Upheld, recommendations

Summary

C complained about the care and treatment that their parent (A) received during an admission to a community hospital.

A had a degenerative condition which affected their mobility and was latterly diagnosed with a form of vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain). A was admitted to hospital following a fall. C told us that A had a number of falls in hospital and suggested that one of these falls led to an injury to A's leg. C raised a number of general concerns regarding the nursing care and implied that A was allowed to become dehydrated, only drinking when assisted by family members or when family members prompted the ward staff.

C also raised concerns about the clinical aspects of A's care. C said that A became lethargic and unresponsive during their admission to hospital. Family members expressed their concern to staff that this may have been the result of sepsis (blood infection) or a urinary tract infection. However, they were reassured that A's symptoms were likely caused by antibiotics.

A suffered a heart attack. Staff performed cardiopulmonary resuscitation (CPR) and revived A. A was then transferred to a general hospital for care where A died five days later. C explained that A was uncomfortable and agitated during their final days. C said that staff there had expressed concern that no Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) had been signed for A. C complained that the additional five days of suffering that A experienced could have been avoided had a DNACPR been discussed with family members.

We found that A's condition and medical history meant that clinical staff should have considered DNACPR each time that they reviewed A. Whilst we were critical of the board for failing to do so in A's case, we acknowledged that they had already taken action to improve their procedures and ensure that the consideration of DNACPR is not left until an emergency situation develops.

We found that A had developed sepsis, likely as a result of the leg injury sustained during their admission. We noted an apparent delay of several days before the cut to A's leg was identified. However, once the nursing staff were aware of this, they appropriately escalated the situation to the clinical team. We found that no clinical review was carried out and that the nursing staff instead consulted NHS24 for advice as to how to treat A's leg. A was treated with oral antibiotics. We found that had A been reviewed in person by a member of the clinical team, the severity of their infection may have been recognised and intravenous (into a vein) antibiotics may have been prescribed. We noted an overall lack of clinical input into A's care during their admission and concluded that this led to a failure to diagnose A's sepsis.

With regard to the nursing care that A received, we found that there was a four day delay to A's falls risk being assessed and mitigated after their transfer to hospital. The number of falls A had and the severity of the harm caused increased during this time and we found that this was a clear failure to adapt to a patient's specific needs. We were critical of the board for failing to record and monitor A's leg wound in a wound chart.

Whilst we were satisfied that there was evidence of the nursing staff monitoring A's food and fluid intake, we noted that their focus was on the weekly variations in A's weight. This meant that A's significant weight loss over a longer period was not identified. Had it been, staff may have taken proactive steps to increase A's intake and increase their weight. We upheld all aspects of this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family 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:

• That the board conduct a review of the nursing care provided on A's ward and take steps to ensure that they are compliant with the relevant standards for falls risk assessment, nutritional assessment and wound care.
• The board conduct a review of the medical provision available to patients on dementia wards at the hospital and take steps to ensure that they meet the standards of inpatient care set out in the guidance from the Royal College of Psychiatrists.
• The board share this decision with the nursing staff.

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 board after suffering wound care complications following a caesarean section (an operation to deliver a baby. It involves cutting the front of the abdomen and womb) during the birth of their child. They considered that a number of factors meant that the board had failed to provide reasonable treatment in relation to the birth of their child.

We took independent advice from a consultant obstetrician (specialist of pregnancy, childbirth etc) and gynaecologist (specialist of the female genital tract and its disorders). We found that the board had failed to provide reasonable treatment. In particular, we found that the board failed to follow up on a phone call to ensure C's safety when a full triage could not be completed; that they had failed to ensure a timely review by a senior doctor when complications occurred; that they failed to keep reasonable records of C's care; that they failed to identify that a Significant Adverse Event Review (SAER) should have been carried out, meaning that the staff in question were unable to clearly recollect events by the time the complaints investigation was completed and additionally, that the board made insufficient attempts to establish a cause for the complication, which may possibly have been operator error or the result of faulty sutures, either of which would have required further action to ensure wider patient safety and avoid a repeat. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide reasonable treatment relating to the birth of their child. 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 relevant staff should know when to suspect complications in post-caesarean wound care and escalate for review by a senior doctor as soon as possible, if indicated.
• If a triage is unable to be completed for any reason, the board should have robust procedures to ensure the safety of the patient in question.
• Sufficiently detailed records should be made of all operations carried out.
• When a wound has ruptured following surgery, the board should ensure reasonable steps are taken to invsetigate the cause of this.
• When a relevant adverse event occurs, the board should promptly carry out an SAER to investigate the cause and identify any potential 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 complained about the care and treatment provided to their late spouse (A) by the practice. A died due to invasive bladder cancer and urinary sepsis (blood infection). C complained that the practice unreasonably delayed referring A to secondary care for investigation despite presenting with recurrent urinary tract infections (UTIs) that did not respond to antibiotic treatment. C considered that A's bladder cancer may have been identified earlier, and that their death avoided, had the practice referred them for investigation much sooner.

