Upheld, recommendations

Summary

C complained about the care and treatment provided to their adult child (A) by the partnership. A had received care from mental health services for several years prior to their death by suicide. C complained that the partnership failed to reasonably share information with A’s family and failed to involve them in A’s care. C also complained about the HSCP’s complaint handling.

We took independent advice from a consultant psychiatrist. We found that the partnership had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable. We upheld this aspect of C’s complaint.

We found that there were delays in the partnership responding to C, and that they did not answer all points of the complaint. We upheld this complaint about complaint handlings.

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/meaningful-apologies.

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

• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented; and revisited regularly.

In relation to complaints handling, we recommended:

• Complaints should be responded to in a timely manner and in line with obligations under the NHS Model Complaint Handling Procedure. Complaint responses should attempt to address individual concerns, or explain why that is not possible.

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 partnership about the care and treatment of their late spouse (A). A suffered from Progressive Supranuclear Palsy (a rare neurological condition that can cause problems with balance, movement, vision speech and swallowing). A was admitted to a community hospital for care and support of their complex needs. C complained about unreasonable falls prevention, nutrition, personal hygiene and incident management. C was concerned that there was little information in the medical notes to show that A was being reasonably cared for. They noted that A had fallen on several occasions, that A had dirty hair, had not been washed and was not receiving enough to eat and drink.

The partnership advised that A was on continuous intervention during the day and 15 minute observations at night for falls prevention, and that falls risk assessments were carried out as part of routine care, although did not provide evidence of this. They advised that Person Centred Care Plans (PCCP) were recorded in A’s records, risk assessments were completed and updated regularly and all staff were receiving personalised one-to-one training on documentation and PCCP.

We took independent advice from a nurse. We found that there was insufficient evidence of falls risk assessments or malnutrition assessments in the records provided, that there were significant gaps in care rounding records and a 5 day period during which A was not offered a wash. We found this to be unreasonable and upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that the care provided did not meet A’s basic needs or keep them safe. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

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

Summary

C, a tenant of Albyn Housing Society Ltd, reported antisocial behaviour (ASB) from a neighbouring family who were also tenants of the association. The ASB related to an overwhelming and pervading smoke and smell as a result of the neighbouring family’s cannabis smoking. The association reported having visited the family and the volume and frequency of smoke and smell reduced. Over the next several months, C made three further reports of the same ASB recurring, including reporting deterioration in their own and their family’s respiratory health. On each occasion the association reported visiting, or attempting to visit, the neighbouring family it resulted in temporary reductions in the volume and frequency of smoke and smell.

When C complained that the association had not responded reasonably to the reports, the association’s response indicated that they considered that they had taken reasonable action. C felt that they had no option but to end their tenancy and raised their complaints with SPSO.

We found that the association did not progress matters in line with a number of parts of their ASB Procedure regarding administration, categorisation and investigation of reports of ASB, subsequent review of progress, consideration of possible solutions to the reported ASB, or taking into account how the situation had developed over a number of months. The association did not explain to C that evidence and corroboration was required to enable them to take action, and they did not follow through with their belated requests that C keep a log of dates and times when issues arose. The association also failed to keep reasonable records of the actions that they did take or pursue and fulfil actions they indicated they intended to take. We upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C that they did not take reasonable action in response to C’s reports of ASB from neighbouring tenants. 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 association’s actions in response to reports of ASB are in line with their ASB Procedure, including actions being reasonably or consistently recorded and reasonably considered including consideration of progression within the ASB Procedure when further reports about the same matters are made.

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 adult child (A) by the board. A had received care from mental health services for several years prior to their death by suicide. C complained that the board failed to reasonably share information with A’s family and failed to involve family in A’s care. C also complained about the board’s adverse event review process, and their complaint handling.

We took independent advice from a consultant psychiatrist. We found that the board had failed to evidence that there was any discussion with A about sharing information with their family or involving family in care and treatment, including risk assessment. We considered that not to have had this discussion, or to have had the discussion and failed to document it, was unreasonable.

The board told us that records were kept briefer than they would normally, because A was an employee of the NHS and was concerned about their records being kept confidential. We did not consider this to be a reasonable position to take, as all patients, including those who are NHS staff, should be confident that their records will be kept confidential. We considered it unreasonable that the board had not addressed this concern. We upheld C’s complaint about information sharing and involvement of family.

In relation to the adverse event review process, we found that the board had not appropriately taken account of C’s view on the scope of, and information to be contained within the review, and because it did not identify the failings in care. We upheld this aspect of the complaint.

