Upheld, recommendations

Summary

C complained about the care and treatment they received from the urology (a speciality in medicine that deals with problems of the urinary system and the male reproductive system) service at Wishaw General Hospital. C was referred to the service with penile fracture symptoms. Following the referral, C was reviewed by two consultant urologists and investigations were performed over the following months. These investigations did not identify what the precise cause of C's symptoms were.

We took independent advice from appropriately qualified advisers. We identified a number of delays in the investigation of C's symptoms and concluded that there had been an unreasonable delay in making a diagnosis. We also found that there was an unreasonable delay in the board sending a discharge letter to C's GP after a surgical procedure was performed. Therefore, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for unreasonable delays in the investigations of C's symptoms which resulted in an unreasonable delay in diagnosis. 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:

• In line with Scottish Government standards, no patient should wait longer than 12 weeks for a new out-patient appointment at a consultant-led clinic. Delays in arranging subsequent consultations and tests should be minimised to ensure patients do not experience significant delays.
• When an operative procedure is performed a discharge summary or letter outlining the procedure should be sent promptly to a patient's GP in case of any complications.

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 wife (Mrs A) about 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) assessment she underwent. The assessment found that Mrs A could safely use a three-wheeled walking aid outdoors under close supervision. Subsequently, Mrs A suffered a fall while using the three-wheeled walking aid on a downhill slope. Mr C raised concerns that the assessment did not include a slope; it did not assess Mrs A's ability to use the brakes; and that close supervision would not have prevented the accident.

We took independent advice from a physiotherapist. We found that Mrs A's assessment was unreasonable. We found that the record of the assessment lacked appropriate detail. We found it did not address Mrs A's ability to safely negotiate slopes or to use the brakes and that the advice given to Mrs A and Mr C during the assessment was unreasonable. We upheld Mr C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr C and Mrs A for the failings identified in her physiotherapy assessment. 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' ability to safely use walking aids should be assessed appropriately; both physically and in light of any cognitive impairment they might have. The assessments should then be documented in sufficient detail.
• Patients and their carers should be given appropriate advice on the benefits/risks of using a particular walking aid and appropriate guidance on using it safely. This should then be appropriately 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, a support and advocacy worker, complained on behalf of their client (B), regarding the care and treatment provided to B's late partner (A) when A was admitted to the Royal Alexandra Hospital with back pain. C complained that:

A was inappropriately prescribed Pabrinex (a vitamin infusion injection often given to patients with alcohol dependency);

the Abbreviated Mental Test 4 (AMT-4, a rapid test to detect cognitive impairment) and 4AT test (a slightly longer screening test for cognitive impairment and delirium) were not carried out appropriately;

there was a delay in carrying out an MRI; and

A was treated differently due to the incorrect assumption that they were experiencing symptoms due to alcohol access.

We took independent advice from a consultant in orthopaedics (a specialist in the treatment of diseases and injuries of the musculoskeletal system). We found that:

the prescription of Pabrinex was unreasonable;

it was unreasonable that the AMT gave a score of zero, which would indicate severe cognitive impairment, but there was no documented action taken as a result of this outcome;

there was no indication that an MRI scan needed to be carried out earlier than it was; and

there was no indication that A was treated differently because of an incorrect assumption that they were suffering from alcohol excess.

We also found that in relation to the AMT score, the board gave inaccurate information to C and B in the complaint responses as they stated that a score of zero indicates no cognitive impairment. We upheld C's complaint about care and treatment.

C also complained that the minutes of the complaint meeting and follow-up actions were unreasonable. We considered that it was clear from the minutes of the meeting that there were several things that the board had committed to during the meeting that then do not appear to have been taken forward. We upheld this aspect of C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to B for the unreasonable prescription of Pabrinex, the failure to take appropriate action on the AMT score of zero; the inaccurate information in the complaint responses, and failing to take forward actions agreed during the complaint meeting or provide an explanation as to why this was not possible. 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:

• If the AMT gives a score of zero, which would indicate severe cognitive impairment, appropriate action should be taken as a result of this.
• Pabrinex should only be prescribed where clinically appropriate and the reasons for the prescription should be documented.

In relation to complaints handling, we recommended:

• Complaint responses should be accurate.
• During and after complaint meetings, care should be taken to ensure that all agreed actions are documented and either taken forward, or if it is not possible to take forward actions, an explanation is given to the complainant as to why this is.

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 to us about the care and treatment provided to her father (Mr A) before his death from suicide. Mr A was admitted to Forth Valley Royal Hospital after expressing suicidal thoughts. He was discharged on the following day. Ms C complained that it was unreasonable to discharge Mr A at that time.

We took independent advice from a psychiatric adviser. We found that there was no evidence that Mr A had been adequately assessed and we upheld the complaint that he was discharged unreasonably.

