Upheld, recommendations

Summary

Mr C complained that the housing association unreasonably delayed reimbursing the credit balance on his mother-in-law (Ms A)’s rent account. The account had been closed because Ms A was moving house and it had a credit balance, both of payments that Ms A had made herself and benefits that the council had paid directly to the association. Although the association had refunded the payments that Ms A had made, they had not refunded the remaining amount.

After Mr C complained, the association contacted the council to ask what they should do. The council explained that they had made a discretionary housing payment (DHP) into Ms A’s rent account. After the DHP had been made, they explained that Ms A’s entitlement to housing benefit increased and this combination had left the account in credit. They also explained that, in general terms, their guidance said that overpayments would ordinarily only be recovered if there was misrepresentation by the claimant. As this had not been the case, the council confirmed that the association should reimburse the money to Ms A.

The council said this again in later correspondence with the association but, in light of their concerns over what they perceived to be public money, the association returned the money to the council and not Ms A. The association’s handling of the matter resulted in the money being transferred months later than it might otherwise have been. Although we recognised that this may have been an unusual situation for the association, we considered that their handling of the matter was unreasonable, viewed as a whole, and given Ms A's personal circumstances (she was quite unwell and had the inherent stress of a house move).

Recommendations

We recommended that the association:

• apologise to Ms A for their handling of the matter.

Summary

Mrs C complained that her medical practice had removed her from their list of patients. She had visited the practice to try to get an emergency appointment. She had a sore throat and had lost her voice so she used a pen and a scrap of paper to communicate with the receptionist. As a suitable appointment was not available she became frustrated and left the practice. The following day, the practice wrote to Mrs C saying that because of her behaviour, and after seeing relevant CCTV footage, they had no option but to immediately remove her from the practice list. Mrs C told us that she disputed the practice's interpretation of her behaviour. We explained that the practice were entitled to act on any concerns they had and that it was not our role to comment on the incident itself. We confirmed that our investigation would focus on the process the practice followed in removing her from their patient list.

We reviewed the relevant regulations and guidance, and discussed the case with one of our medical advisers. In order to remove a patient with immediate effect, the incident must have been reported to the police. Failing this, the practice should send the patient a warning letter. Only where a warning has been issued in the preceding 12 month period can they remove the patient without having involved the police. We upheld the complaint, as we found that in this case, the practice did not issue Mrs C with a warning, nor did they contact the police.

Recommendations

We recommended that the practice:

• review their removal policy to ensure it reflects the terms of the General Medical Services Contracts Regulations and associated guidance, particularly in respect of giving patients relevant prior warning if they are at risk of removal; and
• apologise to Mrs C for not following the proper procedure when removing her from their list of patients.

Summary

When Mrs C’s husband (Mr C) was taken to hospital by ambulance, the crew could not get the ambulance doors open, and there was a delay getting him to the hospital. Mr C passed away the following month and Mrs C then complained that the Scottish Ambulance Service (the service) had never apologised for the incident. When looking into the complaint, the service were unable to trace any details of the ambulance journey or crew involved. However, they formally apologised to Mrs C for the incident and assured her that steps had been taken to avoid a similar future problem.

Mrs C complained to us that the service had been unable to trace details of having transported her husband to hospital. The service told us what they had done to try and trace the journey. They said that no incident report was completed on the day in question and they received no reports of a vehicle with faulty doors. We were satisfied that they had fully investigated Mrs C’s complaint and gone to considerable effort in trying to trace the ambulance and crew involved. We also recognised that, despite not having traced the incident, they had apologised. However, we did not consider that they had taken appropriate action to try to avoid this happening again. We, therefore, made a recommendation.

Recommendations

We recommended that the service:

• issue an appropriate written reminder to staff of their obligations to formally report any incidents and also any related vehicle maintenance issues.

Summary

Mr C's late mother (Mrs A), who suffered from dementia, was admitted to hospital with hip pain after a fall. X-rays suggested that she had fractured a bone in her pelvis. Healthcare professionals assessed her as having moderate cognitive impairment (a condition affecting the ability to think, concentrate, formulate ideas, reason and remember) and noted that she was confused and disorientated. Mrs A had a further fall some days later, when no injuries were noted. However, she then fell again several weeks later and fractured her left hip which was repaired in an operation. She fell again in early December 2012. Her medical records said she made no complaints of pain, and she was discharged to another hospital for rehabilitation shortly afterwards. Five days later, Mrs A was transferred back to the first hospital complaining of hip pain, and a fracture to her right hip was identified. Following surgery to repair the fracture, Mrs A died.

