Upheld, recommendations

Summary

Ms C complained about the care and treatment her late mother (Mrs A) received at Gilbert Bain Hospital. Mrs A had widespread bladder cancer and she was admitted to the hospital because she was experiencing pain and discomfort. Medical staff decided it would be appropriate to try to insert a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag). Ms C raised concerns that the decision to try to insert a urinary catheter was unreasonable; and that medical staff should have stopped the attempts sooner, as Mrs A was in pain and shouting for them to stop.

We took independent advice from a general surgeon. We found it was reasonable that medical staff tried to insert a urinary catheter. However, we found that the repeated and distressing attempts to do so were unreasonable. We considered that the first attempt to insert a urinary catheter should have been carried out by a more senior member of medical staff. We considered that Mrs A should have been given better pain relief/sedation before any further attempts were made. We also considered that medical staff had failed to recognise Mrs A's distress and to respond to her clear withdrawal of consent. We upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms 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, at the end of their life, should only undergo invasive procedures and interventions if they will ease their distress or pain. When such procedures are carried out, it should be by medical staff with an appropriate level of expertise; with appropriate consent from the patient; and only after adequate pain relief has been administered.

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

After injuring her finger, Mrs C was referred to the orthopaedic department. Her injury was reviewed on a number of occasions before being diagnosed as dislocated. A procedure was carried out to put the joint back into place. The pain in Mrs C’s finger did not improve, despite cast treatment and physiotherapy, so she was referred back to the orthopaedic department. After a further review, it became apparent that Mrs C had developed a complex regional pain syndrome (CRPS) in her right hand.

Mrs C complained to the board that there was an unreasonable delay in identifying that her finger was dislocated. She considered that the procedure to correct the dislocation should have happened sooner and, if it had, she would not have developed CRPS. She remained unhappy with the board’s response so brought her complaint to us.

We took independent advice from an orthopaedic consultant (a doctor specialising in the treatment of diseases and injuries of the musculoskeletal system). We found that there were a number of opportunities in Mrs C’s case for her dislocated finger to be identified earlier. We concluded that there was an unreasonable delay in reporting of the x-rays taken of her hand. We upheld Mrs C's complaint.

Recommendations

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

• The board should ensure timely reporting of images to avoid delays as identified in Mrs C’s case in future.

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

Mr C complained that the practice failed to provide his late wife (Mrs A) with reasonable care and treatment.

Mrs A had presented to the practice several times with severe back pain over a ten month period. Mrs A was told to self refer for physiotherapy. Mrs A subsequently went to A&E due to the pain she was suffering in her back. Mrs A was diagnosed with renal cancer which had spread to her spinal column and brain. Mrs A died from her illness.

We took independent advice from a GP and a nurse. We found that although the practice doctors had been involved in prescribing painkillers and muscle relaxants to Mrs A, her back pain management and treatment plan was effectively being managed by the physiotherapy service who are independent practitioners. It was reasonable for a GP to expect that if a physiotherapist was concerned about deteriorating or urgent clinical signs in a patient that they would arrange appropriate hospital assessment or a scan. Mrs A had at no stage when she saw the practice doctors presented with red flag signs (indicators that a more serious problem may be developing/underlying) to suggest cancer. As such, the care provided by the practice doctors was reasonable.

We found that with regard to Mrs A’s consultations with the advanced nurse practitioner, she had presented with potential red flag signs including unexplained weight loss. While Mrs A’s presenting symptoms were very atypical of renal cancer, it had not appeared that cancer had been considered given Mrs A had shown potential red flag symptoms and signs. We found that these red flag symptoms and signs had not been acted upon. Therefore, we upheld the complaint.

We acknowledged that the practice in their complaint response to Mrs A and to this office accepted there were failings by the practice. They said they had learnt from Mrs A's case and we acknowledged the action the practice had taken to address this.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for the failure to identify that Mrs A had presented with red flag symptoms and signs for cancer at consultations with the Advanced Nurse Practitioner and to take appropriate action. 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 staff should be aware of the local and national guidelines on presentations with acute and chronic back pain and ensure they are up-to-date with current best local and national practice, including red flag presentations.

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 treatment provided to their parent (A) while a patient at Glasgow Royal Infirmary. A was admitted with a large bowel obstruction. C complained about the delay in a stent procedure being carried out (a procedure where a small tube is inserted to keep a passageway open).

