Upheld, recommendations

Summary

C’s adult child (A) was awaiting surgery for germ cell cancer when they became unwell and were taken to A&E. A was transferred to a ward where C raised concerns about the treatment that A was receiving. C felt that A was deteriorating and requested on a number of occasions that A be transferred to the High Dependency Unit (HDU) or another hospital. A number of reviews were undertaken and a transfer to HDU was agreed and actioned. Acute deterioration of A was noted and they were intubated and invasive mechanical ventilation began. It was also decided that A should be transferred to a different hospital. The transfer took place following the surgical removal of the catheter. A sustained a subdural haematoma (when blood escapes from a blood vessel, leading to the formation of a blood clot that places pressure on the brain and damages it), and developed multi organ failure and right and left ventricle failure. A died just over two weeks later.

C raised complaints with the board regarding A’s care and treatment, including concerns that information C had sought to provide staff, and requests that they had made about A’s treatment, had been ignored. The board’s response concluded that generally A’s care and treatment had been reasonable. C was dissatisfied with this and raised their complaints with us.

We took independent advice from a consultant emergency physician adviser. We found that a significant adverse event review (SAER) would have been justified in the circumstances. We advised the board of this and they indicated that they intended to undertake an SAER regarding A’s care and treatment. In the circumstances, we suspended our investigation whilst the SAER was undertaken. We became concerned about the time that was being taken to progress and finalise the SAER and when we began to progress the investigation again, the finalised SAER report was provided to C shortly afterwards. A later meeting led to a revised SAER report being provided.

We found that the conclusions in the revised SAER, which acknowledged specific actions in the assessment, care and treatment of A, had not been reasonable and upheld this aspect of C’s complaint. We found that the actions the board have taken, or have committed to taking, to address the learning points and areas for improvement were reasonable.

We found that the gathering of staff views, accuracy and initial failure to identify the need to conduct an SAER in the board’s investigation and review of their actions was not reasonable and we would normally expect the SAER process to take within the 24 working weeks from commissioning to final approval estimated in the relevant national framework. We considered that the time taken in this case was unreasonable and, therefore, we upheld C’s complaint about the board’s response to their complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they unreasonably failed to initially identify the need to conduct an SAER into their actions regarding the assessment, care or treatment of 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 board implement recommendations 1-7 found at Section 7 of the SAER report.

In relation to complaints handling, we recommended:

• The board take steps to ensure SAERs are undertaken when appropriate.

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 communication provided to their step-parent (A) before their discharge. A was diagnosed with lung cancer and then admitted to hospital with left leg weakness after falls at home. A was discharged home two weeks later, and re-admitted after three weeks with severe chest pain. A died two days later.

C complained that the prognosis of ‘weeks to months’ was not shared with A or their spouse when the treatment plan was discussed. C also complained that A was discharged home without an Occupational Therapy (OT) assessment having been completed, and with no other offers of support for A who required end of life care at home. Finally, C complained to SPSO about complaint handling.

We took independent advice from a medical director with specialism in palliative care and a qualified physiotherapist. The board acknowledged that A was not provided with an adequate supply of medication on discharge. We found that this could have had serious consequences, and would have caused anxiety and distress.

The board apologised for not arranging an OT assessment before A was discharged, but said that no concerns were raised during A’s admission suggesting this was required. We found that the board should have considered a full assessment for A who was subject to falls and whose health would deteriorate. We also found that no consideration was given to home set up before discharge, and that A’s anticipatory needs were not considered when they should have been. Therefore we upheld this complaint.

We found that the board failed to discuss with A and their family whether an OT assessment or OT screening assessment might be appropriate when planning A’s discharge home. Additionally, we found that the board should have shared that A was reaching end of life stage sooner, and provided appropriate support with adapting to this fact. The discharge letter should have been clear in alerting A’s GP to the seriousness of the situation. The board have acknowledged that there was no early referral to palliative care and no joined up review of A. We found that the approach and investigation into the complaint and associated communications did not manage C’s expectations and failed to deliver on what had been agreed. Therefore 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 should be discharged with appropriate supplies of medication. Consideration should be given to a patient’s anticipatory needs as well as their needs during admission. Patients and carers / family should be involved with, and know what the plan is post discharge. Consideration before discharge should be given to how patients will cope once home and in the community. Communications should be clearly documented, including with regard to prognosis and recognising end of life. Healthcare services should plan for the deterioration of people with palliative care needs, enabling them to remain in their preferred place of care for as long as possible.
• The board should ensure that immediate discharge and clinic information reaches the GP as soon as is practicable in every case, ideally on the same day, in order that GPs receive essential information that enables continuity of care.
• When a relevant adverse event occurs, the Board should carry out a formal review to investigate the cause and identify any potential learning.

