Upheld, recommendations

Summary

C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had sore gums and an ulcer in their mouth. C also complained that A had red, sore skin in the groin area.

The board apologised for the fallen medication and advised that they were undertaking a project to reduce medication errors. They advised that A had not wanted to shower and that both personal and oral care had been undertaken regularly. They also said that the skin in the groin area had been checked and had only become red on the day that C visited.

We took independent advice from a nurse. We found that there appeared to be a design fault with the lockers, such that medication could fall out of the medication pod. We also found that A should have had a personal care plan and had not been offered sufficient personal care or oral care. We found that red skin had been noted 11 days prior to C's visit but had been recorded as healthy in the interim period. This would suggest that the skin was not properly checked. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for providing unreasonable personal care and unreasonable skin 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:

• Person centred care plan to be put in place for patients within 24 hours, as per board policy and skin care guidance to be followed 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.

Summary

C complained about the care and treatment provided to their late spouse (A). A was diagnosed with pancreatic cancer. C was unhappy with the delays with A's treatment and said that these prevented A from receiving any treatment before their death.

The board said that their intention was to treat the cancer and that A was required to meet with a consultant to assess their fitness for surgery. The board said that the delay in meeting with a consultant was to allow the health board to carry out two multidisciplinary meetings, for some of A's symptoms (such as jaundice) to improve, and for other investigations and procedures to be carried out (such as, imaging scans and the fitting of stents). The board acknowledged that there was a delay in a PET-CT scan (where a drug is injected before the scan to help clinicians identify how certain body functions are working) being carried out due to failures in the drug production. The board said that when this fails, there is no back-up facility in Scotland to provide a replacement batch.

We took independent clinical advice from a consultant colorectal and general surgeon. We found that the timeframe for A's treatment could have been improved even with the allowable delays from the PET-CT scan. We considered that the investigations carried out were reasonable and the early scan and procedure to fit a stent were good points in the treatment pathway. However, the length of the pathway could have been improved and A's lengthy pathway to the offer of chemotherapy was unreasonable. The timing of the clinic appointment and PET-CT could also have been improved. Whilst we recognise some of the delays experienced could not be predicted or avoided, on balance, the timescale for A's pathway was unreasonable. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in assessing A's fitness for surgery and the impact this had on other investigations i.e. arranging a PET-CT scan, the delay in the PET-CT scan being carried out and A being identified as unsuitable 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 who are considered suitable for surgery should have early assessment to establish fitness for surgery.

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 B about the care and treatment provided to B's spouse (A) by the practice. A attended the practice on a number of occasions over a few years with ongoing and worsening abdominal and lower back pain. C complained that the practice assumed A was suffering from a musculoskeletal problem and failed to consider other diagnoses sooner. A was later diagnosed with lymphoma and died at the time of diagnosis.

In responding to C's complaint, the practice undertook a Significant Adverse Event Review (SAER) and noted it was not clear when the lymphoma started. The practice also found that A had several normal or reassuring examinations and tests, and that several of A's presentations and tests pointed towards other diagnoses including liver disease and prostate disease. The SAER ultimately concluded that it seemed very unlikely that A had lymphoma for a long period of time given the very aggressive nature of their disease.

We took independent advice from a GP. We found that a number of tests and investigations were reported as normal and therefore there was no cause to refer A to specialists on suspicion of cancer. However, when concerns were raised about a possible missed renal cause for A's pain, we found that further investigations should have been undertaken at this time. These did not occur until almost a month later. A was suffering from an aggressive and difficult to diagnose cancer and, while the care and treatment provided by the practice was generally considered to be reasonable, the review should have triggered further tests at the time. On balance, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the issues identified 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:

• That the practice share this decision notice with their GPs with a view to identifying any points of learning.

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, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with sepsis.

The board carried out a Significant Adverse Event Review (SAER), in which A expected greater involvement. C also complained that the SAER failed to identify that the incident met the Duty of Candour threshold and did not address the key issue, which was the inadequate care provided. The board stated the staff involved used their clinical judgement to assess the wound, which did not show signs of infection. However, it was difficult to investigate the adequacy of the wound assessment due to the omission of notes they made. The board acknowledged communication between health care professionals was impeded by a reliance on a paper-based system and the clinical record keeping was inadequate.

