Upheld, recommendations

Summary

C complained on behalf of their deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic (dead) tissue on the back of their heels. C also complained that communication with the family and the incident management response had been unreasonable.

We took independent advice from a nursing adviser. We found that pain relief, personal care and rehabilitation support had been appropriate. However, we found that there was no evidence that assistance was provided with eating and drinking, and that fluid and nutrition charts had been poorly completed. We also found that the pressure sores on A's heels were poorly managed, that there were significant gaps in repositioning and that effective preventative measures were not appropriately implemented.

We found that information given to the family was insufficient and incorrect. We also found that the incident management response was unreasonable, as the necrotic heels were not deemed to be serious avoidable harm and therefore no serious adverse event review or duty of candour was undertaken. We therefore upheld C complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not offering sufficient support with eating and drinking and for not preventing and treating the pressure ulcers on A's heels appropriately. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for not recognising the seriousness of the incident and the avoidable harm caused. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to C for providing incorrect and incomplete information about their grandparent's condition. 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:

• Nursing staff are aware and correctly implement HIS Pressure Ulcer Prevention Standards 2020 (including introducing 2 hourly repositioning, therapeutic mattress and skin protection at the point that skin becomes red). Nursing staff know how to correctly diagnose and grade pressure ulcer damage (including “ungradeable”), correctly follow CPR for feet guidelines (such that they make timely referral to a Tissue viability specialist) and develop person centred treatment plan for the pressure ulcer. Nursing staff provide relevant handover information and relevant equipment such as therapeutic mattress and boots when moving a patient between wards.
• Nursing staff should ensure that fluid balance and MUST charts are completed to a reasonable standard. The board should also be reassured that they have appropriate processes in place to monitor performance in this area.
• That a duty of candour review is considered in the light of the SPSO findings.

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 their sibling (A) had not received appropriate care and treatment from their GP practice in relation to symptoms of an infection. C felt the on-call GP failed to arrange for A to be admitted to hospital and that the practice failed to see and examine A, who died the following day of sepsis (an infection of the blood stream).

C also complained that they were unable to access the practice, and that the practice failed to follow its emergency protocol. As such, C complained that the practice had failed to provide reasonable care and treatment to A. The practice considered the care and treatment provided to A had been reasonable.

We took independent advice from an experienced GP adviser. We found that it was reasonable for the on-call GP not to admit A to hospital as this was a decision for the Scottish Ambulance Service (SAS) to make and paramedics expressed no concerns. It was also reasonable for the practice to not examine A as they had already been assessed by the Out-of-Hours Service, the District Nurse and paramedics.

However, we fund that the practice failed to follow the emergency protocol and C and A were unable to access the practice. We also found that the practice's handling of C's complaint was unreasonable due to the quality of investigation carried out. Therefore, on balance, we upheld these complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow the emergency protocol when they attended in person to seek an appointment for A. 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:

• For SAER's to be carried out within prescribed timescales.
• Patient Problem Lists should be appropriately summarised with major diagnoses and events to be included.

In relation to complaints handling, we recommended:

• For administrative staff to be reminded of their duty of candour.
• For all complaints to be dealt with empathetically and sincere apologies provided.

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 made a complaint about the care and treatment provided to their late spouse (A) by the board. C was concerned that A had sepsis (an infection of the bloodstream) at the time of their discharge. C considered that A would not have died had they remained in hospital.

We took independent advice from a consultant in geriatric medicine (a doctor who specialises in treating older patients) and general medicine. We found that there was a failure to properly assess A's blood and urine test results prior to their discharge. Had this been done, there would have been a greater likelihood that infection could have been diagnosed and treated prior to A's discharge from hospital. Although A may still have died had they remained in hospital, this could have given A a better chance of surviving their illness.

We found that there were failures in communication with A's family. A's family should have been provided with 'safety netting' advice about repeating A's temperature or looking for other potential signs of infection once A had returned home. We also found that there were failings in the board's handling of C's complaint. The board's own complaint investigation did not include all relevant staff for comment, the response was brief and did not provide fully accurate information in relation to A's condition.

In light of the above, we found that the board failed to provide A with reasonable medical care and treatment. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C 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 whose test results are suggestive of an underlying infection should be fully and appropriately investigated, in line with recognised guidelines. When a patient is discharged, appropriate 'safety netting' advice about worsening condition should be provided.

In relation to complaints handling, we recommended:

• The board's complaints handling system and their investigation should ensure that relevant staff have the opportunity to comment, that complaint responses appropriately address the issues raised and are accurate and that failings (and good practice) are identified, and enable learning from complaints to inform service development and improvement.

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 late spouse (A) by the board while they were an in-patient at hospital. During A's admission they were diagnosed with stage 4 cancer and COVID-19. A died of COVID-19 in hospital.

C complained to the board about A's care and treatment. C also complained about communication with A's family. The board apologised for aspects of their communication, but did not identify any failings with A's care and treatment. C remained unhappy and asked us to investigate.

