Upheld, recommendations

Summary

C complained that the board failed to reasonably investigate and/or diagnose the cause of their symptoms of significant weight loss, intense abdominal pain, vomiting, altered bowel habit and nausea. C also complained that they were discharged from the board’s gastroenterology service (specialists in the diagnosis and treatment of disorders of the stomach and intestines) despite these ongoing symptoms. C said that they were left with no option but to obtain private care and treatment in England where they were diagnosed as suffering from mesenteric ischaemia (restricted blood flow to the intestines). C underwent surgery to correct this privately. While this resulted in significant improvements in C’s health, C complained that this course of action should not have been necessary and that there were cost implications.

In their complaints response, the board acknowledged and apologised for issues with delays in providing investigations, and failings with respect to communication. However, they considered the clinical decisions made in relation to the investigation and management of C’s case were appropriate.

We took independent advice from a consultant gastroenterologist and a consultant radiologist (specialist in diagnosing and treating disease and injury through the use of medical imaging techniques such as x-rays and other scans). We found that the board should have considered a diagnosis of mesenteric ischaemia as a strong possibility based on C’s presenting symptoms. Furthermore, when a CT scan was undertaken there was a failure to report the narrowing of the blood vessels supplying the gut. We found that the decision to discharge C from the gastroenterology service was unreasonable given their ongoing persistent symptoms and, of particular concern, their ongoing weight loss. Therefore, we upheld C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.
• Calculate and reimburse C in relation to their private treatment (including the cost of travel to and from London for C after their discharge from the gastroenterology service) on production of appropriate receipts. The calculation should be based on what the treatment / surgery would have cost the NHS (rather than the full cost of the treatment) and what proportion of that C had to pay. The payment should be made by the date indicated; if payment is not made by that date, interest should be paid at the standard interest rate applied by the courts from the initial date to the date of payment.

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

• Care should be taken when discharging patients with ongoing and persistent symptoms and, in particular, who have ongoing weight loss when there is no clear explanation or diagnosis established.
• Where a patient presents with post-prandial abdominal pain and weight loss with no apparent cause despite extensive investigation there should be a high index of suspicion of mesenteric ischaemia as a strong possibility being the diagnosis, there should be interdisciplinary working between a multi-disciplinary team (the investigating team and radiology) so as to reduce the risk of missing mesenteric ischaemia as a diagnosis and there should be a specific review for evidence of any mesenteric blood vessel atherome on CT scans carried out.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the service that they received from Social Security Scotland (SSS) in relation to a backdated disability payment. C accidentally gave the incorrect bank account number and the payment was paid into the incorrect bank account. While C contacted SSS to inform them that they had not received the payment, SSS did not action C’s concerns and despite C’s attempts to contact SSS, they did not receive a response.

We found that SSS provided incorrect information to C about the backdated payment process and reassured C that the money would, ultimately be returned to them. We also found that they failed to check the full account number when C alerted SSS of the missing payment, that they failed to follow guidance, that they failed to return C’s calls and provided an unreasonable level of service and that they unreasonably delayed starting the payment trace (although an earlier trace would not have guaranteed that the payment be returned). We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failing identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Where it is identified that a payment trace should be carried out, this should be done promptly.
• The SSS should provide correct information to clients.
• The SSS should check the full account number if a concern is raised that a payment has been issued to the wrong account.
• When a client requires a call back, that there is an internal agreement for who will contact the client and that this is actioned without unreasonable delay.
• When a payment is not received, SSS should have clear, robust procedures with version control to ensure it is clear, what procedures are available at any time.

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 delays in Social Security Scotland switching their child (A)’s payment of Child Disability Payment (CDP) to their bank account after A moved in with them. Social Security Scotland continued paying Child Disability Payment to C’s ex-partner and did not process the change for over three months from the date that C notified them of the change. C complained that as a result, A did not receive payment of Child Disability Payment for over two months.

We found that when C reported that A was living with them, Social Security Scotland told C that they were working to get a process in place for these changes and that they would progress C’s request and would contact C. However, they did not do so for over two months until C followed this up. We found that Social Security Scotland unreasonably delayed in changing responsibility for CDP. We upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in reimbursing them. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful apologies.
• Reimburse C for the amount of Child Disability Payment that A was entitled to.

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

• When a change in responsibility for Child Disability Payment is reported to SSS, they should ensure that this is actioned without unreasonable delay.

Summary

C complained to us that the housing association unreasonably failed to investigate and repair defects in relation to the doors, windows and the heating system in their home. We found that that the length of time C waited for replacement radiators, repairs to the windows and a replacement door was unacceptable. The housing association did not carry out the repairs within a reasonable period of them becoming aware that they were needed. We therefore upheld this aspect of C’s complaint.