Finally, we considered the board’s handling of C’s complaint to be unreasonable. This was because answers to multiple questions about care and treatment were responded to using generic and repetitive phrasing, the complaint response contained several inaccuracies and C was not made aware that some aspects of the complaint could only be responded to by another organisation until the final complaint response,. We upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings with regard to information sharing and involvement of A’s family, the adverse event review process and the complaint handling and response. 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:

• Adverse event review teams should be open to the requests of family when making decisions about scope and information contained in the final report. Adverse Event Reviews should be a reflective and learning process that appropriately consider events in sufficient detail to ensure failings and any appropriate learning and practice improvements are identified.
• Patients who are also employees of the NHS should have confidence that records will be confidential.
• Records should be comprehensive and completed in line with professional standards. In particular, mental health services should seek to discuss involving family in care planning and risk assessment. These discussions and outcomes of such should be documented and revisited regularly.

In relation to complaints handling, we recommended:

• Where some aspects of a complaint cannot be responded to by the board, the board should coordinate responses or make the complainant aware that they need to approach another organisation at the earliest possible point. Complaint responses should attempt to address individual concerns, or explain why that is not possible. Complaint responses should be accurate.

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 practice’s treatment and diagnosis in respect of issues C had with their leg over a period of 18 months and being diagnosed with deep vein thrombosis (DVT). In C’s view, the practice missed various opportunities to diagnose DVT or refer onwards to an appropriate specialist. C also raised concerns about the general treatment that they received from when they presented with a lesion on their left leg. The practice had acknowledged that there was a delay in diagnosing C’s DVT. However, there remained uncertainty regarding when the practice should have diagnosed a DVT or explored the possibility of this diagnosis.

We took advice from an independent GP adviser. In respect of the DVT, we found that this was a more difficult case of DVT to diagnose. However, there were signs that the practice unreasonably missed. C attended a consultation after they had been on a flight. We found that, from this point onwards, there was an unreasonable failure to fully take into account risk factors and symptoms pointing to an alternative diagnosis of DVT. There were also missed opportunities to carry out appropriate investigations that would have supported or ruled out such a diagnosis. We considered that there was less certainty over whether the DVT was present prior to C’s flight. We upheld this complaint.

In respect of the more general care of C’s leg, we found that this was initially of a good standard. However, this became less reasonable as the months went on and C’s symptoms persisted. We found that, at a certain point, the practice were not treating C’s symptoms proactively. We also considered an apparent absence of a dermatology referral, despite C’s records indicating that this was part of the treatment plan. For these reasons, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose or explore the possibility of DVT, for failing to treat C’s leg issues pro-actively after a period of time and for not following through on a referral to dermatology. 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:

• DVT should be explored as a possible diagnosis when relevant symptoms and risk factors are present, even when another diagnosis is considered more likely. Treatment for potential DVT should be provided in line with SIGN, NICE or other relevant guidance unless there is a specific reason not to do this. If a decision is taken not to follow relevant guidance, then the reason for this should be recorded.

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 on behalf of their relative (A) in relation to the nursing care and treatment that the board provided to A in hospital following orthopaedic surgery. A received nursing care in hospital before being transferred to another hospital for rehabilitation, where they died. In the second hospital, A was found to have a large wound on their foot and C complained that they had been unreasonably transferred with this.

We took independent advice from an experienced nursing adviser. We found that the wound care management that A received was unreasonable. We also found that it was unreasonable for the board to transfer A to another hospital without documenting this on the transfer document and without an adequate wound care management plan in place. We therefore upheld these complaints, although we found that the board had subsequently taken action to support improvement with regards to care rounding and pressure ulcer prevention.

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:

• Adequate wound healing management plans should be in place for staff to follow prior to transferring patients to community hospitals.

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 and treatment provided by the board to their late parent (A) during two hospital admissions and the communication around this. C also complained about the way that A was discharged and when they felt that they were unfit to be discharged. A was hard of hearing and a non-English speaker. C said that the failings led to a great deal of mental and physical stress and A’s premature death shortly after the second discharge.

We took independent advice from a consultant physician specialising in medicine for older adults. We found that while aspects of the care and treatment were reasonable, there were failings. The board failed to communicate adequately in relation to A’s care and treatment. In particular, in relation to the seriousness of A’s illness and ensuring that A’s family understood that A was at the end of their life, and the lack of an in-person professional translator for A. Finally, we found that A was not discharged in a reasonable way on the second discharge home, that they should have been reviewed by a senior clinician and had all the relevant tests and investigations carried out and reviewed, and that on discharged, should have had all the required support from the community in place to meet their needs. We 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:

• Patients and their family should be informed of significant treatment events.
• Patients should be discharged when they have been appropriately reviewed by a senior clinician and all relevant tests and investigations, have been carried out and reviewed.
• Patients should be discharged with all the required support from the community in place to meet their clinical needs.
• Patients who have a hearing impairment or do not speak English as a first language (or both) should have appropriate language support to enable them to fully access NHS services in the same way as patients who do not have barriers such as disability and language.

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) 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.