Upheld, recommendations

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C did not receive a meaningful response from the council until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C did not receive a meaningful response from the council until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Ms C, a solicitor, complained to the council about the provision of community care for one of her clients. As Ms C had not received a final response to her complaint, just over eight months after writing to the council, she complained to us about the delay.

We found that Ms C's complaint was acknowledged the day it was received by the council, but she did not receive a meaningful response until more than 11 weeks had passed. This was after Ms C had contacted the council twice to enquire about their response. In the council's initial response, they incorrectly told Ms C that legal advice was being sought in relation to her complaint. However, this was not requested until nine months later (during the time that we were investigating the complaint). It was clear to us, and it was accepted by the council, that there was an unreasonable delay in dealing with Ms C. We upheld Ms C's complaint.

Recommendations

We recommended that the council:

• apologise to Ms C for the unreasonable delay in dealing with her complaint; and
• provide Ms C with a response to her complaint.

Summary

Mr C complained that he was not given his prescribed medications on his first days in prison, and that all his medications were stopped soon after entering prison. Mr C also complained that the board did not investigate when he complained about this.

The board said Mr C's medications were stopped in accordance with his signed medications agreement after he was found concealing suboxone (a medication used to manage addictions) and after he refused to open his mouth to let staff check that he had taken his medication. The board said that, as Mr C had raised these issues with healthcare staff rather than complaining to complaints handling staff, they had treated this as a 'concern' rather than a 'complaint'. They also said that, in any case, they had responded to Mr C's verbal complaints reasonably, by discussing the complaints with him directly on each occasion.

After taking independent advice from a psychiatrist, we upheld Mr C's complaints. We found there was no evidence the health centre had given Mr C his prescribed medication on his first days in prison, aside from one drug, for which there were two conflicting prescriptions (and he had been given one of these). We also found Mr C had been given incorrect medication on several other occasions. However, we found that it was reasonable for the health centre to decide to stop Mr C's medications when they did. Two medications were stopped or reduced soon after Mr C arrived in prison, and the adviser said this was appropriate, as these medications were addictive and not intended for long term use. Mr C's suboxone was stopped after he was found concealing this, and we found this was reasonable, as suboxone is used for addictions management, and there is a risk of overdose or harm if it is taken other than as directed. However, we were critical that the health centre were not able to show that Mr C had been warned about the consequences of concealing medications, as he had been asked to sign the wrong medications agreement (for 'in possession' medications, rather than 'supervised' medications). Mr C's remaining medications were stopped when he refused to comply with instructions to open his mouth. We found this was reasonable, as these medications were not essential for Mr C's condition and there is a risk of harm when medications are taken other than as directed.

We found that the board did not investigate Mr C's complaints appropriately. Although we found it was reasonable for the board to treat these issues as a 'concern' when Mr C initially raised them, when Mr C continued to raise these issues, and was not satisfied with the board's response, they should have been fully investigated.

Recommendations

We recommended that the board:

• remind nursing staff of the need to take care when administering medications (particularly where there are multiple prescriptions);
• review the processes for issuing prescriptions for incoming patients to the prison to ensure that existing prescriptions (from the community and/or time in custody) are continued or amended without delay, and the patient’s agreement is obtained to the applicable medication process ('supervised' or 'in possession');
• apologise to Mr C for the failings our investigation found; and
• take steps to ensure that complaints raised verbally with healthcare staff at the prison are appropriately handled and reported in accordance with the 'Can I help you?' guidance.

Summary

Mrs C complained about the treatment she received from the board in the lead up to the birth of her twins. During her pregnancy she developed HELLP Syndrome (this is the term used to describe a range of symptoms that can affect women with pre-eclampsia or eclampsia; HELLP Syndrome is characterised by the breakdown of red blood cells, elevated liver enzymes and low platelet count). Following diagnosis of her condition, Mrs C's caesarean section was brought forward. Whilst one of her daughters was born healthy, the other was stillborn. Mrs C complained that staff did not monitor her and her babies adequately, and that there was an unreasonable delay to the diagnosis of her HELLP Syndrome and to the delivery of her twins.