C complained about the care and treatment A received for COVID-19 and about the communication A's family received regarding their COVID-19 diagnosis. C complained that the board had failed to adequately investigate the complaint and had failed to adequately investigate how A caught COVID-19.

We took independent advice from a general medicine adviser. We found that aspects of the care A received after their COVID-19 diagnosis, along with aspects of the board's communication with A's family regarding A's COVID-19 diagnosis and treatment were unreasonable. We also found that the board's response to C's complaint contained inaccuracies and that there was a lack of detail. We found that the response failed to adequately address, from a medical perspective, the concerns C had raised, in particular, in relation to A's COVID-19 diagnosis. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for the failure to provide A with reasonable care and treatment, failure to adequately investigate C's complaint and for failure to communicate adequately with C about A's COVID-19 infection. 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:

• DNACPR forms should be appropriately completed by staff who should ensure its implications are discussed with and fully understood by the patient and/or family members at the time of completion. When a patient tests positive for COVID-19, in particular where they have other serious underlying illnesses, a detailed medical review of the patient should be carried out as soon as possible. The reasons for treatment decisions should be clearly documented on a TEP. Prompt consideration should be given to closing a ward where an outbreak of COVID-19 occurs.
• Patients families should receive clear explanations, and be provided with appropriate information that addresses their concerns when responding to complaints.
• Communication with patients and/or their families should be proactive and timely, especially in relation to a serious diagnosis. Where discussions have taken place they should be documented.

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 parent (A) by the practice. Over a period of several months, A and/or family members had multiple contacts with the practice. A started to physically decline more rapidly and was experiencing severe pain which was presumed to be from a prolapse (a displacement of a part or organ of the body from its normal position).

Shortly afterwards, there was a more acute clinical deterioration and an Out-of-Hours medical assessment concluded that A was terminally ill and in need of end-of-life care. There were subsequent assessments by the practice and discussion on best management. A's care was continued at home with general practitioner (GP) and district nurse involvement until A's death.

We took independent advice from a GP adviser. We found that there were occasions where a face-to-face review or examination of A would have been appropriate, or where a more comprehensive assessment of the history and more detailed management discussion would have been reasonable.

Whilst a number of the reviews and adjustments of medication made by the practice were reasonable, we found that there was a lack of medication review on two occasions.

We found that the documentation of the consultations was often lacking in detail and that there was little history or clinical findings to support clinical decisions taken. On some occasions, consultations were not documented at all. Overall, we upheld the complaint that the practice failed to provide reasonable care and treatment to A.

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.

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

• Consideration should be given to assessing elderly patients with confusion face to face following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way, the reasons for this should be recorded.
• Consideration should be given to examining patients following communications about a deterioration in their condition and any decisions should be recorded. If a decision is taken not to assess a patient in this way the reasons for this should be recorded.
• Pain medication should be appropriately reviewed to see if it is adequately working.
• Patients should be given timely, clear and accurate information about the management options for their condition.
• The position in relation to referrals to other specialist services should have been discussed in a timely way without delay.
• The practice should ensure the standard of record keeping meets General Medical Council Good Medical Practice standards.

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 their parent (A) received from the board. A was admitted to hospital and later discharged into a care home. C complained that during A's admission to hospital, communication with the family was very poor. Despite numerous requests for a call from clinical staff, no contact was made and the family were left with very little information as to A's condition or the treatment that they were receiving. C complained that as a result of this the family did not have sufficient information to make informed decisions about A's care. C said that they could see that A's health was declining. A died a few days later.

A's discharge notes recorded that they had vascular dementia (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory), significant cognitive impairment, and lacked capacity for health and welfare decisions. C highlighted that A's hospital records made no mention of a dementia diagnosis and that this was never discussed with the family. C questioned whether A's capacity to consent to changes in their medication and about treatment was properly assessed.

C complained about poor communication from the clinical team and about the assessment and treatment of A prior to the decision to transfer them to the care home. C said that, had the family known the extent of A's deterioration, they would have arranged for them to be cared for at home, rather than in the care home.

In their response to C's complaint the board acknowledged C's concerns about not speaking with clinical staff. They said that attempts were made for A to be assessed by a Mental Health Liaison Nurse but that this was not possible due to A's level of distress. A was deemed medically stable for discharge to a care home. C was dissatisfied with the board's response and brought their complaint to our office.

We took independent advice from a consultant geriatrician adviser (an expert in the health and care of older adults). We found that A was initially appropriately assessed for capacity to make decisions but that this was not appropriately reviewed during their admission. Further reviews could have resulted in further investigations of A's condition. As a result, we found that the assessment and treatment of A was unreasonable.

With respect to the assessment of A prior to discharge, we found that discharge went ahead without proper consideration of their condition at the time and was therefore unreasonable. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informa.on-leaflets.

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

• The board should provide us with a full and detailed update as to the outcome of the reviews outlined in their action plan and any resulting changes to policies or procedures.

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 council's handling of reports of anti-social behaviour and their subsequent complaint about the way that these issues were handled. The council housed a number of vulnerable and high-risk tenants in the same block of flats as theirs. C complained that, over a period of seven years, the council tenants were involved in a number of incidences of anti-social behaviour, some involving serious criminal activity.

