Upheld, recommendations

Summary

Mrs C's daughter (Ms A) was admitted to Forth Valley Royal Hospital after taking an overdose of a mixture of medications, including venlafaxine (an anti-depressant) and propanolol (a beta blocker, used to treat conditions such as heart problems, blood pressure and anxiety), which are absorbed into the system slowly. She had called an ambulance herself and was taken to the emergency department, where she was seen immediately by a staff nurse. She was assessed before being seen by a trainee doctor. Ms A was groggy and her blood pressure was low. She was treated with intravenous fluids (fluids put directly into a vein). Blood tests and an electrocardiograph (a test that records the electrical activity of the heart) were also arranged. Over the following hours, Ms A's blood pressure remained low. Around seven hours after being admitted she began to have seizures and breathing difficulties. Her condition deteriorated further and the intensive care unit was asked to review her. Shortly afterwards, Ms A's heart stopped. Attempts were made to resuscitate her and she was treated with glucagon (medication used to increase blood sugar levels, which can be used in the treatment of propanolol overdose). This failed to improve her condition, however, and she died.

Mrs C complained that staff did not provide glucagon until it was too late. She considered that, had this medication been provided earlier, Ms A might have survived. She also complained about the board's record-keeping. The board said in response to her complaint that glucagon is not the first line of treatment for propanolol overdose and, as Ms A had been responding to intravenous fluids, it was not considered a necessary treatment for her at the time.

After taking advice on this complaint from one of our medical advisers, who is a consultant in emergency medicine, we upheld both of Mrs C's complaints. The adviser reviewed Ms A's medical records, and said that she had not been responding adequately to the intravenous fluids and that glucagon should have been considered far sooner. Although we found evidence that clinical staff consulted TOXBASE (the national poisons information database) we were critical that there was a delay in doing so. We found that Ms A's overdose would have been treated differently had the guidance been consulted and followed earlier in her admission. We were also critical of the board's record-keeping. Important information about medication had been lost from Ms A's records and there was no documented record there of staff having consulted TOXBASE.

Recommendations

We recommended that the board:

• provide a copy of our decision letter to the doctor to ensure that he is fully aware of the outcome of our investigation and discuss any learning points with him at his next appraisal;
• apologise for the lack of appropriate record-keeping in this case; and
• remind all nursing and medical staff of the importance of maintaining accurate contemporaneous records.

Summary

Miss B and Miss C complained that the nursing and physiotherapy care and treatment given to their mother (Mrs A) in hospital was inadequate. They said that although their mother had advanced dementia she had been living an active life. Although not independent, she had been fully mobile unaided, eating by herself, interested in her surroundings and reading and talking. However, after she was discharged from hospital she had a urine infection and pressure ulcers on her heels. She was immobile, and no longer able to swallow tablets or eat solid food. She also took little notice of her surroundings and did not talk. Her daughters believed that this was a result of what happened in hospital.

Our investigation considered all the relevant documentation, including the complaints correspondence and Mrs A's medical records. We also obtained independent advice from two of our advisers (a nursing adviser and a physiotherapist). We upheld the complaint, as our investigation found that there were aspects of Mrs A's care and treatment that were unsatisfactory. A care plan should have been put in place when Mrs A's heels became discoloured. Although we found no evidence that Mrs A developed a urine infection while in hospital, we found that her medical records lacked detail. The content of the physiotherapy treatment provided was appropriate, but the frequency of treatment was not. It was not in accordance with Scottish Intercollegiate Guidelines Network (SIGN) guidelines and was inadequate, although our adviser noted that the outcome was unlikely to have been different even with more sessions. We also found that Mrs A's overall management and treatment lacked documented evidence of planning and what was done. There was also no documented evidence of discharge planning or contact with community physiotherapy about follow-up treatment.

Recommendations

We recommended that the board:

• provide the Ombudsman with a copy of the board's own implementation plan relating to the national standards for dementia care implemented in 2011;
• undertake an audit of current practice of skin care in the hospital and report back to the Ombudsman;
• provide the Ombudsman with a copy of an action plan to illustrate learning from this complaint in relation to the prevention and management of pressure ulcers;
• provide the Ombudsman with a copy of an action plan to address the failings identified in relation to medical records;
• apologise to Miss B and Miss C for the failings identified;
• review their processes to ensure that they meet relevant standards;
• remind physiotherapy staff of the need to maintain full and accurate records in line with the Chartered Society of Physiotherapy guidance; and
• bring the issues raised in this complaint to the attention of the physiotherapy staff involved to see if lessons can be learned, and report back to the Ombudsman.

