Upheld, recommendations

Summary

Mrs C complained about the delay in diagnosing her late husband (Mr C)'s cancer. Mr C suffered intermittent pain over about two years, following a fall. Mrs C said Mr C attended A&E at Glasgow Royal Infirmary on numerous occasions, as well as being seen by colorectal (bowel) and gastroenterology (digestive system) specialists. Mr C's cancer was first diagnosed over two years after his fall, following a scan which showed possible cancer in his liver. Mrs C raised concerns that Mr C should have been given this scan earlier.

The board considered that Mr C received appropriate treatment and investigations. They said they only had records of Mr C attending A&E on two occasions, although Mrs C said he attended numerous times.

After taking independent medical advice from A&E, colorectal and gastroenterology specialists, we upheld Mrs C's complaint. We did not find any evidence that Mr C attended A&E on more than two occasions, and we found that the care and treatment at A&E was mostly reasonable. However, on one occasion the A&E doctor did not specifically record checking whether Mr C was losing weight (which would have been a 'red flag' symptom), and we were critical of this. We found the investigations carried out by the colorectal service were reasonable and timely, and there would have been no reason for them to arrange a scan, based on Mr C's symptoms and the results of other tests and examinations at that time. We also found the gastroenterology clinic arranged appropriate investigations. However, we found there was a delay of several weeks in performing the initial investigations (including the scan) and reviewing the results, which meant that Mr C's care did not meet the Scottish Government's standards for cancer waiting times (HEAT targets).

Recommendations

We recommended that the board:

• issue a written apology to Mrs C for the failings our investigation found;
• raise our findings about the A&E review with the doctor involved for reflection and learning; and
• review their processes for scheduling investigations arising from suspected cancer referrals, taking into account the 62-day HEAT standard.

Summary

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer.

We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the error made in the administration of his medication;
• explain to us what steps have been put in place to prevent such an incident from occurring again; and
• provide us with a copy of a drug recording sheet.

Summary

Mr C complained that the board had contributed to the decision that he no longer needed to be managed under the Scottish Prison Service's process for prisoners at risk of suicide or self-harm (the ACT 2 Care process). Mr C had been managed under this process for a number of days, as he had carried out acts of self-harm. During that period, two medical reports had been obtained identifying that he was at risk of further self-harm, and successive case conferences had also reached the decision that he was at risk of this. However, a further case conference decided that Mr C was not at risk. A mental health nurse was a participant at this case conference and agreed with the decision reached. Mr C carried out a further act of self-harm and was put back on the process.

We took independent medical advice from our mental health nurse adviser. Our adviser said that Mr C was removed from the process on the basis that he was not suicidal, however, as it is also a strategy for minimising the risk of self-harm this was not a reasonable decision. We found that the risk of life-threatening self-harm had not been sufficiently taken into account when the board contributed to the decision to remove Mr C from the process. The adviser also said that an entry that had been made in Mr C's healthcare record was unreasonable in both tone and clinical approach to self-harming behaviour. We also upheld a second complaint that Mr C made about the board's failure to provide him with a legible copy of his completed complaint form.

Recommendations

We recommended that the board:

• issue a written apology to Mr C for their role in the decision to remove him from the ACT 2 Care process at the meeting in question, and also for the inappropriate entry made in his healthcare record;
• ensure all relevant staff are aware of the ACT 2 Care approach to self-harm;
• make the mental health nurse involved in this case aware of the adviser's comments and ensure that this is included for discussion at their next appraisal; and
• issue Mr C with a legible copy of the complaint form.

Summary

Mr C was taking rivaroxaban (medication that thins the blood in order to minimise the risk of a stroke) when he was scheduled for non-emergency surgery. Due to the possibility of excessive bleeding during a surgical procedure, Mr C was advised to stop taking his medication seven days prior to surgery. Four days after Mr C stopped taking his medication, he suffered a stroke.

When Mr C complained, the board and Mr C's consultant appeared unclear about whether Mr C was on rivaroxaban or warfarin (another drug used to prevent blood clots, which Mr C had previously been taking). The board said they had followed guidelines for warfarin as rivaroxaban was a very new type of medication. They also said Mr C was classed as 'low risk' of stroke and the advice he was given was accurate. They said that, in light of his complaint, they would develop further protocols for staff.

Mr C complained he should not have been classified as low risk, and should not have been advised to stop his medication. We sought independent advice from one of our advisers, who is a consultant geriatrician with specific experience in stroke medicine. The adviser was clear that Mr C was given incorrect advice about stopping his medication. Warfarin guidelines are not applicable to rivaroxaban, and Mr C should only have been advised to stop his medication for 24 to 48 hours prior to the surgery. The adviser accepted rivaroxaban was a relatively new drug, however, he stressed that this meant clinicians should be more cautious and seek guidance from colleagues if they were unclear. The adviser also noted that the board did have specific guidelines for the drug and there were many more available online. The adviser also concluded, in light of Mr C's previous medical history, that he should have been classified as being at 'moderate risk' of stroke.