The council's investigation report concluded that the view they were failing in their duties under anti-social behaviour legislation may have been based on a lack of understanding of the priority for support rather than enforcement, the level of evidence required for enforcement, and a lack of clarity around activities and behaviours which sit within the scope of the relevant legislation. They did, however, recognise that their communication fell short of the level of consistency that is expected.

We were largely satisfied that the Family and Household Support team investigated C's reports of anti-social behaviour in line with the council's procedure.

However, in terms of the procedure there is a clear expectation that the nature of the complaint should be agreed at the outset, that updates should be given at agreed times, and that discussion should take place regarding what outcomes could realistically be achieved. We found no evidence of a structured approach to this communication. Therefore, we upheld this part of C's complaint.

With regard to the complaint handling, we found the total length of time taken to respond to C's complaint was unreasonable. There was a significant delay to the response being issued, and we found no evidence of regular updates during this delay. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the issues highlighted in this decision. 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 council should review how communication with anti-social behaviour complainants follows a structured pathway as suggested by the antisocial behaviour procedure and that complainants are kept informed through to their complaint's conclusion whilst maintaining confidentiality for the other parties involved.
• The council should review how they communicate with anti-social behaviour complainants with a view to ensuring complainants are fully aware of how the anti-social behaviour procedure works and whether their concerns are being progressed through this, or another 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 that the association did not respond reasonably to reports of anti-social behaviour C made about a neighbouring tenant (B).

The association and the police jointly visited B, discussed the reports and agreed an acceptable behaviour contract. C raised further complaints of anti-social behaviour by B. The association undertook action following consideration of these complaints. C raised further complaints and C left their property temporarily to get away from the stress and exhaustion they had experienced. C also requested the tenancy of another property. The association issued B with a warning letter and C moved to another property. C complained to the association regarding B's history of anti-social behaviour and the association's action in response to these reports. In their response, the association said they believed their actions had complied with the relevant tenancy agreements and their Anti-Social Behaviour and Harassment Policy.

We found that the association were not able to demonstrate that C's reports of anti-social behaviour were categorised in line with their Anti-Social Behaviour and Harassment Policy. We also found that the association did not record all of the reports they received from C, did not record what information or other factors were taken into account when reaching their decisions on C's reports and did not record the reasons why they reached the conclusions they did on what the most appropriate action to take in relation to the reports were. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to respond reasonably to reports of anti-social behaviour. 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 association should follow their anti-social behaviour procedures when handling all reports of anti-social behaviour, including the categorisation of reported anti-social behaviour, the recording of reports of anti-social behaviour, the investigation of reports of anti-social behaviour and the recording of decision-making in relation to reports of anti-social behaviour.

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 practice failed to properly investigate their hip pain symptoms, resulting in a delayed cancer diagnosis. C raised concerns that questions were not asked, or tests carried out, that might have led to an earlier diagnosis. The practice responded to the complaint and carried out a Significant Event Analysis (SEA). They noted that a muscular injury was suspected at the initial consultation. At the time of the second consultation, an x-ray had been incorrectly reported as normal by the hospital. Therefore, the practice were not alerted to any need for further tests at that time.

We took independent medical advice from a GP. We found the practice's management of C reasonable at the initial presentation. However, when C re-presented a month later with worsening bone pain despite a normal x-ray, further investigation (blood tests) should have been carried out. C was then diagnosed after orthopaedic (specialists in the treatment of diseases and injuries of the musculoskeletal system) review the following month. We upheld C's complaint. However, given the extensive nature of the disease identified, we did not consider that further investigation by the practice at the second consultation would have altered the overall outcome.

We also found that the SEA should have reflected the further investigation that should have been considered at the second consultation. We gave some feedback to the practice on learning from adverse events, with reference to Healthcare Improvement Scotland's relevant guidance.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to carry out further investigations when they re-presented with ongoing and worsening pain. 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:

• Blood tests should be considered when patients present with worsening bone pain.

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 they did not receive appropriate care and treatment from their GP practice in relation to the diagnosis and treatment of menopause symptoms.

C felt the practice did not take their menopause symptoms seriously and that GPs were not up to date with current guidance when C was offered antidepressants in response to menopause symptoms. As such, C complained that the practice failed to recognise and appropriately treat the symptoms of menopause, leading to a delay in diagnosis and treatment. The practice considered that the care and treatment provided to C had been reasonable.

We took independent advice from a GP. We found that there had been a number of missed opportunities to diagnose menopause, that consideration had not been given to the relevant NICE Guideline NG23 (National Institute for Health and Care Excellence guideline on Menopause: Diagnosis and Management), and that GPs had failed to consider alternative hormone replacement treatment (HRT) preparations during a period of national shortage. This led to a delay in the diagnosis and treatment of C's menopause. As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in diagnosis and treatment of their menopause symptoms. 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:

• Where patients report symptoms of menopause, they should be appropriately assessed in accordance with relevant national guidelines.

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.