Mr A returned to the hospital on the day he was discharged and asked to be readmitted. However, it was decided that he would not be readmitted. Ms C complained that this decision was unreasonable. We found that it was unreasonable that the nursing staff did not consult a doctor and carry out an assessment when Mr A returned to the hospital. We also upheld this complaint.

Ms C complained that Mr A's medical records were inadequate. We found that there were failings in relation to describing the assessment of risk, the clinical rationale for the management of Mr A, discharge planning, changes in his mental state and information available from his family. We upheld this complaint.

Finally, Ms C complained that the board had delayed in completing a significant adverse event review. The board had accepted that there were delays in this and had apologised for this. We upheld this complaint.

We were satisfied, however, that the board had taken reasonable and appropriate action to try to prevent all of these failings recurring. They had also apologised to the family for most of the failings, although we recommended that they issue a further apology for the delay in completing the significant adverse event review.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Ms C for the delay in completing asignificant adverse event review. The apology should meet the standards set out in the SPSO guidelines onapology 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

Mrs C complained about the care and treatment she received from Victoria Hospital following a car injury. She attended A&E with injuries to her right hand. An x-ray identified a fracture at the joint of her right middle finger. Mrs C was advised to keep her hand elevated in a high arm sling but the injured finger was not strapped or splinted.

The following week, she was reviewed by an orthopaedic consultant (a specialist in the treatment of diseases and injuries of the musculoskeletal system) at a fracture clinic. Mrs C stated that, at that point, the tip of the injured finger was noticeably bent over. After assessing Mrs C's injury, the consultant did not consider any additional treatment to be required at that time and discharged Mrs C to the care of her GP. However, Mrs C's finger continued to be bent over and she was later assessed by a consultant hand surgeon who identified this as a mallet deformity.

Mrs C complained that she did not think the board had treated her injured finger appropriately. She queried why her finger was not strapped when she attended A&E and why it was left untreated following the consultation at the fracture clinic. In addition to this, Mrs C queried why she was not referred to a hand surgeon and was not provided with appropriate advice and information on how best to aid the recovery of her hand.

We took independent advice from an orthopaedic consultant. In respect of the care and treatment provided in the emergency department, we found that it would have been appropriate to apply a mallet splint at this point. Although a mallet injury may not have been visible at this point and it could not be known at the time whether splinting Mrs C's injury would have a beneficial outcome, we were satisfied that the evidence suggested it would have been reasonable to support splinting the finger on a 'just in case' basis. Therefore, we upheld this aspect of the complaint.

In respect of the care and treatment provided following Mrs C's discharge from A&E, we found that the possibility of a mallet deformity was underappreciated following Mrs C's discharge and, in particular, at the consultation at the fracture clinic. We considered there to be enough evidence to suggest that Mrs C's finger should have been splinted when she attended the fracture clinic. A referral to a consultant hand surgeon would not have been a required course of action given the nature of Mrs C's injury. In respect of physiotherapy, we felt this is unlikely to have prevented the mallet deformity from developing.

However, the more general hand injuries may have benefited from earlier physiotherapy or home exercise. We concluded that the board failed to provide appropriate care and treatment after Mrs C was discharged from the emergency department. Therefore, we upheld Mrs C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs 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 who present with hand injuries of this type should be provided with appropriate advice and information about physiotherapy or home exercise.
• Relevant staff should be aware of when it is appropriate to apply a splint to injuries of this type.

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 various aspects of the care and treatment that their parent (A) received from the board.

We took independent advice from a consultant geriatrician (a doctor specialising in medical care of the elderly) and from a nurse. We found that A was unreasonably discharged from Victoria Hospital when they had an infection, which may only have been partially treated, and that there may have been uncertainty about the effectiveness of the antibiotics A was receiving. We also found that A did not receive medical reviews when their delirium was active; that there should have been an earlier assessment of the possibility that A had a chest infection; that A was discharged from Queen Margaret Hospital to a care home without a prescription for stronger pain medication; and that no nursing transfer letter or discharge summary was provided to the care home when A was transferred from Queen Margaret Hospital.

We upheld C's complaint that the care and treatment provided to A was unreasonable.

C also complained about the board's communication. We found that there was a failure to discuss A's transfer arrangements, ongoing care (including palliative care) and medication with C prior to A's transfer to the care home. Therefore, we upheld this aspect of C's complain.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for: discharging A from Victoria Hospital, not carrying out a medical review of A, not carrying out an earlier assessment of the possibility that A had a chest infection, discharging A from Queen Margaret Hospital to the care home without a prescription for stronger pain medication, not providing a transfer letter or discharge summary to the care home when A was transferred, and for failing to discuss A's transfer arrangements, ongoing care (including palliative care) and medication prior to A's transfer to the care home. 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:

• Consideration should be given to the pain medication prescribed to patients who are approaching the end of their life and are being discharged from a hospital to a care home.
• Patients who are known to have delirium should receive regular medical reviews.
• Staff should discuss transfer arrangements, ongoing care (including palliative care) and medication with a patient's family when a patient is being transferred from hospital to a care home.
• Where a patient has been identified as potentially having a chest infection this should be assessed at the earliest opportunity.
• Where appropriate, the effectiveness of antibiotic treatment should be assessed prior to discharging a patient with an infection.