The board further advised the SAER was a formal process, which did not allow for A's inclusion and maintained the incident did not meet the Duty of Candour threshold. They considered the SAER to be adequate, as an investigation had taken place that had identified a number of learning points and recommendations.

We took independent clinical advice from a registered nurse specialising in tissue viability. We found the wound assessment to be inadequate, leading to a missed opportunity for appropriate wound management and that those involved in A's care lacked knowledge of current best practice in terms of wound assessment, wound management and antimicrobial stewardship. We also found the SAER to be inadequate as it failed to address the key issues of wound assessment, wound management and antimicrobial stewardship and failed to identify the incident met the Duty of Candour threshold.

As such, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to 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:

• A person centred approach should be adopted.
• For all patients with a wound to have an adequate wound assessment undertaken and documented in a formal wound assessment chart. This should be in line with the following guidance Vale of Leven Inquiry Scottish Government Recommendations 2015NMC: The Code 201Scottish Ropper Ladder for Infected Wounds 2020 and HIS Scottish Wound Assessment and Action Guide 2021.
• A Duty of Candour Investigation to be undertaken, unless there is definitive evidence that the UTI caused the sepsis as wound deterioration is still a strong possibility.
• All staff involved in wound management are competent in appropriate management and familiar with the relevant guidance.
• Pathway to be developed to ensure timely referral to tissue viability specialist for deteriorating or non-healing wounds.
• Recommendations added to the SAER to address learning and improvement around wound assessment, management and antimicrobial stewardship.
• Staff to be reminded of Stage 3 of the Scottish Ropper Ladder for Infected Wounds, and consideration of antibiotics.

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 late sibling (A) should have been given a telephone or face-to-face consultation with a GP following increasing contact with the practice and an escalation of symptoms relating to chest pain that resulted in A's death from acute myocardial infarction (heart attack). C also complained that the practice's handling of the resulting Significant Adverse Event Review (SAER) was unreasonable.

The practice considered the care and treatment of A to be reasonable. The GP was shielding at home during the COVID-19 pandemic and could not see patients face-to-face. The practice stated it was subject to restrictions imposed by the Scottish Government at the time. The practice also said that A was appropriately triaged and their care managed by a range of healthcare professionals.

We took independent clinical advice from a GP. We found that A should have been offered a telephone consultation with the GP and a face-to-face appointment with the locum GP. We found that A's care was delegated to nursing staff when GP input was required and there was a lack of review between the GP and nursing team when A's symptoms failed to resolve.

We also found that the SAER failed to identify learning points, failings and reflection and did not include the health care professionals involved in A's care.

Therefore, we upheld C's complaints.

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 should receive appropriate treatment in relation to their presenting symptoms and potential causes considered as appropriate.
• Significant Adverse Event Reviews should be a reflective and learning process that appropriately considers events in sufficient detail, to ensure failings are identified and any appropriate learning and practice improvements.
• When appropriate, patients should be reviewed by a GP either by phone or in person dependant on their symptoms.
• When necessary and required, patients receiving treatment from the nursing team should have their care appropriately reviewed and discussed with a GP.

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 partner (A) about the care and treatment they received from the practice. A was prescribed an anti-inflammatory drug by a rheumatology consultant (specialists in diagnosing and managing chronic inflammatory conditions). The medication was issued on repeat prescription by the practice. C told us that the medication had risks and the practice failed to carry out appropriate medication reviews or update A about the risks. C said A was not aware of the risks of the medication and trusted that it was safe to use long-term. They felt it was unreasonable for the practice to assume A would have read the leaflet with the medication to identify any changes or to know to ask for a medication review.

The practice said that the medication was prescribed by the rheumatology service and would have been monitored by them. The practice highlighted that at the time the medication was prescribed, it was not considered high risk, and that the risks only became known after A had been prescribed the medication for a number of years. The practice noted that A did not proactively contact the practice to review their medication periodically but acknowledged that they did not contact A either.

