Upheld, recommendations

Summary

C is a carer for their child and was previously in receipt of direct payments. C raised concerns that the partnership had said that C spent their direct payments inappropriately. C disputed that this was the case. They complained about the length of time taken to complete the Carers Respite Funding assessment and approve the budget and that the partnership overruled decisions made by C's allocated social worker about the use of C's Carers Respite Funding. In particular, C was concerned that they were not permitted to use their Carers Respite Funding to attend particular training courses or towards the purchase of a caravan/campervan. They also complained that the partnership told C that unspent budget could not be carried over into the next financial year; and that the partnership had not paid C Carers Respite Funding.

We took independent advice from a social worker. We found that the majority of the partnerships actions regarding C's respite funding were reasonable. However, we also found that there was an unreasonable delay in providing C with a decision regarding their carer's respite budget for short breaks. We upheld C's complaint on this basis.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in providing them with a decision regarding their carer's respite budget for short breaks. 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:

• Carers should be provided with timely decisions regarding respite budgets.

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

A GP practice contacted the Scottish Ambulance Service (SAS) to request that C's grandchild (A) be transferred from a local hospital to a hospital with a paediatric unit after A became unwell with suspected meningitis. The practice prioritised the request as urgent, therefore requiring a response within an hour. SAS contacted the practice to request approval for a delay in responding to the request. The practice agreed to the extension based on the information provided by SAS.

C complained that the time taken for A to be transferred to the main hospital was unreasonable for A's suspected ailment. C considered that an air ambulance should have been sent to transfer A to the main hospital.

We took independent advice from a consultant paramedic. We found that the SAS failed to provide the practice with accurate clinical information about A on which the practice could base their decision to agree or refuse the extension to the transfer time. As SAS failed to obtain confirmation from the local hospital that A's condition was unchanged, and therefore the practice's decision to agree to the delay was based on incomplete information, we upheld this aspect of the complaint.

C also complained that SAS's response to their complaint was unreasonable. We found that the investigation of the complaint did not identify SAS's failure to provide accurate information regarding A's condition to the practice. As a consequence, the complaint response failed to provide an accurate account of how the decision was made to delay the transfer. For this reason we upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C, and A's mother, for SAS staff failing to share accurate clinical information on A's clinical condition with the GP.
• Apologise to C for failing to provide a reasonable response to their complaint. The apologies 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:

• SAS staff should provide accurate clinical information on a patient's clinical condition with relevant healthcare professionals.
• SAS staff should seek relevant information where necessary from the healthcare professionals in direct care of a patient.

In relation to complaints handling, we recommended:

• SAS should provide accurate responses to complaints.

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

Ms C's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr A sooner, including that a community first responder (CFR) was not used. She also complained that the crew did not carry out cardiopulmonary resuscitation (CPR).

The Scottish Ambulance Service (SAS) responded to Ms C's complaint and then carried out their own internal clinical review with the ambulance crew to enable further reflection on the incident. SAS identified that the call had been inappropriately downgraded from a cardiac arrest to chest pain category. It was identified that a satellite navigation failure contributed to the delay in the ambulance arriving. It was also noted that a CFR was not showing as available due to software and systems issues, and was therefore not used.

We took independent clinical advice which agreed with some of SAS's findings. We noted that there were differing interpretations of the guidelines on when CPR should or should not be attempted. We found that the crew should have taken steps to establish all the available facts in order to fully inform their decision-making in this regard. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C that SAS were unable to utilise a CPR due to software/systems issues; that a satellite navigation system failure added to the ambulance response time; and that the ambulance crew failed to take steps to determine with more accuracy the facts of the cardiac arrest, in order to support the decision-making process prior to the cessation of resuscitation. 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:

• Steps should be taken to establish all available facts before taking the decision to terminate CPR, including asking relevant questions of family/friends. SAS should give consideration to ways in which aide memoire/checklists might be used to support clinical decision-making during resuscitation attempts.
• There should be confidence that control dispatchers are able to identify logged on CFR when checking for available resources.
• Call handlers should be familiar with Medical Priority Despatch System (MDPS) protocol and should ensure calls are accurately categorised.
• SAS should confirm they have a suitable organisational back-up system in place for directing crews to an incident in the event of a failure of satellite navigation systems.

