Upheld, recommendations

Summary

C complained about the care and treatment provided to their spouse (A). A suffered from progressive lung disease and required prostate surgery. There was a significant delay in performing A's surgery, during which time A's health deteriorated. A was discharged home following their operation, but was readmitted the following day and died shortly afterwards.

C believed that A would have survived had the operation been performed sooner, as their health would have been better. C also said that A's death certificate was inaccurate, as it stated that A had died from community acquired pneumonia. C said that A had not been well when they were discharged, had been at home for less than 24 hours and had spent the majority of that period in bed.

We took independent medical advice. We found that A's condition had not been properly monitored following their operation, as the board's assessment had been based on assumptions about A's condition prior to admission. This meant that A had been discharged without evidence of a deterioration in their condition being properly considered. We also noted that it was not possible to determine that A's pneumonia was 'community acquired'.

We considered that A's care and treatment had fallen below a reasonable standard. However, we noted that it is not possible to be certain what the outcome would have been had A been operated on sooner.

We also found that C's complaint had not been handled to a reasonable standard. The board had initially informed this office that it had nothing to add to its response to C's complaint. However, following our enquiries, the board accepted that it was unlikely that A had acquired pneumonia in the community. Additionally the board's complaint investigation had failed to identify that A's condition was not properly assessed prior to discharge.

We upheld both of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to asses A's condition, incorrectly describing their pneumonia and issuing an inaccurate death certificate. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Assist C with obtaining a corrected death certificate.

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

• Medical staff should correlate information about a patient's condition on admission, such as oxygen saturation levels as part of the patient's assessment prior to discharge.
• The board should remind relevant medical staff that, when issuing a death certificate, careful consideration needs to be given to ensuring it accurately reflects the cause of death.

In relation to complaints handling, we recommended:

• Complaint responses should respond to all of the points of complaint raised by a complainant.

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 underwent sequential cataract surgery (a surgical procedure to replace the eye lens with an artificial one when the cataract makes the vision cloudy, specifically, in this instance, monofocal lens implantation). C complained that the board had failed to communicate reasonably with them prior to the cataract surgery, including that the risks and benefits were not explained to them and that their concerns following first cataract surgery were not taken seriously.

We sought independent advice from an ophthalmologist adviser (specialist in the branch of medicine that deals with the anatomy, physiology and diseases of the eye). We found that there was no record that C was given information about the risks and benefits of the surgery. The lack of written information about the risks and benefits of the procedure was unreasonable. We noted that this was contrary to the General Medical Council's guidance to keep an accurate record of the exchange of information. We also found that there was no record of what was discussed with C following the first cataract procedure. As there is no written record, we were unable to determine what was discussed with C when they raised concerns.

In light of the above, we considered that there was a failure to communicate reasonably with C prior to the cataract surgery and we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not giving them information about the risks and benefits of monofocal lens implantation and for not recording what was discussed with them following the first cataract procedure. 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:

• Discussions with patients following cataract procedures should be clearly recorded.
• Patients should be advised of all material risks and benefits of cataract procedures and the discussion should be clearly recorded, in accordance with relevant standards and guidance.

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 from the board when they were admitted to Hairmyres Hospital with a psychotic episode. C raised a number of issues, including that the nursing and clinical staff at the hospital failed to adequately explore the possible link between the unpleasant/harmful physical symptoms C was experiencing, which they said they reported on a daily basis, and the medication they were given.

We took independent advice from a mental health nurse and a consultant psychiatrist. We found that, generally speaking, staff responded appropriately to C's complaints; observations, examinations, investigations and onward referrals were appropriately initiated when C voiced concerns. However, there was a clear failure to carry out daily monitoring of C's pulse and blood pressure in a consistent and reasonable manner, and record the readings and C's resulting National Early Warning System (NEWS, a pro forma for recording patients' physical observations that generates a score to alert staff to potential changes in a patient's physical condition) score on the NEWS chart. We noted that the failings in recording of C's pulse and blood pressure on the NEWS chart and the resulting NEWS score was a potential contributory factor to C developing hypotension (low blood pressure). Interventions to manage this, such as the withdrawal of Olanzapine (an antipsychotic drug), were delayed at a time when this would have been beneficial in alerting the clinical team to physical issues experienced by C. This resulted in C experiencing short term discomfort and distress from hypotension. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to consistently monitor C's pulse and blood pressure and record these, along with C's NEWS score, on the NEWS chart. 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' vital signs observations should be conducted in line with agreed frequency and the readings and resulting NEWS scores recorded on the NEWS charts.

