Upheld, recommendations

Summary

Mrs C was in the Royal Infirmary of Edinburgh for emergency surgery. After she was discharged, she experienced pain, swelling and numbness in her forearm and hand. She felt this was the result of the insertion of a cannula (a thin tube to administer medication, drain fluid or insert a surgical instrument) in her wrist.

We took independent advice from a nursing adviser and a medical adviser, who is a hospital consultant. We found there was poor record-keeping in relation to the care of Mrs C’s cannulas, and that not all of the cannula care was in line with expected good practice. We upheld Mrs C’s complaint.

Recommendations

We recommended that the board:

• provide us with the most recent audit of cannula care to show that it has improved;
• remind staff of the importance of expected good practice in cannula care, in line with relevant local and national standards and guidance; and
• remind staff of the importance of record-keeping as noted in the relevant guidance.

Summary

Mrs C complained to the board about the nursing care and treatment provided to her late grandfather (Mr A) during admissions to the Royal Infirmary of Edinburgh (RIE), Astley Ainslie Hospital (AAH) and Midlothian Community Hospital (MCH). Mr A had a fall at home and broke his hip. He was admitted to the RIE and underwent surgery. During his time as an in-patient at the RIE, Mr A developed pressure ulcers on his lower back and heel. Mr A was later transferred to AAH for rehabilitation, then moved to MCH to wait for a place in a nursing home. His condition deteriorated at MCH and it was decided that he would remain in hospital. Mr A died in MCH. Mrs C complained about Mr A's pressure ulcer care, hydration and nutrition, access to call buzzers, nursing care of his contracted leg, and communication with her family, particularly regarding the collection of Mr A's death certificate.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint. The adviser considered that Mr A's pressure ulcers could potentially have been prevented from developing if an appropriate care plan and other interventions had been used at the RIE. The adviser said that there was a reactive rather than proactive approach to pressure area care at the RIE. The adviser noted that risk assessments and care plans (Adapted Waterlow Pressure Area Risk Assessment and SSKIN (Surface, Skin inspection, Keep Moving, Incontinence, and Nutrition) bundle) were not completed at appropriate times during Mr A's care. Although the adviser considered that on Mr A's admission to AAH, appropriate assessments of his pressure areas were carried out, his subsequent care in this area was not reasonable. The adviser said that the SSKIN bundle care plan was not used until Mr A had been in AAH for several weeks, and interventions to prevent pressure had not been implemented at appropriate times.

We noted that the board had apologised to Mrs C about communication with her family regarding two visits by Mr A to other hospital sites during his admission at the AAH. We received advice that it is good practice to keep family informed unless the patient says otherwise. We also noted that the board had apologised to Mrs C for any distress caused about the death certificate. The adviser explained that nursing staff would have no control over when this was available. We considered that other areas of Mr A's care were reasonable.

Recommendations

We recommended that the board:

• issue Mrs C with a written apology for the failings in pressure care identified by this investigation;
• ensure that all relevant staff are aware of the requirements in completing the Adapted Waterlow Pressure Area Risk Assessment and SSKIN bundle;
• highlight to all relevant staff the adviser’s comments on the use of proactive preventative strategies for pressure care;
• take steps to remind relevant staff of the need to keep call buzzers within the reach of patients; and
• ensure that all relevant staff are made aware of the adviser’s comments on keeping family and carers informed of patients’ visits to other sites.

Summary

Mrs C complained about the care and treatment she had received at the Royal Infirmary of Edinburgh after the birth of her son. We took independent advice from a midwifery adviser. We found that, in general, the care and treatment provided to Mrs C had been reasonable. However, on the night of her son's birth, Mrs C had been left in bed with a buzzer that was not working. Given that she was sedated and had had a spinal anaesthetic, we considered that this was unreasonable and upheld the complaint. The board had already apologised to Mrs C for this and had reminded staff to check that buzzers are working when patients are admitted, and so we did not make any recommendations.

Mrs C also complained about the care and treatment provided to her baby. We found it was unreasonable that he had been left unclothed all night, although this did not cause the subsequent deterioration in his condition. We also found it had been unreasonable that staff had taken the baby away during the night without documenting Mrs C's consent to this. Although we upheld this aspect of her complaint, we were satisfied with the action that the board had taken in response to Mrs C's complaint and did not make any recommendations.

Mrs C's baby had then been admitted to the neonatal unit (specialising in the care of newborn babies). Mrs C complained that they had carried out procedures on her son without her consent. We took independent advice on the treatment the baby received there from a medical adviser who is a consultant neonatologist. We found that staff in the unit should have taken steps to obtain verbal consent from Mrs C before carrying out a lumbar puncture (where tests are carried out by inserting a needle into the lower part of the spine). We also upheld this aspect of her complaint, although we noted that the board had already apologised to Mrs C for this.

