Upheld, recommendations

Summary

Miss C complained that her dental practice had decided to remove her from their patient list without providing her with treatment for a three month period in accordance with national guidance. She also told us that she made a complaint to the practice in 2012 and that she had not been told the outcome.

We found that, although the practice had the right to give notice of removal from the list, they also had a statutory duty to provide dental treatment for a three month period after their decision. Their final letter to Miss C did not mention this, and so gave the impression that termination would take effect immediately. We also found that the practice did not deal with the previous complaint appropriately and should have told Miss C of the outcome of their investigation into that complaint.

Recommendations

We recommended that the practice:

• remind staff of their obligation to provide dental treatment for a period of three months after their intention to withdraw from a continuing care arrangement and to communicate this to the patient;
• apologise to Miss C for the failure to explain that dental treatment would continue for a period of three months or until she registered at another dental practice;
• remind staff of their obligations under the NHS complaints procedure; and
• apologise to Miss C for the failure to respond to her complaint in an appropriate manner.

Summary

Mr C, a member of the Scottish Parliament, complained on behalf of one of his constituents (Ms A) about the care and treatment she received following an operation at Gartnavel General Hospital. He said that the plans for Ms A's discharge home were inadequate and that there was a failure to ensure that she was technically able to deal with the catheter (a thin tube used to drain and collect urine from the bladder) that was a consequence of the operation. He also complained that there was a failure to review her in a timely manner, that arrangements for reviews were confused, that Ms A's concerns about her operation were dismissed and that the operation had not greatly improved her condition.

The complaint was investigated and carefully considered all the relevant documentation (including all the complaints correspondence and Ms A's clinical records). We also obtained independent advice on Ms A's care and treatment from one of our medical advisers, a consultant urological surgeon (dealing with issues of the urinary tract).

Our investigation showed that the clinical aspects of Ms A's care and treatment were reasonable, as were her discharge plans. We found no evidence to suggest that her concerns about her operation had been dismissed. However, plans to review her were frustrated by confused administration and poor communication between departments which no doubt caused Ms A unnecessary stress and inconvenience at what must have been a difficult time. This was unacceptable and amounted to a service failure, and we upheld the complaint.

Recommendations

We recommended that the board:

• make a formal apology to Ms A for the added stress she experienced;
• confirm to the Ombudsman that procedures for making x-ray appointments are now effective and robust, and advise of the actions taken to ensure this; and
• advise the Ombudsman that they are satisfied that the communications problems affecting Ms A's appointments have now been addressed.

Summary

Ms C complained that after reconstructive breast surgery, there was an avoidable delay by staff at the Royal Alexandria Hospital in diagnosing that she was suffering from a hernia (a condition where an internal part of the body pushes through a weakness in the muscle or surrounding tissue). She said that she complained several times to staff at the hospital that there was a large protrusion on her waist on the side of the reconstruction and that she was in pain, but that this was not addressed appropriately. Ms C also said there was an unreasonable delay of five months between an ultrasound scan (a scan that uses sound waves to create images of organs and structures inside the body) that showed there was a problem, and a CT scan (a scan that uses a computer to produce an image of the body) that confirmed she had a hernia.

We obtained advice on this case from one of our medical advisers, a general surgeon with a specialist interest in breast surgery. The adviser said that in the 12 months following surgery, the board acted in an appropriate and reasonably timely manner in dealing with Ms C's symptoms, as the likelihood was that the underlying cause of the pain and swelling was commonly recognised complications of her surgery. The adviser said it would not have been acceptable to carry out surgery based on the results of the ultrasound, without a CT scan to help identify the problem.

The adviser confirmed, however, that there was an unacceptable delay between the ultrasound report 12 months after surgery and the CT scan report that confirmed the hernia more than five months later. Ms C suffered a prolonged period of pain and discomfort from her hernia as a result. The adviser noted that Ms C's hernia was recorded by the board as having increased in size during the three months following the ultrasound report. However, he explained that such hernias were generally slow growing, wide necked and very rarely life threatening and that the delay did not change the final outcome in Ms C's case.

Recommendations

We recommended that the board:

• feed back our decision on this case to the staff involved to ensure that a similar situation does not occur in future; and
• provide Ms C with a written apology for the failures identified in our report.