For these reasons we upheld Mr C's complaints. We were also critical of the complaint investigation, which was unable to clarify whether or not Mr C's consultant was aware of the type of medication Mr C was on.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• provide us and Mr C with the updated protocols regarding rivaroxaban;
• ensure Mr C's consultant discusses this complaint as part of their annual appraisal; and
• feed back to staff the importance of clarifying at the time why a situation occurred, not retrospectively.

Summary

Ms C's daughter (Miss A) was born with hydrocephalus (a build-up of fluid on the brain causing pressure), and from the age of about two years old, she began to suffer multiple infections and seizures. She was admitted to hospital on many occasions and Ms C was informed that her daughter was likely to have epilepsy. Miss A was diagnosed as having gastroenteritis (inflammation of the stomach and intestines) when she was three. Meanwhile, her seizures continued and Ms C was advised that they were probably due to her underlying fever and gastroenteritis. Ms C was unhappy as she considered that no progress was being made to establish the cause of her daughter's symptoms or to treat her properly. In the circumstances, she took Miss A to a children's hospital in another board area where she was diagnosed with a cerebral abscess and where she remained for five months.

Ms C complained of the delay in diagnosing her daughter and of the board's failure to refer her to the children's hospital in another board area for treatment. She was unhappy with the way they responded to her complaint.

We investigated the complaint and took independent advice from one of our medical advisers, who is a consultant paediatrician (doctor dealing with the medical care of infants, children and young people). We found that there had been a delay in diagnosing Miss A and that there may have been a missed opportunity to do this sooner. We also found that, while the board had intended to refer Miss A to the children's hospital in another board area, for reasons unknown, no appointment was made. We also found that there had been undue delay in providing a response to Ms C's concerns and that although a detailed letter was drafted, it was not sent. A meeting arranged to replace the letter took place months later. The complaint was upheld.

Recommendations

We recommended that the board:

• make a formal apology to recognise the delay in diagnosis;
• advise us what actions have been taken since the meeting to improve the two-way flow of communication between the hospitals identified;
• make a formal apology for their failure to respond adequately to the complaint; and
• emphasise to the staff concerned the importance of adhering to their complaints process and of the necessity for good, clear and timely communication.

Summary

Mrs C complained about the care the treatment her late mother (Mrs A) had received from the medical practice in the months prior to her death. Mrs A had been admitted to hospital as it appeared she had suffered mini strokes. However, following her admission she was diagnosed with metastatic cancer (cancer that spreads to other parts of the body), and died shortly thereafter.

We took independent advice from one of our GP advisers, who said that Mrs A had been suffering from anxiety symptoms and memory problems for which she had been prescribed medication. Our adviser considered that Mrs A had been regularly reviewed by the practice, and there was no pattern or evidence to suggest Mrs A had an underlying diagnosis of metastatic cancer or the medication she had been prescribed masked any symptoms of metastatic cancer or strokes.

Although we considered the care and treatment Mrs A received was mostly reasonable, we found certain aspects of her care fell below this standard.

While, generally, the medication Mrs A was prescribed and its monitoring was appropriate, one of Mrs A's medications which had been stopped was still being prescribed.

We found a failure to action the results of a liver function test result although we accepted the result would not have triggered any concerns of underlying metastatic disease.

While communication with Mrs A's family was of a reasonable standard, we found that one of the doctors had used insensitive and inappropriate language during a home visit to Mrs A, and the practice could have done more to ensure that they had complied with a specific request from Mrs A's family to be present during a home visit given Mrs A's memory problems and that they were her carers.

Recommendations

We recommended that the practice:

• ensure they discuss Mrs A's case and the complaint as a significant event review, paying particular attention to safe acute and repeat prescription prescribing for the elderly and in their communication with carers of patients;
• share with relevant staff our adviser's comments concerning the apparent failure to action and follow-up the abnormal liver test result, and advise what action has been taken to ensure this does not recur;
• provide confirmation that the doctor in question will discuss the inappropriate use of colloquial language at his yearly appraisal; and
• apologise to Mrs C and her sister for those aspects of Mrs A's care which fell below a reasonable standard.

Summary

Mr C was escorted to the sheriff court by an escorting agency which provides all custody and court escorting services on behalf of the Scottish Prison Service (SPS). He said that when he arrived, the escorting officers were instructed to keep him double cuffed. This meant that Mr C had one set of cuffs linking his wrists and a second set linking one of his wrists to an officer's wrist. Mr C said he remained in double cuffs until he was returned to prison. Because of that, Mr C complained that the agency held him in double cuffs for an unreasonably long period of time. In addition, he said they failed to carry out any risk assessment.