C also complained that the housing association failed to communicate reasonably with them regarding the repairs. We found several examples of C requesting a call back, of long intervals between receiving a response and of C having to chase a response, over the 14 month period we considered. Many of these occurred after the housing association’s initial response to their complaint and promise of improvements. We therefore also upheld this aspect of C’s complaint. We also identified some failures in the handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• The association should communicate effectively with customers and ensure that calls are returned or emails responded to within a reasonable timeframe.
• The Housing Association should carry out repairs within a reasonable period of time of becoming aware that they are needed.

Summary

C complained to us that the board failed to provide them with reasonable care and treatment during an appointment for a cataract procedure. We took independent advice on the complaint from a consultant ophthalmologist. We found that the scratch on the lens was not caused by the doctor but rather by the folding process of the lens in the lens introducer. However, it was unreasonable that a large scratch on the lens had not been identified after it had been inserted during the procedure. Had the issue been noticed at the time of the procedure, C would have been put into an informed position regarding the issue, of the symptoms that they would likely experience and the plan to remedy the issue. It could have been resolved much sooner, thereby lessening the pain and discomfort C endured over an extended period of time and the subsequent effect this had on their life.

C also complained that the board failed to provide reasonable follow up care and treatment following the appointment. We found that early follow up and intervention by the board would have allowed for a relatively straightforward lens exchange. Better information and communication throughout this process would have allowed for smoother patient care. Therefore, we upheld both of C’s complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the specific failings identified in respect of the complaints considered. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients should receive appropriate follow up care and treatment and a review appointment should be promptly arranged at the hospital when this is appropriate.
• Surgical staff should routinely inspect the intraocular lens post insertion.

Summary

C complained on behalf of a family member (A) about the care and treatment that A received during two presentations to hospital following a fall at their home. Prior to their fall, A was fit and well and independent for activities of daily living.

During our investigation the board had accepted that there were failings and had taken action to address these. This included using this case as a case study to ensure any training and development requirements were implemented, delivering training sessions on significant adverse events review and carrying out a review of the duty of candour arrangements which would include training.

We took independent advice from a consultant in emergency medicine and a trauma and orthopaedic consultant. We found serious failings in A’s care and treatment and that a number of red flags (specific symptoms or signs that indicate a potentially urgent or serious underlying condition requiring immediate medical attention) had been missed in this case. In particular, we found that there was a failure to take into account relevant national guidance and to perform imaging which meant that the fractures of the vertebrae in A’s thoracic spine were undiagnosed. There was also a failure to take account of the National Institute for Health and Care Excellence guidance which the board had accepted.

We found that it had been unreasonable that A had been left to sit during their second visit to hospital for a prolonged period before being assessed given their symptoms. There were also missed opportunities to complete a more thorough neurological examination with a failure to appreciate the presence of a spinal injury and to realise the significance of the signs of limb weakness and incontinence. We also found that the board failed to immobilise A while awaiting the results of a CT scan and during their transfer between hospitals. In view of the failings identified, we upheld C's complaint.

During our investigation, we identified issues with the board’s handling of the complaint. We made a recommendation to the board to support improvement of their complaint handling.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for the failings identified in this decision. The apology should meet the standards set out in the SPSO guidance on apology available at www.spso.org.uk/meaningful-apologies.

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

• Patients attending the emergency department should be appropriately assessed and thoroughly examined, taking into account relevant guidance and, where appropriate, imaging performed. Account should also be taken of presenting symptoms, for example where a patient is presenting with ongoing back pain and new incontinence they should be laid flat and where appropriate immobilised, for example during patient transfer.

In relation to complaints handling, we recommended:

• Complaints should be investigated and responded to in accordance with the board’s complaint handling procedure and the NHS Model Complaints Handling Procedure. When an incident occurs that falls within the Duty of Candour legislation, the board’s Duty of Candour processes should be activated without delay. Staff should be aware of the board's adverse event review processes and ensure they are appropriately applied.

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 (B) about the care and treatment provided to B's late family member (A) during their admission to hospital. In particular, in relation to pain management, standard of care and communication.

In response to the complaint, the board apologised for the failings identified in nursing care and communication. As a result of the failings the board had taken action. This included reiterating the importance of following the National Early Warning Score (NEWS) policy, reminding nursing staff of their obligations to comply with their code of professional conduct in the workplace, and reflecting on A’s care for the purpose of improving person centred care. B was dissatisfied with the board’s response and brought their complaint to the SPSO.

During our investigation, the board accepted that aspects of A’s care and treatment should/could have been better and explained that reflection had taken place, and learning had been taken forward for the purpose of improving the level and standard of person-centred care provided to other patients. In addition, relevant staff had been given the opportunity to reflect on their communication with A’s family.

