Upheld, recommendations

Summary

Mr C raised a number of concerns regarding the care his father (Mr A) received in Ninewells Hospital. Mr A had existing diagnoses of lung cancer and diabetes when he was admitted to the hospital with an infection. Mr C said that his father's initial treatment was excellent, but when he was later transferred to another ward, the standard of care dropped. Mr C raised a number of concerns regarding the standard of clinical and nursing care on that ward, where Mr A died three days after his admission. Mr C complained that family members were not made aware of Mr A's deterioration. He also complained that staff failed to adequately manage Mr A's diabetes and food and fluid intake. Mr C believed his father's death was caused by a failure to identify and treat hypoglycaemic shock (severely diminished blood sugar levels), rather than as a result of his underlying cancer and infection as the board suggested.

After taking independent advice from a nursing adviser and a medical adviser, we upheld Mr C's complaints. We were satisfied that Mr A's condition was appropriately assessed upon admission and that the proposed treatment with intravenous antibiotics was appropriate. That said, we were concerned by the ward staff's management of his blood glucose levels. Mr A's diabetes was clearly recorded when he was admitted to hospital, but we found evidence to suggest that the ward was not equipped to react to significant changes to his blood glucose levels, and the board's own procedure for managing hypoglycaemia was not followed. We also found that medication was omitted from the list of existing medications for Mr A and that this likely contributed to his hypoglycaemic episode. However, we accepted medical advice that the hypoglycaemic episode was ultimately dealt with appropriately and that there was no evidence to suggest that this contributed to the decline in Mr A's condition, or to his death. We were, however, critical of the board for failing to contact the family when Mr A deteriorated, and for their poor handling of Mr C's complaint.

Recommendations

We recommended that the board:

• provide us with an update on their plans for electronic palliative care summaries;
• conduct an audit of the ward staff's compliance with their obligations in terms of maintaining full, accurate medical records;
• provide us with an update on all of the actions taken to improve their performance as a result of Mr C's complaint;
• conduct a review of their approach to catering for in-patients with diabetes;
• share our decision with the clinical staff involved in Mr A's care; and
• apologise to Mr C and his family for the issues our investigation highlighted.

Summary

Mr C complained on behalf of his father (Mr A) who lives in a care home. Mr C was unhappy that Mr A's GP did not visit his father there, but instead spoke to care home staff by phone. He was also unhappy with the GP's responses to his complaint about this. We looked at Mr A's medical records, as well as the GP's file on the complaint, and took independent advice on the complaint from one of our medical advisers, who is a GP.

We found that on two occasions the GP did not take sufficient time to fully assess and clarify the situation after Mr A had collapsed. Instead, the GP made an assumption about why he had collapsed. We also found that the GP did not take account of key aspects of Mr A's medical history when considering how to manage his situation. In addition, we found that it was inappropriate for the GP to use the fact that Mr A was being seen as a day patient at a local hospital as a reason not to visit him.

We upheld both of Mr C's complaints. We found that, in the main response to Mr C's complaint, the GP appeared to have given up responsibility for Mr A's primary care, as they had said there was little they could do because he was being supervised by various hospital departments. The GP also made general statements about the workload of modern medical practices, and said that other patients in residential care visited the surgery. We concluded that, while this may be contextual information, it did not explain why the GP failed to visit Mr A. We found these responses unreasonable and highlighted that the GP may not have recognised the serious nature of Mr A's situation.

Recommendations

We recommended that the practice:

• ensure that the GP apologises to Mr C for failing to assess and care for Mr A appropriately, and for not visiting Mr A in the care home;
• ensure that the GP apologises to Mr C for failing to provide reasonable responses to his complaint;
• ensure that the GP apologises to the care home manager and nursing staff for failing to respond appropriately to their requests for help; and
• ensure that the GP reflects on our adviser's comments and informs us of how they would deal with similar events in future.