The practice's position was that A had a long history of intermittent UTIs, which were usually treated with antibiotics. At one point, all of A's urine samples showed pus cells but a normal range of red cells, which was suggestive of simple UTIs. The early signs of bladder cancer such as blood in the urine were not apparent in A's case until a relatively late stage. The practice considered that abnormalities in A's blood results (increased platelet and white cell count) were caused by A's unrelated medical conditions.

We took independent advice from a general practitioner adviser. We noted that patients over a certain age with recurrent or persistent UTIs (i.e. three episodes in 12 months) associated with haematuria (blood in the urine) should be referred for urgent investigation in accordance with national guidelines. In A's case, they had attended the practice three times in four months with recurrent UTIs and haematuria found on dipstick testing. At this point, we found that A should have been referred on an urgent basis in line with the guidance but that the practice did not do so for a further ten months. We found that the practice had failed to identify that A's blood results showed signs of recognised malignancy and that they had repeatedly failed to record A's clinical history and review the results of investigations performed. As such, we upheld this 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:

• In view of our findings, carry out a reflective Serious Adverse Event Review (SAER) of this case which includes: a review of the failure to refer A for further investigations, including the lack of detail of their presenting symptoms and the lack of relevant clinical history in A's records; a review of the practice's result handling processes and, where issues are identified, how these are monitored and actioned by a responsible clinician; a review of the guidelines for early referral of suspected urological cancers; and a review of the failure to exclude a urine infection in relation to the care and treatment A received for a kidney infection. Information regarding a patient's care and treatment and diagnosis should be accurately recorded in their 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's complaints related to a council-run football pitch next to their home. C reported that the noise levels from the pitch, as well as foul language by the users of the pitch were reaching unreasonable levels, particularly later in the evening before the pitch closed at 10pm, and that this was keeping their young child awake. They explained that they had provided recordings to the council to evidence this, but that the council had refused to take action to address it.

We found that the council had, in response to C's concerns, amended their letting terms and conditions to ensure that there were clear rules prohibiting unreasonable noise levels and language by renters of the pitch. However, the only steps that the council had taken to address this with users, was to send a general email about unreasonable noise to all renters of pitches they ran, warning that leases may be removed if terms and conditions were breached by unreasonable behaviour.

Given that C had been providing clear reports and recordings of specific times and behaviours, we considered it was unreasonable for the council not to take any steps to raise these issues with the specific users responsible. We also considered that the council had failed to provide sufficient explanations to C of the kind of evidence that they would consider and how they would investigate their concerns.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Explain to C what they need to do to report and evidence unreasonable use of the pitches going forward.

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

• When receiving evidence of misuse of council facilities, the council should take appropriate action to ensure the users responsible abide by the letting terms and 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.

Summary

C is an advocate for A who is a parent of child B. C complained to the Comhairle about the management of B's schooling, in particular the management of various periods of exclusion due to B's behaviours. C complained that there were occasions where B was not permitted to participate fully in their education alongside their peers and that these should have been considered as formal exclusions. The Comhairle said that there were only two periods of time that B was formally excluded and that on other occasions B was cared for in the Extended Learning Resource (ELR) unit.