Mr C said that the family were very distressed that Mrs A suffered two fractures while in the care of the hospital and that the board failed to take reasonable steps to prevent her from falling. He was also concerned about the lack of documentation concerning Mrs A's fall in early December and said that the board failed to provide a reasonable standard of nursing and medical care after the falls. The medical records showed that Mrs A fractured her left hip following her third fall, and that a second hip fracture was diagnosed in mid-December 2012. Mr C, however, believed that the second fracture occurred during her fall in early December.

We took independent advice on this complaint from one of our medical advisers. The adviser said that while there was clear evidence of risk assessment and planned interventions, these did not take account of Mrs A's cognitive impairment. Moreover, there was a lack of an overall score in the risk assessment tool used, which was significant as the score could have indicated the need to use falls prevention aids or to consult a falls specialist. The adviser also said that there was evidence of ineffective record-keeping of pain assessment, which was not suited to patients who were less able to report this themselves. In light of this, we were not satisfied by the entry in the medical records of early December that said that Mrs A was not in pain, particularly as we noted that Mrs A's sister, her main carer, had said that Mrs A was in more pain than usual on the evening of the fall. In the absence of records relating to Mrs A's admission to the second hospital and her return to the first hospital, however, we could not say definitively when Mrs A fractured her hip.

Having said that, we were extremely concerned about the board’s failure to properly assess Mrs A's levels of pain and the lack of evidence to show that Mrs A was checked by medical staff following her fall (including that there was no evidence of their findings). We were also concerned about a lack of nutritional screening and of effective use of the adults with incapacity legislation. The board acknowledged shortcomings in record-keeping, in particular following the fall in early December. They said they had raised this matter with the staff concerned and had apologised to Mr C for this. We found failures in record-keeping by nursing and medical staff in relation to all three falls. Given the risk this posed to Mrs A, we were very critical of these failures, particularly of those by medical staff. We upheld Mr C's complaints and made a number of recommendations.

Recommendations

We recommended that the board:

• ensure the failures in record-keeping are raised with relevant staff;
• ensure that the systems for transferring records from one care setting to another and for storing and retrieving medical records securely are robust;
• review the falls assessment documentation and policy in light of our adviser's comments;
• ensure that effective nutritional screening of all patients in the hospital takes place;
• introduce a pain assessment tool appropriate for people with dementia;
• ensure effective compliance with adults with incapacity legislation; and
• apologise to Mr C for the failures identified.

Summary

Mrs C complained on behalf of the family of her late aunt (Mrs A) that the care and treatment Mrs A was given whilst she was in the care of the board was unreasonable. Mrs A had died after being diagnosed with a form of cancer, which it had taken some time to identify. Mrs C said that because of this, her aunt suffered more than she should have done, and wanted to know why tests had failed to detect her condition earlier.

We considered all the complaints correspondence and Mrs A's medical records, and obtained independent advice from one of our medical advisers on the care and treatment provided. Our investigation found that Mrs A's illness was complicated and very difficult to diagnose. Doctors were considering three possible diagnoses, which were also rare. While it was reasonable for them to explore and treat the possibility of tuberculosis (which was initially considered), we concluded that insufficient acknowledgement had been given to irregularities that had been found. A scan had confirmed a mass that could be felt, and two colonic investigations (examinations of the bowel) had failed to reach a particular part of it. No single doctor took the lead in Mrs A's case, which was not ideal. In the circumstances, we upheld the complaint, as we concluded that there was a missed opportunity to make an earlier diagnosis. While this may not have affected the outcome, it might have allowed an extension to Mrs A's terminal care.

Recommendations

We recommended that the board:

• apologise to Mrs C for the failings identified in this complaint;
• review the circumstances of Mrs A's case and put in place processes to ensure that lead responsibility is taken for progressing a diagnosis; and
• ensure that those clinicians involved in Mrs A's case are made aware of these findings so that they can take forward the learning from it.

Summary

Miss C complained about the care and treatment she received from a consultant urologist. (Urology is the branch of medicine that relates to the urinary system.) She said that the level of aftercare she received was insufficient. Miss C also complained that the consultant did not communicate adequately with her, and did not communicate adequately with her GP after the procedure.

