Upheld, recommendations

Summary

Mrs C complained about the care and treatment that her late mother-in-law (Mrs A) had received. Mrs A had been referred to an orthopaedic consultant (a doctor who specialises in conditions involving the musculoskeletal system) and was seen in January 2013. She was re-referred by her GP practice in May 2013 but was not seen again until late July 2013. Mrs A died of widespread secondary cancer in October 2013, having been diagnosed a matter of weeks previously.

Our role was to assess whether the evidence indicated that Mrs A’s treatment was reasonable in the circumstances at the time. We took independent advice from our medical adviser, who said the steps taken by the orthopaedic consultant had been reasonable. In light of the symptoms Mrs A displayed in January 2013, the advice we received was that it would not have been normal practice to have carried out additional investigations for cancer.

The board did, however, acknowledge their delay in arranging Mrs A’s second appointment (the GP practice’s re-referral appeared not to have been acted upon promptly). We considered this to have been unreasonable and, although the advice was that this did not affect Mrs A’s overall outcome, the board acknowledged that earlier diagnosis would have led to better pain control and palliative care. We recognised the importance of receiving such care and so, on balance, we upheld Mrs C’s complaint because of the delayed second appointment and its possible impact on Mrs A’s palliative care. We also made two recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified; and
• send us evidence of the steps taken to address referrals promptly and their effect.

Summary

Mr C underwent a magnetic resonance imaging (MRI) scan (scan used to diagnose health conditions that affect organs, tissue and bone) at the Western General Hospital to investigate back pain he was experiencing. The report of the scan did not mention the presence of an aortic aneurysm (a swelling of the main blood vessel leading away from the heart, down the body). It was only when a further MRI scan was taken two years later that the aneurysm was noted and operated on. Mr C complained that this was unreasonable.

We found that, in their response to the complaint, the board had recognised the error. The error occurred because, while the aneurysm was visible on initial scans (taken to ensure that the full MRI scan would be taken in the correct place), in the main images the aneurysm was largely obscured by images of the spine. The board had discussed this finding with the reporting radiologist (a doctor specialising in medical imaging) and submitted it to the department meeting for wider discussion about the importance of assessing the initial images thoroughly. The board had apologised to Mr C.

We took independent advice from one of our medical advisers. They confirmed that the board should have noted the presence of the aneurysm. The adviser was satisfied that the action taken by the board since the error was brought to their attention was reasonable. However, they suggested that the reporting radiologist discuss the case at their annual appraisal. We agreed with this view. We recommended that this happen and upheld the complaint.

Recommendations

We recommended that the board:

• ensure the radiologist concerned discusses this case at their annual appraisal.

Summary

Mrs C complained on behalf of her sister (Ms A) about the continence nursing care she had received during a stay in Campbeltown Hospital. During the first few months at the hospital, a catheter was used to manage Ms A's continence. Mrs C complained to the board about urinary care issues that arose during this period including urinary tract infections. Following their investigation of Mrs C's complaint, the board apologised for the lack of involvement of a specialist continence care nurse and, more generally, for the wider record-keeping for Ms A.

After taking independent advice from a nursing adviser, we upheld Mrs C's complaint. We found that, while many aspects of Ms A's urinary nursing care were appropriate, the lack of involvement of a specialist continence nurse and record-keeping matters (such as a lack of evidence that the continuing need for a catheter was reviewed) meant that, overall, the care could not be considered as reasonable.

Recommendations

We recommended that the board:

• apologise to Mrs C directly for the specific record-keeping issues they highlighted; and
• provide evidence of the action taken by the clinical services manager at Campbeltown Hospital to prevent recurrence of these events.

Summary

Mr C complained about aspects of the medical and nursing care and treatment provided to his brother (Mr A) during four admissions to Glasgow Royal Infirmary. Mr A was diagnosed with lung cancer. His deterioration was sudden and significant, and he died within four weeks of diagnosis. Mr C said that Mr A's cancer was not diagnosed within a reasonable time, and that his various discharges and the management of his pain was not reasonable. Mr C was particularly concerned about an attempt to resuscitate Mr A when they had agreed with nursing staff the night before that, as he was at the end of his life, he should not be resuscitated. Mr C also said that communication with nursing and medical staff was not reasonable, and that the family had explained to staff that they should be present when staff talked to Mr A because he had a fear of hospitals.

After taking independent advice from one of our medical advisers, we found that the treatment decisions and discharges were reasonable, as was the time it took to diagnose Mr A's cancer. Also, we could not reconcile the different accounts of the level of pain Mr C said Mr A experienced in light of the evidence from the medical records. However, in relation to the attempted resuscitation, we found that there were significant failings which resulted in a serious injustice to Mr A and his family, who were traumatised by the attempt. We also found communication failures between nursing and medical staff, which then affected communication with the family.