In relation to complaints handling, we recommended:

• Relevant staff should be aware of the requirements of the complaints handling procedures, particularly with respect to dealing with complaints which span more than one NHS organisation. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 late relative (A) with reasonable nursing care whilst in hospital. C told us that they felt nursing staff did not take A seriously when they reported pain, that information given was not passed to medical staff as agreed, and that A was left feeling abandoned and ignored.

The board said that A was admitted with a blockage in their bowel which was likely caused by bowels being stuck together after a previous operation. A underwent surgery to free the bowel and was cared for initially in the surgical high dependency unit. The board said that due to A’s co-morbidities, A began to experience worsening symptoms, including very advanced heart failure and respiratory issues. The correct diagnosis was made for heart failure and A was receiving correct treatment for this.

We took independent clinical advice from a specialist nurse practitioner. We found that the nursing notes were completed to an acceptable standard with the exception of the infection control documentation. The board’s infection prevention control team identified and documented some issues with the documentation relating to a possible clostridium difficile infection (a type of bacteria that can cause a bowel infection). The nursing notes indicated a lack of recording and documentation of when A’s bowels had moved and there were no stool charts completed. There was a non-compliance of the completion of clostridium difficile infection paperwork. We considered that this indicated a lack of understanding in nursing staff of the importance of the infection control guidance and that the process was not followed or recorded appropriately. This indicates that the management of infection control in A’s care was unreasonable.

We found that there was no evidence that matters raised by the family were recorded in the notes, or escalated to medical staff as the family thought. We also found that other documentation was incomplete, specifically, the ‘Getting to Know Me’ documentation, which is a document that records what matters to the patient, helps to understand the patient, and enhances their case. The fact this was incomplete, was unreasonable. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to provide A with a reasonable level of nursing 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:

• All of the recommendations of the guidance on the prevention and control of clostridium difficile infection should be implemented. All relevant documentation should be clearly and accurately documented in a patient’s records to a reasonable standard.
• Staff should ensure that the Getting to Know Me documentation is reasonably completed and understand the importance of and act upon concerns raised by patients and their families about their condition.

In relation to complaints handling, we recommended:

• Responses should be completed in line with the NHS Model Complaints Handling Procedure. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at https://www.spso.org.uk/training-courses.

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 adult child (A) had been referred to the board's Community Mental Health Team (CMHT). A had some contact with both psychiatry and psychology services over the next few weeks. A later died.

The board commissioned a Significant Adverse Event Review (SAER) into the care provided to A. In the SAER it was concluded that, following an initial face-to-face assessment by Community Psychiatric Nurses (CPNs), a further face-to-face consultation should have been arranged and that not doing so compromised the care provided to A.

C complained to the board about the care and treatment provided to A, and communication during the SAER process.

We took independent advice from a psychiatry adviser. We found that the SAER conclusion regarding face-to-face consultation of A was reasonable. We also found that no evidence of a contemporaneous record of the examination carried out by a consultant psychiatrist had been provided and that the record that had been provided does not indicate a comprehensive Mental State Examination (MSE) was undertaken at this time. We found that this was unreasonable given the other evidence available of A’s presentation at this time. Given this, and the conclusion of the SAER that the care and treatment of A had been compromised, we upheld C’s complaint about the care and treatment provided to A.

C’s concerns about the SAER process originated in the delays and lack of communication throughout the process, and the failure to provide a final copy of the SAER. We found that the SAER in itself was reasonably thorough but are concerned that no contemporaneous record of the MSE was identified by the SAER. We found that the extended timescale for completion of the SAER and the board’s communication with A’s family, which did not include regular or on-going communication and was subject to a lack of clarity around the status of the SAER report that continued for a period of years, was unreasonable. We also considered that during the SAER process, A's family were not provided information that they requested and there is no evidence that they were invited to meet with the review team or have engagement and involvement during the SAER processor as the report was finalised. Given this, we upheld C’s complaint about the undertaking of the SAER.