The agency told Mr C that every prisoner would be risk assessed throughout the day. They said the assessment would consider information supplied to them by partner agencies and could also include known behavioural factors from previous times when held in custody by the agency.

We reviewed the relevant operational instructions which confirmed that prior to taking a decision to hold a prisoner in double cuffs, a risk assessment should be carried out to assess whether they are required. In addition, the instructions confirmed that if an assessment indicates that double cuffs are required, permission should be sought from the sheriff. In Mr C's case, no evidence was offered by the agency to suggest that the relevant risk assessment or the appropriate permission was sought prior to taking the decision to hold him in double cuffs. Therefore, we upheld Mr C's complaints.

Recommendations

We recommended that SPS:

• apologise to Mr C, on behalf of the agency, for the failures that our investigation highlighted; and
• remind the agency of the requirement to make an appropriate record of any risk assessment carried out and permission sought when taking the decision to hold a prisoner in double cuffs at court.

Summary

Mr C was taken into his trial at the sheriff court whilst wearing double cuffs. This meant Mr C was wearing one set of cuffs to link his wrists together and a second set linking one of his wrists to the escorting officer's wrist. Mr C complained that the escorting agency inappropriately failed to seek permission to double cuff him. He said the agency also failed to provide an appropriate response to his complaint.

An agency provides all custody and court escorting services on behalf of the Scottish Prison Service (SPS). That agency's operational instructions confirm that handcuffs in sheriff and jury trials will normally not be allowed. However, where a risk assessment dictates that handcuffs should be applied, the appropriate paperwork should be completed and forwarded to the clerk of court for approval by the sheriff. The instructions also confirm that the outcome of the request should be appropriately recorded. In Mr C's case, the SPS were unable to provide any evidence to show us that a risk assessment had been carried out prior to the decision taken to hold Mr C in double cuffs during his trial. Therefore, it was not clear why the decision was actually taken. In addition, there was no evidence available to confirm that the request was approved by the sheriff. We also concluded that the agency did not respond appropriately to Mr C's complaint because they failed to establish the facts in his case and because of that, it was unclear what had actually happened.

Therefore, we upheld Mr C's complaints.

Recommendations

We recommended that SPS:

• apologise to Mr C, on behalf of the agency, for the failures that our investigation highlighted;
• remind the agency to ensure that appropriate records are kept to evidence that proper process has been followed prior to taking a decision to hold a prisoner in double cuffs during a trial; and
• provide feedback to the agency in relation to good practice when investigating and responding to complaints from prisoners.

Summary

Mr C said the prison failed to reasonably investigate a complaint about the problems he had making an appeal against a disciplinary decision. Mr C's appeal was rejected because it was made too late. Mr C told the prison that an earlier appeal had been made within the two week deadline.

We agreed with Mr C. We found that the prison should have done more to investigate Mr C's claim that an earlier appeal had gone missing, both when Mr C raised the matter in a further appeal and, later, when he complained. Some sections of the forms which should have been filled in by the prison were incomplete or not signed. It was difficult to see how the prison had arrived at their decision. As there was no system in place for issuing receipts, Mr C had no way of proving that he had made an earlier appeal. The prison had no way of proving that an earlier appeal had not been made. We recommended that a system of issuing receipts is implemented for prisoners who want one.

We also found that the prison took too long to make a decision on the appeal Mr C made. They exceeded the 20 day timescale, without any explanation to Mr C.

Recommendations

We recommended that Scottish Prison Service:

• implement a system whereby prisoners are provided with a receipt for PAF 2 forms where they request one.

Summary

Mr C complained that the Scottish Prison Service (SPS) delayed sending all of his property when he was transferred from his previous prison to his current prison. Mr C also complained about how the prisons had dealt with his concerns and complaints about his property.

We found that Mr C's property was not returned to him until eight months after his transfer, and Mr C said there were still missing items. The SPS' records showed that the items Mr C specified were at his previous prison, but they were not recorded as being received at his current prison. Based on the records, we concluded that all of Mr C's property had not been returned to him.

Over a period of several months, Mr C tried to get his property returned by speaking to several different prison staff. Information we obtained from the SPS did not record any action being taken about Mr C's property until he complained, and although both Mr C and the SPS agreed that some action was taken, it had no effect until after Mr C complained. We could not find evidence of any coordinated effort between the two prisons in trying to locate and return all of Mr C's property. We upheld Mr C's complaints.

Recommendations

We recommended that SPS:

• ensure that both prisons work together and with Mr C to compare his property records to determine what, if any, items of property are missing;
• provide replacements, or provide Mr C with funds to purchase replacements for all items that are confirmed as missing;
• apologise to Mr C for the failure to send all of his property with him, and their failure to locate and return his property in a reasonable time; and
• examine what should have happened in this case compared with what did happen, in order to work out what went wrong and why, and determine what measures they will take to prevent it from happening again. This examination and its findings should be copied to us.