Upheld, recommendations

Summary

C, a support and advocacy worker, complained on behalf of their client (B) about the care and treatment provided to B's spouse (A). A experienced urological symptoms including blood in their urine and a number of infections. After a number of investigations, A was diagnosed with bladder cancer which had spread to their prostate. A died a short time later.

C raised a number of complaints and we agreed to investigate four main concerns: that the board failed to provide a reasonable standard of urological treatment following insertion of a catheter, the delay in diagnosing A’s cancer; poor communication with B and A, and A’s poorly managed discharge from hospital.

We took independent advice from a consultant urologist.

C raised concerns that A’s catheter had to be refitted a number of times, which was difficult to do and caused A pain and discomfort. The board explained that a catheter is commonly fitted after surgery and a permanent catheter was fitted due to A’s past urology history and difficulty in emptying their bladder. We found that whilst it was reasonable to insert a catheter, the reasoning behind the decision was poorly documented and that as A required a number of emergency admissions for catheter related issues, the board should have considered an emergency cystoscopy (a procedure that uses a tube to examine the bladder and the urethra) and TURP (transurethral resection of the prostate) and they failed to do this.

Whilst it is agreed that A’s case was complex and a number of investigations were required, we found that there was a delay in arranging a diagnostic cystoscopy following an emergency admission, a breach of the waiting time target for cancer referrals and a failure to recognise the significance of paraaortic lymphadenopathy (lymph nodes of an abnormal size) which contributed to the delay in diagnosis of A’s cancer. We accepted that had this delay been avoided, A’s outcome likely would have been the same, although their quality of life would have been improved.

With regards to communication, we did not identify any issue with the volume or frequency of communication with A. However we concluded that important medical details were overlooked or not explained clearly, such as A’s urological diagnosis and overall management plans.

Our investigation also concluded that whilst it was appropriate to discharge A home due to their condition being manageable with pain relief and antibiotics, there was a failure to ensure adequate pain relief would be available to A.

We upheld all four complaints and made appropriate recommendations for learning and improvement.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues highlighted 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 A’s case be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A’s diagnosis and ways of ensuring similar delays do not affect future patients.
• That the board review the record keeping in A’s case and take steps to ensure their junior doctors and trainees are receiving adequate training in good medical record keeping and that senior clinicians are reminded of their responsibility to maintain sufficiently detailed records of discussions with patients and relatives.
• That the senior staff involved in A’s care be asked to reflect on the way that bad news was delivered on this occasion, and in general, with a view to ensuring they do so in as inclusive and compassionate a way as possible and with reference to the MDU guidance on breaking bad news.

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 the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate.

C complained about the care that they received from the board during two hospital admissions. In particular, that staff were unprofessional and unempathetic and became impatient and abrupt when C was unable to do as staff asked.

We took independent advice from a senior nurse. We found that there was a lack of communication and understanding of C’s cognitive impairment which resulted in staff not fully understanding the issues C was dealing with on a daily basis and the challenges their diagnosis presents. There was also a lack of appropriate care planning and a failure to complete all documentation and risk assessments. This led to a failure to provide reasonable emotional and psychological care to C whilst an inpatient, a poor patient experience for C and anxiety over future hospital care. Therefore, we upheld C's complaint.

In addition, we also found that the board’s response to C’s complaint was poor and did not demonstrate the learning or improvement required.

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:

• Documentation and communications regarding care needs should be highlighted at admission, with all relevant risk assessments completed reflecting accurate assessment and planning of care needs. Care plans should be person-centred to incorporate patients who have a cognitive impairment.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the Model Complaints Handling Procedures (www.spso.org.uk/the-model-complaints-handling-procedures). The board should fully investigate and address the issues raised and appropriately 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 that social work did not adequately safeguard their child (A) when they disclosed that they had been a victim of assault. C also complained that they were not informed of the incident. The council considered that appropriate support had been offered to A.

We took independent advice from a social work adviser. We reviewed the relevant case records and the council’s child protection procedures. We found that the council failed to meet their obligations and take the appropriate action in response to the disclosures made by A. We found that there was sufficient concern about A’s ability to maintain their wellbeing and that social work should have instigated their child protection procedures. We also found that there was insufficient recording within the case records of a clear plan and rationale to explain decision making. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to meet their obligations and correctly apply their child protection procedures in response to the disclosure made by A. 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:

• Case records should include details of discussions held with relevant persons, rationale for any decision making, and evidence of risk assessments, where appropriate.
• Staff should be familiar with the requirements of the council’s child protection procedures and have a clear understanding of when an Inter-agency Referral Discussion should be held.

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 council’s handling of a planning application. C’s next door neighbour made a retrospective application for planning permission for the erection of a garden room/store and timber fencing to the boundary at the rear of the property. This followed an earlier enforcement enquiry in respect of the garden room structure being erected without the necessary permission in place.

C objected to the planning application through a solicitor on the basis that it constituted overdevelopment and would adversely impact neighbours’ residential amenity and did not contribute towards quality place making. Planning permission was granted with no conditions attached.