We considered the way that the board communicated with C regarding the time limits for making complaints to themselves and the SPSO was overly focussed on reiterating that the complaint was out with normal timescales and unnecessarily negative. The board also stated that SPSO were “unlikely to undertake review of the complaint”. We found that this was misleading as any such decision would depend on our own assessment of any special circumstances which should be taken into account when considering time restrictions. We also considered that this statement unreasonably failed to recognise how the board’s own handling of communication and commitments made to C had led to the complaint being raised much later. Given this, the delay in responding to C’s complaints and the failure to directly respond to a specific concern raised by C, we upheld C’s complaints about how the board had handled their complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that no comprehensive Mental State Examination of A was carried out. 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 that the board did not reasonably enable A’s family to be engaged and involved during the SAER process as the report was finalised, that the board did not update A’s family regarding the delays in the progress of the SAER and that there was a lack of clarity around the status of the SAER report. 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 that they reiterated on an unreasonable number of occasions that they had decided to investigate C’s complaint despite it having been made out with the time limits in their Complaints Handling Procedure, and that the board unreasonably speculated that the SPSO were “unlikely to undertake a review of the complaint” if C escalated it. 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:

• Relevant board staff complete and record comprehensive Mental State Examinations on patients referred to psychiatry.
• The board undertake SAERs reasonably and in line with relevant guidance.

In relation to complaints handling, we recommended:

• Information in the board’s complaint responses is not unreasonably negative or inaccurate.

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 Scottish Prison Service (SPS) failed to appropriately investigate their lost property claim. C submitted a claim for lost items which went missing during a transfer to another prison. C complained about the handling of the claim, including the timescale for receiving a decision. C maintained that three bags of property were missing, whereas the SPS concluded that only one bag was unaccounted for. This office does not provide a route of appeal, and it was not our role to assess what property was missing or what compensation should be offered. Our focus was on the administrative handling of the claim, including whether the SPS assessed all relevant information and provided a clear explanation as to how they reached the conclusion that they did.

The evidence we received from the SPS of their assessment of the claim was difficult to follow. It was unclear to us how they concluded that one bag of property was unaccounted for. We found that this was based on a bag seal check eight months after C’s prison transfer. C noted in the claim that much of the missing property had been kept in storage at their previous prison and was not in their possession (‘in use’). The SPS said that C packed their own property prior to the transfer. It was not clear from the records what items C had ‘in use’ at their previous prison, and there did not appear to be a method in place for itemising ‘in use’ items packed from a prisoners cell prior to being placed within a sealed bag for transfer. C also alleged that some items were damaged during the transfer and we found no evidence that the SPS assessed this part of C's claim. The SPS communicated their final position more than three years after C initially raised matters following their prison transfer. It was not clear why this took so long. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the unreasonable length of time it took to progress their claim and communicate a final outcome. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Reconsider C’s claim and communicate their finding to both C and the Ombudsman, explaining how the issues identified in this decision were considered.

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

• In light of the issues identified in this decision, the SPS should consider what improvements could be made to the process of maintaining accurate and legible records of prisoners property to ensure any claims for missing or damaged property can be considered efficiently, and without unreasonable delay.

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 communal repairs at a tenement in which C owned a property. Extensive work was required following a fire. The council owned the majority of properties in the building and took the lead in arranging and managing the work. During the work to repair the fire damage, extensive dry rot was identified. Work was completed around four years after the fire.

The invoice C received from the council for the dry rot works was approximately £15,000 over what C had expected to pay, based on the estimates for work given two years prior. C complained about the council’s management of the repairs, including their communication.

We found that the council’s communication with C during the period of works and in respect of the increasing costs was unreasonable. The council also failed to follow their own processes or act in line with their obligations under the Tenements (Scotland) Act 2004. The final invoicing included substantial costs for which C was not liable, and which should not have been included in the invoice. The council also failed to notify C of the costs of an emergency repair to the roof following a storm within a reasonable period of time, resulting in C missing the opportunity to submit an insurance claim for the costs.

Overall, we found that the council’s management of communal repairs was unreasonable. Therefore, we upheld this part of C's complaint. We considered that regardless of communication issues and delays, the costs would likely have been incurred and therefore are duly payable by C. However, given the multiple failings in relation to communication and administration, we recommended that the council refund the administration fee to C.

C also complained about the council's handling of their complaint. We found that the council’s complaint handling was unreasonable. The council failed to identify C’s expression of dissatisfaction as a complaint, failed to respond within a reasonable timescale or provide timely updates, misinterpreted C’s complaints, and made contradictory statements in the complaint response. Therefore, we upheld this part of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to reasonably manage the communal repairs and the failure to reasonably handle C's complaint. 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 .
• Clarify whether the scaffold and site establishment costs were charged to C, and consider whether these funds should be reimbursed.
• The council should make a financial payment to C of £2,278, the equivalent of the 7% administration fee charged by the council for these works, in recognition of the poor standard of administration and failure to act in line with their responsibilities under the Tenements (Scotland) Act 2004 when arranging for these repairs to be carried out.

