Upheld, recommendations

Summary

C complained about the care and treatment provided by the board to their late spouse (A) who was diagnosed with muscle-invasive bladder cancer. C complained about various aspects of the care that A received. These included delay, and ultimate failure, to carry out surgery to remove A's bladder, inappropriately high and missed doses of medication, and initial refusal to offer chemotherapy (a treatment where medicine is used to kill cancerous cells). C also complained about a failure by an out of hours doctor in identifying a deep vein thrombosis (DVT, a blood clot in a vein) that A developed and subsequent provision of insufficient information on medication used to treat the DVT. C further complained about various failures of communication as well as concerns about arrangements for visiting A due to the Covid-19 pandemic and end of life care.

We took independent advice from medical advisers with expertise in oncology (cancer specialist), urology (a specialty in medicine that deals with problems of the urinary system), general practice and community nursing. We found that A's pain medication regimen was reasonable and that the timescale for the scheduling of A's bladder removal surgery had been appropriate. We also found that decisions made about the timing of chemotherapy and communication with A had been reasonable. This included communication about A's end of life care and how rules relating to visiting A during the pandemic had been applied.

However, a number of failings in the treatment provided to A were also identified. We found that A had not been given appropriate information on the extent of their cancer, the prognosis and the potential treatment options. We also found that there had been an unreasonable delay in the discussing of A's case by the board's multi-disciplinary team, which also understated the extent of A's cancer. Furthermore, we found that A missed doses of regular medication when attending for palliative chemotherapy, that the DVT A developed was unreasonably not initially identified and, once diagnosed, insufficient information was given to A about medication given to treat the DVT.

For these reasons, 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:

• Patients diagnosed with DVT should be given appropriate information on anticoagulants (drugs that reduce the body's ability to form clots in the blood), in line with relevant clinical guidance.
• Patients should be given a comprehensive assessment of their end of life care needs, including support for sleeping, which is then clearly recorded in their nursing records.
• Patients should be given timely, clear and accurate information about the extent of their cancer, prognosis and management options. Patients should also receive appropriate support from clinical nurse specialists, in line with relevant clinical guidance.
• Patients requiring urgent care should be referred to specialists within a reasonable timeframe.
• Patients should be appropriately referred to the multidisciplinary team within a reasonable timeframe.

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 parent (A), who was admitted to hospital with severe back pain after suffering a suspected fall and later diagnosed with osteoporosis (a condition that affects the bones, causing become fragile and more likely to break). C complained about the physiotherapy and occupational therapy assessments carried out during A's admission, the communication by staff and a lack of recognition of A's cognitive impairment (a condition that affects the ability to think, concentrate, formulate ideas, reason and remember). C also complained about the lack of written information about osteoporosis/fragility fractures and how they should be managed after A's discharge, and A's follow up care, in particular, the failure to carry out a DEXA scan (a special type of x-ray that measures the density of bones).

In order to investigate C's complaint, we took independent advice from a trauma and orthopaedics (conditions involving the musculoskeletal system) adviser. We found that it was reasonable, in light of cognitive assessments undertaken by A, for staff to have taken the information A provided at face value. It was also reasonable in light of current practice and guidance for the board not to have provided A with written information about the management of osteoporosis upon discharge. We also found that the decision not to offer a DEXA scan was appropriate given the diagnosis, and that the appropriate treatment for this type of injury (osteoporosis/fragility fractures) was conservative management and therefore follow up care was not a requirement.

However, we identified a number of failings including that the board unreasonably delayed in starting A's osteoporosis treatment and that there were also failings in communication. In view of these specific failings, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the delay in starting A's osteoporosis 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:

• There should be a clear treatment pathway in place for patients starting osteoporosis treatment which is based on the relevant national guidance so as to avoid unreasonable delay in the start of their treatment.

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 their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after a long wait, C had the hip replacement carried out privately later in the year.

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 was correctly removed from the waiting list because their personal circumstances meant that they would be unable to undergo hip replacement surgery. However, this decision was not explained to C at the time. We also found that C was unreasonably added back on to the waiting list, when they remained unfit for surgery. We also concluded that there was no out-patient clinic letter to match the date that C was added back onto the waiting list. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not informing them of the decision to remove them from the waiting list for surgery, for adding them back onto the waiting list when they were not fit for surgery and for there being no out-patient clinic letter to match the date that C

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

• Out-patient clinic letters should be in place to match the date a patient is added to the waiting list.
• Patients should be informed when a decision is made to remove them from the orthopaedic waiting list 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 about the standard of support provided by the partnership following their adoption of their child. C lived in another partnership area and told us that there had been disagreements between their local social work team and West Lothian which had not been appropriately resolved. They also had concerns in a number of other areas, including a general lack of contact and a failure to provide appropriate support following a disclosure of past abuse by their child.

We took independent advice from a social work adviser. We found that the partnership had not provided a reasonable standard of support. We found that there were failures in the resolution of the disagreements between the partnerships and the support provided following the disclosure of abuse. In addition, we considered that many of the partnership's actions had not been sufficiently recorded and that they failed to handle C's subsequent complaints in an appropriately empathetic manner, given the sensitivity of the issues involved. For these reasons, we upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide a reasonable level of support, failing to reasonably document their assessments, and failing to reasonably handle C's complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The partnership should review the support being provided to C, to assess and ensure whether current supports are appropriate and sufficient.

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

• A detailed record should be made of any assessments carried out by social workers, explaining and justifying the conclusions reached.
• Following a disclosure of abuse, appropriate support should be identified and provided to meet the needs of the child and any carers.
• Where outside social work agencies are involved and there is a disagreement in approach, the partnership should ensure that this disagreement is resolved before deciding how to proceed.