We took independent advice from a planning specialist. We were satisfied that the assessment of the impact of the fence was an issue of discretion and that carrying out site visits and allowing additional comments/objections to the planning application were matters of planning judgement. Whilst we found that the council did reach the right planning decision, we considered that there had been a lack of clarity and explanation and that the council’s calculations in relation to the coverage of rear curtilage in the Report of Handling were ambiguous and are not in line with the relevant guidance. On balance, we upheld the complaint.

Recommendations

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

• Case officers should be aware of how to measure curtilage areas and calculate the proportion proposed to be built upon. The calculation should be clearly set out and a record made.

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 health and social care partnership’s (HSCP) investigation of a medicine protocol breach identified at their relatives (A) care home in the week before A's death. A social worker investigated the breach in response to an Adult Support and Protection (ASP) notice raised by the care home, and determined that no further action was required. Separately, the Care Inspectorate had investigated other concerns raised by C about the care and treatment provided to A, including the medicine protocol breach. The Care Inspectorate’s investigation identified failings and made recommendations for improvement. In light of this, C contested the partnership’s position, indicating their view that the investigation was faulty, particularly noting the outcome of the Care Inspectorate’s investigation of the same matter.

C received a stage two complaint response letter from the partnership. We considered the response had not fully considered C’s concerns, therefore, we asked the partnership to provide a further response to C’s complaint. C remained dissatisfied with the partnership’s second response.

We took independent advice from a social work adviser. We found that the partnership had a duty to investigate the concerns raised in keeping with ASP legislation. We noted that this matter had been investigated by a single social worker. However, we found that the Care Inspectorate were better placed to investigate the matter in keeping with the Health and Social Care Standards, with the partnership’s role being to liaise with the Care Inspectorate and the care home regarding the outcome and recommendations. While the social worker’s report was in itself reasonable for an inquiry, we found that it was better suited to be used in collaboration with the other relevant agencies. We upheld the complaint.

We also upheld a complaint about complaint handling, noting that C had not been made aware that their concerns were being managed in line with the complaint handling procedure, that the matters to be investigated had not been confirmed at the start of the process and that the complaint responses did not fully address C’s concerns.

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:

• The partnership should reflect on this decision, particularly taking into account the professional judgement and the decision-making process applied in this case, in reference to the guidance and how this is interpreted in practice.

In relation to complaints handling, we recommended:

• The partnership should ensure complaints are correctly identified and processed in accordance with their complaints handling procedure. Responses to complaints should be clear and answer the points of concern raised.

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 ophthalmology treatment (the branch of medicine that deals with the anatomy, physiology and diseases of the eye) that they were provided by the board. They were referred by a consultant (Doctor 1) for a second opinion from a corneal specialist. C complained that they should have been seen by a consultant (Doctor 2) but were instead treated by a junior doctor (Doctor 3). Additionally, C complained about the treatment provided by Doctor 3 and the decision to discharge them from the ophthalmology service.

We took independent advice from a consultant in ophthalmology. We found that it was clear that Doctor 1 intended a specialist to examine C and that this did not happen. Although it may have been reasonable for C to have been seen by a junior doctor in clinic, there should have been clinical oversight by Doctor 2, with direct input to C’s management plan. We found that it would have been good practice for the outcome of the consultation to be reported back to Doctor 1, copying the letter to the GP and C. Instead, the outcome was only reported to C’s GP. We upheld this complaint. We also found that Doctor 3 should have tested C’s eye pressure before prescribing fluorometholone (a mild steroid). We upheld this aspect of C’s complaint. Finally, we also found it was unreasonable for the board to discharge C from their ophthalmology service, when Doctor 1 had agreed to follow-up in one year. We upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings our investigation has identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• When apologising to C, the board should address their treatment plan and communications in relation to their discharge.
• The board should offer C a further consultation with Doctor 1, given they had agreed to a follow-up consultation with C.

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

• Clinical staff ensure that they write back to the referring clinician, copying to the GP and patient.
• Eye pressure is tested, in accordance with good clinical practice, prior to FML being prescribed.
• Where a tertiary consultant to consultant referral is made, the consultant should be aware that the case is there for their specialist opinion and provide some direct input to their management plan.
• Where referrals are made for a second opinion, the patient is discharged back to the referring clinician.

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 the practice had prescribed them with Hormone Replacement Therapy (HRT) for a period of approximately four months despite knowing that they were trying to conceive. C said that they had subsequently attended a fertility clinic and were advised by a specialist that HRT would have a negative impact on their fertility. The practice identified learning and improvement from C’s complaint. They apologised to C for the frustration and distress caused to them by their experience.

We took independent advice from a GP adviser. We found that it was unclear from the medical records if the prescription of HRT was fully discussed with C to ensure that they understood the implications on their fertility and general health. We found that it was unreasonable for the practice to have prescribed C with HRT in the absence of their clear informed decision. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the prescription of HRT in the absence of their clear informed decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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’s spouse (A) was provisionally diagnosed with torticollis (a condition in which the head becomes persistently turned to one side) by their GP resulting in a routine referral to orthopaedics (specialism in the treatment of diseases and injuries of the musculoskeletal system). A’s symptoms continued to worsen and their referral was upgraded to urgent. A had a telephone call with an orthopaedic consultant and an MRI scan was organised. The pain continued to intensify despite strong medication. A presented to the out-of-hours service and also to A&E with worsening pain in their neck. A was referred to the hospital by their GP and advised that they were terminally ill with bladder cancer which had spread to the spine. A later died.

