Upheld, recommendations

Summary

Miss C complained about the care and treatment she received at Raigmore Hospital. Miss C said that when she arrived at the accident and emergency department (A&E) with abdominal (stomach) pain, her symptoms were not taken seriously enough and staff dismissed her view that she had an ulcer, even when she told them she had been treated for one in the past. She also said that after she was transferred to a ward, staff inappropriately gave her a drug, which she said caused her ulcer to bleed or perforate (break open the stomach wall) and her pain to treble, resulting in her needing immediate surgery. Miss C said that, as a result of the board's failings, she had to have an operation that she did not need and now has an unnecessary scar.

We obtained independent advice on this case from one of our medical advisers, a consultant surgeon specialising in gastrointestinal (digestive system) surgery. The adviser said that the consultant who initially examined Miss C in A&E mistakenly concluded that her bowel might have been obstructed. However, as the consultant was not sure of that diagnosis, he correctly sought advice from the surgical team and organised a prompt referral to the on-call senior surgical trainee for further assessment and observation.

The senior surgical trainee, however, failed to recognise that Miss C's signs and symptoms suggested peritonitis (inflammation of the lining of the abdomen) and despite these signs, placed undue reliance on the x-ray appearance of possible constipation. He failed to seek advice from the consultant gastrointestinal surgeon and/or arrange further investigations. He prescribed a drug that was advised against, given Miss C's condition, and which may have exacerbated her pain. The adviser explained that Miss C's ulcer had almost certainly perforated when she initially went to A&E and so it was highly unlikely that the treatment she received from the board influenced her need for surgical intervention. However, the senior surgical trainee's failure to make the correct diagnosis meant that Miss C's pain was prolonged unnecessarily, and we upheld her complaint.

Recommendations

We recommended that the board:

• provide Miss C with a written apology for the failings identified in this case;
• feed back our decision to all staff involved; and
• ensure that the senior surgical trainee uses our decision letter on this case as part of his training record and discusses it with his educational supervisor as part of a reflective case-based discussion.

Summary

Ms C, who is an advocacy worker, complained to us on behalf of her client (Mr A). Mr A said that he had complained to the board some time ago about care and treatment he received. Having received no reply, he asked Ms C to complain on his behalf. For a period of around 15 months the advocacy service tried to make Mr A's complaints or receive updates on them. Having received no response they then complained to us.

After making enquiries of the board, we found evidence that they received most of the letters and emails sent by the advocacy worker between September 2012 and November 2013, but that of 15 contacts, only four were directly responded to. Having considered the circumstances and the content of the letters and emails, we considered this unreasonable and we upheld the complaint. The board had, however, taken action before we became involved to try to ensure that a similar situation would not recur, so our recommendations related only to apologies for the failure.

Recommendations

We recommended that the board:

• apologise to Mr A that they did not respond reasonably to complaints and subsequent correspondence raised on his behalf; and
• apologise to Ms C that they did not respond reasonably to complaints and subsequent correspondence raised on Mr A's behalf.

Summary

Mr C suffers from excessive sweating over most of his body, and was referred to a dermatologist (a specialist in diseases of the skin, hair and nails). At the dermatology appointment at Inverclyde Royal Hospital, a consultant dermatologist examined Mr C but said there was no treatment they could offer him. He was unhappy about this and complained to the board.

We took independent advice from one of our medical advisers, also a consultant dermatologist, who reviewed the board's response to Mr C's complaint as well as the relevant medical records. He explained that to say there was no treatment that could be offered was incorrect. He said that, in Mr C's circumstances, he would have expected the consultant to have considered an anticholinergic drug (a drug that blocks the action of a particular neurotransmitter in the brain). We upheld Mr C's complaint. Although we were aware that the appointment had been a difficult one, there was no evidence that an anticholinergic drug was considered or discussed with Mr C there, and the information he was given was incorrect.

Recommendations

We recommended that the board:

• apologise to Mr C for the failings identified; and
• share this letter with the consultant concerned and ask them to reflect on their actions.

Summary

Mr C had surgery at Inverclyde Royal Hospital in July 2011 to fix a finger flexion (where one or more fingers start to bend into the palm of the hand) of the right little finger. Afterwards, Mr C was given a splint for his finger, and started physiotherapy. In early August, the surgeon noted that the wound had healed. Mr C was discharged from physiotherapy later that month. The discharge report was, however, dated early October. It outlined the physiotherapy treatment provided, said that the range of movement had worsened and noted that Mr C was happy to continue with exercises at home. In September, the surgeon saw Mr C and noted that his little finger had stiffened up dramatically, and had no movement at the middle joint. His ring finger joint had also stiffened. The surgeon also noted that Mr C had returned to work and had stopped wearing a splint at night. Mr C was referred to a hand therapist and for further splinting, which did not take place, and he then sought a second opinion.

Mr C complained to us that he cannot use the finger, and another finger is now bent over. He said that within weeks of starting physiotherapy, the physiotherapist advised him that nothing more could be done and discharged him to the care of the surgeon. Mr C said he is now in constant pain and may have to have further surgery. He said that he believed the operation was not successful.