In relation to complaints handling, we recommended:

• When upholding a complaint, an apology should be offered and appropriate steps should be identified and explained to avoid similar failings in future.
• Where complaints are sensitive in nature, complaint responses should be appropriately empathetic, whether or not the complaints are being upheld.

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 decision by their housing association to issue them with a final warning in respect of their tenancy following a decision by the police to charge C with two offences in respect of alleged anti-social behaviour. In particular, C stated that the housing association had failed to follow their own anti-social behaviour policy when issuing the warning in that they had not offered C the opportunity to discuss the incidents prior to the final warning being issued.

The housing association stated that the decision to issue C with a final warning had been made on the basis that C had breached the terms of their tenancy agreement and was already well aware of the likely consequences for their tenancy if they continued to behave in what the housing association considered to be an anti-social manner following a previous meeting to discuss a separate incident. The housing association also advised that C could not have been invited into the housing association's offices to discuss the incidents giving rise to the police charges prior to issuing the final warning due to the coronavirus restrictions in place at the time.

We found that the housing association had failed to follow their policy on antisocial behaviour by proceeding to issue a final warning to C in respect of their tenancy without firstly having offered C the opportunity to discuss the incidents resulting in the police charges. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the association's failure to follow its anti-social behaviour policy prior to issuing them with a final warning in respect of their tenancy. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Offer C the opportunity to discuss the issue and then, based on any matters discussed, review the decision to issue a final warning in respect of their tenancy.

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

• Staff should act in line with the association's anti-social behaviour policy.

Summary

C complained about the treatment of their spouse (A) by the Scottish Ambulance Service (SAS). A became unwell at home and whilst on route to hospital in an ambulance they experienced a cardiac arrest and later died in hospital. C complained that the ambulance took a long time to arrive; that the care and treatment A received in their home was poor; that there was a delay in transporting A to the hospital; that C was asked to commence cardiopulmonary resuscitation (CPR) on A whilst on route to hospital and that C was not assisted by the ambulance technician and that they alone performed CPR on A until they arrived at hospital.

C was dissatisfied with the way in which their complaint was investigated. It was initially investigated by the SAS, however, when contacted by SPSO, SAS requested to reinvestigate the complaint in light of an error that they identified in their initial response. C remained unhappy after receiving the SAS's further response and asked us to consider the matter.

We took independent advice from an emergency and retrieval medicine adviser. We found that the way in which the dispatch of the ambulance was handled was unreasonable, that the initial care provided to A in their home was reasonable, nevertheless it should have been clear to the ambulance crew that A was seriously unwell and that the time spent on scene was unreasonable and that the decision to ask C to perform CPR in the ambulance was not reasonable.

We found that the initial investigation was not sufficient, although we acknowledged the proactive steps taken by SAS to address this issue and acknowledge failings, including asking C to commence CPR. We also found that in this case the full crew should have been interviewed. We upheld C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified that have not already been acknowledged in previous responses including the length of time taken to assess A in their home and the delay in transporting A to hospital, the failure to follow clinical guidelines appropriately and the failure to handle C's complaint appropriately. 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:

• Complaint investigations should be thorough and accurate in the first instance.
• For patients suffering cardiac arrest out of hospital such as in this case, relevant clinical guidelines should be followed by ambulance crew. Ambulance crew should accurately record what treatment was performed to demonstrate adherence to the clinical guidelines.
• When it is clear from initial assessment that a patient is seriously unwell, their transfer to hospital should be expedited and delays should be avoided.

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's decision to discontinue the prescription for gluten free foods for their adult child (A). The board explained that as A did not have a confirmed diagnosis of coeliac disease, that they would not be expected to prescribe gluten free foods. To make a diagnosis, a patient would be required to include gluten in their diet for a number of weeks prior to testing. C said that due to A's additional needs and the distress that they would suffer from the symptoms associated with taking gluten, it would be reasonable for the board to take a flexible approach when applying their policy on the matter.

We took independent advice from both a GP adviser and a gastroenterologist (a doctor specialising in the treatment of conditions affecting the liver, intestine and pancreas). It was noted that it was agreed by all parties that it would be distressing to A to require them to include gluten in their diet in preparation for testing. We considered that a more flexible approach should be taken to the application of the relevant policies and guidance and that a diagnosis could be made by probability. We found that principles of realistic medicine and patient-centred care should be applied and we recommended that consideration is given to other means of non-invasive tests to determine the presence or absence of coeliac disease in A's case. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• The board should explore and discuss with C other means of non-invasive testing to determine the presence or absence of coeliac disease in A's case.

Summary

C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the food record charts were not completed properly to monitor A's intake.

We took independent advice from a nursing adviser. We found that it is not usual to document a patient's position in bed (whether they are upright or lying flat). Therefore, we were not critical of the board's record-keeping in this regard. We found that the monitoring of A's nutrition and fluid intake was unreasonable because the Malnutrition Universal Screening Tool (MUST) assessment was not completed within 24 hours of A's admission to hospital, the food record chart and the fluid balance chart were not completed appropriately during A's admission and A's personal centred care plan was not updated to reflect their condition. We upheld C's complaint in this regard.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not completing the MUST within 24 hours of A's admission, not appropriately completing the food record chart and fluid balance charts during A's admission and not updating A's person centred care plan to reflect their 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:

• Patient intake of fluid should be accurately and timeously recorded.
• Person-centred care plans should be reviewed and, where necessary, updated to reflect the needs of 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 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.