Recommendations

We recommended that the board:

• provide evidence that staff in the neonatal unit have been informed of our decision that they should have obtained verbal consent before carrying out the lumbar puncture.

Summary

Mr C complained about the treatment his father (Mr A) received from the board. Mr A had had a history of Parkinson’s disease, dementia and type 1 diabetes. However, Mr A controlled his diabetes well and lived independently before having a fall. He was admitted to Hairmyres Hospital with hip pain and reduced mobility. X-rays showed no sign of a fracture, but Mr A was kept in hospital due to his poor mobility. His pain and mobility worsened, and a second x-ray was taken around four weeks later. This showed a displaced fracture in his hip. Mr C complained that his father’s diabetes was poorly managed during his admission, causing increased confusion and unsafe blood sugar levels. He also complained about a delay to the second x-ray and the diagnosis of Mr A’s fracture.

We took independent advice from a nursing adviser, and found that the nursing staff failed to properly manage Mr A’s diabetes. The board had already identified failings in this respect and we were satisfied that they had learned lessons from Mr A’s experiences.

We also took independent advice regarding the diagnosis of Mr A’s hip fracture from a consultant in orthopaedic and trauma surgery and a consultant physiotherapist specialising in orthopaedics (relating to the musculoskeletal system). Whilst there was no visible sign of the fracture on the first x-rays, Mr A's pain and mobility did not improve. We concluded that, in line with national guidance, further x-rays or scans should have been ordered to rule out a fracture. There was a clear delay to this happening and, by the time of the second x-ray, the fracture had displaced. This required a more invasive operation than would have been needed had the fracture been diagnosed before it displaced. We were critical of the board for this delayed diagnosis.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's performance in terms of effectively managing diabetic patients' insulin regimes to gauge the effectiveness of action taken in response to Mr C's complaint;
• apologise to Mr A and his family for the delay in diagnosing his fractured hip;
• share our decision with their orthopaedic staff with a view to learning from Mr A's experiences; and
• consider whether orthopaedic staff would benefit from refresher training on the national guidance on treating hip fractures in elderly patients.

Summary

Mr C had a longstanding spinal problem and the board had been providing treatment to him for many years. When Mr C's condition deteriorated to the point that he could no longer walk 100 yards without pain, his regular consultant at Raigmore Hospital referred him to a specialist colleague. Mr C said he heard nothing and after 12 weeks he phoned the board. He was told they did not know when he would be offered an appointment. He phoned again two weeks later and was told the same thing. After 18 weeks Mr C complained. He said there had been an unreasonable delay and no communication from the hospital.

We upheld both of Mr C's complaints. We found that the time taken to give Mr C an out-patient appointment (30 weeks) was too long. We found the board had not been proactive in communicating with Mr C, which they should have been, given the known pressure the service was under at the time.

Recommendations

We recommended that the board:

• review the process for managing the orthopaedics waiting list to ensure that people receive clear and accurate information about waiting times.

Summary

Miss C complained about treatment she received at the Glasgow Dental Hospital. She provided a copy of the board’s response to her complaint. Our initial view was that the actions the board said they took in response to her complaint were reasonable. These actions were, firstly, that a clinician would review Miss C’s case and bring to the attention of all staff the need for clear and open communication with all patients. Secondly, Miss C’s case would be used as a learning opportunity with staff.

We asked the board for evidence of the actions they took. We found that the review of Miss C’s case by the clinician was done as part of the board’s investigation into her complaint. The board should have told Miss C that the clinician had reviewed her case as part of their investigation, rather than promising future action which had, in fact, already happened for a different purpose. The board were unable to provide us with sufficient evidence that the other actions had been carried out. We upheld Miss C’s complaint, and recommended that the board take the actions they told her they would.

Recommendations

We recommended that the board:

• bring to the attention of all staff within the service the need for clear and open communication with all patients;
• ensure that Miss C's case is used as a learning tool with staff; and
• ensure that Miss C's case is discussed with the dentist involved.

Summary

Mr C complained that the board unreasonably failed to repair a hernia (where an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) above his navel during surgery at Glasgow Royal Infirmary. He said that, after the operation, his hernia was still in place and the scar from the operation was located below his navel, rather than above it. Mr C was concerned that his hernia had not been operated on at all. He said that he repeatedly asked to speak to a member of the operating team about this but no one came to see him. Mr C also said that the board provided an inadequate response to his complaint.

