Upheld, recommendations

Summary

Mr C's GP had referred him to the board in November 2014 as he required the removal of his gallbladder. Although Mr C was not a resident in the board area he had received previous treatment there and his daughter lived nearby. The plan was that Mr C would stay with his daughter on his discharge following the surgery and the board had indicated that they were willing to accept him for surgery on this basis. Mr C emailed the board three times in January 2015 as he had heard nothing more. He was then advised that the board could not accommodate the GP's referral, and that the board had referred him to the health board where Mr C was resident. Mr C complained about the delay by the board in responding to his GP referral.

The board apologised for the delay in responding to Mr C's emails and explained that the reason they could not carry out the surgery was due to pressure on their services and that to accept a referral from another health board would put added pressure on an already pressured system. We upheld the complaint and found that between November 2014 and January 2015 there was no action taken regarding the GP referral as two staff members thought the other was dealing with the matter.

Recommendations

We recommended that the board:

• ensure that the staff members who considered whether to action the GP referral reflect on their actions and discuss the complaint at their next appraisal.

Summary

Mrs C complained about the care provided to her late mother (Mrs A) by Forth Valley Royal Hospital. Mrs A had dementia and was admitted to the hospital suffering from a urinary tract infection and increased confusion; she was noted to be generally unwell. One evening, Mrs A fell out of bed just before 21:00 but Mrs C was not told about this until the following morning.

Mrs A had been reviewed by a doctor and her head and shoulder were x-rayed, but despite having pain in her leg this was not x-rayed. Three days later, after Mrs C pointed out to nursing staff that Mrs A's foot was at an odd angle and she was in severe pain, an x-ray was done and it was found that Mrs A had broken her hip. Remedial surgery was considered but due to Mrs A's on-going and recurrent infection and her general frailty, it was agreed with the family that only palliative (end of life) care was appropriate. Mrs A died less than a fortnight after her fall.

Our investigation included taking independent medical advice from two of our advisers, a doctor specialising in care of the elderly and a senior nurse. The advisers found some evidence of reasonable care, especially in Mrs A's initial care - but they were critical of the lack of communication with Mrs C about Mrs A's fall and later about what happens when a patient dies in hospital; the delay in diagnosing Mrs A's broken hip; that at one time Mrs A's notes were missing and later found in another patient's room - resulting in a delay in prescribing pain relief for Mrs A; and that when surgery was still being considered, Mrs A was found to have an incorrect identification wristband on.

Recommendations

We recommended that the board:

• ensure that all staff involved in this complaint are made aware of our findings and reflect on them to inform their future practice;
• consider the introduction of an information leaflet for relatives explaining the procedure when a patient dies in hospital;
• remind staff involved in this complaint of the requirements of the General Medical Council and Nursing and Midwifery Council guidance on record-keeping, and in particular with regard to protecting patients' confidential information;
• ensure that staff involved in this complaint are reminded of the importance of good, and timely, communication with relatives where patients have sustained a fall and/or injury while in hospital; and
• issue a written apology for the failings identified during this investigation.

Summary

Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop the treatment, but they did not tell Mr A's GP that they had done so. The GP didn't found out that Mr A required palliative care until a home visit three weeks later.

In response to Mrs C's complaint, the board said the consultant in charge was unable to locate the letter he dictated after meeting with the family. The board apologised for this and said that the consultant would try to ensure that in future information is passed on appropriately. Mrs C was dissatisfied with the response, as the board did not explain whether the letter was in fact dictated or typed, or whether the consultant had any recollection of signing it. Mrs C also considered that the board's response was not robust enough to prevent a reoccurrence of the situation, and she brought her complaint to us.

After taking independent medical advice, we upheld Mrs C's complaint. We found that the consultant had failed in his responsibility to inform the GP of Mr A's discharge (with the most likely explanation being that the letter was never dictated). We were also critical that the consultant did not give a clearer response to Mrs C's complaint, as this could have resolved it at an earlier stage. We noted that the board had already apologised to Mrs C and taken steps to improve their system for signing letters. As the failing in this case appeared to be caused by human error, rather than a system failure, we considered that asking the consultant to reflect on his practice was an appropriate and proportionate response.