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 provided to their parent (A). A was admitted to Inverclyde Royal Hospital after they had fallen at home. The following night, A had an unwitnessed fall in the hospital. Around ten days later, A's leg was noted to be at an odd angle and A was found to have a fractured hip.

C complained about the nursing care A received. We took independent advice from a nurse and an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system).

We found that A's initial falls risk assessment was unreasonable and A's family was not informed about A's fall. We upheld this aspect of the complaint. However, we noted that the board had already taken action to address failings in nursing care they had identified.

C also complained about the medical care A received. We found that after A fell both at home and at the hospital, appropriate medical examinations were not carried out and/or documented. We found it was highly likely this led to a delay in identifying A's hip fracture and in treating it. We also found that when A had hip surgery, there was no record that the risks of general anaesthetic had been discussed with A or their family. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in A's nursing care (in relation to their initial falls risk assessment and their 'getting to know you board'); and the failings identified in A's medical 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:

• Patients should be given clear information about the risks of general anaesthetic; and the discussion should be clearly recorded.
• Patients who have fallen should be given appropriate medical examinations, which are clearly documented.

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

Summary

C complained to the prison about the treatment of their parent (A) who was involved in an incident which resulted in them being restrained by prison staff. C said that the use of force was excessive, causing A to sustain injuries. C also complained that A was denied medical assistance after being relocated to the prison's separation and reintegration unit (SRU) and denied the opportunity to make any telephone calls.

The Scottish Prison Service (SPS) issued a response to C who remained dissatisfied and complained to us. We found that the SPS's response was extremely brief, failing to address the issues raised. We returned the complaint to the SPS, advising that they submit a further reply to C. After receiving a further reply, C returned to us again, noting that the second response was inadequate and still failed to address the issues raised.

Our investigation found that the SPS failed to properly investigate C's complaint, as we did not see adequate evidence that they sought to establish relevant facts. SPS also failed to provide a full, objective and proportionate response to the issues raised. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to properly investigate and respond to their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Properly investigate the matters raised by C in their complaint and provide a full and detailed response to the matters raised.

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

• The SPS should provide complaint responses that: clearly set out the matters that have been investigated; confirm the relevant evidence assessed as part of the investigation of the complaint; and fully explains the organisation's response to the complaint.

In relation to complaints handling, we recommended:

• The SPS should confirm that staff are familiar with the model complaint handling procedure and should ensure that it is accessible to staff as a complaint handling tool.

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 that they received from the partnership when they were visited by a health visitor following the birth of their baby. C declined the health visitor's offer to observe their latch while breastfeeding. C felt that the health visitor did not understand the importance of obtaining C's consent and that they had not respected their right to decline. In the partnership's response, they said that health visitors are required to identify any breastfeeding problems but that they apologised for how the health visitor had communicated with C.

During our investigation, we took independent advice from a midwife. We found that it was appropriate that the health visitor offered to observe C while breastfeeding but that if a patient declines any offer of care, this should be respected. We found that the health visitor's communication with C had been unreasonable and we, therefore, upheld C's complaint. We found that the partnership had already taken appropriate steps to address the health visitor's communication with C, however, we found that their response had not clearly addressed C's right to refuse care and we made recommendations about that.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not properly addressing this aspect of their complaint. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

In relation to complaints handling, we recommended:

• Complaint responses should address all relevant issues and should clearly explain the relevant clinical position (in this case, that patients have the right to refuse 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's adult child (A) had anxiety and a functional neurological illness (a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts). One morning A was found to be anxious and unwell. A's other parent (B) thought it appeared different to A's previous episodes and called the GP who visited A at home.

The GP believed that A should be admitted to hospital and called 999. An ambulance crew attended the scene. There was some discussion between the GP and the hospital about which department A should be admitted to; the Mental Health Unit or the Clinical Assessment Unit. The ambulance crew transported A to hospital where they were quickly assessed and taken to the Intensive Care Unit. A died later that day.

C complained that the Scottish Ambulance Service (SAS) crew did not take A's observations, failed to follow normal protocols and failed to transfer A to the Clinical Assessment Unit straight away.

We took independent advice from a paramedic. We found that the ambulance crew attended promptly and appropriately transferred A to hospital. However, during their time at A's address they did not carry out or document a thorough patient assessment. There were multiple assessment tools (F.A.S.T; blood oxygen saturation levels) which could have been used and were not. When A's breathing rate was abnormally high, further action was not taken as it should have been.