We took independent medical advice from a consultant obstetrician (a doctor specialising in pregnancy and childbirth) and gynaecologist (a doctor specialising in the female genital tract and its disorders). We were generally satisfied that Mrs C's condition, and that of her twins, was monitored adequately and in line with national guidance. Blood tests raised concerns for Mrs C's wellbeing but gave no indication of a problem with the twins. When abnormalities were identified, staff acted appropriately. However, we found that one of Mrs C's blood test results was checked and action taken by clinical staff before the full extent of the test results was known. Crucial information about Mrs C's liver enzyme levels was not identified until the day after the information was entered onto the hospital's system. Whilst appropriate action was taken to prioritise Mrs C's delivery once this information was highlighted, we accepted advice from our adviser who considered that the delivery would have taken place sooner had the blood test results been noted on the day they were reported. The available evidence suggested that, had this happened, both twins would likely have been alive at birth.

We were also critical of excessive delays and poor communication in the board's handling of Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr and Mrs C for the failings identified;
• review their systems for reviewing blood results to ensure those taken in clinic and those taken on the ward are seen and acted upon in a timely fashion;
• take steps to ensure clear communication of the urgency of non-elective c-sections, and to develop a policy for escalation at times of high workload when c-sections are delayed longer than expected; and
• review their procedures for conducting root cause analyses to ensure they follow a structured process in keeping with the principles of the NHS Scotland complaints handling procedure.

Summary

Ms C complained on behalf of Ms A, who was diabetic, that after she had a stent (a mesh tube) inserted into her kidney in April 2013, staff at the Southern General Hospital failed to monitor or remove it. As a result, Ms C said that Ms A was caused extreme pain, which led to her having an emergency operation early in 2014 to remove her kidney. Ms C believed that early intervention with regard to the stent could have avoided this.

We took independent medical advice from a consultant urologist (a doctor who treats disorders of the urinary tract). We found that after the insertion of the stent, it was planned to remove it in July 2013. However, at her anaesthetic pre-assessment for the removal of the stent, Ms A was found to have poor diabetic control, which meant that her operation could not go ahead. Her GP was asked to inform the hospital when Ms A's condition improved so that her operation could be rescheduled. However, the hospital was never updated. The investigation also showed that Ms A's name continued on the waiting list for stent removal and this should have provided an adequate safety net, but it did not. In the meantime, Ms A's stent was removed in England. In these circumstances, we upheld the complaint about the monitoring of the stent. However, in reaching our decision we did not conclude that the failure to monitor the stent ultimately led to Ms A losing her kidney, as there was no evidence that this had been the case.

Recommendations

We recommended that the board:

• make a formal apology in recognition of the failures identified; and
• advise us of the processes that have since been put in place as a consequence of the complaint made.

Summary

Mr C complained that after breaking a bone in his foot, despite four visits to hospital over a six month period, staff at the Southern General Hospital failed to diagnose and treat him properly. As a consequence, he said that he suffered prolonged and unnecessary pain. Mr C subsequently had an operation abroad to remedy his foot problem. He then complained to the board. The board said that, generally, with the exception of his final attendance at hospital, he had been treated appropriately. However, they apologised that his final visit had been below the standard expected. They said that they had since learned from the situation.

The complaint was investigated and we took independent advice from a consultant in emergency medicine. We found that when Mr C first went to hospital after injuring his foot, he had been diagnosed with a low risk, undisplaced fracture (a break in the bone, where the two parts of the bone are still aligned) and treated accordingly. Although it was more rare, we found that he had actually suffered a high-risk, complex fracture (a Jones fracture) which required significantly different management as the blood supply to his foot could have been affected. His further attendances at hospital also failed to establish the nature of Mr C's fracture, so we upheld Mr C's complaint.

Recommendations

We recommended that the board:

• make a formal apology recognising the failures in care and treatment identified; and
• ensure that appropriate staff in the A&E department are made aware of the circumstances of this case and the failures identified, particularly with reference to a Jones fracture.