We took independent advice from a consultant colorectal (a surgeon who specialises in conditions in the colon, rectum or anus) and general surgeon. We found that there was an unreasonable delay in the stenting procedure being carried out and a combination of the delays and A’s deteriorating health, with rising C-reactive protein (CRP - an inflammatory marker) and National Early Warning Scores (NEWS a system that records key observations about the health of a patient with the higher the score the greater the clinical risk), was not reasonably responded to. When the stent procedure was delayed there was a lack of alertness to A’s deterioration and the management plan was not reviewed. We found that the board could have been better in assessing A’s fluid balance, noting their continued deterioration over a several day period, and attention to the worsening CRP. We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their sibling for failing to provide reasonable treatment to A during their admission and for the inaccuracies in the complaint response. 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:

• Fluid balance recording and management in critically ill patients should be reasonably managed.
• The board staff should actively review trends in NEWS scores in critically ill patients.
• When management plans are in place and patients are awaiting treatment, there needs to be ongoing review of the management plan.
• Treatment for bowel obstruction should be appropriately prioritised in the board's hospital.
• Stenting in bowel obstructions should be appropriately prioritised, based on the clinical picture and have a limit of no longer than 48 hours from admission, when there is evidence of obstruction in an emergency setting.

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 was diagnosed with diabetes (a condition that causes a person's blood sugar level to become too high) and they were given treatment with insulin (a hormone made in your pancreas. It helps your body use glucose (sugar) for energy. In type 1 diabetes your pancreas no longer makes insulin, so you have to inject it to control your blood glucose levels) and had follow-up care with the diabetes clinic. After several months, C decided to stop injecting insulin as they felt that this caused pain in their legs. C complained that the board had misdiagnosed them, that insulin had caused pain in their legs, and that their concerns were not taken seriously by staff at the diabetes clinic.

We took independent advice from a consultant diabetologist (doctor specialising in the diagnosis and treatment of diabetes). We found that once the diagnosis of diabetes had been made, insulin was the correct treatment and was reasonable. However, we found that it appeared that there had been a missed opportunity to diagnose the diabetes several months earlier and this was unreasonable. On this basis, we upheld C’s complaint. We also found that the pain C had experienced could have been caused by the administration of insulin. Whilst we were clear that insulin was the correct treatment for C, we suggested that the board could have acknowledged the possibility of the insulin contributing to C’s pain.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to diagnose them with diabetes at an earlier point. 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:

• Where low blood sugars indicate a diagnosis of diabetes, this should be followed up.

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 them by the board. C presented to hospital with abdominal pain and bleeding and was told that they were either experiencing a miscarriage or an ectopic pregnancy (a pregnancy in which the foetus develops outside the uterus, typically in a fallopian tube). C was told to return for a scan in several days.

C complained that the board did not offer a scan at the time of presentation, keep them in for observation or discuss treatment options. C felt that, as a result of the delay in scanning, their condition deteriorated and they had fewer treatment options when they attended another hospital several days later.

We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in the female reproductive system, pregnancy and childbirth). We found that it was reasonable that C was not given a scan on presentation as this was outwith scanning hours; and that it was reasonable that they were not kept in for observation or to discuss treatment options. However, we found that C should have been offered a scan within 24 hours of presenting at the hospital, or failing this, as soon as scanning services were available, as opposed to being given the next routine scan appointment. On this basis, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to offer them a scan in a timely manner. 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 requiring emergency scanning should have this carried out 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

Mr C complained on behalf of his mother-in-law (Ms B) about the care and treatment Ms B's late husband (Mr A) received during his admission to University Hospital Ayr with suspected renal colic (a type of pain experienced when urinary stones block part of the urinary tract). After Mr A collapsed in the hospital he was assessed by a consultant vascular surgeon (a specialist in the treatment of diseases affecting the vascular system including diseases of the arteries, veins and lymphatic vessels) who suspected a ruptured abdominal aortic aneurysm (a bulge or swelling in the main blood vessel from the heart that has burst). This was confirmed on an urgent CT scan. Mr A was taken to theatre where he died.

Mr C told us that he considered the care and treatment Mr A received was unreasonable because the aneurysm was misdiagnosed for the vast majority of Mr A’s time in the hospital; that no urine test was ever performed and as a result nitrites (nitrites can be a sign of infection) in Mr A’s urine could not have pointed towards the diagnosis of renal colic; no effort was made to investigate or test for an aneurysm prior to Mr A’s collapse; no ultrasound or CT scan was performed prior to Mr A’s collapse; and there was delay in starting the operation once the suspected ruptured abdominal aortic aneurysm was identified.