Summary

Mr C, who is an independent advocate, complained on behalf of his client (Mrs A) that the board did not take reasonable steps to prevent Mrs A's husband (Mr A) from developing a pressure ulcer (bed sore) during his stay in Inverclyde Royal Hospital. Mr A had terminal cancer and was admitted to hospital for palliative care (care provided solely to prevent or relieve suffering). He was there for ten days, and was then discharged home with no mention of a pressure ulcer. Later on the day of his discharge from hospital, a district nurse examined Mr A and found that he had a pressure ulcer.

We took independent advice from our nursing adviser, who said that the board had not thoroughly assessed Mr A during his admission and so had not recognised his increased risk of developing a pressure ulcer. If this had been done then Mr A's condition would have been more regularly assessed. The adviser was critical that staff relied on the assessments made when he was admitted, and said they had not exercised good clinical judgement. The adviser also said that the record-keeping was poor. In light of these failings, we upheld the complaint. As, however, the board had already taken positive steps to stop this happening again, we made only one recommendation.

Recommendations

We recommended that the board:

• provide Mrs A with information about steps taken to address the shortcomings identified.

Summary

Ms C, an advice worker, had written to her client (Mr A)'s medical practice to seek clarification about whether a request that Mr A made to his GP for a referral had been carried out. She received no response. After two follow-up letters were also ignored and two months had gone by, Ms C complained to us.

The practice told us that they did not consider that entering into correspondence with Ms C would serve any practical purpose as the issues Mr A was concerned about had been dealt with some years previously. We decided, however, that the practice should have explained this to Ms C. We, therefore, upheld her complaint that the practice did not reasonably respond to her correspondence.

Recommendations

We recommended that the practice:

• apologise to Ms C and Mr A for the failure to reply to correspondence; and
• review their communication policies to ensure that they clearly advise correspondents when a decision is taken that correspondence will not be responded to, and explain the reasons for that decision.

Summary

Ms C complained that the council failed to cut back trees outside her property. Ms C told us the trees were overhanging her house to the extent that they were nearly touching her roof. Ms C said her television reception had been affected, and she was living in constant darkness on the side of her house facing the trees, which meant she had stopped using her living room due to the lack of natural light. Ms C said her roof was black with moss from the trees, and she had to clean up leaves and bird droppings regularly.

We found that the council had told Ms C the trees would be dealt with; however, nearly a year later, the work had not been carried out. The council said there was a breakdown in communication between work teams, which led to confusion between shifts and, as a result, there was a delay in the work being started. We upheld Ms C's complaint as it was unacceptable that the work had not been carried out.

In our recommendations to the council, we had asked them to arrange for Ms C's roof to be cleaned. The council refused, and so we asked them to make her a goodwill payment of £100 to Ms C instead. The council again refused. Their reason, in both instances, was that payment or any works other than the actual tree works was disproportionate to their failure to deal with the trees. We were disappointed by the council's intransigence as, in our view, it was entirely reasonable for the council to make a tangible expression of regret, in line with our office's guidance on apology, given the effect that their very poor service had on Ms C.

Recommendations

We recommended that the council:

• apologise to Ms C for failing to deal with the trees outside her property;
• provide Ms C, in writing, with a date for the work to be carried out on the trees, and copy that communication to us;
• draw up an action plan to ensure that such delays do not happen again, and copy the action plan to us.

Summary

Mr C had lived close to a semi-industrial property for a number of years without problems, but more recently the owners of the property had sought to diversify and to develop the site and their business. Work started on the site but without the necessary planning permission. Mr C and his neighbours complained to the council about this and about the noise coming from the site, and the council told the developer that he needed to obtain planning permission.

The developer took five months to make a retrospective application and meanwhile noise complaints continued. Although the council had a target to consider the application within two months, it took them nine months to do so. The application was then refused by a committee of councillors. Throughout this time Mr C had been complaining of noise and disturbance in his home.