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 an operation to their eye at Ninewells Hospital. C considered that they were not provided with information about the medical reasons why an operation to their eye was necessary. There were complications following this surgery. C raised concerns about what happened and why there was a failure to involve them in discussions about subsequent treatment options. C was concerned that the operation was not necessary and put them in a worse position than they had been before the operation.

We took independent advice from an ophthalmologist (a specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye). We considered that the operation was necessary. However we found that:

there was no evidence in the clinical notes that C was informed about the reasons for their options for treatment when they attended the hospital;

there was no evidence in the clinical notes that the risks of surgery were specifically discussed with C. There were the usual risks of bleeding and infection, but in this case there were also extra risks;

when C presented with severe pain after the initial eye surgery they should have been able to attend Ninewells Hospital within the same day to obtain advice from the surgical team who carried out the operation. We found that there was an unreasonable delay in C obtaining definitive treatment from the hospital after they suffered a complication from the original surgery; and

there was an unreasonable failure to include C in any subsequent discussions about treatment options after the first operation.

We upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for an unreasonable failure to provide them with information about the medical reasons why an operation to their eye was necessary; an unreasonable failure to provide them with information about possible complications following surgery and alternatives to the planned operation; an unreasonable delay in them obtaining prompt advice from the surgical team at Ninewells Hospital when they developed severe pain following the eye surgery; and an unreasonable failure to include them in any subsequent discussions about treatment options after the first operation. 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:

• Information about reasons for treatment, possible complications, and alternative management of non-intervention should be provided to and discussed with the patient prior to consent for treatment being obtained.
• Patients undergoing eye surgery at Ninewells Hospital should have access to a reliable pathway where they can obtain advice urgently in the event of postoperative problems.

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 to us on behalf of his late father (Mr A) who was diagnosed with, and subsequently died as a result of, septic arthritis (a serious type of joint infection). Mr C complained that the board failed to provide reasonable care and treatment in relation to Mr A's shoulder pain at a minor injuries unit (MIU) consultation and at a physiotherapy (the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) consultation. Mr C also complained that the board did not refer Mr A for x-ray or to orthopaedics (conditions involving the musculoskeletal system). Mr C considered that this had caused delays with Mr A being ultimately diagnosed with joint sepsis.

We took independent advice from an emergency nurse practitioner and from a consultant physiotherapist. We found that the board's consultations with Mr A were unreasonable in that Mr A should have been referred for an x-ray at the MIU consultation and that Mr A's presenting symptoms were not appropriately assessed at the physiotherapy consultation; it also had not been demonstrated that infection had been ruled out as a differential diagnosis. We found that Mr A should have been referred for further investigations/assessment at the physiotherapy consultation. Therefore, we upheld this complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologiseto Mr C for the failures 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 referred for x-ray as appropriate. Patients presenting for physiotherapy should be appropriately assessed in line with recommended clinical guidelines, taking in account their presenting symptoms, and this should be 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

Mr C complained about the care and treatment his partner (Mr A) received from the board. Mr A was diagnosed with Functional Neurological Disorder (FND, a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts) and depression. Mr A was seen by a consultant neurologist (a specialist in the diagnosis and treatment of disorders of the nervous system) at a neurology clinic. Mr C complained about the length of time it took to arrange appointments for the joint Functional Neurological Clinic (the joint clinic); the communications surrounding these appointments; the changes in medication and the lack of subsequent review. Mr C also complained about the length of time it took the board to respond to the complaint.