We took independent advice from a consultant vascular and general surgeon. We found that aspects of Mr A’s care and treatment were reasonable. In particular, that the initial diagnosis of renal colic was reasonable. We noted that once the diagnosis of an aneurysm was made there was no delay in getting Mr A to theatre. However, we found that there was an unreasonable delay in carrying out a CT scan which would have identified the presence of an aneurysm. As such, there was an unreasonable delay in making the diagnosis of a ruptured aneurysm. The board have accepted that the diagnosis should have been considered earlier than it was and have taken action to prevent a similar incident happening again.

We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family for the unreasonable delay in carrying out a CT scan and as a result, an unreasonable delay in making the diagnosis of a ruptured aneurysm. 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 presenting with apparent renal colic should have differential diagnosis considered and also be considered for urgent CT scanning.

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 way the university made the decision to remove them from their course. C complained that they was not given prior notice that they might be withdrawn, that the decision was made as they returned from medical leave and that their appeal against the decision was treated as a complaint instead.

We found that the university had repeatedly raised clear concerns with C about their academic progress in monthly progress reports. We also found that C should have been aware that this could have resulted in the university deciding to withdraw them. We also found that as C did not raise grounds for an appeal, it was reasonable that their concerns were considered through the university's complaints process instead.

However, we were concerned about aspects of how the university handled C's withdrawal. There was no record of the decision-making process and so there was no evidence that their medical leave and health issues had been taken into account. We also found that the university should have told C the reason that they were being withdrawn, before directing them to their appeals process. We considered that this meant C was not given a fair opportunity to consider and lodge grounds for an appeal against the decision to withdraw them. For these reasons, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified in these aspects of the university's handling of their withdrawal. 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 appeal; after allowing them an opportunity to submit any further evidence in support of their appeal.

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 is the welfare and financial guardian to A who requires residential care. C complained to the Care Inspectorate about the service A was receiving at the care home in which they reside. The Care Inspectorate upheld C's complaints and made a requirement and recommendation for improvement. C later complained that these had not been implemented, however the Care Inspectorate did not uphold this complaint. C complained to us that the Care Inspectorate failed to take into account the evidence they provided in support of their complaint.

The Care Inspectorate confirmed that all of C's concerns were taken into account and they had noted that some improvements were being made by the care provider.

We found that the Care Inspectorate failed to satisfactorily address the detailed evidence submitted by C in support of their complaint. While it was not unreasonable to note that some improvements had been made by the care provider, we considered that if the Care Inspectorate had reviewed C's evidence in detail, they could not have reached the conclusion that the provider had met the requirement and recommendation. As such, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for failing to investigate their complaint to a reasonable standard. 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 demonstrate that evidence has been considered in the course of an investigation.

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

Mr C attended his brother's integrated case management (ICM) case conference. This meeting is held each year when the prisoner and those involved in supporting them get together to discuss their sentence management.

A document used to minute the discussions is then shared with all attendees. On receiving this document, Mr C wrote to the ICM coordinator raising concerns about inaccuracies and omissions in the record. The ICM coordinator responded to Mr C confirming that the content of his letter had been noted and placed on file. Mr C complained that the Scottish Prison Services' (SPS) handling of his submission about the ICM case conference record was unreasonable. Mr C also complained that the SPS failed to properly address his complaint.

In response to Mr C's complaint about the way his submission was handled, the SPS told him that his brother's own submission had been filed and was used as the record that both Mr C and his brother felt that the minutes captured were inaccurate.

We found that the relevant guidance indicates that all attendees at the case conference have a responsibility to check that the minute is an accurate, factual representation of discussions held and that they are content that their contribution has been accurately reflected. It confirms that attendees should notify the chair within 14 days of receiving the document of any concerns or requests for changes. The guidance does not explain how requests for amendments from any of the attendees should be considered, recorded or filed. Therefore, the administrative handling of this part of the process is a matter of discretion for the SPS to decide on.

By inviting all attendees to check that the minute is an accurate, factual representation of the discussions held, our view is that it is reasonable for all attendees to expect that any comments made by them, particularly regarding factual error or omission of irrelevant information or inclusion of relevant information are considered, and where appropriate, changes are made. We also concluded that the SPS' response to Mr C's complaint did not properly address the issue raised by him. Therefore, we upheld Mr C's complaints.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C for failing to properly address his complaint and for not handling his submission reasonably. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• The SPS should review Mr C's submission in relation to the ICM case conference and consider what changes, if any, will be made to the record of the case conference. The SPS should share the findings of their review with Mr C, highlighting any changes agreed and, where appropriate, offer an explanation as to why requested amendments have not been included.

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

• The SPS should reflect on our findings and consider what process could be introduced to support section 10.7 of the ICM guidance to ensure submissions made by all attendees about the record of the ICM case conference are given fair and reasonable consideration and that this is communicated in an appropriate way.

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.