C complained to the board with concerns about A’s initial referral to orthopaedics not being treated as urgent, for the delay for an MRI scan, for orthopaedics not being consulted by A&E and further testing not being arranged. C additionally complained about the lack of process for a patient to be moved up the list of clinical priority when presenting to A&E. The board’s response indicated that no red flags were raised in the initial referral, that the orthopaedic consultant organised an MRI scan after speaking with A and that the out-of-hours assessments did not identify immediate orthopaedic review was required. The response also noted that A&E noted a plan was in place for further investigation, that there was no emergency issue which required immediate referral and that the GP was best placed to expedite further care with the orthopaedic team.

We took independent advice from a trauma and orthopaedic consultant, a GP and a consultant in emergency medicine. We found that it was reasonable for orthopaedics to treat the original referral as routine, but it was unreasonable that there is no evidence of a clinical summary of the orthopaedic consultation, and thereby no evidence that red flags were explored. We upheld this aspect of the complaint. We found that it was unreasonable that a more detailed history and clinical examination was not undertaken at the out-of-hours consultations, especially of red flags. We upheld this aspect of the complaint. We found that it was reasonable that A&E did not refer A urgently to another speciality or arrange further investigation or immediate assessment. We did not uphold this element of the complaint.

We also found that the board failed to identify that a Significant Adverse Event Review should have been carried out and that their complaint response did not clarify that it was a joint response with a second board, resulting in a lack of clarity and transparency.

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:

• Orthopaedic telephone consultations should be recorded, including evidence that any possible red flag symptoms have been explored and considered.
• Patients should be examined thoroughly and a clear history should be taken which considers the presence or absence of red flag symptoms.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to dealing with complaints which span more than one NHS board.

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 the partnership did not provide reasonable care and treatment to their parent (A). A was admitted to hospital on three occasions during one month following falls. After their third admission, A was discharged to C’s home due to the COVID-19 pandemic. A week later, A was admitted to another hospital and was diagnosed with a lumbar (spinal) fracture and incomplete spinal cord damage. C raised a number of complaints with the partnership about the care and treatment A received and about their discharge.

The partnership did not indicate any concerns about A’s care and treatment or discharge but noted that discharge planning had been disrupted due to the COVID-19 pandemic. The partnership also undertook a Significant Adverse Event Review (SAER).

We took independent advice from an appropriately qualified adviser. We found that the partnership did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of changes in A’s condition. Therefore, we upheld this part of C’s complaint.

In relation to A’s discharge, we found no clear evidence that the concerns expressed by the physiotherapist about deterioration were assessed before the decision to discharge A was made. Therefore, we considered A was unreasonably discharged and upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A’s family that partnership staff did not reasonably document communication, from physiotherapy staff to medical staff, of the observation of increased leg weakness in A, that concerns expressed by physiotherapy staff about deterioration in A were not assessed before the decision to discharge A was taken and that the findings of the SAER were not shared with A and their family. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets. Enquire whether A’s family wish to meet with the hospital manager and lead nurse and, if so, arrange and hold that meeting.

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

• Communications related to changes in patient care or decisions are reasonably documented.
• Decisions to discharge always take into account the circumstances of the patient at the time, and that if any change in a patient’s condition could affect the decision to discharge them, this must be considered at the time.

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) during an admission to hospital. At the time of admission, A was taking medication for atrial fibrillation (a heart condition affecting the rhythm and rate of the heart). The medication included a blood-thinner to reduce the risk of blood clots. While A’s condition was being assessed, a decision was made to withhold this medication. A developed pain and discolouration in their leg and was unable to weight bear. C complained that there was a delay of 12 hours before medical staff acted upon this. A required a transfer to another hospital by ambulance, where they underwent emergency surgery for clots in the leg. A has been left with deep incisions in the lower leg and their mobility has been significantly reduced.

The board discussed the case at a Morbidity and Mortality meeting, and following review of the circumstances did not think that there was anything from a system perspective that should be changed.

We took independent advice from a consultant physician and geriatrician (specialist in medicine of the elderly). We found failings in record keeping and examination. We found that the board ought to have been alert to the risk of A developing blood clots after the blood-thinning medication was withheld, and should have acted more promptly when A started to deteriorate. We considered that A suffered pain for a longer period because their deterioration was not recognised in a timely manner. Their situation might not have been so serious had their condition been recognised sooner. We also found that the board did not carry out a suitably rigorous analysis of what happened, including review by staff who were not involved in A’s care. The board’s review failed to identify appropriate learning. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failings our investigation has 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:

• Before reaching a decision to stop anticoagulant medication in patients with atrial fibrillation, full consideration should be given to the risks and benefits of doing so. Clear records of patient care should be maintained, with all patient examinations documented. Deterioration in patients should be escalated appropriately including clinical examination where merited. Staff are confident in identifying adverse events and conducting appropriate reviews.

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.