Summary

Mr C, an advice worker, complained on behalf of his client (Mr A) who had injured his back at home while breaking wood. Mr A was seen at the practice and complained of pain, pins and needles, and numbness. Mr A asked for an MRI scan (magnetic resonance imaging scan), but was referred for an x-ray which raised no concerns. He continued to experience severe pain and numbness in his legs. Following further consultations at the practice he was advised to attend the local A&E department. He was admitted to hospital and diagnosed with a compressed disc which required surgery.

Mr C complained that the practice had ignored serious red flag symptoms of spinal injury on three occasions and considered that Mr A should have been referred for an MRI scan.

We took independent medical advice from one of our GP advisers, and found that the practice would not have been able to refer directly for an MRI scan. However, the GPs at the practice followed the wrong diagnostic pathway and, as such, failed to identify three red flag symptoms. We concluded that, had the correct pathway been followed, Mr A would have been referred urgently to a specialist.

Recommendations

We recommended that the practice:

• apologise to Mr A for failing to make the appropriate referral during his initial consultations; and
• ensure that all the practitioners involved in reviewing Mr A in this case undertake a review of their practice in relation to management of patients with lower back pain. This should include familiarising themselves with the scope of the relevant Pathway for Management of Lower Back Pain referred to in our decision.

Summary

Mr C complained about the board's role in the decision-making that he should be taken to a respite care facility (run by a private care provider) for 24 hours when he had already told them that he did not want to go, and then kept there against his express wishes. Mr C told staff when they arrived at the facility that he did not want to be there, but was persuaded to stay until the following day when his father picked him up. Mr C also raised concerns about an earlier decision by the board to instruct members of staff from the private care provider to covertly befriend him at a radio station where he was volunteering given the effect this had on him, particularly when he saw the staff members at the facility the following year.

We took independent advice from our medical adviser. We found that the board failed to act in line with the relevant legislation, which meant that Mr C's rights were not respected. We also said that it was not reasonable that Mr C was told he was going to the facility on the journey there and that this posed a risk. In relation to Mr C's stay at the facility, we found that there was a responsibility on board staff to ensure that Mr C would be returned to his home if that was his wish. The board had accepted that Mr C told staff when he arrived that he did not want to go in and refused initially to leave the car. We found that most of the healthcare professionals involved were doing everything they could to provide Mr C with treatment, despite his clearly stated wishes to the contrary, believing it was in his best interests. We were critical of the board's actions in relation to the decision that staff should befriend Mr C covertly. In doing so the board failed to respect his autonomy. It was our view that the board failed to act in a reasonable way in respect of Mr C's stay at the facility.

Recommendations

We recommended that the board:

• inform us of how they intend to ensure that decision-making capacity is assessed and clearly documented;
• review their actions in light of our findings and bring our decision to the attention of relevant board staff;
• consider using this decision as a case study to inform current practice in similar circumstances; and
• apologise to Mr C for the failings we found.

Summary

Miss C complained that a paediatric consultant carried out a manual labial separation (separation of the small inner lips around the entrance to the vagina which have become sealed together) on her young daughter at an out-patient clinic without the consent of her and the child's father (Mr B), and without anaesthetic. Miss C said the procedure had caused her daughter to suffer pain and bleeding, ongoing distress, and develop a fear of doctors.

Our investigation included taking independent advice from one of our medical advisers who was of the view that the consultant should have explained and discussed the treatment options with Miss C and Mr B, and had them sign a consent form prior to carrying out the procedure. However, there was no evidence the consultant did so. We were satisfied the consultant failed to obtain informed consent before he carried out the procedure. Our medical adviser also was of the view that undertaking the procedure without a topical anaesthetic (a local anaesthetic whereby a substance is applied directly to the skin to temporarily numb the skin) was unreasonable.

Recommendations

We recommended that the board:

• ensure that the consultant reviews his record-keeping and his practice in relation to the obtaining of informed consent;
• review their policy for the treatment of labial adhesions and consider providing parents with an information leaflet about the procedure and treatment options;
• ensure a consent document is signed by the child's parent or guardian prior to any clinical intervention being carried out;
• apologise to Miss C and Mr B for failing to obtain informed consent;
• ensure that the consultant is made aware of our adviser's comments and reflects on them; and
• apologise to Miss C and Mr B for the performing the procedure on the child without anaesthetic.