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 to us about the time she waited for a psychology appointment from the board. While she waited, Ms C went back to see her GP because she felt her condition had worsened. Several months after her referral to the board, Ms C had a telephone assessment with a psychologist to assess her needs. Some months after that, Ms C was offered a psychology appointment. The board apologised to Ms C for the delay and explained that they were taking steps to reduce their wait times.

We took independent advice from a psychologist. We found that there was an unreasonable delay in carrying out Ms C's telephone assessment. We found that it was unclear why there was such a delay, as it was a relatively routine referral. We found that the delay meant the psychology service was unaware of the worsening in Ms C's condition and they missed the opportunity to offer her an earlier psychology appointment. We found this led to an unreasonable delay in offering Ms C a psychology appointment and we upheld the 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, who are on the psychology wait list, should be assessed promptly. This would allow the board to identify high-risk patients or identify where there is some other need for urgent treatment (e.g. pregnancy) and help the service to identify appropriate treatment options. It would also enable patients to be given timely information about sources of support/guidance while they wait to be seen; and give the patient reassurance and motivation.

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

Mrs C complained on behalf of her late mother (Mrs A) whose hip fracture was not diagnosed until approximately nine weeks into her hospital admission, following a fall at home and a further fall during her first night in hospital. We took independent advice from a consultant geriatrician (a specialist in medicine of the elderly). We found that Mrs A's hip fracture should have been diagnosed within one week of her admission as there was enough information present to indicate she had a fractured hip and more detailed assessments should have been carried out during this time. Therefore, we upheld this aspect of the complaint.

Mrs C also complained that the board did not take reasonable falls prevention measures as Mrs A fell during her first night of hospital, despite having been admitted post-fall, and with a history of falls. We took independent advice from a nursing adviser. We found that there was no evidence that a falls risk assessment was carried out when Mrs A was admitted to the Combined Assessment Unit and there was no evidence of falls prevention measures being put in place at this time, which was unreasonable. Therefore, we also upheld this aspect of the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings identified in Mrs A's care. 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:

• Nurses should keep clear and accurate records relevant to their practice, in line with the Nursing and Midwifery Council code.
• Falls risk assessments should be undertaken on patients when indicated.
• When the need for further assessment is identified by therapy staff, this should be notified to appropriate parties and actioned.

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

Mrs C complained that the board failed to discharge her late husband (Mr A) in a reasonable way. After a period of admission to Borders General Hospital, staff planned Mr A's discharge which was discussed with Mrs C. Mrs C said that staff unreasonably failed to fully consider her concerns about Mr A's discharge and to record these in Mr A's clinical records in a reasonable way. As a result, the couple struggled to cope when Mr A was discharged home and he was readmitted to hospital the following week.

We took independent advice from a nurse. We found that while the decision to discharge Mr A was reasonable, staff communication did not meet Mrs C or Mr A's needs. It would have been reasonable for staff to have fully discussed (and recorded) their concerns about discharge with Mrs C and the consultant responsible for Mr A's care during his hospital admission beforehand. We also found that Mrs C's concerns about Mr A's discharge home were not recorded and the board gave inaccurate information during the complaint process about a meeting Mrs C had with staff. Therefore, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mrs C for the failings in communication. 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:

• Feedback the findings of our investigation in relation to communication to relevant staff for them to reflect on.

In relation to complaints handling, we recommended:

• Feedback the findings of our investigation in relation to complaints handling to relevant staff for them to reflect on.

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, an advocacy worker, complained on behalf of her client (Mr A) about the treatment he received following a cataract operation (a surgical procedure to replace the eye lens with an artificial one). During the surgery a complication occurred whereby the lens unfolded in an unusual fashion. Mr A underwent a number of other procedures and is concerned that these may have been unnecessary had his concerns about his eyes been listened to. The board accepted that a complication occurred during the cataract surgery, however, they consider it was managed appropriately. The board consider Mr A was kept informed of his clinical condition as it evolved.

We took independent advice from a consultant ophthalmologist (a clinician who treats disorders and diseases of the eye). We found that Mr A suffered a recognised complication during the cataract surgery and there is no evidence to suggest that his post-operative symptoms were not managed appropriately. However, we did consider that there was an unreasonable delay in performing the second surgery to repair the complication. Therefore, we upheld Ms C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to Mr A for the unreasonable delay in dealing with the complication that occurred, which caused Mr A unnecessary and prolonged pain and discomfort. 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 surgeons who perform cataract surgery for the board should know how to deal effectively with the complications of posterior capsular rupture during cataract surgery efficiently and promptly.

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.