Recommendations

We recommended that the board:

• bring the findings of our investigation to the attention of the relevant consultant, for reflection as part of his next annual appraisal.

Summary

Mr C has a history of back problems. He complained that he was only given an x-ray for his back pain and had to arrange for a magnetic resonance imaging (MRI) scan privately because a clinician at Dumfries and Galloway Royal Infirmary refused him one. Unlike an ordinary x-ray, MRI shows the soft structures in the spine such as disc, nerves, ligaments and muscles.

In response to the complaint, the board said that Mr C had an increase in back pain with no new symptoms and there was no indication that an MRI scan would be needed in accordance with national guidance on the early management of persistent non-specific low back pain.

We took independent advice from our medical adviser who said that Mr C's presentation was not straightforward and did not properly fit with the diagnosis of non-specific low back pain or any existing spinal guideline. The medical advice we received was that Mr C should have been assessed for the possibility of spinal cord compression and either have had an MRI scan or his case discussed with a spine specialist given he had a pre-existing deformity of his spine and had several red flags (symptoms that are likely to indicate a particular serious illness). We only found records to show that an orthopaedic specialist had interpreted the x-ray but no evidence to show that the specialist was aware of the red flags and the pre-existing deformity.

Recommendations

We recommended that the board:

• apologise for the failings identified;
• review their local guidance with a view to including information on spinal presentations, such as spinal deformity and myelopathy pathologies;
• ensure the clinician reflects on the shortcomings in their next appraisal; and
• consider reimbursing Mr C for the cost of the private MRI scan on provision of appropriate receipts.

Summary

Mrs C's mother (Mrs A) was admitted to Dumfries and Galloway Royal Infirmary following a fall at home. She had previously been diagnosed with Alzheimer's disease and was noted to be confused upon admission. Staff found no evidence of bone fractures, but kept Mrs A in hospital until her mobility improved. A few days following her admission, Mrs A began vomiting. Medical staff suspected a bleed in her stomach and proposed an endoscopy (a camera inserted into the stomach to find the source of the bleed). Mrs A was fasted for the procedure, but it was delayed on several occasions due to a lack of patient consent.

Mrs C complained that her mother was fasted unnecessarily on a number of occasions in preparation for the procedure. She noted that staff had been informed that she had power of attorney for her mother (a legal document appointing someone to act or make decisions for another person) and complained that she was not asked to provide consent for the procedure. She also complained about Mrs A's hygiene, the monitoring of her fluid intake and poor communication from staff.

We were critical of the board's handling of the consent for Mrs A's procedure. There are clear guidelines for obtaining consent from patients who lack capacity to discuss their own treatment and these were not followed. The record-keeping in Mrs A's case was very poor and suggested a lack of consultant review over a number of days during her admission. We were critical of this, and the lack of discussions with Mrs C regarding Mrs A's treatment plan. We also found the staff's communication to be poor with no proactive plan to discuss Mrs A's care with Mrs C. This led to impromptu discussions in open corridors which we found to be inappropriate.

Recommendations

We recommended that the board:

• conduct an audit of the relevant ward's compliance with malnutrition universal screening tool, falls risk, and adults with incapacity responsibilities;
• review the standard of record-keeping in Mrs A's case and identify any requirements for additional staff training;
• provide us with details of the outcome of the Endoscopy User Group's review and the action taken to prevent further consent issues;
• apologise to Mrs C for the inadequate level of care and treatment Mrs A received during her admission at the hospital; and
• ask senior staff responsible for the relevant ward to review how staff communicate with family members to ensure regular, proactive, communication with particular emphasis on complying with the national standards for care of dementia patients.

Summary

Ms C, an advocate, complained to the board on behalf of her client (Mrs A) about the care she received at A&E at Borders General Hospital after she had fallen at home. Mrs A had fractured a bone in her arm and was discharged home the same day. The following day, she returned to the hospital in significant pain and further tests showed that she had fractured her kneecap and had bone cancer. Ms C also complained about a delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy.