We took independent advice on Mr C's complaint from one of our medical advisers. The adviser said that from the evidence available it appeared that the operation was carried out to a reasonable standard, noting that the surgeon believed that the operation was successful, but that Mr C's post-operative rehabilitation was poor. The adviser outlined a number of factors that might explain this, including pre-existing arthritis at the middle joint of the finger; a complication of the operation; a lack of physiotherapy from the end of August, and failure to wear a splint for the recommended period. We noted that Mr C said that he wore the splints as instructed and that the physiotherapist discharged him saying she could not do anything further. The board said that he declined further physiotherapy, but were unable to substantiate this. Moreover, we found that it was some six weeks before the physiotherapist told the surgeon that Mr C's range of movement had worsened, and that physiotherapy had stopped. Our adviser was concerned about this, given its importance to a positive outcome. We recognised that the operation itself appeared to have been carried out appropriately, and that there were a number of factors that could explain the poor outcome Mr C experienced. However, we upheld his complaint because there was no evidence to support the board's view that it was Mr C's decision to stop physiotherapy, and because of the shortcomings in communication between the physiotherapist and the surgeon.

Recommendations

We recommended that the board:

• review their practice relating to the storage of patients' medical records to ensure it accords with the Scottish Government Records Management: NHS Code of Practice (Scotland); and
• ensure the failures identified are raised with relevant staff.

Summary

Ms C went into premature labour and was taken to Aberdeen Maternity Hospital as an emergency. She said that, after admission, staff failed to manage her labour and delivery properly, as a consequence of which her daughter was deprived of oxygen and suffered serious brain injury. Ms C also said that when she made a formal complaint about this, the board failed to deal with it properly.

During our investigation, we took into account all the relevant documentation, including the complaints correspondence and the clinical records. We also took independent advice from a consultant obstetrician and an experienced midwife.

We upheld Ms C's complaints. We found that the board delayed in dealing with Ms C's complaint, and that the evidence showed that her labour was not managed reasonably, as there had been some delays by nursing staff in seeking medical assistance and Ms C should have been transferred to a labour ward earlier than she was. However, despite these failings, we found no evidence to suggest that Ms C's baby should have been delivered sooner, or that care was compromised.

Recommendations

We recommended that the board:

• apologise for the shortcomings identified by the investigation and in particular that they did not keep Ms C updated about her daughter and failed to change her soiled bed;
• remind staff of the necessity and importance of keeping accurate and timely records and of their responsibility for signing them and detailing the reasons for any amendments. Midwifery staff should also be reminded of the NICE Clinical Guideline 5 and Nursing and Midwifery Guidance;
• provide details of the action they have taken in order to resolve the communication issues which existed and which were acknowledged by the chief executive; and
• remind staff of the necessity of adhering to their stated complaints policy.

Summary

Ms C, a former prisoner, complained that while in prison her pain relief medication (pregabalin) was stopped suddenly. This was after a spot check of medicines found that she had removed powder from the capsules and not taken them as instructed. Ms C had been prescribed pregabalin for pain caused by nerve damage, and told the prison health centre that she had taken extra medication to help her cope with difficult family circumstances. She also said that she was unable to appropriately progress her complaint through the NHS complaints procedure.

We took independent advice on this complaint from one of our medical advisers. Although we found that the prison health centre doctor had noted that Ms C had not demonstrated objective neuropathy (nerve damage), it appeared from the records that the stopping of her medication was influenced by her interference with the capsules (Ms C had been given a warning two months earlier to be more careful with her medication). Our medical adviser said that pregabalin can also be used to treat anxiety, and explained that a patient's perception of pain and their mental health are closely linked, and that treating anxiety can improve the management of pain. We decided that the prison doctor did not give proper consideration either to whether pregabalin assisted Ms C in managing her anxiety, or to gradually reducing the dosage in line with best practice.

In terms of the complaints handling, we found that even after Ms C met with the clinical manager to discuss her concerns about a lack of response, she still did not get a reply. Her complaints were logged but not responded to, contrary to the NHS complaints handling guidance. It also appeared that some complaints information was inappropriately held in Ms C’s medical records.

We upheld both Ms C’s complaints.

Recommendations

We recommended that the board:

• draw to the doctor's attention the British National Formulary's guidance on avoiding abrupt withdrawal of pregabalin;
• put in place suitable guidance for prisoners in the prison about the consequences of misusing prescribed medication;
• apologise to Ms C for failing to handle her complaint in line with the NHS complaints procedure guidance; and
• ensure that health centre staff in the prison do not record complaints information in a patient's medical records, in line with the NHS complaints procedure guidance.