We found that the SAS had not responded to the complaint reasonably and failed to clearly identify errors and what would be done to remedy them going forward. We, therefore, upheld the 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:

• Share the findings of this investigation with the ambulance crew and those involved in the reflective learning exercise.

In relation to complaints handling, we recommended:

• SAS should provide as full an explanation as possible in complaint responses as to what mistakes may have occurred (where appropriate) and why they occurred in this case, in order to allow complainants a better understanding of what happened.

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 a failure to diagnose that their new born baby (A) had a dislocated hip from birth. A was reviewed by a physiotherapist (a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) at the Royal Hospital for Sick Children, and C raised concerns that their request for an ultrasound scan was refused despite the presence of a number of red flag risk factors for hip dysplasia (where the 'ball and socket' of the hip are not properly formed). A's condition was not diagnosed until some months later.

The board noted that the physiotherapist found A's hips to be functioning normally. They accepted that initial screening will always have the opportunity for human error. They said that this is mitigated by regular teaching and peer review, and ensuring staff are competent in examination before reviewing patients. However, as a result of this complaint, they made changes to their hip screening procedures.

We took independent advice from a paediatric physiotherapy specialist. We considered that the presence of a number of recognised risk factors of hip dysplasia, together with a doctor's prior positive clinical assessment of hip instability, should have led the physiotherapist to arrange an ultrasound. The decision not to carry out a scan of A's hips was unreasonable and resulted in a delayed diagnosis. We upheld this complaint. We were advised that the changes already made by the board to their hip screening procedures should improve the clinical process going forward.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to arrange an ultrasound scan, and the resulting delay in diagnosing A's 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:

• An audit process should be established to ensure that improvements in teaching and peer review are followed through and that staff continue to meet their competencies.
• The board should share this decision with the physiotherapist in a supportive manner, and ask that they reflect on A's case.

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 them with reasonable care and treatment. C experienced a sudden loss of sensation in their left leg. C initially contacted their GP and after sypmtoms did not improve, they were referred to orthopaedics (specialists in the treatment of diseases and injuries of the musculoskeletal system) and reviewed by the on-call orthopaedic service at Royal Alexandra Hospital. C was examined by a junior doctor.

C told us they were concerned that their back was not examined; that they did not received a scan, that they were not reviewed by a senior orthopaedic doctor or a neurosurgeon, that there was a failure to contact them after a multi-disciplinary team discussion was held, that there was a delay in receiving a scan as an out-patient, that there was a significant delay between the reporting of the scan and C (and their GP) being made aware of the results and that there was a delay in receiving an out-patient appointment.

The board acknowledged that the examination C received was not in keeping with usual process, however, they considered that the junior doctor appropriately discussed C's condition with a registrar and received advice from the neurosurgery team.

We took independent advice from a consultant orthopaedic surgeon. We found that the initial assessment was reasonable and that it was reasonable for a scan to be completed as an out-patient. We considered that it was appropriate for the board to discuss C's case with the on-call neurosurgeon and that the treatment plan agreed was reasonable. However, we found that the delay in acting on the scan report was unreasonable, given that it contained significant findings.

In light of this, on balance, we upheld C's complaint.

Recommendations

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

• The board should take steps to ensure outcomes of multi-disciplinary team meetings are documented, and it is clear whose responsibility it is to contact the patient to communicate the outcome.
• The board should take steps to ensure that the results of urgent scans are managed reasonably, and that the referring clinician is made aware when significant findings are flagged up on a scan.

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 parent (A) at Queen Elizabeth University Hospital. A was admitted to hospital for an operation, which required a long period of rehabilitation. A's condition began to deteriorate after the operation and they died a few weeks later. C complained that clinical failings relating to hydration, record-keeping and communication were contributing factors to A's deterioration and death. C was also concerned about the way clinicians communicated with them.

We took independent advice from two advisers: a nurse specialist in critical care and respiratory and a consultant in acute medicine. We found that there were unreasonable failings in nursing care including record-keeping, which had an adverse effect on the management of A's hydration, and that the lack of fluid management had a distressing impact on A and their family at the end of their life. However, these failings did not substantially impact on A's chance of survival or death. We also found that opportunities were missed to inform A's family of their condition which meant that they were unprepared for A's deterioration and death. We upheld all of C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in this investigation. The apology should meet the standards set out in the SPSO guidelines on apology available atwww.spso.org.uk/information-leaflets.

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

• Ensure a reasonable standard of communication which meets the needs of patients and their families.
• Ensure a reasonable standard of fluid management.
• Ensure patients' hydration is managed reasonably.

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.