Upheld, recommendations

Summary

C was a carer for their parent (A). A carer's assessment self-referral form was submitted on C's behalf to the partnership's Carers Team. C was contacted by the Carers Team and advised that, in the circumstances, the requested assessment would be carried out by A's social worker. Within 24 hours the social worker had discussed and clarified the situation with the Carers Team. The Carers Team had also emailed C to advise that they had been under a mistaken impression the previous day and to request that C contact them to progress C's request. Relations between C and the Carers Team broke down during further email correspondence involving C, the Carers Team and the social worker the same day. Within this correspondence the Carers Team had made clear that they required further information from C to progress C's request and that they would end consideration of C's request if they had not received a response from C.

The partnership responded to a complaint from C, and accepted that there had been short comings in the Carers Team's communication with C and stated that the social worker would contact C to discuss carer support further. Some time later, a further referral for carer support was submitted to the Carers Team. Relations between the Carers Team and C again broke down and C submitted a complaint about the Carers Team's actions and the partnership's failure to provide carer support.

The partnership's response outlined their view of events regarding C's requests for carer support over a period. The partnership gave their view that C had not received carer support during this period because it had been unclear what supports C wished to access. The partnership accepted that there appeared to have been some confusion on the part of their staff as to who was ultimately responsible for moving forward with the matter and that this may have caused some delay. Given this, the partnership partially upheld C's specific complaint about this. The partnership noted that matters were now being progressed via the social worker and considered that, in those circumstances, there was no further resolution that they could offer.

C raised their complaint with SPSO shortly after receiving the partnership's response. We took independent advice from a social work adviser. We found that there had been confusion between the social worker and the Carers Team about who would provide C with support and that this led to a delay. On balance, we upheld the complaint on this basis. The partnership had already acknowledged this delay but had not provided a direct and clear apology to C for this or taken steps to ensure that the situation could not recur. We made recommendations to address these matters and provided feedback to the partnership.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the confusion on the part of partnership staff that caused some of the delay in the provision of carer support to C. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The partnership review and update their internal protocols, process flows and triage systems for carers assessments to ensure clarity, for staff and the public, regarding what staff are ultimately responsible for moving forward requests for carers support in a given circumstance.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the board's decision not to fund the travel and accommodation costs they and their spouse had incurred as a result of travelling to visit their child (A) who was receiving treatment under a compulsory treatment order (CTO) in a different part of the country. C complained that the board's decision had failed to take into account the provisions of section 278 of the Mental Health (Care and Treatment) (Scotland) Act 2003 (the 2003 Act), which they considered placed a duty on the board to continue funding travel costs until A became 18, in addition to other legislation they considered to be applicable. C also complained about the board's failure to respond to correspondence in relation to this issue.

The board's position was that C was an adult once they turned 16 and that their patient travel policy did not allow for the funding of visits to adult patients. The board stated that it would have nevertheless considered funding C's visits to A had it been deemed critical by the consultant in charge of A's care but that no request for C's attendance had been made by clinicians.

We found that the board's patient travel policy did not allow for visits to patients over the age of 16 years to be funded by the board. However, we found that the board had failed to demonstrate that they had meaningfully considered the provisions of section 278 of the 2003 Act and had not adequately explained why they considered it did not apply to C and A's circumstances. We also found that the board had unreasonably failed to respond to C and their spouse's correspondence.

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The board should reflect upon the findings of this investigation and reconsider their position in relation to the award of travel expenses to C under their policy and in particular consider whether section 278 of the 2003 Act applied to C and A's circumstances between the relevant period. Having done so, the board should consider whether C's travel and accommodation costs should be met. If the board does not consider section 278 to be applicable, the board should provide sufficient reasons for its position to C.

What we said should change to put things right in future:

• The board should acknowledge and/or respond to correspondence which requests specific information.

In relation to complaints handling, we recommended:

• The board should ensure that complaints are identified and processed in accordance with their complaints handling procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A) who had been admitted to hospital with an infection of the gallbladder. A Magnetic Resonance Cholangiopancreatography (MRCP, an MRI scan of the gall bladder) was ordered and gallstones were found to be present. However, A did not hear from the hospital for several months following the scan until they proactively chased up a response. The board later confirmed that the MRCP report had not been provided to the consultant who had ordered the test causing the delay.

A was subsequently admitted for an Endoscopic Retrograde Cholangiopancreatography (ERCP, a procedure combining an endoscopy and X-rays to examine and treat conditions of the bile and pancreatic ducts) and discharged the following day. A was admitted again a few weeks later suffering from a complication of pancreatitis and a drain was inserted. A was discharged to be seen again as an out-patient. However, a few days later A was readmitted as an emergency patient suffering from a significant infection and died shortly after. C complained about the delay between the MRCP and ERCP procedure and questioned whether this had led to A's death. C also complained about the general standard of care provided to A.

We took independent advice from a consultant general surgeon with a specialist interest in upper gastrointestinal problems. We found that there had been a failing in both the board's paper and electronic reporting systems. Despite these failings, we were of the view that the delay did not, on this occasion, lead to a worse outcome for A clinically.

However, we were critical of the care provided to A following the ERCP procedure. We also found that A was discharged too soon, despite having developed pancreatitis, against both local policies and clinical best practice. We considered that A should have been admitted for longer, under the care of the original consultant, and that better initial care for A may have facilitated earlier intervention to possibly allow for their ultimate recovery. Therefore, we upheld C's complaint.

