Upheld, recommendations

Summary

C complained about the care and treatment that their spouse (A) received from Scottish Ambulance Service (SAS). C called for an ambulance after A fell from a height at home. A was assisted to their feet after an initial check and then walked to the ambulance for further checks. After returning to the house, A became pale and reported a brief loss of sight. It was decided A should be transferred to hospital where they were later diagnosed with a broken pelvis.

C said that one of the crew members was rude and dismissive when they had tried to describe the height A had fallen from. C complained that SAS had not fully assessed A, failed to consider the accounts given by eyewitnesses and unreasonably concluded that A could remain at home and take painkillers. A was clear that they did not want to go to hospital, however, C considered the crew failed to recognise A was in shock.

In responding to the complaint, SAS advised that a full assessment had been carried out. It was also noted A did not initially wish to be transferred to hospital and had declined to be immobilised on a spinal board. The response advised of actions for learning and improvement which would be taken with the crew in response to C’s complaint. This included actions in relation to the mechanism of injury (in this case a fall from height), moving and handling, consideration of silver trauma (the impact of trauma on older patients), and communication with patients and relatives.

C was unhappy with this response and brought their complaint to us. We took independent advice from a senior paramedic adviser. We found that SAS failed to undertake a reasonable assessment of A as they did not act in keeping with the Joint Royal College Ambulance Liaison Committee guidance on Spinal and Spinal cord injury. In particular, there was a failure to immobilise A at the scene given the mechanism of injury. We also considered that SAS failed to reasonably document the incident, consider A’s age and the effects of ‘silver trauma’ and to correctly calculate the National Early Warning Score. SAS did not document any discussion about the risks/benefits associated with immobilisation or fully record A’s reported initial refusal to comply with treatment or to be transferred to hospital. Finally, we noted a failure to document a pain score before and after analgesia had been given. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to provide a reasonable standard of care. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The patient record should be completed in full to reflect the presenting condition/mechanism of injury; the assessment and observations undertaken including NEWS, pain score, the accounts of eye witnesses and consideration of other relevant factors such as age; and the patient’s decision regarding treatment and the information shared to inform this decision.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to provide hip replacement surgery within a reasonable period of time. C experienced back and buttock pain for several years due to an existing condition. C started to experience new pain in their right leg. Their GP referred them for an x-ray and made an urgent referral to the orthopaedic department (specialists in the treatment of diseases and injuries of the musculoskeletal system) as C had been off work due to debilitating pain in the hip and was concerned about losing their employment as a result.

C had a consultation with the orthopaedic surgeon and was told that the hip was badly damaged. C was listed as a priority 4 case (a lower priority) for a total hip replacement. C’s condition continued to deteriorate; they were in severe pain and it was affecting their day to day life. C contacted the board to explain the severity of the problems that they were experiencing and they were reviewed in clinic. Shortly afterwards, C underwent surgery privately.

We took independent advice from a trauma and orthopaedic consultant. We found that a number of failings occurred that were not simply as a result of the delays caused by an extensive waiting list. It was unreasonable that C was incorrectly categorised from the outset and that an outdated prioritisation tool was used by the board. It was also unreasonable that the radiological deterioration was not documented and that C’s surgical treatment was not expedited at the further clinic appointment. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Calculate and reimburse C in relation to their private surgery on production of appropriate receipts. The calculation should be based on what the surgery would have cost the NHS (rather than what it cost C). The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

What we said should change to put things right in future:

• Patients should be given timely, clear and accurate information about their clinical prioritisation and potential waiting times for surgery.
• Patients should receive the appropriate clinical priority level based on assessment and the clinical evidence available.
• Patients who report clinical deterioration during their wait for surgery should be appropriately assessed and reprioritised where this is appropriate.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

This case was reviewed and closed in October 2024. This summary was published prior to review. No changes are required to this summary as the outcome of the review was unchanged from the initial decision from April 2024. 

Summary

C complained on behalf of their parent (A) that the board unreasonably failed to proceed with hip replacement surgery within a reasonable timeframe.

C said that A was referred for physiotherapy before being added to the waiting list for surgery. They complained that this was unreasonable as it was known that it would not help given the extent of deterioration in A’s hip joint. C also complained that several of A’s appointments had been cancelled or postponed, and that the board had failed to act on an urgent referral sent by A’s GP. As it was unclear when A would receive their surgery, they opted to have this carried out privately.