Summary

Ms C complained that the Care Inspectorate unreasonably delayed in dealing with her complaint, which was related to her late brother sustaining a serious injury whilst receiving 24-hour care. Ms C was unhappy that they did not explain why there had been a delay, and that they failed to explain what matters were outwith their jurisdiction and why.

We considered that taking a year to investigate Ms C's complaint was unreasonable even although the Care Inspectorate had experienced difficulties in agreeing all of the issues to be investigated. We upheld the complaint, although we did find that after this they conducted a thorough review of how they had handled Ms C's complaint, to ensure that they adopted a more cohesive and coordinated approach towards future complaints. They also identified a number of factors that impacted on the time taken to respond. Whilst the Care Inspectorate had acknowledged that there was a delay in progressing their investigation, we also found that Ms C was not told about this or the reasons for it until she contacted them. We were critical that it then took a further four months for them to clearly explain that they were unable to look into an aspect of her complaint.

Recommendations

We recommended that the Care Inspectorate:

• provide the Ombudsman with evidence that action has been taken to address the failings identified in the review they conducted;
• ensure timely investigations are conducted into complaints that have been agreed, whilst giving prompt consideration to those complaints that require further agreement prior to investigation;
• ensure that complainants are notified about delays and given clear reasons for the delays in a timely manner; and
• provide a written apology to Ms C for the failings identified.

Summary

Mrs C applied to the council for assistance through a community care grant. This is available to help people on a low income live independently in the community and is paid out of the Scottish Welfare Fund, which is a national scheme delivered by local authorities. Mrs C applied to the scheme mainly for help with purchasing household items, including carpets and curtains. The council decided not to award Mrs C assistance for carpets and curtains because they said her circumstances did not match the situation with which community care grants were set up to help. They said she purchased the items herself before the decision on her application was made, and pointed out that they normally awarded items in goods, not cash.

Mrs C complained about the way the council handled her application. She said she was not told that, if her application was successful, the award for carpets and curtains would be in goods. She also said the council failed to appropriately respond to her complaint.

We listened to a copy of the recording of Mrs C's phone call in which she applied for assistance. This confirmed that she was not told that if her application was successful the council would provide the relevant items. We noted that both the council's decision makers guide and Scottish Government guidance confirm that the council are entitled to decide whether to make such awards in goods or cash. However, the council should have clearly explained this to Mrs C at the start. Also, after listening to the call, we found that the call handler was often vague when trying to explain what the council needed from Mrs C to progress her application, and their position often conflicted with the information in the Scottish Government guidance. We also found that the call handler commented inappropriately about other benefits that Mrs C received. In light of this, we upheld Mrs C's complaint that the council's handling of her application was poor.

In addition, when responding to Mrs C's complaint, the council wrongly told her she was advised when she applied that any award would be provided as goods, and that they could find no evidence of call handlers asking unnecessary questions. As already noted, the tape of the call evidenced that she was not told how any grant would be made, and we were concerned by the call handler's approach and line of questioning. Because of that, we upheld Mrs C's complaint that the council did not respond appropriately to her complaint.

Recommendations

We recommended that the council:

• apologise for the failings identified with the handling of Mrs C's application;
• make a time and trouble payment - from the council's own budget - in recognition of the significant customer service failings identified with the handling of Mrs C's application for a community care grant;
• revise any community care grant publications to ensure it is clearly explained that the council have discretion in deciding whether to award goods or cash;
• apologise to Mrs C for failing to respond appropriately to her complaint; and
• reflect on the response provided to Mrs C's complaint and feed back to the Ombudsman any actions taken as a result of that.

Summary

Mr C's son (Mr A) had been suffering from headaches and vomiting for several days. When Mr A's condition got worse, Mr C took him to the emergency department at Perth Royal Infirmary. They arrived at 01:17, and at 01:29, a triage nurse assessed Mr A and gave him paracetamol (triage is the process of deciding which patients should be treated first based on how sick or seriously injured they are). She arranged for Mr A to see an out-of-hours GP in the department at 03:15, and, without having taken any observations (temperature, blood pressure, pulse and oxygen levels) sent him home to wait for that appointment. After arriving home, Mr A's condition deteriorated further, and he could not move his neck or lift his knees. Mr C returned with him to the hospital at around 03:00, where Mr A saw a GP and was admitted to a medical ward at 03:36 with suspected meningitis, which was confirmed by tests. He was treated with antibiotics and discharged a week later.

Mr C complained that the board failed to provide Mr A with a reasonable standard of care and treatment, in that the triage nurse failed to take any observations and recognise the seriousness of Mr A's condition. He also said that the delay of two hours between Mr A being seen by the nurse and by the GP was not reasonable in light of the serious and potentially life-threatening disease Mr A was suffering from. He complained that the board failed to respond appropriately to the complaint, including that they failed to adequately explain why the nurse did not undertake observations when she examined Mr A.