We obtained independent medical advice from a consultant in general and colorectal surgery. The adviser said that the notes of Mr C’s original operation, together with the notes from the operation to finally repair the hernia the following year, indicated that the consultant did operate on the hernia above Mr C’s navel during the original operation. The adviser said that the location of Mr C’s surgical scar below his navel did not mean that his hernia was not operated on. The adviser explained that it was standard practice to make an incision in the natural skin crease just below the navel when repairing a hernia around the navel. However, the adviser said that Mr C’s hernia was inadequately fixed as it was present after his surgery.

We considered that the evidence in the nursing notes suggested that Mr C did ask to speak to a member of the surgical team after his operation. We accepted the adviser’s view that there was a failure by the board to communicate with Mr C at this time. We also found that the board did not appropriately investigate and address each element of Mr C’s complaint.

Recommendations

We recommended that the board:

• take steps to contact the consultant and feed back our decision on this case;
• feed back the failing identified in Mr C's complaint about complaints handling to the staff involved; and
• provide Mr C with a written apology for the failings identified in our investigation.

Summary

Mr C complained about the treatment provided for a wrist injury that his client (Mr A) suffered while overseas.

Mr A attended hospital overseas where his wrist was put in a cast. He was told to attend hospital on his return home, which he did. The doctor arranged x-rays of the fracture and changed the cast. Mr A was reviewed a week later, and the cast was changed again. Mr A was reviewed four weeks later and told his wrist had healed (although the joint was tilted back slightly). He was discharged. However, Mr A continued to suffer symptoms of pain and loss of movement in his wrist, which he said were worse than his pre-existing symptoms from an old injury. He attended a private hospital, where he was told that his fracture had healed badly, and he had corrective surgery, which improved his symptoms. Mr A complained to the board about his initial care.

The board acknowledged that Mr A’s fracture had healed with the wrist tilted slightly, but said this was satisfactory. The board noted Mr A’s history of wrist pain going back to his old injury, and said that his pain was due to the new fracture exacerbating his osteoarthritis from the old injury.

After taking independent advice from a consultant orthopaedic (relating to the musculoskeletal system) surgeon, we upheld Mr C’s complaint. The adviser said the early x-rays clearly showed Mr A’s fracture was unstable and likely to heal badly, and the board should have offered Mr A the option of surgery at that stage (to prevent the fracture healing badly). The adviser also said that the badly healed fracture was the likely cause of Mr A’s additional pain and symptoms, and the board should not have discharged Mr A without offering him corrective surgery.

Recommendations

We recommended that the board:

• issue a written apology to Mr A, acknowledging that the treatment for his wrist fracture was unsatisfactory; and
• ensure this complaint is raised with the consultants involved as part of their annual appraisals, and that any training needs are addressed.

Summary

Mr C complained that his prison kept him locked in his cell for 23 hours each day for several weeks, without completing the relevant paperwork such as that relating to rule 95 of the Prisons and Young Offenders Institutions (Scotland) Rules 2011. Rule 95 provides for the confinement and custody of prisoners, and allows prisoners to be removed from association with other prisoners. Mr C also complained about how the prison dealt with his complaints.

We found that rule 95 had been applied at the start of the period Mr C complained about, when he was in the prison's segregation unit. There is a difference of opinion about what happened after Mr C left segregation and returned to his cell. Mr C said he was kept in his cell, but the Scottish Prison Service (SPS) said Mr C chose to lock himself in his cell. When Mr C complained to the prison, it was clear that he did not want to remain locked in his cell each day. It appeared to us that prison staff were trying to act in Mr C's best interests. However, after Mr C complained, the prison should have applied rule 95 again, but they did not. The authority to keep Mr C in his cell in this way came from rule 95. Applying it would have meant that the prison had the authority either to move Mr C back to the segregation unit, or to keep him in his cell awaiting transfer to another prison.

The SPS acknowledged that responses to Mr C's complaints were not as good as they should have been, and that one response was late. We also found that the prison were using an old version of the complaints form. We upheld Mr C's complaints.

Recommendations

We recommended that SPS:

• discuss this case with the prison's management, to learn from what happened and ensure that appropriate records are kept and that rule 95 is applied appropriately;
• reflect on the responses to Mr C's complaints, to ensure that relevant staff provide better responses in future; and
• ensure that the prison remove all old versions of complaint forms from use.

Summary

Mr C complained that he was put on closed visits (where a prisoner and their visitor cannot make physical contact) following an allegation of fighting. The prison was unable to demonstrate they had followed the correct process as paperwork which should have been completed was not obtainable. For this reason, we upheld the complaint. As the prison had already noted the missing paperwork and were conducting a review, we asked them to let us know the outcome of the review. Mr C was no longer on closed visits, and we asked the prison to apologise to Mr C.

Recommendations

We recommended that Scottish Prison Service:

• apologise to Mr C; and
• inform us of the results of the prison's review.