We took independent advice from one of our planning advisers. Our investigation showed that while council officers were encouraged to support small businesses, they also had obligations to the wider public. In this case, there was no doubt that works had been undertaken without the necessary planning permission and that noise was affecting those who lived nearby. While the council advised the developer of this, they allowed him too long before he submitted his retrospective application. Although it was clear that during this time they were negotiating with the developer to mitigate the noise, matters took too long to resolve. We upheld Mr C's complaint.

Recommendations

We recommended that the council:

• make a formal apology to Mr C for their failures in this matter;
• ensure that officers involved in this case are made aware of our decision;
• make a further formal apology for the failures identified; and
• ensure that appropriate officers are informed of the circumstances and outcome of this complaint.

Summary

Ms C, who is an advice worker, complained on behalf of her client (Mr A) that the council had unreasonably failed to carry out repairs to prevent water coming into Mr A's council house. Ms C said that Mr A contacted the council many times about this and the council had failed to permanently resolve the situation.

Our investigation considered the council's policy on water ingress and whether they followed it. The policy said that for top floor flats such as Mr A's they would arrange a temporary roof repair to ensure the home was wind and watertight. The council indicated that, in such cases, temporary repairs should be carried out within one day.

The evidence showed that on eight separate occasions the council were advised of water ingress problems at Mr A's property. On two of these, they arranged repairs in accordance with their policy. However, on the remaining six, the evidence suggested that no temporary repairs were completed. We acknowledged that, during that time, the council organised more permanent repairs for the roof, but this did not remove the requirement for them to carry out temporary repairs to make Mr A's home watertight. Given the number of times Mr A reported the same issues, we also found that the council failed to identify the problem and to take appropriate action earlier.

We were also concerned that in their response to Ms C's complaint the council said they were not aware of a recent problem, when their records clearly showed that this had been reported to them no fewer than seven times. We were, therefore, critical of the council's failure to investigate Ms C's complaint properly.

Recommendations

We recommended that the council:

• feed back our decision on this case to the staff involved to prevent such failings occurring in future;
• review Mr A's compensation claim in light of their acknowledgement that they had previously failed to review their repairs system properly in this case and carry out sufficient repairs to rectify the water ingress problem and advise Mr A of the outcome; and
• provide Mr A with a written apology for the failings identified.

Summary

Ms C complained on behalf of her daughter (Ms A) about the care and treatment she received at the Western Infirmary for appendicitis. She complained that her daughter was not fully diagnosed soon enough, as there was a delay to her initial scan, and she was not monitored appropriately. She also said that a delay in operating to remove Ms A's appendix caused a rapid deterioration in her condition and a more complex operation. Ms A was operated on some 24 hours after she was admitted to hospital. Ms C also complained about the board's handling of her complaint.

The board had accepted that there was poor communication in relation to some elements of Ms A's care, and that the family were misled in relation to when the operation might take place. They apologised for the distress this caused.

After taking independent advice from two of our advisers - a consultant surgeon and a nursing adviser - we upheld both complaints. The surgical adviser was satisfied that Ms A's treatment was reasonable, and that the operation took place within a reasonable timeframe. However, the nursing adviser was concerned that Ms A was not monitored frequently enough, given that the reason for admitting her to hospital was to keep her under close observation. We were also critical of the communication between ward staff and Ms C. She was given inaccurate information on at least three occasions, increasing the family's distress.

We found that the board had delayed in responding to Ms C's complaint, and did not act on assurances they had given during that process. The board explained to us, however, what they had since done to ensure that this did not happen again, so we made no recommendation about this aspect of Ms C's complaint.

Recommendations

We recommended that the board:

• reflect on the failures in communication that our investigation identified, and consider how communication with patients and their families could be improved to ensure information is as accurate as possible; and
• ensure that nursing staff within the surgical unit are aware of the importance of carrying out vital signs observations as part of their role in the assessment and monitoring of surgical patients.