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

• The council should manage repairs carried out under the terms of the Tenements (Scotland) Act 2004 in line with their obligations. When managing repairs, the council should ensure tenants and homeowners are updated of the progress of the project regularly, particularly where the scope of the works and the costs escalate.

In relation to complaints handling, we recommended:

• Complaint handling should be in line with the Model Complaint Handling Procedures. We offer SPSO accredited Complaints Handling training. Details and registration forms for our online self-guided Good Complaints Handling course (Stage 1) and our online trainer-led Complaints Investigation Skills course (Stage 2) are available at  HYPERLINK "https://www.spso.org.uk/training-courses" https://www.spso.org.uk/training-courses .

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 reasonable personal care and treatment to their sibling (A). A was admitted to hospital to initiate and titrate Clozapine (an antipsychotic drug used to treat schizophrenia and other psychotic disorders). A had a history of diabetes and experienced episodes of incontinence which placed A at greater risk of infection. C complained that the discharge letter did not mention a pressure sore which was treated by A's GP upon discharge. This could have resulted in A’s Clozapine treatment being temporarily suspended.

We took independent advice from a mental health nurse and from a wound-care specialist nurse. We found that A’s feet were examined following concerns raised by C. However, no treatment was prescribed and the doctor's advice about caring for A’s feet was not passed on to C. We found that there was no conclusive evidence to determine whether A had a pressure sore or an ulcer which might have impacted on A’s Clozapine treatment. We also found that it was reasonable for the board to conclude that the wound A had was not a pressure ulcer. However, the board failed to evidence that relevant assessments relating to pressure ulcer risk and skin inspections were carried out. We also found that there was no person centred care plan in place to identify A’s needs in relation to activities of daily living, including personal hygiene. We found that the immediate discharge letter was dated the day after discharge which suggests it was not available to C at the point of discharge, or on the same day, when it should have been. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific personal care and treatment failings. 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:

• Patients should be appropriately assessed and treated by staff. Where clinical needs are identified via assessment, corresponding interventions should be planned and initiated to address the situation and prevent complications arising. Care should be provided in line with the assessments carried out and in a timely manner. Records about a patient's care and treatment and decisions made should be clearly and accurately documented and accord with the relevant professional standards and guidelines and reflect a person-centred approach. Patient's records should include clear details explaining why a decision about care and treatment has been made, and show that this has been communicated appropriately.
• The board should ensure that immediate discharge information reaches the GP as soon as is practicable in every case, ideally on the day of discharge, in order that GPs receive essential information that enables continuity of care.

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 care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed medication and inform A and their family that the medication had not been given to them. This led to A’s mental health deteriorating.

We took independent advice from a registered nurse. We found that the board failed to deliver the required service in relation to medicines, maintain adequate recordkeeping, communicate appropriately, recognise the harm done to A and undertake the appropriate review. Therefore, we upheld this part of C’s complaint.

C complained that the board failed to deal with their complaint in a reasonable way. We found that the board’s investigation did not look into an important part of the complaint and that their response did not address the impact on A as a result of the medication being withheld. Therefore, we upheld this part of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation in relation to the standard of medical care and complaint handling. The apology should meet the standards set out in the SPSO guidelines on apology available at HYPERLINK "http://www.spso.org.uk/information-leaflet" www.spso.org.uk/information-leaflet .

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

• Clinical records should appropriately document the action taken to ensure prescribed medication has been reconciled and administered to the patient and medicine reconciliation documentation appropriately completed. Where clinical staff are unable to do so, there should be appropriate communication with the patient and/or their family about this.
• Where an adverse event occurs there should be a thorough review in line with relevant national guidance to ensure that there is appropriate learning and service improvement to enhance patient safety. Where an incident occurs that falls within the Duty of Candour legislation, the board's Duty of Candour processes should be activated without delay.
• Patients admitted to hospital should have their prescribed medicine reconciled without delay and in line with the relevant standards.

In relation to complaints handling, we recommended:

• Complaints should be investigated fully and the complaint response should address all the points raised in line with the 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 complained about the care and treatment provided to their spouse (A). A had a history or recurring urinary tract infections (UTI's) and was self-catheterising. The board gave A an indwelling (long-term) catheter to be changed every three months. Over the next several months, A attended A&E five times before being admitted and diagnosed with bladder cancer. C complained about the lack of arrangements to change A’s indwelling catheter, that requests for appointments were ignored and that A was only admitted after multiple visits to A&E.