Summary

Mr C's late wife (Mrs C) had cancer and was terminally ill. After one of their daughters phoned the medical practice, a GP prescribed a strong morphine-based liquid painkiller. The family also phoned community services, and a community nurse visited Mrs C at home the following week. A few days later, another phone consultation was held with another GP who ordered an electrocardiogram (a test that measures the electrical activity of the heart). Further visits were made by a community nurse and the family agreed that a 'just in case' box (containing medicines that may be needed to help relieve a patient's unpleasant or distressing symptoms while being looked after at home) should be provided. Early the following month, one of Mrs C's daughters was concerned about her condition and spoke to the duty GP at the medical practice, who advised the family to use painkillers and said that Mrs C would be reviewed the following week. When a GP then visited Mrs C at home, they noted that she was at the terminal stage of her illness, and Mrs C died later that day.

Mr C complained about the way that GPs at the medical practice dealt with Mrs C's medical problems, saying that they did not visit and relied on the community nurses instead. He said that his wife was in severe pain and great distress. For four weeks she was not examined by a doctor and additional medication was not prescribed, as the community nurse was not able to prescribe medication. The family accepted that a 'just in case' box was in the house, but Mr C said that they did not know at what point to give Mrs C the medication and that a GP should have provided an explanation.

We took independent advice from one of our medical advisers, after which we upheld the complaint. We found that the medication and explanation provided were reasonable but that, by not visiting Mrs C, the practice failed to provide her with a reasonable standard of care. This led to a great deal of distress for her family, and made a very difficult time worse for them during the final stages of her illness. The adviser also said that while there was evidence that use of the 'just in case' box was explained to the family, it would have been reasonable for this to have been reinforced and for staff to have checked that the family understood what to do.

Recommendations

We recommended that the practice:

• review their management of patients with advanced cancer in light of our adviser's comments; and
• apologise to Mr C for the failures identified.

Summary

Mrs C, who is an advocacy worker, complained on behalf of a client (Ms B) about the care and treatment that Ms B's late father-in-law (Mr A) received from a GP practice run by the board. Mrs C said they did not provide reasonable care and treatment to Mr A, did not discuss his intended treatment at a home visit and did not reasonably respond to Ms B's complaints.

We obtained independent advice on the complaint from one of our medical advisers, who is a GP. The adviser said that while the care and treatment from the practice was largely reasonable, he was concerned about the care and treatment a doctor provided during the home visit. Mr A's symptoms had deteriorated and the doctor should have examined him, assessed his pain (including the likely causes) and examined his abdomen before giving him an injection. As a result there was a failure to appropriately manage Mr A's pain and distress and to assess whether his care required re-prioritising, including whether he needed to be admitted to hospital.

The board had said that the doctor gave assurances that, to the best of his recollection, he had provided a full explanation to Mr A before giving him the injection. However, we found no evidence of this in the papers the board sent us, and it was not clear when a statement could have been made, as we could see no evidence that the board consulted the doctor after Ms B complained. The General Medical Council guidance on consent requires doctors to explain proposed treatment and check that their explanation has been understood. We found no evidence to support the board's assertion that either of these things happened.

The evidence also showed several failings by the board in handling the complaints. They did not treat an initial complaint made by Mr A's wife as a formal complaint, they did not update Ms B on the progress of their investigation of her complaints and they did not tell her that she had a right to bring her complaint to us. We also noted that the board's complaints handling procedure did not accurately reflect the current NHS Scotland guidance on acknowledgment letters, investigation reports or timescales.

Recommendations

We recommended that the board:

• bring our decisions to the attention of the doctor and ensure that he reflects on our adviser's conclusions at his next performance review meeting;
• ensure the practice provide Ms B and her family with a written apology for failing to adequately assess Mr A at the home visit;
• ensure the practice provide Ms B with a written apology for failing to ensure that Mr A was given an adequate explanation of his treatment at the home visit and consent obtained;
• review their complaints handling procedure to ensure it is compliant with current NHS Scotland Guidance 'Can I help you?'; and
• provide Ms B with a written apology for failing to properly handle and investigate her concerns.

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.