Upheld, recommendations

Summary

C complained about the care and treatment their spouse (A) received from the practice. Following a routine smear test, A was advised to see a gynaecologist (specialist in the female reproductive system) as soon as possible and they attended a private appointment the same day. Investigations confirmed A had stage four endometriosis (a severe case of tissue similar to that found in the uterus growing outside of the uterus). The private gynaecologist advised A that they should ask their GP to refer them to the Endometriosis Speciality Clinic.

C complained that there was an unreasonable delay to A's referral for a specialist review. They noted that, when a referral was issued, it was sent to the local gynaecology department, rather than the endometriosis specialists.

We took independent advice from a GP. We found that an urgent gynaecology referral was created promptly following the smear test. We noted that the NHS appointment was cancelled by A while they pursued private investigations. Following a telephone consultation between A and the practice, during which they discussed the findings of the investigations and the recommendation that they be referred to the Endometriosis Speciality Clinic, we found there was an unreasonable delay in the practice sending a referral back to gynaecology. We noted the referral was not marked as urgent and A later had to ask for this to be prioritised.

We found that A was appropriately referred to local gynaecology services but we were concerned by the communication around their desired referral to the Endometriosis Specialty Clinic. There was a lack of clarity regarding what referral had been made, and why. Therefore, we upheld this part C's complaint.

C also complained about the practice's handling of A's complaint. We found that there were delays in the handling of A's complaint and that communication with A regarding the complaints procedure was lacking. We also found that the complaint response did not address some of the key aspects of A's complaint. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A 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 practice should reflect on A's experience of merging private and NHS care with a view to identifying any ways that communication and onward referral could have been better managed.
• The practice should review their procedure for processing and authorising referrals to ensure that referrals are tracked right through to the point where they are sent.
• The practice should take steps to ensure all staff, including temporary or locum staff, are trained to understand and operate the referral system so that they can identify any potential delays to a referral being issued.

In relation to complaints handling, we recommended:

• The practice should review their complaints handling procedure and make sure that it is in line with the NHS 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, an advocate, complained on behalf of their client (A) about the care and treatment they received from the board. A had attended the board for a chest x-ray following respiratory symptoms but the x-ray was reported as normal. A had a second chest x-ray a few months later which led to them being diagnosed with lung cancer. On review of the first chest x-ray it was found that this had been abnormal and was reported incorrectly.

The board's response to C's complaint recognised a mistake had been made by the reporting radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). The board advised that the chest x-ray had been outsourced to an external provider for reporting, and they had fed back this incident to the provider and radiologist, which had been investigated accordingly. The board apologised to A and confirmed the event met the criteria for duty of candour (a legal requirement on all health and social care providers in Scotland which seeks to ensure there is openness and transparency with the aggrieved party when something has gone wrong, and which seeks to learn from the incident). The board also advised the incident had been reviewed internally and concluded that the mistake had occurred due to human error, and that it was not considered to be indicative of a wider problem within the organisation.

We took independent advice from a lung cancer physician. We confirmed that A's diagnosis of lung cancer had been delayed by around three months due to the first chest x-ray being incorrectly reported. We found that it was reasonable for A to have expected the abnormality in their chest x-ray to be identified. However, once the mistake had been recognised, the steps taken by the board had been reasonable in alerting the external radiology company to the problem, and in terms of the board's own internal investigation into the matter. Therefore, we upheld this aspect of C's complaint but made no further recommendations due to the appropriate action taken by the board.

C also complained about the board's handling of their complaint. We found that the board had been transparent with A by alerting them to the mistake and that they had reasonably advised A of the incident meeting the criteria for duty of candour. However, we found that the board had failed to explain to A what this meant in terms of their obligations to them as the aggrieved party. It was our view that the board had not reasonably fulfilled their obligations in keeping with the duty of candour guidance. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should ensure they have met their obligations to A in respect of duty of candour. The board should offer to send A a copy of their report on the incident.

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

• Where duty of candour applies, the board should ensure they take all of the necessary steps in keeping with the guidance, and inform the aggrieved party of the organisation's obligations to them in keeping with the legislation, irrespective of whether a complaint has been made or not.

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 is the parent of a child (A) who has conditions affecting their mobility and continence. C complained about how A's school was managing their personal care and how the council's disability social work department behaved towards C and A.

We took independent advice from a social worker. We found that the Intimate Care Guidance in place at the time should have been updated and that having a written intimate care plan in place for A would have helped to ensure clarity regarding C's concerns about the management of A's personal care. We upheld C's complaint that the council's response to their concerns had not been reasonable.