We took independent advice on this case from our nursing adviser, who said that the care and treatment Mr A received from the triage nurse fell below a reasonable standard. She did not carry out a set of observations, which meant that her decision to refer Mr A to the out-of-hours service was based on minimal information that might have resulted in his further deterioration. The adviser was also critical that Mr A was not allowed to remain in the emergency department and instead was sent home. These failings made a stressful situation more difficult for the family, given Mr A's serious condition. In relation to complaints handling, we were satisfied that the board provided as full an explanation as they could in the circumstances, but in light of the delays, inaccuracies and use of technical terms in the complaint response, we upheld the complaint.

Recommendations

We recommended that the board:

• review the triage process and provide evidence that appropriate protocols and/or guidance are in place;
• take steps to ensure nursing staff in the emergency department at the hospital carry out observations and document patients' vital signs during triage, and report back to the Ombudsman the actions taken;
• provide evidence that their processes ensure staff involved in triage have the appropriate education, training, skills, competencies and adequate supervision in place to provide a reasonable standard of care;
• consider the failings identified to ensure that future responses are appropriate; and
• apologise to Mr C for the failures identified.

Summary

Ms C had welfare power of attorney (a legal document appointing someone to act or make decisions for another person) for her late brother (Mr A) who had profound learning difficulties and significant communication difficulties. Mr A was admitted to Hairmyres Hospital but died three days later from sepsis (blood infection). Ms C had concerns about some of the clinical decisions that were made and said that staff failed to communicate with her as welfare power of attorney. If they had, Ms C said she could have provided additional and important information about her brother's normal condition and that she could have contributed to the treatment plans that were set up. The board apologised to Ms C that staff failed to act on changes in her brother's medical condition but maintained this was not due to his learning disabilities.

Our investigation found that the board have an 'Adults with Incapacity: Best Practice Guide', in line with the principles of the Adults with Incapacity Act (Scotland) Act 2000. The guide says that, along with the patient's wishes, staff should take account of the views of relevant others as far as it is reasonable and practicable to do so. We took independent advice on the board's actions from our nursing adviser. She said that the best practice guide was very good, but that staff failed to implement it in relation to Mr A's care, and the level of communication fell below the level she would have expected. Ms C was not consulted or involved in the decision-making process and, more importantly, her information about her brother's deterioration was not taken seriously. We upheld Ms C's complaint, as we found staff did not communicate adequately with her, when she was best placed to advise on her brother's medical history and usual state of health, and so failed to act in accordance with the principles of the Adults With Incapacity (Scotland) Act 2000.

Recommendations

We recommended that the board:

• apologise to Ms C for the failings in communication; and
• remind staff of the best practice guidance and ensure it is implemented in appropriate circumstances.

Summary

Mrs C complained about the nursing care that her late daughter (Ms A) received while in Monklands Hospital, where she had been admitted with severe stomach problems. While in hospital Ms A was transferred to a second ward, and Mrs C's complaint was about the nursing care her daughter received in that ward. Ms A suffered two falls there and Mrs C complained that nurses had referred to her daughter as a 'boarder' and that she had not been treated with dignity or respect. After the second fall, and some two and a half weeks after being admitted, Ms A was transferred to intensive care after she had a seizure. Her condition deteriorated further and she died the next day.

We took independent advice on this complaint from our nursing adviser, who considered Ms A's relevant clinical records and the complaints correspondence.

Our investigation found that, while the key areas of nursing care were reasonable, a falls assessment and care plan was not implemented after Ms A's first fall, although our adviser said that this might not have prevented the second fall. We also found that the level of communication with Mrs C and her family in the ward before Ms A was transferred to intensive care was not of an acceptable standard. We upheld the complaint, and noted the action already taken by the board in response to it. This included explaining the learning that had come from the complaint, and apologising that an SBAR report (a situation-background-assessment-recommendation report, used as a communication tool) was not completed on transfer between wards; that Mrs C had felt that the nursing staff had not provided the standard of care or communication expected; and that there had been a lack of communication.

Recommendations

We recommended that the board:

• remind nursing staff on the ward of the need to complete appropriate falls assessment and care planning in line with their falls assessment procedure; and
• ensure that staff on the ward are reminded about the importance of communication with relatives and carers.

Summary

Mrs C complained that, after her husband (Mr C) died in Raigmore Hospital, the board lost his property. Mr C was very ill and was on a high-dependency ward before he died. The board had said that although they understood this had been very distressing for Mrs C, they would not offer compensation for the loss of Mr C's watch and hearing aid.

During our investigation we looked at correspondence provided by Mrs C and the board. We also looked at the board's personal property disclaimers, and we took advice from a nursing adviser with practical experience of dealing with cases like this on hospital wards.