In responding to C’s complaint, the board confirmed that they must take all reasonably practicable steps to ensure that they comply with treatment time guarantees. This includes considering whether to send patients to another care provider if they cannot provide treatment by the patient’s treatment time guarantee. In A’s case, the board noted that A had elected to make their own arrangement for private surgery and, therefore, the NHS offer of treatment was no longer relevant to them.

We took independent medical advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). At the point of referral to orthopaedics, we found that A was reasonably referred for physiotherapy and added to the waiting list as a routine category patient. At the pre-operative assessment clinic, we found that an x-ray was taken but it had not been reported or reviewed. At this point, A should have been re-prioritised to urgent in keeping with the physical changes that they had reported and the radiological deterioration evident on the x-ray. It was unreasonable not to re-prioritise A at this time. In reference to the urgent referral sent by A’s GP, A continued to be considered as a routine category patient. However, it was clear A’s case had been expedited as they were offered a place on a private sector list for surgery run by the board at the time. The board could not provide evidence to support their decision making. We also found that the board did not meet their legislative requirements when communicating with A about their treatment time guarantee date. On balance, we upheld C’s complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for not reasonably communicating with A about the breach of their treatment time guarantee date, for not acting on the changes reported by A at the pre-assessment clinic, for not reviewing or reporting the x-ray, for not appropriately reviewing and reprioritising A following the urgent GP referral, and for not documenting the reason for the decision to add A to the private list for surgery. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients on waiting lists for surgery should be managed in keeping with the relevant policies and guidance, and they should be kept informed about delays particularly when a treatment time guarantee has been breached. The outcome of assessments and test results including x-rays taken at pre-assessment clinics should be timeously reviewed and documented in the medical record. Patients should be appropriately reviewed and reprioritised based on assessment and the clinical evidence available. Decisions made in respect of the patient should be documented by the relevant person in the medical record.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are appropriately investigated and that failings (and good practice) are identified and learning from complaints are used to drive service development and improvement The final complaint response should include information about the SPSO, including the timescale for making a complaint, in line with the Model Complaints Handling Procedure.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated.

In response to C’s complaint, the board acknowledged that documentation of A’s wounds was not started in critical care wards, and A’s wounds were not initially logged on the board’s system for reporting adverse events. The board told us that after C’s complaint, the tissue viability service developed online learning for staff, and developed and promoted a wound management policy. The board apologised that A sustained wounds after surgery.

We took independent advice from a nurse with a specialism in wound care. We agreed that the board did not reasonably document C’s wounds; however, we also found that they did not follow their guidelines in treating A’s wounds. We found that there was a delay in referral to a tissue viability specialist; a lack of skin inspection; inadequate repositioning to prevent pressure damage occurring or deteriorating; and inappropriate wound management. We also found that the board did not provide C with a full and informed complaint response. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should be regularly assessed for tissue damage in line with board procedures. Where tissue damage is found, appropriate treatment including timely escalation to a tissue viability specialist as required should be provided.

In relation to complaints handling, we recommended:

• The board’s complaint handling monitoring and governance system should ensure that complaints are properly investigated and responded to; are accurate; and that failings and good practice are identified.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board failed to carry out a reasonable assessment of their late parent (A) when they were admitted to hospital. They were also unhappy with the decision to discharge A and said that the board failed to communicate adequately with them and their family during the time A spent in the hospital. C complained that the board’s complaint response was not consistent with A’s clinical records.

We took independent advice from a consultant in geriatric and general medicine. We found that while a reasonable assessment of A’s clinical condition was carried out, the assessment of A’s physical condition and the discussion with their family before discharge fell below a reasonable standard, particularly with respect to A’s mobility. We also found that communication with A’s family fell below a level that they could reasonably expect. Finally, we were critical of the board’s complaint response which appeared to be selective in terms of the information provided rather than being objective. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified and provide an explanation to C about why the discharge document mentioned ‘urosepsis’. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The gap between a patient’s previous and current abilities should always be assessed and considered when making a decision about discharging the patient. Where a patient’s family is involved in their care at home, they should be involved in discussions about the patient’s discharge and any follow-up care and treatment.
• Complaint responses should be objective, clear, accurate and address the issues raised.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C and B complained about the support that they had received as foster carers from the partnership. C and B told us that they had been foster carers to two young people for a number of years. Following a significant incident in the fostering placement, social work services had taken the decision to remove both young people from their care. Following the end of the placement, C and B complained to the partnership about the adequacy of support and intervention offered to both them, and the young people, by social work services during the placement, the decision to remove both young people from their care and the lack of transition planning.

