs A's penultimate A&E attendance. On this occasion, A&E staff considered that admission was warranted, but the on-call physician decided to discharge her, pending pre-planned follow-up, without seeing her. We were critical of this. We upheld the complaint and made a number of recommendations, including one about record-keeping as the board could not locate the records from one of Mrs A's A&E attendances.

Recommendations

We recommended that the board:

• provide Mrs C with a written apology for the failings identified in this investigation;
• ensure that all relevant staff are made aware of the outcome of this investigation, including those no longer employed by the board;
• take steps to have this complaint included for discussion at the annual appraisals for all relevant staff, including those no longer employed by the board, to ensure learning opportunities are captured; and
• take steps to ensure that Hairmyres Hospital is complying with 'Records Management: NHS Code of Practice (Scotland)' following the missing A&E attendance records.