Recommendations

We recommended that the board:

• bring to the attention of relevant staff the medical adviser’s comments in relation to senior clinical review for distressed patients at the end of their lives;
• review their process in relation to end of life care to ensure that inappropriate CPR (cardiopulmonary resuscitation) attempts are avoided;
• bring the shortcomings in record-keeping to the attention of relevant staff;
• ensure the failures around the attempted resuscitation are raised with relevant nursing staff in the annual appraisal process;
• ensure the failings in communication are raised with relevant staff in the annual appraisal process;
• take steps to ensure the involvement of senior clinicians with seriously ill patients and their families in light of the medical adviser’s comments; and
• apologise for all the failings this investigation identified.

Summary

Mr C complained to us on behalf of his daughter (Mrs A) in relation to two assessments she had at Forth Valley Royal Hospital’s psychiatric services. Mrs A’s mental health was deteriorating, and her family initially sought help for her from a GP, who referred her for a psychiatric assessment. She was subsequently sent home, so her family sought GP assistance again. Following a home visit, Mrs A was again referred for a psychiatric assessment, with a very similar outcome. Mr C complained that the family were only given the opportunity to explain why they were so concerned about Mrs A after her second psychiatric assessment, when they insisted on speaking to the doctor.

We took independent advice on this complaint from one of our advisers in psychiatry. The adviser was critical that Mrs A’s family were not expressly involved in either of the assessments. He said that this should be a standard part of such assessments. He also noted that insufficient weight was given to the GP’s concerns and findings. He noted that the first GP had done a detailed assessment and history, and this was not fully considered during either of Mrs A’s psychiatric assessments. The adviser noted that both doctors who assessed Mrs A were trainees, and expressed concern that there was insufficient documentation as to why Mrs A did not meet the criteria for detention at hospital. He also found that the plan for future follow-up was not practical and did not sufficiently involve her carers.

We considered the advice we received, and found that the psychiatric assessments had not been sufficiently robust. We therefore concluded that she was not given a reasonable standard of treatment. We also noted that the failings in this case potentially put Mrs A at significant risk, as her family no longer felt able to keep her safe.

Recommendations

We recommended that the board:

• review the training for those involved in emergency assessments to ensure it highlights the importance of a corroborative history from relatives and carers; the concerns and findings of GPs; full documentation of consideration of a patient for detention in hospital, including clear links to the legal criteria for that detention; and a practical plan when a patient is not detained, involving carers, and including advice and guidance on potential future action;
• remind existing staff involved in emergency assessments of the requirements specified above; and
• apologise to Mr C and to Mrs A for the failings identified, for the distress they caused, and for the risks that these led to for Mrs A.

Summary

Mr A was referred by his GP to the ear, nose and throat clinic at Forth Valley Royal Hospital with a swelling below his left ear. This was found to be cancerous and Mr A was referred to another health board for surgery. This surgery resulted in extensive facial disfigurement and Mr A's daughter (Mrs C) complained that the board failed to explain the extent of Mr A's cancer and the impact the surgery would have on him. Mrs C also complained about delays following surgery in arranging onward referrals for Mr A to various specialists.

The board apologised that Mr A and his family were not adequately prepared for the life-changing results of the surgery, and they developed an improvement plan to address the concerns raised. They noted that their consultations with Mr A occurred at a very early stage in the process of preparing him for major surgery. They indicated that their role was to provide an overview and the intention was for a more detailed explanation to be provided by the board who were carrying out the surgery.

We took independent medical advice from a consultant maxillofacial surgeon (doctor specialising in the treatment of diseases affecting the mouth, jaws, face and neck). The adviser confirmed that the board carrying out the surgery were responsible for explaining the procedure and obtaining informed consent. He considered that the board had appropriately carried out their duties in this case. However, he noted that the communication between the two boards appeared to be lacking. He found no evidence of a formal referral to the other board having been made and he considered there was a lack of clarity regarding the respective role of each board. This also applied to the handover between the cancer nurse specialists at each board, which meant that relevant patient information literature was not given to Mr A. The absence of clear lines of responsibility also resulted in a delay in arranging relevant onward referrals following surgery. We accepted the advice we received and upheld the complaints, recommending that the board further develop their action plan in light of our findings.

Recommendations

We recommended that the board:

• develop their action plan further to take account of the failings this investigation has identified and the adviser's suggestions for areas of improvement.

Summary

Mr C raised concerns about the care and treatment he received when he attended the practice in 2014. In particular, he complained that the practice had failed to take reasonable account of his hearing condition. He said the dental nurse had spoken to him while standing behind him and, as a result, he had been unable to lip read. In addition, she had roughly moved his head. He also complained about the handling of his complaint.

During our investigation we found no evidence that the dental nurse had roughly moved Mr C's head or spoken to him while standing behind him. We were satisfied that, in line with the practice's policy, the dental nurse was required to wear a mask during the treatment. We were pleased that the dental nurse had re-read the relevant guidelines to try to prevent a similar situation occurring in the future. However, we considered that had a translator been present, as detailed in Fife NHS Board's policy, Mr C's communication needs would have been fully met.