In response to our investigation, the Comhairle provided evidence of B's attendance and their Included, Engaged and Involved Guideline (2013) which is the policy for managing periods of exclusion. The evidence confirmed that there were occasions B was not educated alongside their classmates but did receive specialist provision elsewhere and in accordance with the policy, these periods were not regarded as formal exclusions. We also found that during the periods where B was formally excluded, the school followed the guidelines correctly. However, there were occasions where A was requested to take B home from school early and this was contrary to the policy. The Comhairle acknowledged this and offered to formally apologise to A. We upheld the complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for failing to follow their policy when B was sent home early from school. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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 became kinship carers of A and B. C complained that the council had decided that they were not entitled to a kinship care allowance relevant to a period of nearly two years (in respect of both A and B). C said that they approached the council about kinship support and an allowance but this was not responded to appropriately at the time (including a lack of record-keeping by the council). C was of the view that if they had been given appropriate information in at the beginning, they and A and B would have been awarded what they were entitled to.

We considered the relevant legislation and guidance and took independent advice from a social work adviser. We found that C was not provided with information and advice about eligibility for a kinship care allowance and Kinship Care Orders. We also found that there was an unreasonable failure to maintain case records regarding C and A and B's involvement with social work.

We upheld C's complaint and made recommendations to the council, which, as far as possible, aim to put C back in the position that they would have been in had the failings not occurred.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not providing them with information and advice about eligibility for a kinship care allowance and Kinship Care Orders. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Complete an assessment, in line with relevant guidance, in respect of C's care of A and B. As far as possible, consideration should be given to the circumstances of the household when the assessments would have originally taken place (not just the current circumstances). If, following the assessments, the council is satisfied of A's and B's eligibility, consideration should be given to making a backdated ex gratia payment equivalent to the amount of kinship care allowance that C would have received had they been appropriately informed about the need to obtain a kinship care order.

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

• Information and advice should be provided to kinship carers about eligibility for a kinship care allowance and Kinship Care Orders in accordance with the relevant legislation and guidance.
• Written case records should be appropriately maintained and retained.

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 us about the care and treatment that they had received from their GP practice. C told us that the practice had failed to carry out appropriate prostate specific antigen (PSA) testing after they found out that C was at increased risk of prostate cancer genetically. They told us that after an initial test, which was normal, there was a delay of around four years in carrying out a further test, at which time the test showed elevated results and they were subsequently diagnosed with cancer. C considered that this delay had a considerable impact on their prognosis, as their cancer had by that time spread, which they had been told was unlikely to have been the case had they been diagnosed earlier.

C also complained that the practice had failed to appropriately respond to their concerns about this, both in the way that they had investigated the concerns, and the manner in which they had responded, which C had found to be uncaring.

We took independent advice from a GP adviser. We found that the practice had failed to handle C's testing appropriately. In particular, that they unreasonably assessed that regular testing was not required based on guidance intended for those not at increased genetic risk and that they unreasonably failed to seek further advice and clarity from specialist services on the request to consider regular testing. We also noted that when the test was subsequently agreed as part of other blood tests, this was missed in error, and they then failed to identify this had been missed or notify C, leaving them with the impression that this had provided normal results.

Therefore, we upheld C's complaint that their testing had been mishandled.

Our investigation also found that the practice had not responded reasonably to C's concerns, as the Significant Event Analysis (SEA) they carried out was not of a reasonable standard, and they had failed to provide appropriate apologies for the failures that were identified by their own investigations.

On this basis, we also upheld C's complaint that the practice had not responded reasonably to their concerns.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide appropriate PSA testing. 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 failing to respond reasonably to their concerns. 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 appropriately consider the results of any tests requested to ensure that they are fit for the purpose they were requested for.
• The practice should ensure that there is clarity around any request received from secondary care services that they choose to accept.
• The practice should provide appropriate screening for any patient at increased risk of developing cancer.

In relation to complaints handling, we recommended:

• All complaints should be processed in line with the Model Complaints Handling Procedure and any apologies offered in complaint responses should meet the terms of the guidance on apology.
• All SEA (Significant Event Analysis) investigations should include an assessment of whether the treatment provided was of a reasonable standard, and a consideration of the root causes of any failings 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 there had been an unreasonable delay in their late parent (A) receiving a prescription of antibiotics following a consultation with an out-of-hours GP from the unscheduled care service, operated by the board. During the consultation, the GP considered that A had developed a lower respiratory tract infection (an infection of the lungs), which should be treated with Co-amoxiclav (a type of antibiotic). However, the GP had attended the consultation without a prescription pad and did not carry the medication in their vehicle. The GP subsequently arranged for A's prescription to be faxed to a pharmacy on their return to base to be provided to A the next day. However, the pharmacy to which the prescription had been faxed was closed the following day due to a public holiday, which resulted in a delay of 48 hours before the prescription could be provided to A.