We took independent advice from a GP. We found that national guidance states that patients should have annual checks when taking medication of this sort. The responsibility for carrying out these checks lies with whoever is issuing the prescription. When discharged from the rheumatology service, the practice should have invited A for a review and arranged appropriate follow-up. The practice should have carried out medication reviews and informed A about the change of risks associated with the medication.

We found that it was unreasonable for the practice not to have carried out medication reviews or informed A about the change in risks. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failingto alert them to the changes in risks associated with the medication, having a discussion about the risks, and allowing them to make an informed choice on whether or not to continue with the medication; failing to carry out medication reviews annually as they should have done; and failing to invite A to a review of their health when the practice became aware they were discharged from the rheumatology service. 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:

• GPs should recognise that as the prescriber of the medication it is their responsibility to carry out medication reviews on medications provided via repeat prescription. When a GP is alerted to the fact a patient is discharged from a secondary care service due to non-attendance, they should contact the patient to arrange a review and consider appropriate follow-up. Medication reviews should be carried out annually.
• When medication alerts are issued nationally, the practice should identify and review any of their patients to whom such an alert might apply.

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 to the practice about the care and treatment provided to their relative (A). A began to experience abdominal pain and was reviewed by doctors at the practice a number of times before being admitted to hospital as an emergency. Following discharge, A was seen at the practice again with continuing symptoms and unintended weight loss. They were referred to hospital and again discharged. A colonoscopy performed suggested acute diverticulitis (where small pouches from the wall of the gut become inflamed or infected). A attended the practice again with worsening symptoms and was admitted to the hospital after an urgent request was submitted. A died in hospital a few weeks after.

C was concerned about the standard of care provided to A by the practice. The practice met with A's family. The practice carried out a Significant Event Analysis (SEA). The practice responded to C's complaint and noted their frustration that A had been discharged from the hospital without progress in the management of their condition. However, they did not find that they should or could have done anything differently in A's care.

C submitted a further complaint to the practice after they received a response from the health board regarding the care provided at the hospital. The practice responded confirming that an SEA had been carried out. The doctor who had seen A had discussed the case with colleagues in the practice and with their Educational Supervisor. These discussions had been informal and had not been documented in A's notes.

C was dissatisfied with the complaint responses and brought the complaint to our office. We took independent advice from a GP. We found that most of A's care was of a reasonable standard. However, there was a delay in acting on concerns about A's condition following their second discharge from hospital. Given the significance of the failures identified, we considered that A's care fell below a reasonable standard and upheld this part of C's complaint.

C also complained that the practice failed to reasonably respond to C's concerns. We found that the identified failure should have been communicated to the family, by the practice, during their investigation of the family's complaints. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A's family for the failure to act with sufficient urgency following A's discharge. The apology should meet the standards set out in the SPSO guidelines on apology. available at www.spso.org.uk/information-leaflets.
• Apologise to A's family for the complaint investigation's failure to identify a failing in A's 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:

• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• The practice should ensure relevant staff are aware of the need to document discussions about patient care appropriately, in this case discussions between a trainee doctor and their Educational Supervisor, concerning a patient's care.
• Complaint investigations by the practice should address all relevant issues and should clearly identify and address any failings.

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 to their partner (A). A had a seizure and was admitted to hospital for further assessment. C reported their concern to staff that A had dislocated their jaw during the seizure, and advised that this had happened to A before.

A underwent x-rays and was referred to oral and maxillofacial surgery (OMFS, specialists in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck) for review. OMFS concluded that no further treatment was required for A. C continued to report their concern about A's jaw and an urgent referral was made to ear nose and throat (ENT) for further assessment. This was later re-directed on vetting to OMFS, however no follow-up review by OMFS took place by the time of A's discharge some weeks later.

On discharge, C contacted A's GP who arranged for A to be seen by another health board. A was diagnosed as having a dislocated jaw and underwent emergency surgery.

The board said that there had been evidence of dislocation in the right jaw joint. They said that due to A's dementia and reduced mobility, they were unable to fully cooperate during their assessment and would not have been able to manage further x-ray procedures. They noted that A did not appear to be experiencing any pain and appeared to have a good range of movement of their jaw.