We took independent advice from a consultant psychiatric adviser. We found that, whilst the clinic appointment waiting time was not ideal, there was no unreasonable delay in the circumstances. We also did not identify any unreasonable delays in Mr A's follow-up appointments being arranged. Whilst there was some communication shortcomings, we did not consider that these amounted to unreasonable failings. However, given there was no record of a discussion with Mr A about the potential adverse effects of increasing his medication, on balance, we upheld this complaint.

We also found that the board had accepted that the delay in responding to the complaint was excessive and that they had apologised accordingly. We upheld this aspect of the complaint but made no further recommendations.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for failing to demonstrate that discussion took place with him regarding the potential risks of adverse effects when increasing his medication dosage. 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 expected benefits as well as the potential burdens and risks of any proposed investigation or treatment should be explained to patients in line with General Medical Council guidance on consent.

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 late parent (A) regarding nursing and medical care and treatment provided to A during an admission to the Western General Hospital.

We took independent advice from a nurse and from a consultant in general medicine and care of the elderly.

With regard to the concerns about nursing care, we found that there were failures in relation to:

risk assessment completion and accuracy

personal care

pressure sore prevention and management

wound care

continence management

encouraging mobilisation

person-centred care planning

We upheld this aspect of C's complaint.

With regard to medical treatment, we found that there was an unreasonable delay in providing antibiotics for A's urinary tract infection. However, we noted that the board had acknowledged and apologised for this failing previously. We also found that A was kept on the medical assessment unit for the entire admission of over a week, despite this unit being for maximum stays of 48 hours. Given these failings, we upheld this aspect of C's complaint.

C further complained that A had a dental appointment at another hospital in the area whilst they were an in-patient, and no arrangements were made to assist A to attend this or to arrange for them to be seen by their dentist at the Western General Hospital. The board had previously acknowledged that they should have arranged for transport and for a member of staff to attend the appointment with A, apologised, and offered to compensate C for the cost of transport. We upheld this aspect of C's complaint.

Finally, C complained that the board failed to identify that they were making a formal complaint. We found that C's complaints were not appropriately identified and responded to in line with the Model Complaint Handling Procedure and the board had accepted this. We therefore upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failure to provide reasonable nursing care and medical treatment to A, and for the failure to handle C's complaint in a reasonable 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:

• Appropriate care rounding should be carried out in a patient at risk of pressure damage.
• Every patient should have a person-centred care plan, and this should include consideration of how to manage any continence issues and mobility issues.
• Patients should be encouraged to get out of bed and get dressed appropriate to their condition.
• Patients should be transferred from the medical assessment unit to a ward, or be discharged, within a reasonable timescale. If a patient is on the medical assessment unit for more than the board's maximum period of stay (48 hours), the reasons for this, and any attempts to find a more suitable ward or a single room should be documented.
• Pressure sore prevention and management should be carried out in line with Healthcare Improvement Scotland Pressure Ulcer Prevention Standards.
• The Waterlow Pressure Area Risk Assessment Chart should be accurately completed on admission.
• Where appropriate, antibiotics should be provided in a timely manner when lab results become available.
• Wounds should be assessed and managed in line with Healthcare Improvement Scotland Scottish Wound Assessment and Action Guide, and relevant wound formularies.

In relation to complaints handling, we recommended:

• Complaints should be accurately identified and logged. If it is not clear whether the issues are a complaint or a concern, this should be clarified.

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

Ms C complained that the total knee replacement surgery she had undergone had not been carried out appropriately. We took independent advice from a consultant orthopaedic surgeon (a specialist in the treatment of diseases and injuries of the musculoskeletal system). The board were unable to locate the operation note for the surgery. However, we found that the evidence that was available indicated that it was likely there had been a technical error in the operation in that too much bone was resected (removed). However, without the operation note, it was not possible to state this categorically.