In response, the board apologised that the GP had attended the consultation without a prescription pad and for the distress that this had caused A and their family. The board stated that it could not explain why the GP had attended without a prescription pad but had reminded staff in a monthly update to ensure that prescription pads were checked prior to carrying out home visits and that prescriptions were only faxed to pharmacies that could provide medication in a timely manner. The board also confirmed that it was in the process of developing a checklist system and a written policy and protocol specifying the checks that staff were required to complete at the start of each shift prior to commencing home visits.

We took independent advice from a GP. We found that it had been unreasonable for the GP to attend the consultation without a prescription pad and to fail to ensure that the antibiotics A required were available to them sooner based on A's presentation at consultation. We also considered that the reminder provided by the board to staff was insufficient to ensure that a similar occurrence did not happen again. However the checklist system and written policy and protocol the board had indicated it was developing was likely to be appropriate to address the issues arising in this case.

For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with reasonable care and 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:

• Out-of-hours GPs should be in possession of all required equipment prior to the commencement of each shift. In addition, where a patient's clinical presentation requires medication to be prescribed, out-of-hours GPs should take all reasonable steps to ensure that there is likely to be no undue delay in the prescription becoming available to the patient.

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 had a wisdom tooth extracted by the board. Subsequently C experienced an altered sensation in their tongue and was advised that this was likely the result of nerve damage, which was a possible side effect of the extraction of a wisdom tooth. C complained that they were not advised of this possible side effect prior to the extraction taking place. A handwritten note on the consent form C signed included mention of altered sensation but C disputed that this had been present when they signed the form.

We took independent advice from a dentist. While evidence gathered as part of our investigation could not definitively determine which of these positions was most accurate, we considered that based on the available evidence, the board did not make C reasonably aware of why the extraction was considered necessary, what the risks and benefits of extraction, alternative treatments or no action were, what the percentage likelihood of nerve damage was or what 'altered sensation' meant. Therefore, we found that the board did not reasonably advise C that nerve damage was a possible side effect of the extraction of a wisdom tooth as required and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to reasonably advise that nerve damage was a possible side effect of the extraction of a wisdom tooth. The apology should make clear mention of each of the points the board did not make C reasonably aware of. 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 are provided with clear information of the nature of the proposed dental treatment, the purpose of treatment, the risks and benefits to treatment in comparison to no treatment and any alternative treatment options, and valid consent is obtained and recorded in line with the General Dental Council's Standards For The Dental Team Principles.

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 following their hip replacement surgery. Immediately following the surgery, C began experiencing severe and continual pain. The cause of C's pain was eventually confirmed to be loose cement from the surgery causing irritation. C complained that, although the surgeon who had carried out their hip replacement was aware of the loose cement, this was not conveyed to C. Instead, C had consultations with a total of five consultants before the source of their pain was identified two and a half years after their surgery and remedial treatment successfully provided.

C raised a number of concerns regarding the attitude shown towards their symptoms by the board's consultants and the delays to diagnosing and resolving their pain.

We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that C's surgery was carried out reasonably and that there was no immediate indication of the complications that they would subsequently experience. We noted that it is not uncommon for patients to experience pain for up to 12 months following a hip replacement. We were generally satisfied that the board's staff took C's pain seriously and carried out reasonable investigations to establish its cause. We also noted that leaked cement is not uncommon and would not initially be viewed as a likely source of a patient's pain.

We considered that the complications C experienced were extremely rare and required specialist intervention. We found that it was not until an x-ray taken a year after surgery that it became apparent that a large amount of cement had leaked from the surgical site and a later MRI scan identified that C had a degree of psoas tendinopathy (an inflammation of the tendon or area surrounding the tendon).

Whilst we were satisfied that the clinical team followed a reasonable path to establishing and treating the cause of C's pain, we were critical of the time taken to conduct a CT scan following the MRI scan and of the time taken to provide surgery to resolve the issue. Therefore, we upheld C's complaint on that basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable delays during the diagnosis of and in arranging the treatment of C's postoperative complications. 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 board should arrange for this case to be presented at a local clinical governance meeting (with radiologists present) where the case and imaging should be reviewed.

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.