We took independent advice from an oral and maxillofacial surgeon. We found that A's initial assessment on arrival at the hospital and the decision to wait until the x-rays had been reported before referring A to OMFS for further assessment was reasonable. However, we found that the assessment of A's jaw by OMFS failed to elicit the clinical features of the dislocation and failed to consider other types of scan after concluding the diagnosis was unclear.

On the matter of the urgent referral to ENT which was later redirected to OMFS, we were critical that no follow-up review by OMFS took place prior to A's discharge. We considered that the board failed to provide A with reasonable care and treatment and upheld C's complaints.

We also noted that, at the point of C complaining to the board, it was known that A had in fact dislocated their jaw during their admission. The board confirmed in their response to our enquiries that no internal processes for reporting or learning or improvement had been followed on becoming aware of this harm. While the board had responded to C's complaint, we were critical that they failed to initiate or follow other processes to record the event, or to elicit learning and improvement outcomes at the point of becoming aware of it. Therefore, we made a recommendation to the board on this matter.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably assess and diagnose A's dislocated jaw, the referral to ENT being inappropriately accepted, and the unreasonable delay by ENT in reviewing A which did not take place during their admission. 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 findings of this investigation should be fed back to relevant clinical staff in a supportive way for reflection and learning, and to inform future decision making regarding assessment processes.
• Referrals to other specialties for review should be made appropriately and accepted only when it is reasonable to do so. Referrals should be seen within a reasonable timescale.
• When the board becomes aware of a harm through the complaint process, processes should be followed to ensure reporting and learning and improvement takes place. This should be in line with both statutory duties and in keeping with any additional internal processes relevant to the incident type.

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’s child (A) was assaulted at school by other pupils. C complained that the council had failed to protect their child, failed to provide appropriate first aid and failed to provide a reasonable level of support to them following the incident. C also complained that the council failed to safeguard A from the bullying they subsequently experienced.

In their response to C’s complaint, the council provided details of the first aid provided and the steps taken to notify C’s spouse of what had happened. They said that the school had introduced a number of measures to help keep child A safe after the incident. The council initially said that C had refused to take part in restorative meetings, which they considered would have helped to resolve matters. After C complained about the council’s response, the council conceded that C had not been invited to a restorative meeting and apologised for this inaccurate information in their response.

We reviewed the council’s actions with reference to the relevant council policies. We considered that the assault had been taken seriously and acted upon swiftly. However, we found that although the council endeavoured to put in place a number of arrangements aimed at keeping A safe, these did not appear to have been fully implemented. We found that certain aspects of the council’s policies were not followed, that the council acknowledged that no restorative meetings took place and that counselling was not available to child A. We found that the council failed to ensure A was sufficiently supported after the incident and we also found shortcomings in the council’s complaints handling. We therefore upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and C’s family for the reliance on inaccurate information when reaching conclusions in the stage one response, with an acknowledgement of the impact this had on them. 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 the issues highlighted in this decision notice. 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:

• That the council consider creating a structured procedure and guidance for dealing with serious unacceptable behaviour and ensuring that the parties involved receive a full suite of support if required.

In relation to complaints handling, we recommended:

• Information contained within complaint responses should be accurate. In terms of good practice, complaint responses should be person-centred and non-confrontational.

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 their council tax account. They had applied for a single person discount and a council tax reduction. C complained that the council failed to manage their account properly, did not communicate with them and issued warning notices for payment while the account was in dispute. C said that the council’s handling of their account amounted to discrimination.

We found that there were significant delays throughout the council’s assessment. However, we noted that this took place during the COVID-19 pandemic when services were disrupted. We found nothing to suggest the council were discriminating against C but considered that their communication was generally poor.

We were satisfied that C’s council tax reduction entitlement was assessed reasonably, but we considered more could have been done to obtain the relevant information for the purposes of assessing C’s application for single person discount. We upheld 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.
• Invite C to provide evidence of the date that they moved into the property and reassess the start date for their single person discount accordingly. The council should confirm to C what type of evidence they would accept as proof of the date of entry.

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.