We took independent medical advice from a consultant in emergency medicine who considered that Mrs A did not receive a reasonable standard of treatment when she initially attended A&E. There was insufficient evidence to show that the emergency doctor had carried out a thorough examination of Mrs A's joints below the fracture or her lower limbs despite ambulance staff having documented bruising to the right knee. We also took independent medical advice from an orthopaedic consultant who considered that the one day delay in identifying the fractured kneecap was unlikely to have impacted on Mrs A's overall outcome. However, we also found that Mrs A's significant pain level was not reassessed prior to being sent home and had it remained high, then she may have required intravenous morphine and admission to hospital. There was also no evidence to show that any assessment had been carried out of how she might manage at home and who was able to care for her if required.

In considering Ms C's complaint about the delay in Mrs A being reviewed by an orthopaedic specialist and physiotherapy, our orthopaedic adviser told us the eight week delay in Mrs A being reviewed was unlikely to have had a detrimental effect on the healing of her arm fracture. However, given she was to be reviewed within three weeks we found the delay in this case to be unreasonable.

We upheld all of Ms C's complaints, although we noted that the board had apologised to Mrs A that the pain relief they gave her was inadequate and acknowledged that a mistake had been made in her not being referred to the orthopaedic clinic and physiotherapy for further review. They also arranged for the hospital's discharge procedure to be reviewed with a view to making improvements in order to prevent the matter recurring. However, we made recommendations which related to the treatment of Mrs A when she initially attended the A&E department.

Recommendations

We recommended that the board:

• apologise to Mrs A for the failings identified; and
• ensure that the emergency doctor reflects on the failings and confirm when this has been done.

Summary

Mrs C complained about her discharge from a private hospital, which she had been admitted to for NHS-funded hip replacement surgery. She felt she was not fit to be sent home as she had severe diarrhoea, which she blamed on being given too many laxatives on the day of discharge. She needed to be admitted to hospital a few days later, where she remained for over four weeks. The board said that she had not been given any laxatives on the day of discharge and they considered that she had been fit to go home.

We took independent advice from one of our medical advisers and he said there was no evidence of Mrs C having been given laxatives on the day of her discharge. However, he did not consider that her bowel symptoms had been properly investigated and treated prior to sending her home. He said there seemed to have been undue focus placed on meeting the planned discharge date rather than ensuring Mrs C was fit to go home. As such, Mrs C required prompt readmission to have her bowel symptoms addressed. The adviser also noted that the records from Mrs C's admission lacked the detail that could reasonably have been expected. We accepted this advice and upheld the complaint.

Recommendations

We recommended that the board:

• confirm that the identified failings will be discussed at the consultant's annual appraisal;
• remind staff of the importance of comprehensive record-keeping; and
• apologise to Mrs C for the identified failings in her care.

Summary

Mrs C complained about the treatment her late father (Mr A) received from the board. Mr A had died soon after being diagnosed with cancer and Mrs C felt his treatment had been unreasonably delayed (she was aware that her father was very unwell but felt things could have been handled better, including providing end of life care sooner). Although the board had acknowledged certain delays to Mrs C and said they would recruit additional staff, she remained dissatisfied and brought her complaint to us.

We considered whether Mr A's treatment at University Hospital Ayr was reasonable in the circumstances at the time. We took independent medical advice which confirmed that Mr A's cancer had been a very rare and complex kind. Our adviser, having reviewed the records, also said that Mr A's initial treatment pathway had been reasonable and confirmed that Mr A had not fallen between the cracks of different clinical disciplines (Mrs C had been concerned about this). However, our adviser said the delay for a subsequent investigation that was needed for Mr A's diagnosis and treatment was unreasonable and also that end of life care should have been discussed sooner than it was.