Summary

Mr C complained about the care and treatment given to his late father (Mr A) after he was admitted to Ayr Hospital. Mr A had respiratory (breathing) and kidney disease. When he was in hospital he said he did not wish, nor was he able to tolerate, non-invasive ventilation (help with breathing, using a facemask or similar device). He was also recorded as not for cardio-pulmonary resuscitation (DNACPR - a decision taken that means a doctor is not required to resuscitate the patient if their heart or breathing stops). After 24 hours of being fairly stable after admission, Mr A was moved to a general medical ward (Station 16) but he began to decline, and he died after his breathing stopped, although medical staff tried to resuscitate him.

Mr C said that Mr A's care and treatment plan were not discussed with his family. He was also unhappy that after being admitted to the Medical High Care Unit (MHCU) Mr A was then moved to a general medical ward. He said that the notes that accompanied Mr A were unclear, and that the ward was ill-equipped to deal with him. He was also unhappy that although DNACPR was recorded in Mr A's records, an attempt had been made to resuscitate him.

The complaint was investigated and all the complaints correspondence and Mr A's relevant clinical records were carefully considered. We also took independent advice from one of our medical advisers, who is a consultant in medicine for the elderly. Our investigation found that following Mr A's admission to hospital there had been confusion and uncertainty, particularly when he was transferred from the MHCU to the general medical ward (although it appeared that his condition had been discussed with his family). We found this uncertainty unacceptable, and also noted that the medical documentation was unclear regarding DNACPR, which led to unnecessary confusion at the end of Mr A's life.

Recommendations

We recommended that the board:

• make a formal apology for the confusion and uncertainty caused;
• conduct a Critical Incident Review/Significant Event Analysis and provide the Ombudsman with a copy of the outcome;
• audit the completion of Do Not Resuscitate and ward-to-ward transfer forms in the MHCU and Station 16;
• audit documentation and communication of care needs and care planning on these wards; and
• review their procedure regarding handover between wards (particularly from a higher environment to a lower one) to satisfy themselves that it is fit for purpose.

Summary

Mrs C, who is a student association representative, made a complaint on behalf of a student (Mr A). Mr A had lodged an academic appeal (on the grounds of extenuating circumstances) which was only partly upheld by the university. Mrs C had submitted a formal request to the university (on behalf of Mr A) for a review of the decision to only partially uphold the academic appeal. However, this request had been refused. As a result of the university upholding its original decision, Mr A was not able to continue his studies. Mrs C and Mr A felt that the university had failed to reasonably consider Mr A's circumstances both in terms of the original appeal and the subsequent request for a review.

Our investigation found that the university had not accurately taken into account all relevant information in order to consider the complete picture of Mr A's circumstances and to give his appeal fair consideration. Although they had allowed a late application claiming extenuating circumstances, they had not responded fully to that claim, and we found that the whole process was not reasonably followed.

Recommendations

We recommended that the university:

• apologise for not reasonably handling the appeal and review; and
• reconsider the appeal made by Mr A.

Summary

Mrs C complained that Scottish Water had acted unreasonably by asking her to remove concrete blocks and fencing from her land, which they said were restricting access to a water main. We found that under the relevant statutory powers and case law, Scottish Water were entitled to ask Mrs C to remove the blocks, as they were on top of the main, but that there was some confusion about the fencing. Scottish Water's records referred to temporary fencing around the property, but Mrs C said that the fence had been in position for over 35 years, and although it had recently been replaced, it was of the same dimensions and at the same location as the previous fence.

When we asked Scottish Water about this, they said they would need to investigate. However, they then failed to do so satisfactorily. Our investigation found that Scottish Water were not sufficiently clear about the position of the fence in relation to the water main before asking Mrs C to move it. We considered that they should have clarified this before they wrote asking her to do so, so we upheld this aspect of the complaint. We also found that they delayed in responding to her complaint.

Recommendations

We recommended that Scottish Water:

• issue a written apology to Mrs C for asking her to move the fence before confirming its position;
• visit Mrs C's property and carry out a satisfactory investigation into whether the fence in question is simply a replacement fence, and whether it needs to be moved in order that they can protect/access their assets;
• consider if Mrs C is entitled to financial redress under their code of practice for the delay in responding to her complaint; and,
• make the relevant staff aware of our findings.

Summary

Mr C had complained about aspects of his billing, which Business Stream then resolved after we became involved. However, we had concerns about their handling of his complaint. Mr C explained his perspective of this in detail, and Business Stream acknowledged that their service to him was not what they would have expected. They apologised and offered him a payment. However, this outcome took almost three months to provide, needed the intervention of senior staff in SPSO to obtain, was very brief and did not indicate any intention to take action to help avoid a recurrence.

Although we upheld the complaint, after careful thought we decided not to make a recommendation about complaints handling. This was because we published an investigation report in December 2013 (case 201300283), in which we upheld a complaint about Business Stream's complaints handling and made a recommendation that they arrange an independent external audit of their complaints process and how it was being applied. Business Stream accepted this, and were also at the time completing an internal review of their process. We were, therefore, satisfied that they were addressing the issue.

Recommendations

We recommended that Business Stream:

• apologise to Mr C for their poor handling of his case.