We also found that Ms C had been poorly consented for the operation. There was little evidence that she had been informed of the risks of surgery. The risks of ongoing pain, dissatisfaction and the fact that revision might be necessary were not specifically recorded. It was also unreasonable that the operation note was not available. Given this, we upheld this aspect of Ms C's complaint.

Ms C also complained that the board's response to her complaint was unreasonable. We found that the board's response had been inaccurate about who carried out the operation. There was also a delay in responding to the complaint and no evidence that the board agreed revised time limits with Ms C for responding. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the failings we have 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:

• Important documents such as operation notes should be securely retained by the board.
• Patients who are being offered total knee replacements should be given adequate information about the risks and possible complications.

In relation to complaints handling, we recommended:

• Where an investigation takes longer than 20 working days, the board should inform the complainant; agree revised time limits; and keep them updated on progress.
• Responses to complaints 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

Mr C complained about the clinical care and treatment provided to his late mother (Mrs A). Mr C complained that Mrs A had been incorrectly diagnosed with dementia and that the care and treatment Mrs A received during her admission to the Western General Hospital (WGH) and by the community mental health team (CMHT) prior to her death was unreasonable.

We took independent advice from a consultant psychiatrist and a consultant geriatrician (a specialist in medicine of the elderly). We were concerned that the board had failed to follow their retention and destruction policy and that some of Mrs A's medical records had not been retained in line with that policy and were therefore not available during the investigation of the complaint. However, from the available evidence, we found that the diagnosis of dementia was questionable and that there had been a failure to review this diagnosis as new information emerged. Therefore, we upheld this complaint.

In relation to the clinical care and treatment given to Mrs A during her admissions to the WGH, while we found that aspects of the care and treatment given to Mrs A was reasonable, there had been a number of failings and we upheld the complaint. However, we noted that the board had carried out a significant adverse review event and had made a number of recommendations.

In relation to the community mental health care given to Mrs A, we were unable to address all the issues raised by Mr C due to the absence of relevant medical records. However, based on the available evidence we found that there had been a lack of coordination and communication between the various mental health teams and as a result, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and the family for the failings identified in this case. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/informationleaflets.

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

• Medical records should be retained in line with the retention and destruction policy.
• The board should ensure that in psychiatry of old age the diagnosis of dementia is reviewed as new information emerges.

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

Ms C complained that the board failed to take reasonable steps to prevent her father (Mr A) from falling in hospital. We took independent advice from a nursing adviser. We found that staff had completed the required risk assessments prior to Mr A's fall and that the fall would have been hard to predict. However, updates to the care plan in place for Mr A lacked detail and the plan itself was not updated to address the changes in Mr A's functional ability. Although there was an indication on the falls risk assessment that Mr A was attempting to walk alone, there was nothing recorded in the nursing records or care plan to support or address this.

Staff also failed to follow the board's policy in relation to the assessment and use of the bedrails. In addition, there was no evidence of nursing staff updating Mr A's falls risk assessment or his care plan immediately after the fall, nor was there a record of a delirium screening at that time. In view of these failings, we upheld this aspect of the complaint.

Ms C also complained that staff failed to contact the family to inform them of the fall until the following morning. We found that, as Mr A had sustained a significant injury, staff should have called the family at the time of the fall, when the harm was confirmed, or earlier in the morning before the shift changed. Given this, on balance, we also upheld this aspect of the complaint.

Finally, Ms C complained that staff had attempted to use inappropriate equipment on Mr A after his second operation. Staff had to use a commode to transfer Mr A to the toilet because the stand aid had been condemned and the hoist had no battery. We found that when the decision was taken to use a commode in this way, a risk assessment should have been completed and recorded and an agreed approach noted in Mr A's care plan. Given the failure to do this, we upheld this aspect of the complaint.

We noted that the board had apologised for these failings and have made further recommendations for learning and improvement.

Recommendations

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

• All staff should follow the board's bedrail policy.
• Patient care plans and risk assessments should be completed and updated appropriately.

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.