We were also critical of the handling of Mr C's complaint and we made a number of recommendations to improve how the practice communicates with patients, and how they deal with complaints.

Recommendations

We recommended that the dentist:

• reiterate the apology offered in a letter to this office to Mr C;
• review the Disability Policy to ensure that the communication needs of patients are being met in line with Fife NHS Board's policy on Equality and Human Rights;
• apologise for the failures identified in this case in relation to complaints handling; and
• review procedures to ensure that the practice deals with complaints in accordance with the NHS complaints procedure.

Summary

Mr C is the secretary of a club which rents premises from the local council. The premises are in part of a building, the larger part of which is vacant. The council had shut off the building's water supply, including the supply to the club's premises. As the club did not require a water supply, this was not a problem. In 2013, Business Stream identified the property as one that had a water connection but had not been charged for water services. An invoice was issued for water and wastewater services. Mr C complained that the club was unreasonably being asked to pay for a service it did not receive. Whilst Business Stream advised that a water connection remained in place and could be used by the club, Mr C noted that the club did not have any control over the stopcock or pipework and could not influence this. Ultimately, the club arranged for the premises to be disconnected, avoiding further charges. However, Mr C considered the earlier charges to be unjustified.

Although the council had turned the water supply off, the property was not fully disconnected from the water supply. Water services could be reinstated without Business Stream or Scottish Water's involvement, and we considered it reasonable for them to guard against a situation where charges were cancelled, only for water to be used at a later date. We found the charges were applied in line with water industry rules and accepted that it was a matter for the club to arrange for a permanent disconnection. That said, we considered the club's disconnection was unreasonably delayed due to the hold-ups to the investigation into Mr C's concerns. Additional charges were accrued in the meantime which we did not consider reasonable, so we recommended that these were reimbursed to the club.

Recommendations

We recommended that Business Stream:

• calculate and refund the difference in charges had the club disconnected the water supply on 1 January 2014.

Summary

Mr C complained that an inaccurate statement had been inappropriately recorded in a note outlining the risk management team's (RMT) discussion of his case. He said that the statement indicated that several attempts had been made to engage him in a type of therapy. Mr C disputed that. In response to his complaint, the Scottish Prison Service (SPS) said it was not possible or helpful to trace who made the statement. However, it was agreed that the RMT should discuss Mr C's denial that he had refused to engage with the therapy at their next meeting.

We asked the SPS to tell us whether the statement recorded by the RMT about Mr C was accurate and based on factual information. The SPS provided extracts from the notes of discussions held at various meetings which they felt supported the statement recorded. The SPS also explained that whilst working with Mr C in general, staff would have used the therapy techniques but he would not have been aware of that. They accepted that it was not clear from the statement recorded by the RMT that this was the case. The SPS acknowledged that the statement implied Mr C had been provided with specific work, not that techniques were being used during general work with him. In addition, the SPS told us that the RMT had not discussed the matter again as had been agreed.

In considering Mr C's complaint, we looked at whether the statement recorded was accurate and whether it had been recorded appropriately. In our view, the statement led the reader to believe that attempts to have Mr C engage in therapy work were unsuccessful. We considered that whilst the statement was not necessarily inaccurate, it was not completely accurate either. We were concerned that the language used was misleading, and open to misinterpretation and because of that, we considered that the information had been recorded inappropriately. We were also concerned because, in their written response to Mr C's complaint, the SPS noted an inaccurate reflection of the misleading statement.

Therefore, we upheld Mr C's complaint.

Recommendations

We recommended that the SPS:

• take immediate steps to appropriately record the position in relation to Mr C's involvement with the therapy.

Summary

Mr C repeatedly pressed the call button in his cell and was placed on a disciplinary report by prison officers. Mr C complained to the Scottish Prison Service (SPS) about this because he said he pressed the call button because he was unwell. Mr C then complained to us about how the SPS handled his complaint.

We found there was an unreasonable delay in the SPS dealing with Mr C's complaints, and that his initial complaint was not handled in line with the relevant guidance. Mr C made more than one complaint to the SPS, and his last complaint to them was dealt with at all stages of the process by the same officer, which we found to be unreasonable. We also found that the responses provided to Mr C were not in keeping with the complaints guidance and were not entirely reasonable in the circumstances. In addition, we found that in dealing with Mr C's last complaint, the SPS did not handle his request for witnesses in line with the complaints guidance. We upheld Mr C's complaints.

Recommendations

We recommended that the SPS:

• apologise to Mr C for the failings identified;
• review the handling of this complaint with the relevant prison to ensure these failings do not occur in the future; and
• remind the relevant prison of the timescales and the process for delays in exceptional circumstances as set out in the staff guidance on prisoner complaints.