Our investigation found that Miss C was admitted to hospital for a relatively rare urological procedure. The day after the procedure she was discharged, but was not told about any follow-up care, other than an appointment in the urology clinic four months later. After she was discharged, Miss C became unwell, and went to see her GP. She told us that her GP was unable to provide effective care beyond pain management because at that time he did not have any information from the board about her admission. Miss C became more unwell, and was admitted to her local hospital ten days after the operation.

After taking independent advice on this case from a urology adviser and a general medical adviser, we upheld both Miss C's complaints. The urology adviser was critical that Miss C's clinical notes did not mention any discussions with her before the procedure about what was involved and what the risks were. He also said that Miss C had not had a scan a week after her procedure, although this had clearly been intended, and that the scan was not mentioned on the immediate discharge letter for her GP. This meant that neither Miss C nor her GP could follow up with the board appropriately when arrangements for the scan were not made.

In relation to communication with the GP, we found that the board appropriately prepared the immediate discharge letter and a discharge summary letter. We could find no evidence to show when the medical practice received these, but the immediate discharge letter had clearly not been received by the time Miss C consulted her GP. We were also concerned that it did not contain information about the scan, making it impossible for Miss C or her GP to ensure that appropriate aftercare was given.

Recommendations

We recommended that the board:

• remind urology department staff of the need to ensure that all aftercare appointments are in place prior to discharging patients;
• ensure that discussions about consent, including the risks of a procedure, are documented at the time they take place;
• take steps to ensure patients are informed of any follow-up appointments on discharge and that the GP is advised appropriately; and
• apologise to Miss C for their failure to provide appropriate aftercare and for their failure to communicate appropriately with her and her GP.

Summary

Mrs C's father (Mr A) has a complex medical history, including cancer. Early in 2012, Mr A began to suffer backache, and a GP visited him at home. The GP believed the problem was musculoskeletal and prescribed anti-inflammatory gel and pain relief (tramadol). Mr A continued to suffer a great deal of pain and went to the medical practice three days later. The GP saw no obvious signs of infection and diagnosed muscular pain, but also took blood tests to exclude any spread of the cancer. Mr A continued to suffer severe pain and was reviewed by the GP again over the next few weeks. The GP arranged for a chest x-ray and, when the results for this were abnormal, arranged for Mr A to have a scan.

On the day the scan was due, Mr A also had an appointment at a cancer centre, which he attended on his GP's advice. Because of the appointment, the scan was carried out seven days later than planned. The scan results were also abnormal, suggesting possible malignancy or infection in the spine (discitis). The GP urgently referred Mr A to the oncology (cancer) department at the hospital. Mrs C said that Mr A’s pain became excruciating and over several weeks increasingly strong painkillers were prescribed. He was then admitted to hospital by ambulance and diagnosed with discitis. After further investigations and treatment (including an operation) Mr A lost the use of both legs and became doubly incontinent.

Mrs C complained that the GP failed to properly investigate her father's symptoms, provide reasonable pain relief and admit him to hospital, and that the delay in diagnosis was not reasonable. She said that had the relevant scans been carried out sooner, then the outcome for Mr A would have been more positive. She was also unhappy that Mr A's attendance at the cancer centre meant a delay in the scan being carried out.

We took independent advice on this complaint from one of our medical advisers. With hindsight, the significance of the delay in Mr A having a scan, caused by the cancer centre appointment, was apparent. However, what we had to consider was whether the GP's advice that the appointment at the centre should be kept was reasonable in light of the information available to him at that time. Given that this arose from the GP's concern that the abnormality indicated in the x-ray was a spread of cancer (which our adviser said was a reasonable working diagnosis at that time) we were satisfied that his advice was appropriate in the circumstances. On the delay in diagnosis, our adviser said that while discitis is a rare and difficult condition to diagnose (particularly in general practice), there was a delay in carrying out appropriate investigations, in that an x-ray should have been carried out two weeks earlier. However, the adviser also told us that the pain relief was appropriate and that the decision not to admit Mr A to hospital earlier was reasonable. Nevertheless, we were concerned about the delay in arranging a chest x-ray, particularly in light of Mr A's complex medical history, and the impact this had on him. We upheld Mrs C's complaint and made recommendations.

Recommendations

We recommended that the practice:

• review the handling of Mr A's case in light of the findings of our investigation; and
• apologise to Mrs C for the failures identified.

Summary

Mr C, who is a prisoner, complained to us about the board's handling of his complaint to them about healthcare issues. We were satisfied that the board had considered and responded to the issues Mr C raised, but our investigation found that they had failed to deal with the complaint within the timescales detailed in their complaints procedure and had not kept him advised of progress.