We found that the disability social work team poorly handled arrangements to speak to A and did not give C enough notice of their intentions. While the council had accepted that they had used inappropriate language to describe C, we found that they had not fully acknowledged this and the impact that this may have had. We upheld C's complaint that the disability social work department failed to behave in a reasonable manner towards them and A.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for their behaviour in relation to arranging a meeting with the children, and their use of inappropriate language. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• The council should ensure that parents, in particular where they are the main carer, are given sufficient notice of social work's intentions to meet with children. The council should ensure that where inappropriate language may have been used, the impact of this is fully acknowledged.

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 decision-making in relation to the allocation of Scottish Government Town Centre funding. In terms of the relevant governance arrangements, local Area Committees were expected to identify and rank eligible projects for the funding. C complained that their local Area Committee had failed to publicise the scheme, failed to invite applications and failed to discuss the funding in meetings. C complained that there was a lack of transparency in the council’s decision-making process.

With regard to the complaint about lack of community engagement, the council said that they were not operating a challenge fund. The council’s position was that the grant was allocated to projects in accordance with the governance arrangements agreed by the Environment, Development and Infrastructure Committee.

We found that the council failed to follow appropriate processes when making decisions regarding the allocation of Scottish Government Town Centre Funding. Specifically, we found that the council failed to evidence how they followed the agreed process that Area Committees become involved in identifying and recommending projects. There was no public record as to how the decision to recommend a particular project was reached and there was no evidence as to how this project was assessed as meeting the eligibility criteria. Taking all of the above into consideration, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to follow appropriate processes when making decisions regarding the allocation of Scottish Government Town Centre Funding. 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:

• Decision-making processes are followed, and the rationale for decision-making (including which projects to recommend for funding) is publicly available in the form of meeting agendas and minutes.

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 on behalf of their spouse (A) about the care provided by the practice. A developed a wound in their left leg and received several courses of antibiotics and wound treatment but the wound deteriorated. A was referred to a vascular specialist several weeks after they first attended the practice. A was later admitted to hospital and died.

We took independent advice from a practice nurse adviser. We found that there were particular concerns about the lack of robust record keeping. The required wound assessment was not carried out or repeated at least every seven days as required. There was no record of the rationale behind the dressings used. There was no record of leg ulcer assessment being carried out and no documentation to support why this was the case until the referral. We found that the use of inadine (a type of surgical dressing) was inappropriate and that the choices for other wound dressings chosen were not detailed. We also found that the ongoing referral was not made in a timely manner.

Therefore, we upheld the 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 requiring wound care should be managed in accordance with relevant guidance and timely referrals made. In particular, the wound should be appropriately assessed, documented and reviewed, appropriate wound swabs taken and appropriate dressings applied and checked.

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 by the board when they were admitted to hospital. C said that they had collapsed at home and were told on admission to hospital that they had an abscess on the muscle connecting their back and hip, which was treated with antibiotics. C said that their leg continued to swell and bruise and that the pain continued to get worse, resulting in their legs giving way on a number of occasions whilst in hospital.

C complained that the board failed to appropriately diagnose, assess and treat them and failed to arrange appropriate follow up care on discharge. C also complained about the communication from the board throughout their stay in hospital. In particular, C said that the board failed to adequately explain the treatment or care that they were provided with.

C also questioned the board’s conclusion that their further admission to another hospital was not due to the issues that they experienced at the original hospital, but due to an INR issue (International Normalised Ratio: a test which measures the time for the blood to clot when taking Warfarin). C said that this is not what they were told by the hospital.

We took independent advice from a registered consultant physician. We found that there was a failure to provide appropriate follow up for C on discharge, including on-going pain management. There were also record keeping failures during C’s admission to hospital, such as timings of C’s review and ability to identify involved clinicians. We found that the diagnosis, assessment, treatment and follow-up care with regards to C’s leg was not reasonable, and upheld this aspect of the complaint.

We found that the board’s communication with C was unreasonable, specifically that there is a lack of evidence of adequate communication about diagnosis and treatment and also in relation to pain management and follow-up care. We upheld this aspect of the complaint.

We also found failings in the board’s handling of the complaint, such as limited information being available to demonstrate that there had been a local investigation into the complaint. The board’s response to the investigation questions posed by the SPSO was also limited. We upheld this aspect of the 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:

• Adequate medical records should be maintained including signed entries and the times of reviews in line with relevant guidelines. There should be clear documentation of relevant clinical subjective and objective findings to support the process of clinical reasoning and care planning.
• Patients should be discharged with appropriate follow up arrangements in place including for pain management where relevant and discharge documentation should be completed so that full discharge information is provided.