Summary

Mrs C attended A&E at Monklands Hospital in the early hours of the morning with her daughter (Miss A), who was given a liquid steroid to treat croup (an infection of the voice box and windpipe) before being discharged. Later that same day, and after speaking with NHS 24, Mrs C returned to A&E because she felt that Miss A's condition had not improved. Mrs C said she was advised that an out-of-hours (OOH) appointment had been booked for her daughter that evening but that she did not know about it. A nurse examined Miss A, and after a discussion with the duty consultant, advised Mrs C that she could take her daughter home. The following day, Mrs C visited her doctor for an unrelated issue and whilst there, the doctor examined Miss A and confirmed there was a slight wheeze so prescribed steroids. Because of this, Mrs C complained that the care and treatment provided to her daughter in A&E was unreasonable.

The board told Mrs C that because Miss A was well and had a normal set of observations, the duty consultant felt it would be best if she was allowed to attend her booked OOH appointment. They said this was because it was unlikely that she would be seen by an A&E doctor earlier than the time of the scheduled appointment later that evening. However, when we examined the evidence, we identified that the scheduled appointment had already been cancelled because Miss A was seen in A&E. When we asked the board about this, they told us that the appointment with the OOH service would have been cancelled when Mrs C arrived at reception in the A&E department. The board said the receptionists for both services sat side by side and would have liaised with each other about this.

We took independent advice from one of our medical advisers, but he said he was unable to say whether the care and treatment provided to Miss A by the A&E department was reasonable, given that the duty consultant made an incorrect assumption that her OOH appointment was still booked for later in the evening that day. We found that the consultant appeared to have taken the decision to allow Miss A to leave A&E on the basis of inaccurate information and because of that, we upheld Mrs C's complaint.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failure our investigation identified; and
• take steps to review what happened in Mrs C's case and ensure appropriate measures are in place to prevent the same thing from happening again.

Summary

Mrs C complained about the care and treatment of her late husband (Mr C). Mr C was diagnosed with lung cancer and over a five-month period had six appointments with five different consultants. At most of the appointments, which were at both the Beatson Cancer Centre and Royal Alexandra Hospital, Mr and Mrs C had to wait around one and a half hours beyond the appointment time, which was extremely stressful for them. Mr and Mrs C also attended one of the appointments expecting to receive the results of a scan. However, this was not available until 17 days after it was taken, when Mr C began to develop increasing weakness in his legs. He was admitted to hospital the following day and developed complete paralysis of his legs and lack of sensation up to his abdomen. The cancer was found to have spread to his spine, leading to spinal cord compression, and Mr C died shortly after. Mrs C complained that if the results of the scan been available earlier, there might have been a better outcome for her husband, had treatment been administered sooner.

After taking independent advice on Mr C's case from two of our medical advisers, we found that there was a delay in making the scan available, and that the radiologist failed to flag the risk of spinal cord compression when reporting the scan. While there was only a slight possibility that earlier information would have meant that the outcome would have been different for Mr C, these failings led to a significant personal injustice as the delay caused a great deal of distress and there was a missed potential opportunity to diagnose and treat Mr C's spinal compression earlier. We also found an error in the reporting of a previous scan, which might have affected treatment decisions relating to Mr C's pain. Finally, in relation to Mrs C's complaint about the board's appointment handling, we found that there was a lack of continuity of care because of poor record-keeping and the involvement of multiple consultants. This adversely affected the information available to the consultant at each appointment, potentially impacted on Mr C's care and was particularly distressing for both Mr and Mrs C, given the ongoing situation.

Recommendations

We recommended that the board:

• take account of our medical adviser's comments about reviewing report turnaround times and reporting radiology errors, and provide us with evidence on how they intend to avoid a recurrence;
• provide evidence that multi-disciplinary team meetings play a role in the management of patients with lung cancer, in line with the relevant guidelines;
• raise the failures our investigation identified with relevant staff, and ensure it forms part of their annual appraisal;
• provide us with evidence on how they intend to avoid a recurrence of the failures that our investigation identified in the complaint about appointment handling; and
• apologise to Mrs C for the failures our investigation identified.