We found the evidence indicated that Mr A's condition was complex and that his initial care was reasonable. However, we considered the delay to his subsequent investigation to have been unreasonable as was the delay in discussing end of life care. We upheld Mrs C's complaint and made three recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings we identified;
• confirm to us that they have taken steps to recruit the staff detailed in their correspondence with Mrs C; and
• ensure that our adviser's comments about Mr A's end of life care are fed back to the relevant staff.

Summary

In 2002, Mr C purchased an outhouse behind his home. The outhouse had previously been used for commercial purposes and was rated by the Scottish Assessor's Asssociation (SAA) as a non-domestic property. In April 2013, Business Stream issued Mr C with an invoice for water used at the outhouse. The outhouse had been identified as a gap site (a property that is listed as non-domestic and, therefore, liable for water charges, but that has not been charged to date). The invoice was backdated to 2008 and covered a period of six years. Mr C complained, stating that the outhouse had no water supply of its own. Whilst he had installed a toilet in 2012, the water for this had been diverted from his domestic supply, which he paid for through his council tax.

Business Stream considered the charges to be legitimate, as the outhouse was listed as a non-domestic property and Mr C had access to water via his home. They advised that the only way the charges could be cancelled was for Mr C to appeal the outhouse's non-domestic categorisation with the SAA.

We found that Business Stream had failed to check what water services, if any, were in place at the outhouse before 2012. We referred to a previous ombudsman ruling that it is not reasonable to charge for water services that are not being provided, and concluded that no water charges could be applied to the outhouse prior to 2012. We also found that there had been a significant delay to Mr C's outhouse being identified as a gap site. Although Mr C had appealed the non-domestic listing with the SAA, the outhouse remained a non-domestic property and we were satisfied that it was reasonable to apply charges after 2012 in line with normal water industry practice.

Recommendations

We recommended that Business Stream:

• cancel all charges on Mr C's account prior to 1 January 2012;
• apply a ten percent discount to all charges on Mr C's account between 1 January 2012 and 31 March 2014; and
• apologise to Mr C for the incorrect calculation of charges for the outhouse.

Summary

Mr C complained that the prison unreasonably failed to make appropriate arrangements for him to attend court. In their response to his complaint, the prison told Mr C that he had not requested to go to court and, in any event, prisoners would not be ordered to attend civil hearings. In support of his complaint, Mr C provided a copy of the court order which confirmed that the sheriff had asked him to appear. He also provided a note that had been typed by an officer which said he was to attend court and confirmed that a manager had given Mr C permission to take paperwork with him.

Based on what the Scottish Prison Service (SPS) told us, there is no clearly understood process in place that outlines what arrangements can, or should, be made to enable a prisoner to attend a civil hearing at court and whether a prisoner would pay for the transport. The decision on whether to allow a prisoner to attend that type of hearing appears to be a discretionary one for the governor and that is not unusual. Governors have a wide range of discretion. However, it is important that the process for seeking and obtaining approval in a situation like Mr C's is clear and understood.

Having examined the information available in Mr C's case, and having asked the SPS for more information, it was not clear exactly what happened in Mr C's case or what should have happened. The SPS told us that Mr C did not ask to attend court or inform prison staff that he had been ordered to appear. However, the note typed by an officer indicated that Mr C was to attend court and had been given permission to take paperwork with him. In our view, the note suggested that Mr C did inform staff that he was to attend court but it was not clear whether he specified that it was for a civil hearing. Nevertheless, we considered the typed note indicated that an officer and a manager discussed Mr C's attendance at court with him and because of that, we believe proper steps should have been taken to explore whether Mr C had been ordered to attend court and whether transport should be arranged. Those steps did not happen in Mr C's case and, therefore, we concluded that the prison unreasonably failed to make appropriate arrangements to allow him to attend court and we upheld the complaint.

Recommendations

We recommended that SPS:

• reflect on Mr C's case and consider what steps can be taken to avoid the same thing from happening again;
• feed back any learning to both us and Mr C; and
• provide a letter for Mr C to give to the sheriff outlining why he did not attend court on the date ordered.