We took independent advice from a consultant general and colorectal surgeon (specialist in in conditions in the colon, rectum or anus). We found that there had been a number of failings in the care and treatment A received. In particular, we found that there had been a delay in carrying out a CT scan and in diagnosing that A had a bowel obstruction. We found that this may have impacted on their management, including giving consideration to conservative/non-surgical intervention. We also found that A’s pain management had been unreasonable and that an adverse event review should have been conducted, particularly around a diagnosis of bowel obstruction and its management. In view of the failings identified, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for these failings. 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 appreciation and awareness of analgesic requirements in patients with suspected mechanical bowel obstruction and on long term medications for chronic pain.
• There should be appreciation and awareness of a diagnosis of mechanical bowel obstruction and its timely management including the use of Gastrograffin (ASGBI guidelines) and NELA score.

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 carry out their sibling (A)'s hip replacement surgery within a reasonable time. C said that A had made no progress with their surgery since their pre-assessment appointment.

We took independent advice from a consultant orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that A's surgery was Category 2 (urgent) which meant it should have been carried out within 90 days. Given A's significant mobility issues and difficulties with day-to-day living, it was unreasonable to leave their case for more than 90 days. We were concerned that A waited 15 months for their surgery and that the surgery only took place after intervention from this office.

Although the board apologised for the delay in A's surgery, we found that the reasons given were unreasonable. The board had a contract with another health board to provide the type of surgery A required during the time period under consideration and as A met the criteria for acceptance, it was unreasonable that the board did not explore this avenue of care. We noted that the board could also have explored an out of area and exceptional referral for A to another health board and considered the use of non-NHS providers who specialised in filling gaps where there were staffing issues due to staff absences.

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/meaningful-apologies.

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

• The board should put in place a short/medium term solution, in the form of a recovery plan, to prevent this failing from happening to other patients, whether that be three session day operating or six day a week operating, potentially supplemented by other providers if the staffing issues persisted. [In response to a draft copy of this decision notice that was issued to both parties, the board provided some evidence of action they have already taken in relation to this matter.]
• In cases such as this, the board should explore alternative pathways to manage urgent cases in a timely manner.

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 unreasonably failed to provide appropriate care and treatment to their late parent (A). A attended A&E with an injured arm after a fall at home. A was treated and sent home but was admitted to hospital a few days later with low sodium and anaemia. A was discharged after a short stay but re-attended A&E a few days later. An abdominal x-ray showed dilated loops of bowel and blood tests taken showed acute kidney injury. A’s condition deteriorated and they died later that day.

We took independent advice from a consultant in emergency medicine and a consultant geriatrician (specialist in medicine of the elderly). In relation to A's first admission, we found that the management of A’s sodium levels was reasonable. However, there was a lack of accurate charting of A’s bowel movements. We also found that medications to address A’s constipation were not provided at discharge. Therefore, we concluded that the care and treatment with respect to A’s constipation was unreasonable and upheld this part of C's complaint.

C also complained that the board failed to provide A with appropriate care and treatment during their second attendance at A&E. We found that there was an unreasonable delay in A being seen by a doctor on arrival. 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 failures identified in the investigation. This should also include the apologies that were included in the correspondence to our office in response to our enquiries. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Bowel charts should be routinely and accurately completed for patients admitted to hospital. Patients should receive appropriate treatment including assessment and relevant examinations to assess known symptoms.
• Patients should receive appropriate treatment including triage and medical assessment in accordance with their symptoms, when attending A&E. The board should have appropriate staffing to allow timely assessment and treatment of patients in A&E, and escalation plans to address instances where patient numbers become unmanageable. The board should have an escalation plan for instances where overcrowding / patient numbers reach critical levels.

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 in relation to excision of a right sided neck lesion.

C had been undergoing monitoring for a neck swelling thought to be a benign tumour. After a number of years of monitoring, C reported that they were experiencing pain and asked to have the mass removed. C underwent surgery to have the mass removed. The lesion had grown on the vagus nerve (the main nerve of the parasympathetic nervous system, which controls some body functions including digestion) and encased it, so the vagus nerve was cut in order to remove the lesion. Following surgery, C experienced gastroparesis (paralysis of the stomach, resulting in food and liquid remaining in the stomach for a prolonged period) and vocal cord palsy (where the vocal cords are unable to move properly).

We took independent advice from an Ear, Nose and Throat (ENT) consultant. We found that the care and treatment that C received was unreasonable because there was a failure to recognise the lesion involved the vagus nerve and a failure to adequately discuss risks and consequences with C prior to listing them for surgery. We considered that it should have been made clearer to C that the surgery was likely to lead to injury or loss of function of the nerve. We also found that the events should have triggered the Duty of Candour process and that there was a failure to acknowledge the failings had occurred. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable care and treatment in relation to excision of their right-sided neck lesion. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/meaningful-apologies.

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

• Structures involved in benign neck lesions should be carefully considered, and risks and consequences of removal of benign neck lesions should be clearly explained to patients prior to 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.