Recommendations

We recommended that the board:

• apologise for the failures we identified in the handling of the complaint; and
• remind staff of the need to work in accordance with the NHS Scotland complaints procedure.

Summary

After Mr C’'s daughter (Mrs A) experienced several episodes of breathlessness, she was seen by her GP, who concluded she had a virus. Over the following days, Mrs A remained breathless. She collapsed at home and her GP was called out. He found that her blood pressure was low, but rising. He concluded that she had had a vasovagal episode (a temporary loss of blood to the brain) but was improving. Mrs A had further collapses over the following days and was eventually taken by ambulance to hospital. Shortly after arriving there, Mrs A collapsed again and, despite attempts to revive her, she died. Mrs A was found to have had a pulmonary embolism (a blockage in the artery that transports blood to the lungs). Mr C complained that there was a lack of urgency from accident and emergency (A&E) staff in diagnosing the cause of his daughter's symptoms. He also complained that Mrs A was left alone in a cubicle and that he and his wife were not allowed to sit with her.

After taking independent advice on this complaint from one of our medical advisers, we upheld Mr C's complaints. We found that Mrs A was seen by a nurse immediately on arrival at the hospital. However, she asked to use the toilet and was allowed to do so, which delayed triage (the process of deciding which patients should be treated first based on how sick or seriously injured they are) by around 30 minutes. Mrs A was triaged by a nurse and was prioritised as 'urgent', meaning she would be seen by a doctor within one hour. Our adviser said that Mrs A's symptoms were sufficiently abnormal to merit being prioritised as 'very urgent', which should have resulted in a doctor seeing her within ten minutes. Mrs A collapsed around twenty minutes after triage. We were satisfied that Mrs A was treated appropriately following her collapse, but we criticised the board for failing to identify the seriousness of her condition. Although we found it appropriate for Mrs A to be given privacy to use the toilet, we were also critical that Mrs A’s parents were not allowed to sit with her in the cubicle, or that staff did not ask Mrs A whether she wished to be visited.

Recommendations

We recommended that the board:

• apologise to Mrs A's family for the issues highlighted in our investigation;
• share this decision with staff carrying out triage in A&E with a view to ensuring an appropriate combination of tool-based prioritisation and professional judgement;
• take steps to ensure that the Fife Early Warning system (a system based on observation, and used to monitor changes in the patient’s condition) is being properly implemented and understood by staff in A&E;
• take steps to ensure that the triage process and decisions reached regarding treatment priority are properly documented; and
• remind nursing staff of the Nursing and Midwifery Council guidance on standard of conduct, performance and ethics 2008.

Summary

Mr C complained on behalf of his partner (Ms B) that the care and treatment provided to her late mother (Mrs A) was inappropriate. Mrs A, who lived in a care home, was admitted to hospital where she was diagnosed with pneumonia and treated with intravenous antibiotics (drugs to fight a bacterial infection, delivered straight to the patient's vein). Mrs A was discharged to her care home three days later with antibiotic tablets, but died suddenly in the early hours of the following morning.

Our investigation included taking independent advice from two of our advisers, a medical adviser and a nursing adviser. The medical adviser said that Mrs A's condition had improved while she was in hospital. Because she was returning to a care home, it was reasonable for the hospital to consider discharging her. However, there was clearly a lack of discussion with the family and the care home about Mrs A's ongoing care. Ms B was not aware that her mother had been in hospital until the care home phoned to tell her that Mrs A had died. The medical adviser was also concerned that there was a lack of communication with Mrs A about her treatment, including a medical decision not to attempt resuscitation if her heart or breathing stopped (DNACPR). There was also no evidence that Mrs A's mental capacity had been appropriately assessed. The nursing adviser said that there was a lack of communication between nursing staff and Mrs A's family and her carers in planning for her discharge, and a general lack of detail in the nursing notes.

Recommendations

We recommended that the board:

• ensure that relevant staff reflect on the medical adviser's comments in relation to the assessment of patients who lack mental capacity to make complex decisions about their care and treatment;
• issue a reminder to relevant staff of the requirement to keep clear, accurate and legible records;
• ensure that relevant staff reflect on the medical adviser's comments in relation to the completion of the DNACPR form;
• provide evidence that relevant staff have reflected on the specific reasons why there was a failure to communicate with the patient and her family; and
• apologise to Mr C and his partner for the failures identified during this investigation.