We found that, while the board's disclaimers clearly say that patients remain responsible for their personal property when in hospital, there are circumstances when the situation is less clear. In Mr C's case, there was uncertainty over whether some or all of his property had been lost, and the board could not provide an adequate explanation of why an inventory of his property was not taken when he died. We also found statements in the board's responses about this to be contradictory. We took the view that any items of property belonging to a deceased person, no matter the amount or nature, are their personal belongings, and should be catalogued and held until they can be passed safely to the person's next of kin. To do otherwise in such circumstances is disrespectful and, therefore, unreasonable. We upheld Mrs C's complaint and made a number of recommendations.

Recommendations

We recommended that the board:

• apologise to Mrs C for unreasonably losing Mr C's property at the hospital;
• make a payment to Mrs C to cover the cost of the lost watch and hearing aid;
• clarify their procedures on dealing with patients' personal property, taking account of the issues raised in this case and their own audits of lost property; and
• use the learning from this complaint to improve communication with complainants on sensitive matters.

Summary

Ms C's late sister was extremely ill and was admitted to hospital. Ms C, who had travelled from abroad to be with her, wanted to stay with her sister on the receiving ward but was asked to leave as it was outwith ward visiting times. Ms C complained that the nurse who had asked her to leave failed to treat her with appropriate compassion. Ms C's sister died three days after being admitted.

After taking independent advice from our nursing adviser, we upheld the complaint. Our adviser said that the notes showed that Ms C's sister's condition was deteriorating and indicated that she was nearing the end of her life. She said that it did not appear that this was taken into account, and pointed out that staff should be able to assess when it is appropriate to be flexible with policies such as visiting. Our adviser also criticised the language in the medical notes for being rigid, not compassionate and not in keeping with the Nursing and Midwifery Council Code and Patient Rights Act.

Recommendations

We recommended that the board:

• discuss this incident with the relevant staff members and senior managers involved as a learning exercise;
• review their policy in light of this complaint and examine the ethos of relative/patient involvement in the admissions unit; and
• apologise to Ms C and her late sister's family for the distress caused.

Summary

Ms C complained about the post-operative medical care she received after Tension Free Vaginal Tape Obturator (TVTO) surgery for urinary incontinence at the New Victoria Infirmary in May 2011. After the operation, Ms C suffered constant pain until further tests revealed a year and a half later that she had suffered bladder erosion (where the tape has eroded into the bladder). Ms C was concerned that a cystoscopy (where a camera is used to check for abnormalities) was not used when the tape was implanted, and was unhappy about the time taken to identify this injury. Ms C had a further operation at the Southern General Hospital in November 2012 to have the tape removed. She complained about the nursing treatment for her wound, which became infected a week later, and that the board's response to her complaint did not address her concerns that her wound was not checked during the first week after surgery.

There are no national guidelines recommending that a cystoscopy be performed on all patients undergoing TVTO surgery, and the manufacturer's product information says that it is at the discretion of the surgeon whether to perform a cystoscopy. After taking independent advice from one of our medical advisers, we did not consider it unreasonable that a cystoscopy was not performed. TVTO had been introduced to reduce the likelihood of bladder injury, and it was not the board's policy in 2011 to perform a cystoscopy on all patients undergoing TVTO. After numerous cases of injury with the TVTO procedure were reported over the years, however, this eventually led to the board's change of policy in 2012. Nevertheless, we were critical that when Ms C complained five months later of pain and recurrent bladder infections, a cystoscopy was not arranged as supported by guidance issued by the National Institute of Clinical Excellence.

Although we found that Ms C's wound was checked and redressed twice in the week after her surgery at the Southern General Hospital, there was evidence to suggest that there were three consecutive days when it was not checked, before she told nursing staff that it was painful and leaking. Healthcare Improvement Scotland makes clear that wound charts should be started for all patients with a wound, and we noted that in Ms C's case this chart was not started until after her wound became infected. We concluded that the nursing care fell below the reasonable standard that would be expected in this surgical ward. In addition, the board did not respond to Ms C's complaint about her wound not being checked during the week after surgery and instead concentrated on the redressing that took place after the infection was identified. We upheld Ms C's complaints.

Recommendations

We recommended that the board:

• ensure that complaint responses fully address the concerns raised, in line with the Scottish Government's complaints handling guidance;
• ensure that appropriate staff take into account the relevant guidelines on performing a cystoscopy in patients with pain and recurrent bladder infections following pelvic surgery;
• draw to the attention of relevant nursing staff on the surgical ward at the Southern General Hospital the importance of having in place wound charts in line with Healthcare Improvement Scotland guidance and ensure daily dressing and/or wound inspections are conducted; and
• apologise to Ms C for the failings identified.