In response to C and B's concerns the partnership concluded that a reasonable level of support had been offered to them during the placement. They said that the decision to end the placement had not been taken lightly, and staff had made a professional assessment in the young people’s best interests. They apologised for the delay in convening a disruption meeting, citing a number of mitigating factors, including operational constraints and government restrictions.

We took independent advice from a social worker. We found that, in the weeks prior to the incident, the partnership failed to follow their Placement Support Practice Guidance, specifically a Placement Support meeting was not convened to explore how the placement could be supported and maintained. We found that following the incident, the partnership’s communication and support to the family was not robust or proportionate, and an appropriate debrief had not taken place, including an urgent risk assessment. We found that there was a lack of young people involvement in decisions about their future care planning. The partnership did not complete appropriate transitioning planning or risk assessment to assist the young people, and the foster carers, with the immediate impact of the end of placement, including seeking the young people’s views in respect of their onward communication / contact with their foster carers. We also found that there was an unreasonable delay by the partnership to convene a disruption meeting following the placement ending and inconsistencies in their policies and practice guidance in respect of timescales for a meeting. Therefore, we upheld C and B's complaints.

Recommendations

What we said should change to put things right in future:

• Where a long-term fostering placement is at risk of breaking down, a Placement Support meeting should be convened as soon as possible to explore how the placement can be supported and maintained.
• Ensure that there is clarity across all of the partnership’s policies and practice guidance in respect of timescales to convene a disruption meeting so that there are no anomalies that remain for practitioners, foster carers and service users. When there are genuine reasons for delay in adhering to these timescales then this should be consistently conveyed to the foster carers and partners to the child/ young person's plan.
• The child / young person’s views should be sought and clearly recorded in decision-making about their care plan.
• Where a long-term fostering placement breaks down, a robust transition plan with input from the foster carers and the children / young people affected should be formulated to assist with the immediate impact of the end of the placement.
• Where a significant incident has occurred in a fostering placement, appropriate support should be offered to the family and a formal debrief meeting facilitated with the family as soon after the event as safe to do so. This should include risk assessment and care planning in light of any risk identified. All views of the incident should be considered and recorded with any immediate and long-term actions being transparent and recorded in case notes.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C contacted the Scottish Ambulance Service (SAS) when they began experiencing abdominal pain. An ambulance attended but did not take C to hospital. The crew provided advice to contact the service again if their symptoms worsened. C contacted the service again the following day. A telephone assessment was completed but no ambulance was sent. C later made their own way to hospital where they required surgery for a perforated bowel.

C complained that the SAS failed to recognise the seriousness of their symptoms and failed to provide appropriate care and treatment. C said that as a result, they required more extensive surgery than if they had been taken to hospital sooner.

We took independent advice from a paramedic. We found that the ambulance crew had unreasonably failed to carry out an adequate assessment of C. The crew assessed that C had withdrawn consent for further assessment, and did not provide adequate advice on the benefits of assessment or the risks of not completing the assessment. We also found that the telephone assessment the following day was inadequate and was poorly documented. Therefore, we upheld C's complaints.

Recommendations

• What we asked the organisation to do in this case
• Apologise to C for failing to conduct an adequate assessment, failing to recognise the potential seriousness of their symptoms, and failing to provide them with the care that they required. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Clinical staff are able to recognise symptoms of potentially serious abdominal conditions.
• Clinical staff ensure that benefits of assessment, treatment and transport to hospital, and the risks of declining care, are fully discussed with the patient and recorded.
• Clinical staff reflect on and learn from patient experience to improve future practice.

In relation to complaints handling, we recommended:

• Relevant staff and senior managers are familiar with the Adverse Events Policy, understand the criteria for a Significant Adverse Event Review, and apply it correctly.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Amendment - 27/06/2024

When this complaint was originally published (19/03/2024) we made the following recommendation: "Clinical staff are aware of Kehr’s sign and are able to recognise symptoms of potentially serious abdominal conditions."  This has since been amended to "Clinical staff are able to recognise symptoms of potentially serious abdominal conditions." following receipt of new information.  