We took independent advice from a consultant urologist (specialist in the male and female urinary tract, and the male reproductive organs), consultant in emergency medicine and a medical director specialising in palliative care. We found that, as the indwelling catheter was a trial, the board should have followed up with A on their progress. There was also unreasonable delays in A being seen by urology and in being advised of their cancer diagnosis. While it was reasonable that A was not admitted by A&E for examination sooner, the board acknowledged that there was a missed opportunity. Therefore, we upheld this part of C's complaint.

C also complained that A’s cancer diagnosis, discharge and care arrangements were not clearly explained. We found that the board made reasonable efforts to explain the cancer diagnosis to C and A. However, they did not reasonably communicate how they might manage once A was discharged home, and about the challenges associated with A reaching end of life. Therefore we upheld this part of C's complaint.

In relation to complaint handling, we found that the information provided to both C and this office was inaccurate in places and incomplete. Therefore, we made a recommendation to improve the board's complaint handling.

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 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:

• When a relevant adverse event occurs, the board should carry out a Significant Adverse Event Review (SAER) to investigate the cause and identify any potential learning.
• Patients should receive timely review, follow-up appointments and information based on their clinical needs and presentation and in accordance with relevant guidelines. A's case should be reviewed at the local Morbidity & Mortality meeting with a view to identifying opportunities that were missed to progress A's diagnosis and ways of ensuring similar delays do not affect future patients. The Board should consider whether this case could be used as an opportunity to reflect and improve the interface between the urology and emergency departments in order to minimise the risk of a similar case occurring again.
• Discharge planning should be person-centred and holistic and clear to patients, families and community services. In particular, the palliative care team may support complex discharges but it is the ward team who are best placed to support the patient's discharge. Teams should not just focus on their area of interest e.g. urology but on caring for the whole person. Patients with palliative care needs should be supported within their limited function to live well. Expectation of rehab should be realistic. Staff should explore what is realistic, what the patient and their families' concerns are and also be brave and explore where there are gaps in the system of support, what the best possible mitigation is. There should be thorough documentation of this. Spiritual / other support should be available. They are non-denominational / nonfaith and provide support to patients and families. Learning sessions should occur around recognising a palliative deterioration or the acute deterioration covered by NEWS. Recognising someone heading to the end-of-life phase is essential, as are developing communication skills to support staff to engage with patients and families.

In relation to complaints handling, we recommended:

• Information provided to SPSO and the complainant should be accurate and complete. All relevant records in relation to an SPSO investigation should be provided from the outset of our 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 their late partner (A)’s discharge from hospital was unreasonable. A was admitted to hospital with pneumonia and was discharged after ten days. Less than two weeks after discharge, A collapsed and was readmitted to hospital. A died a few days later. C questioned whether A had been fit for discharge. They also raised concerns about not receiving adequate education on the new medications that A was prescribed on discharge.

The board noted that A’s infection had improved with antibiotic therapy and that they had been stable and well enough for discharge home. They explained the rationale for the medications that A had been prescribed and apologised that medical staff did not have a better discussion with them at the time of A’s discharge.

We took independent advice from a consultant in acute and general medicine. We found that A's oxygen levels had been stable and their discharge was clinically reasonable. However, we noted that A's sodium level had been low during their admission but had improved on discharge. We found that no follow-up arrangements were made to ensure that A's sodium level was continuing to improve after their discharge. The working diagnosis on A's readmission was that they had had a seizure due to low sodium which led to hypoxia (deficiency in the amount of oxygen reaching the tissues) and cardiac arrest. It is possible that the fall in A's sodium level could have been detected had there been follow-up to re-check this. Therefore, we upheld C's complaint.

We also noted a discrepancy between the working diagnosis on A’s re-admission and the recorded cause of death on the death certificate. This was not identified by the board. Therefore, C was not provided with a coherent narrative of events surrounding A’s death and we made a recommendation to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this report. 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 robust discharge systems and processes in place, ensuring appropriate communication with patients and carers, and adequate detail in discharge documentation.
• Patients who are discharged with moderately low sodium levels, should be followed up to check that improvement is maintained. There should be clear guidance in place around this, to ensure it happens where indicated.
• The death certification process should be accurate and consistent with the clinical notes.

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.