In relation to complaints handling, we recommended:

• The board's complaint handling, monitoring and governance system should ensure that failings and good practice are identified and that learning from complaints is used to drive service development and improvement. The board should ensure that full responses are provided when responding to SPSO enquiries.

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 their adult child (A) with adequate care and treatment by discharging them from hospital when they were not medically fit to be discharged, highlighting A’s ongoing incapacity at that time.

A was admitted to hospital following an insulin overdose. Following treatment in an intensive care unit, they were transferred to a general ward. A was discharged after an in-patient stay of several days. A was readmitted to hospital by ambulance transfer the day after their discharge.

We took independent advice from an emergency medicine consultant adviser. We found that it was unreasonable for the board to have discharged A. We found that there were failings in the discharge process which had led to A being discharged with an unaddressed medical condition. Therefore, we upheld the complaint.

We also found that there had been delay in undertaking a psychiatric review. We provided feedback to the board about this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A, C, and their family for discharging A from hospital with an unaddressed medical condition leading to their readmission and for the delay in carrying out a psychiatric review. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflets" www.spso.org.uk/information-leaflets .

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

• In similar circumstances, patients should be fully and appropriately assessed prior to their discharge from hospital and the assessment recorded in the patient’s clinical records.

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 presented at A&E with a painful left foot. The diagnosis recorded in the medical records was a foot sprain. A few months later, C was diagnosed with a rare degenerative condition and a possible healing fracture in their foot was also noted.

C complained that the doctor at A&E had not physically examined the foot, had not carried out an x-ray and had not taken a medical history. As such, a possible fracture may have been missed and a diagnosis of the degenerative condition was not considered. As a result, C felt that the correct treatment was not offered.

We took independent advice from an emergency medicine adviser. We found that the condition in question is rare and unlikely to be diagnosed in an A&E setting. It was also not clear whether the possible healing fracture had been present at the time. However, it would have been appropriate to carry out a physical examination, to take a medical history and to carry out an x-ray. Overall, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not carrying out a physical examination and not taking a medical history, such that an x-ray was not considered. 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:

• Clinicians should be reminded of the importance of carrying out a thorough physical examination and recording the patient’s medical history.

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 service provided by the council's social work service in connection with their child (A), who resided with their other parent. C was unhappy with the way the council facilitated contact between them and A, as well as C's other children and A.

We took independent advice from a social worker. For the period of time we considered, we found that the social work service should have engaged with C more proactively in relation to contact with A. We did not find any issues with the way the council managed contact between A and their siblings. On balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to engage with them more proactively in relation to contact with 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:

• The social work service should engage and communicate with families effectively and in the best interests of the child.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.

Summary

C complained about medical treatment provided to their late spouse (A) following their transfer to a community hospital from a regional hospital, where A had been treated for a heart attack. C raised concern about several aspects of the care provided, including the frequency of medical reviews and communication with A’s family about their condition.

We took independent advice from a consultant in care of the elderly. We found that A had been suffering from hypernatraemia (high sodium levels in the blood) at the time of their hospital transfer and that this condition required careful monitoring of A’s fluid balance, planned daily medical reviews and frequent blood tests. Despite this, we noted that A had not been medically reviewed daily at the community hospital. Weekend medical cover was provided by an out-of-hours GP service, which would only attend if required. Given this, we found that the decision to transfer A to this hospital had been unreasonable.

We also found that the frequency of blood tests carried out was insufficient and that no medical review was carried out despite rising sodium levels in A’s blood. We noted that A had not received intravenous fluids over a period of three days despite their oral intake documented as poor and that, when intravenous fluids had been administered, the particular type of fluids given had been inappropriate to treat hypernatraemia and may have worsened A’s condition. However, it was not possible to say how this might have affected A's outcome given the generally poor prognosis associated with the condition and A’s significant comorbidities. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A’s treatment. 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:

• Robust handover procedures should be in place so that staff taking over responsibility for patient care following transfer to community hospitals are clear about ongoing treatment and review requirements.
• Patients should only be transferred to community hospitals when it is clear that the required level of care can safely be provided following transfer.
• In patients presenting with conditions causing electrolyte imbalances, such as hypernatraemia, medical and nursing staff should be clear on (i) the frequency and the means by which such patients require to be reviewed including the frequency of blood tests and; (ii) the appropriate intravenous fluids to be used to manage such conditions.

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.

Please note the events this complaint refers to may have occurred some time ago due to a delay in publication. We publish our findings to share learning and inform improvement.