Summary

C underwent a coronary artery bypass surgery (a surgical procedure that creates a new path for blood to flow around a blocked or partially blocked artery in the heart). C required three further surgical procedures on their chest wound over a period of seven years after their bypass surgery. C’s chest wound developed a sinus (a track that extends from the surface of an organ to an underlying area) and did not heal properly. C also developed osteomyelitis (a bone infection) in their chest wound. C raised concerns about the care and treatment that they received from the hospital.

We took independent advice from a consultant cardiac surgeon. We found that the clinical treatment provided to C was reasonable. However, we found that the hospital failed to provide timely discharge information after C’s bypass surgery and after C’s surgery over a year later. We also found that the hospital failed to reasonably follow up C after discharge from two of their surgical procedures. Therefore, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delays in providing timely discharge information and failure to reasonably follow up two of their surgical procedures. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Discharge letters following surgical procedures should be sent out in a timely manner and clear follow-up arrangements should be given in the discharge letters following surgical procedures.

In relation to complaints handling, we recommended:

• When a complaint involves more than one NHS board, the boards should decide who will lead on the complaint and provide a joint response.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C submitted a complaint on behalf of their relative (A) who received treatment at hospital. A had previously suffered a stroke (causing left sided weakness) and was admitted after being unwell for a few days. C complained about the nursing care provided to A while they were in hospital.

We took independent advice from a nursing adviser. We found that there were failings in relation to nursing documentation, moving and handling practices, a lack of equipment, and a lack of assessments as to A’s needs. In particular, there was no falls assessment and appropriate action and recording did not take place after A’s fall. In relation to moving and handling, we found that glide sheets should have been utilised and that appropriate equipment should have been available in the ward. The board failed to reasonably record the care that they provided, or carried out appropriate assessments to ensure person-centred care to confirm that A’s needs were met. As such, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings as identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• All patients must have a falls risk assessment completed on admission and after a fall a post falls assessment should be completed.
• Every patient should have a person-centred plan of care.
• All patients must have a moving and handling risk assessment undertaken within 24 hours of admission.
• Nursing documentation should be complete and reflect a person's care needs, plan of care, care delivered and evaluation of the care delivered.
• Basic moving and handling equipment should be readily accessible for all patients and staff.
• All patients should have their care needs identified and risk assessments undertaken in order to develop a person-centred plan of care.

In relation to complaints handling, we recommended:

• Complaint investigations should respond to all of the main points raised and identify failings and take learning from what happened.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment that they received from the practice prior to their diagnosis of an abdominal cyst, which was surgically removed some years after C first attended the practice with symptoms. C complained that they did not receive a referral for an ultrasound scan until many months after first attending the practice with symptoms. C also complained that four different doctors were involved in their care and that the practice’s complaint handling was unreasonable.

We took independent GP advice. C’s case was complex and challenging due to the nature of C’s cyst, C’s other diagnoses and the timing of C’s consultations during the COVID-19 pandemic. Nevertheless, we found that there was a missed opportunity for the practice to refer C to the colorectal service based on the positive result of a qFIT test (a test to detect blood in the stool) when C first attended the practice with symptoms, based on the National Institute for Health and Care Excellence (NICE) guidance. We found that there was a further missed opportunity for the practice to consider referring C to secondary care based on C’s subsequent positive qFIT test result, which was taken many months after the first positive qFIT test. We also found that there were delays in the practice contacting C after receiving the result of the subsequent qFIT test and when the practice received the result of C’s ultrasound. We found that, given the state of NHS services at the time C attended the practice, there was not likely a significant delay in C receiving a diagnosis or surgery for their cyst. On balance, we upheld C’s complaint about their care and treatment from the practice.

We found that the practice’s complaints handling was unreasonable, because the first complaint response did not address the issues C raised as a complaint. We upheld C’s complaint about the practice’s complaints handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to action the results of qFIT tests, for the delays and for the unreasonable complaint response. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

What we said should change to put things right in future:

• Administrative systems at the practice should support timely actioning of abnormal results.
• Clinical staff should be knowledgeable about the indication and interpretation of qFIT tests, as per NICE guidance.

In relation to complaints handling, we recommended:

• Complaints should be appropriately acknowledged in line with the Model Complaints Handling Procedure for NHS Scotland, and the complaint response should fully address the substantive issues raised in a complaint.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.