We also commented on complaints handling noting that the complaint had not been handled in line with the board's complaints handling procedure with respect to timescales, and that the initial complaints investigation had not identified issues with post-ERCP care.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients receiving scans should have their scans reported to the relevant and appropriate clinicians; reviewed, and followed up without delay.
• Patients should be under the care of the appropriate medical team during their admission. Any decision in relation to discharge should be taken by the appropriate medical team with appropriate account taken of local protocols and management pathways.
• There should be appropriate learning from serious events that ensure failings are identified and addressed and appropriate learning and practice improvements are made.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures. They should fully investigate and address the issues raised and identify and action learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area.

The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited.

We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for providing unreasonable personal care and unreasonable skin care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Person centred care plan to be put in place for patients within 24 hours, as per board policy and skin care guidance to be followed correctly.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death.

The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch.

We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in assessing A's fitness for surgery and the impact this had on other investigations i.e. arranging a PET-CT scan, the delay in the PET-CT scan being carried out and A being identified as unsuitable for surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients who are considered suitable for surgery should have early assessment to establish fitness for surgery.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis.

In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease.

We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the practice share this decision notice with their GPs with a view to identifying any points of learning.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with sepsis.

The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement. C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided. The board stated the staff involved used their clinical judgement to assess the wound, which did not show signs of infection. However, it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made. The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate.

The board further advised the SAER was a formal process, which did not allow for A's inclusion and maintained the incident did not meet the Duty of Candour threshold. They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations.

We took independent clinical advice from a registered nurse specialising in tissue viability. We found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A's care lacked knowledge of current best practice in terms of wound assessment, wound management and antimicrobial stewardship. We also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• A person centred approach should be adopted.
• For all patients with a wound to have an adequate wound assessment undertaken and documented in a formal wound assessment chart. This should be in line with the following guidance Vale of Leven Inquiry Scottish Government Recommendations 2015NMC: The Code 201Scottish Ropper Ladder for Infected Wounds 2020 and HIS Scottish Wound Assessment and Action Guide 2021.
• A Duty of Candour Investigation to be undertaken, unless there is definitive evidence that the UTI caused the sepsis as wound deterioration is still a strong possibility.
• All staff involved in wound management are competent in appropriate management and familiar with the relevant guidance.
• Pathway to be developed to ensure timely referral to tissue viability specialist for deteriorating or non-healing wounds.
• Recommendations added to the SAER to address learning and improvement around wound assessment, management and antimicrobial stewardship.
• Staff to be reminded of Stage 3 of the Scottish Ropper Ladder for Infected Wounds, and consideration of antibiotics.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that their late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable.

The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals.

We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve.

We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care.

Therefore, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.
• Significant Adverse Event Reviews should be a reflective and learning process that appropriately considers events in sufficient detail, to ensure failings are identified and any appropriate learning and practice improvements.
• When appropriate, patients should be reviewed by a GP either by phone or in person dependant on their symptoms.
• When necessary and required, patients receiving treatment from the nursing team should have their care appropriately reviewed and discussed with a GP.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained on behalf of their partner (A) about the care and treatment they received from the practice. A was prescribed an anti-inflammatory drug by a rheumatology consultant (specialists in diagnosing and managing chronic inflammatory conditions). The medication was issued on repeat prescription by the practice. C told us that the medication had risks and the practice failed to carry out appropriate medication reviews or update A about the risks. C said A was not aware of the risks of the medication and trusted that it was safe to use long-term. They felt it was unreasonable for the practice to assume A would have read the leaflet with the medication to identify any changes or to know to ask for a medication review.

The practice said that the medication was prescribed by the rheumatology service and would have been monitored by them. The practice highlighted that at the time the medication was prescribed, it was not considered high risk, and that the risks only became known after A had been prescribed the medication for a number of years. The practice noted that A did not proactively contact the practice to review their medication periodically but acknowledged that they did not contact A either.

We took independent advice from a GP. We found that national guidance states that patients should have annual checks when taking medication of this sort. The responsibility for carrying out these checks lies with whoever is issuing the prescription. When discharged from the rheumatology service, the practice should have invited A for a review and arranged appropriate follow-up. The practice should have carried out medication reviews and informed A about the change of risks associated with the medication.

We found that it was unreasonable for the practice not to have carried out medication reviews or informed A about the change in risks. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failingto alert them to the changes in risks associated with the medication, having a discussion about the risks, and allowing them to make an informed choice on whether or not to continue with the medication; failing to carry out medication reviews annually as they should have done; and failing to invite A to a review of their health when the practice became aware they were discharged from the rheumatology service. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• GPs should recognise that as the prescriber of the medication it is their responsibility to carry out medication reviews on medications provided via repeat prescription. When a GP is alerted to the fact a patient is discharged from a secondary care service due to non-attendance, they should contact the patient to arrange a review and consider appropriate follow-up. Medication reviews should be carried out annually.
• When medication alerts are issued nationally, the practice should identify and review any of their patients to whom such an alert might apply.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after.

C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care.

C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes.

C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint.

C also complained that the practice failed to reasonably respond to C's concerns. We found that the identified failure should have been communicated to the family, by the practice, during their investigation of the family's complaints. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the failure to act with sufficient urgency following A's discharge. The apology should meet the standards set out in the SPSO guidelines on apology. available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the complaint investigation's failure to identify a failing in A's care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• The practice should ensure relevant staff are aware of the need to document discussions about patient care appropriately, in this case discussions between a trainee doctor and their Educational Supervisor, concerning a patient's care.
• Complaint investigations by the practice should address all relevant issues and should clearly identify and address any failings.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.